Within the past year alone, the American Nurses Association (ANA) terminated its affiliation with its union arm (the United American Nurses [UAN]) and its nonunion workplace advocacy coalition (the Center for American Nurses); three state nurses associations disaffiliated from the ANA; and some very public, very ugly battles were waged between two prominent nursing unions. Although some nursing organizations have recently tackled issues to powerful effect-the American Association of Critical-Care Nurses created standards for nurses' work environments, for example-the lack of cohesiveness and direction in the profession are apparent in nursing's underrepresentation in policymaking. For example, as AJN reported last July, the advisory committee for Healthy People 2020 includes no nurses (see In the News, July 2008). What's preventing U.S. nurses from finding common ground?

"We're a leaderless group," Laura Gasparis Vonfrolio, a nurse, entrepreneur, and outspoken critic of nursing's establishment, told AJN recently. "Nursing administrators and management have never been the spokespeople for nurses at the bedside." But Linda Burnes Bolton, vice president and chief nursing officer at Cedars-Sinai Medical Center in Los Angeles and a past president of the American Academy of Nursing (and an AJN editorial board member), disagrees. "There are leaders throughout the profession at the organizational, coalition, and individual levels," she said.

So who represents nurses? The once-venerable ANA appears to be fighting for its life. Between last June and December, nurses associations in three states-Hawaii, Michigan, and Minnesota-withdrew from the ANA, citing political and financial differences. California's, Maine's, and Massachusetts's had already withdrawn. In 1954, 44% of all licensed U.S. RNs belonged to the ANA; today, 6%, more or less, are members (the ANA Web site cites several membership figures ranging from 150,000 to 200,000 of the nation's 2.9 million RNs; it also says that an additional 250,000 nurses belong to ANA affiliate organizations, but that number may not take into account the recent defections). The ANA questioned the legality of the state associations' disaffiliations in an October 2008 press release and stated that it remains the "only professional organization to ensure the collective voice of all RNs has national power."

Several nursing unions have emerged in the past decade as contenders for that role, even though they do not represent RNs in management or supervisory positions and many nurses have chosen not to unionize. The UAN was founded in 1999 by "activist nurses within the ANA" who wanted a forum for collective bargaining independent of the ANA. Affiliated with the AFL-CIO since 2001-and having severed ties with the ANA-the UAN seeks to "set the standard for RNs in organizing, collective bargaining and groundbreaking contracts"; it represents about 55,000 nurses. In 2004 the California Nurses Association (CNA), which left the ANA in 1995, formed the National Nurses Organizing Committee to aggressively pursue nurses' and patients' interests at the local, state, and national levels; it claims 80,000 members. And the Nurse Alliance arm of the Service Employees International Union (SEIU) has 110,000 members. But some unions have had increasingly bitter relationships; last year the CNA sought a temporary restraining order against the SEIU for "acts of threats, harassment, and stalking." The SEIU sought to overturn the order, calling it a smear tactic.

The Nursing Organizations Alliance was founded in 2001 when the National Federation for Specialty Nursing Organizations and the Nursing Organizations Liaison Forum merged to create "an enduring collaborative that would promote a strong voice and cohesive action." But although its membership roster lists more than 60 organizations, it has taken little action to date.

What might it take for nursing leadership to find its way? As Burnes Bolton said, "Leadership is not organizationally bound." New leaders may have to rise from nursing's ranks.

Sylvia Foley

Senior Editor