Victoria Colliver, San Francisco Chronicle

Nurses from three unions, including the California Nurses Association, have founded a new national union to influence national health care policies and to try and extend California's patient ratio law into other states. Organizers said the 150,000-member National Nurses United, the largest professional union for registered nurses in the country, will also flex its power to push for a stronger voice in the health care overhaul process.

The merger, approved Monday at a convention in Phoenix, combines the California union, which has 83,000 members in several states, with the Massachusetts Nurses Union, with 23,000 members, and the 45,000 members from the United American Nurses, who work primarily in the Midwest. The unions will continue to operate separately, but will be aligned under the larger umbrella of National Nurses United.

The union's creation, which has been eight months in the works, creates a united voice in favor of a national or single-payer health care system, a concept that is not on the table in Washington. Critics questioned whether the new super union is merely an attempt by the already powerful bargaining groups to add to their membership and maintain job security. At a time when health care costs are in the spotlight, some questioned whether the merger could actually add to the price of health care.

“They could increase the cost of health care if they use their leverage to negotiate higher salaries,” said Steven Rousso, principal with HFS Consultants, an Oakland financial consulting firm for clinics and hospitals. He said 70 percent of a hospital's operating costs are consumed by salaries, with two-thirds of that devoted to earnings by registered nurses and other nursing staff members.

The California Nurses Association/National Nurses Organizing Committee and an increased demand for nurses, partially brought on by the union's push for a California law that establishes nurse-to-patient ratios, have been largely credited with helping to dramatically raise nurses' salaries. The average income for a California nurse rose from $59,937 in 2004 to $81,428 last year, with about a fifth of registered nurses reporting salaries of more than $100,000, according to the California Board of Registered Nursing's 2008 survey of nurses. National studies have shown that nurses who are represented by a union make an average of 5 to 10 percent more than non-union members.

Rousso also dismissed California's nurse-to-patient staffing ratios as job security, and said there is little evidence that it improves patient care. The ratio law was phased in starting in 2004 and is still the only such law in the country. Officials from the California Nurses Association rejected the notion that ratios don't improve patient care, citing studies that support their position as well as the introduction of legislation this year by Sen. Barbara Boxer, D-Calif., that would extend those ratios nationwide.

The state association and other nurses unions have been controversial because critics, including some nurses, don't believe that first-line caregivers should ever go on strike. Others don't always support unions' tough negotiation and organizing tactics. “But love them or hate them, you have to respect them,” Joanne Spetz, an economist and faculty researcher at UCSF Center for the Health Professions said of the California group. “A nurse or health administrator might not like their tactics or them as an organization, but they're effective. They have a strong vision and they carry it forth very actively.” Spetz said she is uncertain whether the new, larger union would have an impact on national health policy.

“A hundred and fifty thousand nurses is big, but there are 3 million nurses in the U.S.,” she said.