RN Center

Review of ICU Survey Results regarding Distribution of Break Relief and Action Team Assignments, and PPC Recommendations

Background:

The Union has received numerous complaints from our ICU nurses regarding favoritism, unequal treatment, and unfair distribution of Break Relief (BR) and Action Team (AT) assignments in our ICU. The Union has raised the issue of favoritism on many occasions, but nothing has been done to meaningfully rectify this issue and to establish healthy work environment for all nurses.

The management, as well as few of our ICU nurses (the “Status Quo group”) attempted to justify unfair distribution of BR and AT assignments by arguing:

That the same nurses are always given Break Relief and Action Team assignments because these nurses (about 20 % of our ICU nursing force) poses “merit and capability” and are “skillful” enough to handle Break Relief and Action Team Assignments.

That many of our ICU nurses don’t want and/or refuse to perform in Break Relief and Action Team roles.

That the Break Relief and Action Team assignments are very difficult assignments that most of our nurses prefer to avoid.

That limiting our Action Team to a small number of nurses produces better patient outcomes.

That the Action Team assignments should not be rotated because our current Action Team nurses have a “special” working relationship with doctors that other nurses don’t have.

The nurses involved in discussions with the “Status Quo” group have disagreed and cited favoritism as the primary reason behind the unequal distribution of Break Relief and Action Team assignments.

The Union’s attempts to reconcile differences through discussions with members of the Status Quo group have been unproductive. The meeting held with the opponents of equal distribution of the BR and AT assignments (the Status Quo group) on April 7, 2025 has not resulted in resolution of this issue. Therefore, the Union has decided to conduct the ICU-wide survey providing all of our ICU nurses with an opportunity to share their opinions, insights and ideas on the issue.

Despite the fact that the opponents of equal and fair distribution of BR and AT assignments have expressed reservations about the ICU-wide survey, and were trying to delay the resolution of this issue in attempt to maintain the Status Quo, they were invited to contribute their own questions for the survey to ensure inclusivity. On Tuesday April 8^th, 2025 at 08:33 am, they were given approximately 16 hours to submit their questions for the survey. Because no questions were submitted by the opponents of equal and fair distribution of BR and AT assignments, on the next day, on April 9^th of 2025, the Union-led Professional Performance Committee came up with the questions for the survey during 3 (three) hours meeting in accordance with the Paragraph 1420 of our Collective Bargaining Agreement (CBA).

In addition to evaluating the validity of arguments presented by the Status Quo group, the Union included several Survey items assessing:

if on professional level our ICU nurses support the idea of providing opportunity to all of our ICU nurses to learn the Action Team workflow and to perform in a role of Action Team RN,

general attitudes of our ICU nurses toward favoritism and fairness,

a percentage of our ICU nurses who are interested in, or thinking about joining our Action Team,

how many of our current Action Team members participated in survey,

the opinions of our current Action Team members who chose to participate in survey,

if our current Action Team nurses who chose to participate in survey have any objection(s) to providing an opportunity to other nurses to learn applicable workflows and periodically perform in a role of Action Team RN,

if our current Action Team nurses who chose to participate in survey and have 2 or more scheduled ATRN days are willing to give up at least 1 of their scheduled days to other members of our current Action Team who have no scheduled ATRN days

Survey Execution and Results

After the materials for administration of this survey and the survey itself were prepared for electronic distribution, the Survey was published on April 16thof 2025 and was active for approximately month and a half. A flyer with a QR Code linking to the survey was prominently posted in the ICU break room, and nurses were actively encouraged to participate. At one point the Union has received reports that some nurses were discouraged from participation.

Despite deliberate attempts to undermine participation, an overwhelming majority of our ICU nurses (76.5 %), including nearly two-thirds (Supermajority) of our current Action Team nurses, found the courage to defy pressure and completed the survey, demonstrating exceptional commitment to fairness and resilience.

The ultimate goal of this survey is to promote fairness and to foster a respectful, inclusive work environment in our ICU – empowering every nurse’s perspective and shared expertise to translate into exceptional patient care.

Each survey item underwent rigorous statistical analysis using industry-standard scientific methods at 99% Confidence Level – ensuring the highest degree of certainty that our results accurately represent the perspectives of our entire ICU nursing force. In addition, the Bias Resilience analysis was performed with respect to some Survey items involving our current Action Team situation. There was no need to perform the Bias Resilience analysis for all survey items because the standard Statistical analysis was sufficient to overcome any bias challenges.

Testing validity of suggestion that only few of our ICU nurses possess “merit and capability” to handle Break Relief and Action Team assignments

The validity of suggestion that only few of our ICU nurses possess “merit and capability” to handle Break Relief and Action Team Assignments has been tested by several survey questions including the questions looking for self-report of experience, skill and competence level, feedback from management regarding performance, and for general opinions of our ICU nurses.

The survey results have demonstrated that:

The median ICU experience of our ICU Nursing staff is 17 years. When benchmarked against National ICU experience metrics (median: 8 years), our ICU nursing force demonstrates markedly higher experience levels.

With 99% Confidence Level and a narrow Margin of Error of only 2.69%, the survey provides strong evidence that the overwhelming majority of our ICU nurses (94.59%) are adequately prepared to cover breaks for their colleagues. Particularly, Only 6 out of 111 survey responders have expressed lack of confidence in their competency and skill level to relieve other nurses for breaks.

The survey results clearly demonstrate that very few of our ICU nurses (3.6%), were told by our management and/or by another nurse that his or her skill set is not good enough to provide Breaks to other nurses and/or to handle rapidly changing situations in a role of Action Team RN. Reliability of this result is unassailable given the high accuracy 99% confidence level, with a narrow margin of error of 2.21%.

100% of Survey responders have agreed that every ICU RN must be competent to practice in the ICU environment, and that to be a competent ICU nurse means to have knowledge, skills, and ability to manage and effectively perform in rapidly changing situations.

It should also be noted that the suggestion that only select few of our nurses possess the “merit and capability” to handle Break Relief and/or Action Team assignments is not only offensive and demeaning to our ICU nurses, but wholly unreasonable considering that:

1. Every ICU nurse’s performance is evaluated annually by management;

2. All of our ICU nurses must pass rigorous written and practical exams to obtain and maintain ACLS and BLS Certifications as a condition of being employed in our ICU;

and,

3. It is Kaiser Policy to employ only competent nurses who possess “merit and capability” to practice in any of its ICUs across the country.

Are the opponents of equal distribution BR and AT assignments implying that our local HR and Management have failed in their duty by hiring unqualified nurses to work in our ICU ?

This is a rhetorical question demonstrating the absurdity of the Status Quo group’s arguments.

Conclusion: Therefore, the suggestion that only few of our ICU nurses possess “merit and capability” and are skillful enough to handle Break Relief Action Team assignments is unfounded, contradicts empirical evidence, and has been scientifically debunked.

Testing validity of claim that many of our ICU nurses don’t want and/or refuse to perform in Break Relief and/or Action Team roles

Several of the survey’s questions were specifically designed to test the validity of that claim.

With respect to Break Relief assignments, the overwhelming majority of the survey responders (approximately 82%) have stated that they are in fact willing to perform in a role of Break Relief RN.

With respect to interest in joining our Action Team, survey data reveals limited immediate interest (only 20.7% ‘yes’), with 38.4% declining, and 24.3% undecided (‘maybe’). Current Action Team members (16.2% of responders) excluded themselves from interest calculations by selecting “not applicable” option.

Conclusion:

The claim that “many” of our ICU nurses decline Break Relief and Action Team assignments is simply not true because the survey data reveals a strikingly different story:

An overwhelming 82% (+/- 4.57% at 99% CL) of our ICU nurses are willing to perform Break Relief duties.
A solid majority (56.2% at 99% CL) either, currently serve as Action Team RNs, wish to join, or are considering joining.
Only a minority of our ICU nurses 38.74% (+/- 5.79% at 99% CL) have expressed no interest in Action Team.

III

Dispelling the Myth that Break Relief and Action Team Assignments are Difficult and Undesirable for Most of our ICU Nurses.

The survey data conclusively disproves the claim that Break Relief and Action Team assignments are difficult and undesirable for most of our ICU nurses. The survey reveals:

Willing nurses outnumber reluctant colleagues 5-to-1 for Break Relief assignments (82% willing vs. 16% unwilling to perform in Break Relief role)

Action Team participation has nearly 3-to-2 support (56.2% interested vs. 38.74% declining participation in Action Team)

Nearly unanimous consensus (98.2% +/- 1.58% at 99% CL) endorses the Union’s principle of equal workload distribution, and confirms that to ensure fairness, all shift assignments (both challenging and routine) must be equitably distributed among nurses

It is fundamentally unfair and extremely divisive to constantly assign “difficult” assignments to one group of nurses and easy assignments to another group of nurses.

Conclusion:

This 49-to-1 mandate (98.2% vs. 1.8% opposition) leaves no doubt: Fairness requires equitable distribution of all assignments. Break Relief and Action Team assignments must follow transparent, standardized rotations. The current selection method which is understandably perceived as favoritism-based, creates unfair burdens and violates the principles of equity and fairness endorsed by nearly 98% of our ICU nurses. In other words, when nearly 98% of our ICU nurses demand equity and fairness, a selection method perceived as favoritism becomes institutionally indefensible.

Addressing the assertion that limiting our Action Team to a small number of nurses produces better patient outcomes comparing to other Kaiser hospitals.

The Claim:

Some opponents of expanding our Action Team roster argue that limiting participation to a small group of regularly selected nurses (currently about 15 out of 145 RNs) produces superior patient outcomes compared to Kaiser facilities with rotational models.

The Reality:

Hospital	Action Team Model	Centers for Medicare and Medicaid Services (CMS) Rating
Our Facility: Sacramento Medical Center	Restricted Model (Only 15 out of 145 RNs are regularly perform in ATRN role)
Kaiser Roseville Medical Center	Rotational Model
Kaiser Fresno Medical Center	Rotational Model
Kaiser South Sacramento Medical Center	Semi – Rotational Model
Kaiser Vacaville Medical Center	Rotational Model
Kaiser South San Francisco Medical Center	Rotational Model

The survey data reveals that prior to survey approximately 80% of our ICU nurses were unaware that higher-rated Kaiser Hospitals in our region use rotational Action Team models and outperform our 1-star facility in outcome-based CMS rating.

Conclusion:

The claim that restricted access to Action Team participation improves patient outcomes is a demonstrable fallacy. The CMS evidence shows:

Rotational models correlate with better outcome-based ratings
Our current approach aligns with bottom-tier performance
Equity for nurses and quality of care are not mutually exclusive – they are synergetic

Immediate Action Recommended:

Create and implement sophisticated rotational model using experience of 5-star Kaiser Hospitals as benchmarks.

From ‘Special Relationships’ to Shared Excellence: Why 85% of our Nurses Reject ‘Special Relationships’ by Prioritizing Fairness Instead

The Assertion:

Some claim that Action Team assignments should remain restricted because current Action Team nurses have “special” relationships with physicians.

The Reality revealed by Survey:

92.79% of our ICU nurses (+/- 3.07% with 99% CL) agree that it is unprofessional for any physician (in any US hospital) to practice favoritism.

85.59% of our ICU nurses (+/- 4.17% with 99% CL) affirm that it is unfair to deprive qualified nurses of Action Team opportunities based on non-merit factors such as having “special” relationships with physicians.

Why this matters:

Clinical teams thrive on competence, not exclusivity. Kaiser’s own 5-star hospitals rotate Action Team assignments without compromising patient care.
The existence of “special” relationships between some nurses and physicians raises concerns about potential favoritism and its implications. In practice, this dynamic may embolden nurses to disregard protocols without consequence.
Magnet-Designation Standards explicitly prohibit favoritism in assignments, emphasizing the importance of ‘collaborative practice’.
Favoritism in Action Team decisions clearly violates Kaiser’s Code of Ethics and Joint Commission’s Leadership standard LD 03.01.01.

Conclusion:

The “special relationships” argument has been rejected by nearly 93% of our ICU nurses, undermines Kaiser’s own excellence benchmarks, compromises our journey to Magnet status, and creates liability while harming morale.

Solutions:

Well-structured Action Team rotations promote shared excellence while ensuring that:

All nurses develop physician rapport
No one bears disproportionate burdens
Transparency replaces even perception of favoritism

Let’s build real teamwork – where relationships grow through shared practice, not exclusion.

Breaking Barriers: Overwhelming Nurse Support for Expanding Action Team Access and Training Opportunities

Key Findings:

Strong interest in better training opportunities.

97.3% of our ICU nurses (+/- 1.93% at 99% CL) want to have regular and meaningful “Skill Days” and regular “Hands On” training sessions for all nurses (as we had before COVID) to keep their knowledge and practical skills up to date to ensure top performance of our ICU.

69.37% of our ICU nurses (+/- 5.48% at 99% CL) agree that every one of our ICU RNs should be given an opportunity to learn the Action Team workflow and be capable of performing in a role of Action Team RN.

2. Strong Interest in Action Team participation.

Approximately 45% of our ICU nurses are looking positively at the opportunity to join our Action Team.

20.72% definitely want to join

24.37% considering joining

While only 38.74% of nurses have no immediate desire to join

3. Supermajority of current Action Team Nurses support expansion

94% of surveyed Action Team nurses (17 out of 18) representing Supermajority of our current Action Team, support providing opportunities for all of our ICU nurses to learn Action Team workflows, and to periodically perform in Action Team role.

4. Current system excludes willing nurses

28 Current Action Team Members (only 19% of 145 RNs) control opportunities to perform in Action Team role, and only 15 of them have scheduled days allowing them to actually perform in Action Team role on regular basis.

Currently, the overwhelming majority of our ICU nurses have no access to opportunity to join our Action Team.

Approximately 45% of our ICU Nurses seek greater access to Action Team opportunities.

VII

Survey’s Resilience to Bias

The survey was designed to address potential biases in two key areas related to Break Relief and Action Team assignments.

Break relief Assignments

The survey’s data related to Break Relief assignments is highly reliable and resistant to bias for three reasons:

1. Multiple aligned questions: All relevant survey items assessed the issue from different angles, ensuring consistency.

2. Consistent Responses: The data from relevant survey questions showed strong agreement.

3. Overwhelming Consensus: The results demonstrated such clear and uniform majority that further bias analysis was unnecessary.

Action Team Assignments

For most aspects of Action Team assignments, the survey data demonstrated strong resilience to bias. However, due to the complexity of the issue, a Bias Resilience analysis was conducted on the following two key survey items:

Survey Question for all Nurses asking if every ICU nurse should be given an opportunity to learn the Action Team workflow and perform in a role of Action Team RN.

Survey Results:

69.4% responded “Yes”
16.2% responded “No”
14.4% were “Unsure”

Bias Analysis:

To account for potential non-response bias, we modeled extreme scenario where all 34 nurses who have not participated in survey (non-responders) opposed providing the opportunity to other nurses. Even under this maximum bias assumption:

Support for providing Action Team opportunities to all willing nurses remained at 53.1%, still representing a majority of our ICU nurses.

2. Survey Question for Current Action Team Nurses (ATRNs):

The survey asked our current ATRNs if they have any objection to providing an opportunity to other nurses to learn applicable workflow, and periodically perform in a role of Action Team RN.

Survey Results:

17 out of 18 ATRNs (94.4%) supported providing such opportunity.
1 out of 18 ATRNs (5.6%) objected.

Bias Analysis:

Total ATRNs: 28 (only 18 participated)

Maximum bias assumption: Let’s assume that all 10 non-responders opposed the opportunity.

Result: Even under such extreme scenario, over 60% of ATRNs (17 out of 28) still support the opportunity – a clear Supermajority.

Alignment with the entire ICU Nurse Sentiment:

This finding reinforces the broader ICU nurse consensus, where 69.4% of all respondents (including non-ATRNs) endorsed expanding Action Team opportunities.

VIII

Systemic Unfairness in BR and AT Role Assignments

This survey was initiated in response to persistent staff concerns about favoritism in Break Relief (BR) and Action Team (AT) assignments. The findings confirm a pattern of inequitable practices, with multiple nurses reporting exclusion despite meeting qualifications.

Case evidence: Systematic Exclusion of Qualified Nurses

Example A: A highly experienced nurse with a proven skill set stated that they had repeatedly requested Action Team placement over a three-year period but were consistently denied by the unit manager, while less experienced nurses were admitted to Action Team during the same timeframe.

Example B: Another nurse, who had served in Break Relief and Action Team roles at multiple Kaiser facilities, noted that this was the only location where they were barred from such opportunities – explicitly citing unfair favoritism as the reason.

Key Themes from Comments

Lack of transparency: Nurses reported inconsistent or unexplained decision-making in role assignments.
Demoralization: Several nurses expressed frustration over being repeatedly passed over despite their qualifications.
Perceived bias: Multiple comments suggested that personal relationships, rather than competence, influenced selections.

Systemic Abuse of Break Relief Assignments:

Illegal Exploitation of Nurse Labor

Survey findings confirm that ICU management has been extorting unpaid labor from nurses by tying Break Relief (BR) assignments to performance of managerial auditing tasks – a practice violating California wage laws, Federal labor laws, and Kaiser’s contractual obligations.

The Core Violations

A. Wage Theft (CA Labor Code Sec. 223)

The Law: “Where any statute or contract requires an employer to maintain the designated wage scale, it shall be unlawful to secretly pay a lower wage while purporting to pay the wage designated by statute or by contract.”

The Nexus: Break Relief assignment is preferred by 81.98% (+/- 4.57%) of our ICU nurses due to its lower documentation burden, reduced liability risk, and intermittent activity compared to Primary Care assignments. Yet Kaiser conditions these preferred assignments on additional managerial duties without adjusting pay, thereby concealing underpayment while purporting to pay the wages designated by our Collective Bargaining Agreement – a clear violation of Sec. 223 of the California Labor Code.

B. Union Contract Violations

By requiring nurses to perform additional managerial auditing work as a condition for Break Relief assignments, Kaiser engages in private dealing – a direct violation of Article I, Sec 101 of our Collective Bargaining Agreement (CBA). This section designates the California Nurses Association as the “sole bargaining agent” for all covered nurses regarding “wages, hours, and other conditions of employment”. Kaiser’s unilateral imposition of extra duties bypasses the Union’s exclusive role in negotiating such terms.

As outlined in Section 506 of our Collective Bargaining Agreement (CBA):“The parties have agreed upon complete job descriptions for StaffNurse I-IV in the inpatient setting and in Emergency Departments”.

Managerial duties, such as auditing other nurses, are not included in our job descriptions. Therefore, it is violation of the CBA for our ICU management to compel, coerce, or incentivize nurses – whether through pressure, promises of benefits, threats of discipline (direct or indirect), or misrepresentation – into performing managerial tasks or any other tasks outside the scope of our job descriptions.

Furthermore, the CBA explicitly prohibits the temporary or ad-hoc assignment of managerial duties to staff nurses, as well as any unilateral expansion of job responsibilities without mutual agreement.

As codified in Section 319 of the CBA:

“No employee shall be required nor permitted to make a written or verbal agreement with the Employer which may conflict with the terms of this collective bargaining agreement”.

Thus, any attempt to compel nurses to perform out-of-scope duties (e.g., auditing peers) violates this provision, as it effectively imposes unauthorized, conflicting agreement.

C. Unfair Labor Practice (Multiple violations of NLRA)

Kaiser’s private dealings – conditioning Break Relief assignments on additional managerial work – violate the National Labor Relations Act (NLRA) 29 U.S.C. §§ 151-169, specifically:

§ 158 (a)(1): Interfering with employees’ right to collective bargaining.

§ 158 (a)(5): Refusing to bargain in good faith with the Union.

This mirrors the U.S. Supreme Court’s rulings in J.I. Case Co. v. NLRB (321 U.S. 332) and Medo Photo Supply Corp. v. NLRB (321 U.S. 678) holding that even in extreme cases employers cannot bypass unions by directly dealing with employees.

By unilaterally altering working conditions, Kaiser commits the same unlawful conduct condemned by the NLRB and by the United States Supreme Court.

PPC Recommendations

Based on the ICU survey results regarding Break Relief and Action Team assignment distribution, the Professional Performance Committee recommends:

1. Implement a Fair Rotation System for Break relief Assignments

Rotate Break Relief assignments equitably among all willing ICU nurses.

Post an “Opt Out” sheet in ICU break room to allow nurses to voluntarily without any coercion decline the Break Relief assignments.

Develop and implement the rotation plan in full collaboration with the Professional Performance Committee (PPC).

End all requirements that condition Break Relief assignments on performing additional managerial tasks. Specifically prohibit linking assignments to managerial tasks such as audits and/or any other work beyond standard non-managerial nursing responsibilities.

2. Implement Equitable Action Team Assignment System that must be developed and administered in full collaboration with the professional Performance Committee as follows:

Post accessible “Sign Up” sheet in ICU break room allowing all interested nurses to sign up for joining our Action Team.

Distribute all scheduled ATRN days equally and fairly among all of our current Action Team nurses (One guaranteed scheduled day per pay period), and adjust the Action Team backup schedule accordingly.

Create and implement the rotational Action Team model in full collaboration with PPC. The PPC is currently working on, and will present a proposal for highly effective rotational Action Team model that will eliminate concerns of favoritism while ensuring top performance of our ICU, and best possible outcomes for our patients.

Review and optimize current Action Team workflow.

Develop training materials explaining the Action Team workflow, and provide all nurses willing to join the Action Team with an opportunity to learn the Action Team workflow.

Transition to new rotational model for all willing ICU nurses within next 3 (three) months.

3. Effective Educational Opportunities for all nurses

Restore meaningful “Skill Days” and regular “Hands On” training sessions for all nurses (as we had before COVID) to ensure top performance of our ICU.

Implement adequate educational and training opportunities aimed at improving the quality of care and achieving spectacular outcomes for our patients.

______________

The foregoing document titled: “Review of ICU Survey Results Regarding Distribution of Break Relief and Action Team Assignments, and PPC Recommendations” was submitted to management during Nurse Quality Forum (NQF) meeting held on July 9, 2025 pursuant to Section 1402 of the Collective Bargaining Agreement (CBA). The management’s written response is expected in a timely fashion as required by Section 1403 of the CBA.

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