Nursing representation in the United States is fragmented in a way that confuses nurses themselves. A nurse may belong to a professional association that does not bargain, a union that does, a state association that does both, or nothing at all, and the situation differs building by building rather than state by state.
The distinction that matters
A professional association advocates, publishes standards and lobbies. It has no power over an employer. A union negotiates a contract with a named employer, enforces it through grievances, and can call a strike.
Some organisations do both. Several state nurses associations act as the state affiliate of the American Nurses Association and as a labour union, which is why joining a state association means quite different things depending on the state.
The main organisations
- National Nurses United, formed in 2009 and reporting more than 225,000 members, the largest union of registered nurses in the country. Its signature position is minimum nurse-to-patient ratios set in law.
- New York State Nurses Association, a state association that is also a union, and the organisation behind the January 2026 New York City hospital strikes.
- Massachusetts Nurses Association, similarly both.
- Service Employees International Union, which represents large numbers of health care workers including nurses, generally in units alongside other staff.
- AFT Healthcare, the health division of the American Federation of Teachers, representing nurses and other health professionals.
Beyond these, many nurses are represented by state or regional unions with no national affiliation, and hospital systems frequently have several different unions across their facilities.
How a unit gets organised
Private sector health care employees are covered by federal labour law, which sets out the route.
A group of employees with a shared community of interest, typically the registered nurses at one facility, forms a proposed bargaining unit. Support is demonstrated through signed authorisation cards. A petition goes to the federal labour board, which conducts a secret ballot election, and a majority of votes cast decides it. If the union wins, the board certifies it and the employer is obliged to bargain in good faith.
Two features of the process shape nursing campaigns. Supervisors are excluded from bargaining units, and the definition of supervisor is contested in nursing because charge nurses and other roles direct work without being managers. And public sector nurses, including those at state and municipal hospitals, are covered by state law rather than the federal statute, so their rights differ, and in some states public employees may not strike at all.
What representation changes
Contracts in nursing increasingly cover more than pay. Recent settlements have included staffing provisions, and the 2026 New York contracts contained the first limits on how artificial intelligence may be used in staffing decisions. See nurse strikes and bargaining and patient acuity and staffing systems.
Where a state does not restrict mandatory overtime, a contract is the only place a limit can come from. See nurse overtime.
Representation also changes what happens when a nurse objects to an assignment, because a union contract usually creates a documented objection procedure. See nurse workplace rights.
Finding out what applies to you
Ask three questions. Is there a bargaining unit at this facility, and which organisation holds it? Am I in the unit, given that supervisors and some charge roles are excluded? And is this employer public or private, since that determines which body of law applies.
Federal labour law also protects employees acting together over working conditions whether or not a union exists, which covers a group of nurses raising staffing collectively.
Related
- Nurse strikes and bargaining
- National Nurses United
- Nurse workplace rights
- Nurse overtime
- Nursing organizations
Sources
- 29 U.S. Code section 159. Legal Information Institute, on representatives and elections. Accessed September 9, 2026.
- 29 U.S. Code section 157. Legal Information Institute, on protected concerted activity. Accessed September 9, 2026.
- About National Nurses United. NNU. Accessed September 9, 2026.
- New York State Nurses Association and Massachusetts Nurses Association. Accessed September 9, 2026.
- AFT Healthcare and SEIU. Accessed September 9, 2026.