Spokane's health-care industry is bracing for its largest wave of labor activity in decades.

With its wealth of successful hospitals and clinics, Spokane is fertile ground for organizing.

During the past 11 months, about 750 nurses, technicians and therapists have formed new collective bargaining units in Spokane. Within the next couple of years, the number of locals could more than triple and put new membership above 6,500, dominating the workplace of every hospital.

At stake is patient care and how hospitals spend tens of millions of dollars each year. Some say increased unionization will further fuel runaway health-care inflation, already in the double-digits.

The trend is nationwide, with alliances and rivalries forming between industrial unions like the Steelworkers and the AFL-CIO and service workers' groups.

As Forbes magazine put it: Florence Nightingale, meet Mother Jones.

"There's no doubt the dam has burst," said Peter Diaz, a Spokane-based organizer with the United Food and Commercial Workers Local 1001.

A troubled national health-care system enhances the climate for unions.

"We had too much turnover among our staff, people coming and going and finally, we said, `That's enough,' " said Dale West, who helped usher in a union at St. Luke's Rehabilitation Institute.

With health-care workers increasingly vexed by staff shortages, longer hours, sicker patients and wavering morale, unions are stepping in with big bargaining promises.

Hospital administrators are countering with pay raises and letters aimed at keeping unions out, according to union organizers.

"Do they think they don't drive up health-care costs by what they're doing?" asked Michael Banks, chief financial officer of Sacred Heart Medical Center. "The unions say if the company goes under, it's the company's problem, not ours. Well, follow that out. That's where the Kaiser (Aluminum Corp.) people are, aren't they? Not employed."

Said Barb Heimbigner, an organizer for the Washington State Nurses Association and leader of Sacred Heart's 1,200-member nurses union:

"It comes down to this: Nurses must have a stronger voice in how care is delivered. We're the ones at the bedside."

It's not just nurses, though. Medical technicians and assistants, therapists and scores of other workers are talking with union organizers.

"It makes it look like a wildfire out there. It's important to remember that there's a long ways between organizing and union membership," Diaz said.

Yes votes more common

Organized labor in health care is an American growth industry. Nationally, unions win more votes in health care than in other business sectors, a trend even more pronounced in Washington state.

Labor experts cite the myriad problems of the health-care system, from which union organizers craft powerful messages that connect with dissatisfied workers.

"Unions are laundry-listing the problems in health care. They say, `You pull the cord, the problems stop,"' said Brent Yessin, president of PTI Labor Research in Houston, which provides labor data to management.

Yet unions can't deliver on their promises to fix health care, Yessin said. Hospitals that stay nonunion are the ones that best communicate their financial challenges and involve employees in decision-making.

That's difficult for hospital management.

For a recent public "State of the Medical Center" address at Sacred Heart, chief financial officer Banks explained to about 300 employees why a $150 million building project couldn't be redirected to salaries.

He noticed scattered yawns in the audience as he explained why a 1 percent salary increase adds more expense to the bottom line than adding $150 million for construction: "Because the cost (of construction) gets spread over 40 years. That's how long the building is supposed to last."

Despite the yawns, Banks believes the message got through to most employees.

But the story underscores the difficulty of involving workers in a huge system with dollars-and-cents decisions.

Unions find yes votes when workers are worried, said Paul Clark, a Penn State University professor of labor studies.

"Job restructuring. Downsizing. A greater workload. The end result is a great deal of dissatisfaction among a good many health care occupations," he said.

Historically, nurses have not made great union material. The ideal of nursing as a calling conflicted with the nuts-and-bolts of hashing out contracts and haggling over pay.

Yet the exodus of a half-million registered nurses from the profession has burdened those who stayed with 12- to 16-hour shifts.

Until the job improves, the nursing shortage will persist.

Unions are looked upon as a fix.

"Many have come to see unions as almost an extension of responsibility to their patients," Clark said. "It really wasn't pay and benefits. These are going up because of the shortage."

He said unionizing hospital workers may improve patient care, for a price.

"I'd much rather be cared for by a nurse who's well-rested, isn't overworked with too many patients and is available to me ... and isn't stressed to the point where their judgment is impaired," he said. "It has the potential of costing more for patients. I don't know any way around that."

Competing for the prize

Aside from a small group of maintenance engineers, Spokane's second-largest hospital has until now kept unions out. In fact, Deaconess Medical Center is the largest hospital in Washington state without union representation.

The hospital is a plum, such a lucrative prize that unions are competing for organizing rights.

With 900 nurses and technicians each paying dues of up to $60 a month, a union could capture $648,000 in new annual revenues.

Dues may generate a lot of money, but surgery technician Terra Ayles said workers need a stronger voice.

"I'm not upset or irritated with Deaconess, but there's a lot more pros than cons to organizing," she said.

A registered nurse at Deaconess who asked to remain anonymous said forming a union is the best way to improve patient care and the workplace for staff.

"Health is changing into a huge business proposition, and nurses have a professional responsibility to change and maintain a voice," she said.

During the past five years, the hospital has not dipped into the red, according to audited reports submitted to the state Department of Health.

Last year Deaconess, which operates as a nonprofit, posted earnings of $8.8 million.

Organizing Deaconess nurses and technical employees has pitted two unions against each other. The disagreement landed both the Washington State Nurses Association and the Service Employees International Union 1199 Northwest in an arbitration hearing held by the AFL-CIO, the national umbrella organization overseeing both unions.

The nurses group wants to represent Deaconess' approximately 650 nurses. SEIU 1199 Northwest wants all 900 nurses and technicians.

As an indication of how sensitive an issue union activity is at Deaconess, management declined requests for interviews.

Instead, the hospital's management group issued a two-page statement that included: "Empire Health Services prefers to maintain a direct and cooperative working relationship between management and employees rather than have that relationship change to a third-party labor relationship."

Diane Sosne, president of SEIU Local 1199 confidently predicted a vote among Deaconess employees by summer.

"Workers have expressed tremendous interest in organizing," she said.

The WSNA isn't so sure, said Heimbigner. Once the two unions work out their own differences, organizing Deaconess will be a delicate affair.

The nurses-only union also has a $40 dues cap. The SEIU charges a percentage with the total not to exceed the $60 limit.

"In the past, Deaconess was always able to get what Sacred Heart got. Our union negotiated for wages and Deaconess adjusted," Heimbigner said. "Things are changing. Today it's less about pay and more about patient care and the work environment."

Wages, though, can't be discounted.

The WSNA last week negotiated a new contract with an 18- to 24-percent raise during the next three years for its 330 union nurses at Holy Family Hospital. Nurses earned a seat on a hospital policy panel that will create a new patient care delivery model.

At Deaconess, both unions expect a vigorous fight from management no matter who wins the AFL-CIO blessing to organize.

Taking a stand

Last summer, Dale West realized a change was needed.

A registered nurse at St. Luke's Rehabilitation Institute, West noticed normal office grumblings growing into deep concerns. Nurses felt ignored. Job satisfaction slumped.

Several nurses began talking about a union and momentum grew. So they contacted the WSNA and asked for a meeting.

Twelve people -- including West -- attended.

"It gets to the point where instead of sitting around over coffee and complaining all the time, you do something about it," West said.

A union representative was sent to gauge the level of support.

The answer came 10 days ago when 70 nurses and case managers voted union.

"This is my first time being a member of a union," said West, who works with patients recovering from orthopedic and spinal cord injuries. "We're real excited about all of this, yet know we've got a lot of work ahead of us."

The organizing of St. Luke's nurses may have dismayed management -- a collaboration between Deaconess and Sacred Heart -- but it likely won't be the last go-round with unions.

It may be too late for management to stem the union tide, said Ed O'Neil, director of the Center for the Health Professions at University of California, San Francisco.

Managers instead should take a page out of Southwest Airlines' book, striving to collaborate with unions with an emphasis on customer service.

Southwest is one of the most unionized airlines and continually gets high scores for customer interaction with flight attendants and ticket agents, O'Neil said.

Some unions are better at collaboration and orienting toward service than others, he said, citing SEIU as one of the best.

"The movement toward unionization is inevitable," O'Neil said. "The question is: Can we come up with new ways of working with unions that are more collaborative?"