The threat of as many as 10,000 New York City nurses going on strike intensified Monday as members of the New York State Nurses Association rallied outside the Mount Sinai Hospital in East Harlem. The union announced that nurses at Montefiore Health System, Mount Sinai Health System, and New York-Presbyterian would strike starting at 6 a.m. on April 2nd if those hospital systems do not agree to hire enough staff to maintain minimum nurse-to-patient ratios that the union says are needed to ensure patient safety.

“After nearly 30 negotiation sessions, we still do not have a single item agreed upon,” NYSNA wrote in an email to members Monday morning announcing the potential strike date. “But it is management’s continued refusal to engage in a conversation about minimum nurse to patient ratios that has led us to this moment.”

The NYC Hospital Alliance, which represents those hospital systems in their contract negotiations with the union, clapped back the same day by filing a charge against NYSNA with the National Labor Relations Board, alleging that the union is engaging in unfair labor practices by unlawfully seeking to get hospitals to adhere to mandatory staffing ratios.

For years, NYSNA has been trying to get the state legislature to pass a bill requiring hospitals and nursing homes to maintain certain nurse-to-patient ratios, but has faced continuous pushback from hospital lobbyists who say that rigid staffing requirements would drive up costs without improving patient safety. The Safe Staffing for Quality Care Act is still on the table in Albany and received vocal support from Governor Andrew Cuomo after it failed to pass during last year’s legislative session. In the meantime, the union has been trying to jump-start the process of increasing nurse staffing levels at city hospitals through its ongoing contract negotiations with the NYC Hospital Alliance.

When NYSNA made a similar walkout threat during contract negotiations with the Alliance in 2015, a strike was avoided when the hospitals agreed to hire more nurses, even though they refused to agree to staffing ratios. In its NLRB complaint, the Alliance says that this go-round NYSNA has been “preconditioning negotiations over nurse staffing issues on the Alliance's acceptance [of the] principle of mandatory staffing ratios.”

The current standard practice is that “the nurse managers of individual hospital units assess staffing at the beginning of each shift to design tailored, flexible staffing plans to respond to patient needs,” an NYC Hospital Alliance spokesperson explained.

But some nurses who spoke to Gothamist said their hospital units are chronically understaffed, leading to unsafe conditions for patients.

“Most of the staffing really isn’t safe on most of the units at the Children’s Hospital at Montefiore,” said Naomi Cordova, who has been working as a nurse there for nearly 30 years.

Cordova said she is usually responsible for five patients during her shifts, caring primarily for infants and small children with cardiological or gastrointestinal problems. Nurses say staffing needs vary from unit to unit; Cordova said she believes a safe staffing ratio on her unit would be three to one. She said being understaffed can prevent nurses from reporting children’s respiratory issues to doctors in a timely manner, among other dangers.

“You tend to prioritize when you have four to five patients,” said Cordova. “You say, ‘I’m going to concentrate on one kid, perhaps the sickest kid,’ and you tend to neglect the other patients. I feel horrible having to do something like that.”

Lori Crump, a nurse working in a transplant unit at Mount Sinai Hospital who attended the rally Monday, said she can often handle the five patients she’s assigned on each shift without a problem. But on days when nurses on her unit call out sick or there are a lot of patients with acute needs, she said, she can be forced to make tough decisions about patient care.

“Administrators don’t float us the nurses that we need [when we are short-staffed],” said Crump, who has worked at the hospital for 12 years. “You have to prioritize at that point, but even with prioritizing, patient care is jeopardized because you don’t have enough manpower.”

Michelle Bernabe currently works per diem as a nurse at the psychiatric inpatient unit at Mount Sinai West as well as other behavioral health facilities. She said she stopped working full-time at Mount Sinai, in part, because she felt the staffing levels were unsafe.

“It just doesn’t feel good to be a nurse and feel like it’s a Hail Mary when you’re walking into work and have 10 patients and hope things turn out OK,” she said.

Currently, only California has a law requiring hospitals to maintain minimum nurse staffing ratios, although similar legislation has been introduced in other states and at the federal level. A 2010 study looking at the California case and other research on the subject found that lower nurse-to-patient ratios are associated with lower patient mortality rates and less burnout among nurses.

"Rigid staffing ratios would lower patient care and drastically increase costs for not-for-profit hospitals—resulting in layoffs of other important members of patient care teams,” a spokesperson for the NYC Hospital Alliance said in a statement. “We cannot agree to a staffing approach that would override the professional judgment of nurses and healthcare experts."

While all three hospital systems involved in negotiations through the Alliance are technically nonprofit, they tend to generate a lot more money than they spend on patient care. New York-Presbyterian reported an operating income after expenses of $404.5 million for 2017 (not counting massive gains on investments), while the operating surplus for Mount Sinai Hospital and its Queens campus was $205.2 million that year. Montefiore Health System brought in a more modest $55.3 million operating surplus in 2017.

Hospitals are already in the process of working with temporary staffing agencies to recruit nurses to work in case of a strike, although it’s unclear whether there will be enough nurses available to fill all the positions. In an ad encouraging nurses of all specialties to apply, the U.S. Nursing Corporation offered a $500 bonus to anyone who refers another registered nurse to work during the strike, while Healthsource Global Staffing said $1,000 referral bonuses are available.

When hundreds of nurses went on strike at St. Luke's-Roosevelt Hospital in 1989, the hospital responded by discharging or transferring some of its patients, as well as hiring temporary nurses and having doctors and management personnel perform some of the striking nurses' duties, according to the New York Times. Some medical units and clinics were closed and elective surgeries suspended. This strike could involve thousands, rather than hundreds, of nurses at multiple facilities, however.