Rose Ann DeMoro is always ready for another fight.
And why not? During the past decade, the leader of the California Nurses Association has won so many of her battles.
Largely because of CNA efforts, California is poised to become the first state where registered nurses make an average salary above $100,000.
The union helped defeat gubernatorial candidate Meg Whitman in 2010 and has become a political force, throwing financial support behind candidates for offices ranging from Santa Rosa City Council to state attorney general.
And more recently, nurses flexed their muscles with a series of one-day walkouts in support of other hospital employees who are in tough contract negotiations.
"This is a significant career with responsibility for life and death," DeMoro said. Hospitals, she said, "are looking to make more money off the backs of nurses. That's not going to happen."
The health care industry bristles at CNA tactics, including last Tuesday's one-day nurse walkout at Kaiser Permanente hospitals alongside striking workers from the smaller National Union of Healthcare Workers. Hospital officials say the solidarity strikes put patients at risk.
"We don't see how taking 23,000 nurses out of hospitals and having them walk the picket line advances quality patient care," Jan Emerson-Shea, a vice president at the Sacramento-based California Hospital Association, said before a prior walkout in September.
"They're putting access to care at over 30 hospitals at risk. In this economy, when is enough enough?"
Much of the union's influence is due to a seeming contradiction: California has so many nurses, but not nearly enough.
About 240,000 registered nurses work in California, making it one of the most common professions among those with a college education. But Nevada is the only state with a lower rate of nurses per 1,000 residents, according to the federal Bureau of Labor Statistics.
Just to get to the national average, California would need to hire 80,000 nurses 33 percent more than the state has now.
The shortage is expected to worsen, handing nurses more ability to dictate terms. Already struggling to meet demand, many higher education institutions that train nurses are losing funding. Meanwhile, baby boomers are getting older, requiring more health care services.
And then there's health care reform, which "will increase demand for nursing," said Ken Jacobs, chairman at the University of California, Berkeley Labor Center. "Health care will be the part of the economy that will grow. Nurses will have stronger bargaining power."
Nation's first staffing law
California's nurses have done plenty to increase demand and their own bargaining power.
In 1999, they persuaded the state Legislature to pass a first-in-the-nation law setting nurse-to-patient ratios: the maximum number of patients assigned to a licensed nurse at any one time.
The staffing ratios, implemented in 2004, range from one nurse for every patient in a trauma unit, to one nurse for every four patients in a specialty-care unit.
The ratios eased workloads while increasing the need for nurses, pushing wages higher, said medical labor expert Joanne Spetz, a professor at the Center for the Health Professions at the University of California, San Francisco.
"It's a huge cost for hospitals," Spetz said, estimating about one-sixth of a hospital's total budget goes toward compensation of registered nurses, licensed vocational nurses and nurses aides.
The win was a defining moment for the CNA, affirming its growing influence in the state Capitol.
"We waged a massive war that became a model for the nation," DeMoro said. "It raised nurses' economic standard, and they were able to care for the patient longer. It was a hard battle. We mobilized thousands of nurses and the public. We were relentless relentless through this."
In the years since, the CNA has remained one of the most active players in state politics.
It spent $750,000 lobbying the Legislature during the 2009-10 session. Over the past three years, its political action committee gave more than $2 million to candidates and campaigns statewide.
In the last decade, the union went from "a doormat to being someone that legislators rarely challenge," said Sacramento political operative Steve Maviglio.
CNA's scathing portrayal of gubernatorial candidate Meg Whitman as "Queen Meg" in the 2010 election was among the more memorable images from the campaign, and the union is credited with helping elect Gov. Jerry Brown.
"You softened her up," Brown told a group of nurses at a conference a few months later, "so there was almost nothing for me to do."
Highest nursing pay in U.S.
For many CNA members, there's a more potent measure of the union's success: Nursing pay, already higher in California than anywhere else, is rising fast.
The average salary for a California registered nurse grew from $57,855 in 2001 to $88,714 in 2011, according to the state Employment Development Department. Adjusted for inflation, that represents a 21 percent pay hike, compared with an 8 percent pay bump for other California workers during that span.
At the current pace, the average salary for a California registered nurse will eclipse six figures in three years.
California nurses collectively earned $21 billion last year, and a one percentage point increase in their average salary equals $200 million in additional pay.
Hospital officials say the rapid growth in nurses' pay increases patient costs. They say the recession, reimbursement changes, regulatory requirements and other factors are putting pressure on revenue, so nurses must share the pain.
Hospital officials contacted by The Bee for this story were reluctant to talk about nurses' pay head-on.
"We don't think nurses are paid too much, but they're paid very well," Emerson-Shea said.
But ongoing negotiations between Sutter Health and Bay Area nurses show that hospitals are determined to trim costs. Sutter is seeking a series of reductions in health and retirement benefits.
The CNA is refusing to accept any of the rollbacks, countering that the health care industry is doing well. Hospitals, they say, want to maximize profits instead of giving employees a fair shake.
Kaiser Permanente's hospitals and health care plan, for example, reported a combined $11.9 billion in operating revenue in the quarter ended Sept. 30, 2011, up from $11.1 billion in the year-previous quarter. Even with stock market declines, the health network posted net income of $1.5 billion through the first nine months of 2011.
Nurses repeatedly note that their raises often pale next to the bumps received by their bosses.
The chief executive officer of Sacramento-based Sutter Health, for example, made about $4.8 million in 2010, up from $1.1 million in 2001, tax records show. Kaiser Permanente's CEO made about $7.7 million in compensation and benefits in 2010, according to tax filings.
"Nurses finally achieve middle class and the industry is trying to vilify them? That's a war they don't want to have with us," DeMoro said. "This is one of the most profitable industries. I have not an ounce of sympathy for these employers. None."
Before they organized, she said, "we saw nurses making less than grocery clerks and clerks actually had pensions."
Kay McVay, 78, of Concord is a retired Kaiser nurse who recalls her early career when nurses fetched coffee and a double-digit hourly wage seemed a pipe dream.
"Orderlies made more than we did. Gardeners made more than we did," she said.
Conditions slowly improved, but by the late 1990s, McVay said, the nursing union's growing strength began to pay dividends in wages and with newly mandated staffing levels at bedsides.
"It was tremendous," she said.
The arguments, the walkouts, the pay increases all are likely to continue as long as demand for nurses remains strong. In 2010, as the state buckled under 12 percent unemployment, the jobless rate among nurses was 1.8 percent, census figures show.
The shortages are worst in the state's rural corners and the Southern California's Inland Empire.
"The feeling is that (shortages) are every bit as hard as in the 1990s," Spetz said, adding that it nonetheless can be hard to find a nursing job in a few saturated urban markets.
Local colleges and institutions try to keep up, even as they suffer budget cuts.
At the Sacramento Employment and Training Agency's One-Stop program, one-third of the program's nearly $3.5 million budget is spent on health care training.
"We're still seeing demand," said Terri Carpenter, the agency's spokeswoman. "But we can only train so many a year. There's only so much space at the colleges."