Profiles In Nursing

Marian Alford (1905-1989), Nurse Organizer

Taking action to improve conditions for nurses

Multiple nurses stand around a patient in a bed. They are wearing white dresses and nursing caps

Hard work, low pay. In 1966, nurses earned an average of $5,200 year (about $38,000 today). Low wages and poor working conditions led to a controversial strike of nurses in California that year. Pictured above, student nurses at Mount St. Mary’s College, Los Angeles, 1966.


When we think of labor strife in the United States, we usually think of coal miners, farm or auto workers and maybe air-traffic controllers. In California, however, nursing has often been at the center of some contentious labor disputes. With several major work actions in our state in recent years, it seems like a good time to revisit some of the leading nurse organizers of the past, like Marian Alford.

From Administrator to Activist

Born to a pioneer family in Humboldt County in 1904, Alford earned her nursing degree from the University of California in 1926, followed in 1946 by a master’s from Columbia. Her original interest was obstetrics, but she soon moved into hospital administration, holding positions at Stanford and later Peralta Hospital in Oakland.

Alford took an early interest in local nursing organizations. She was a member of the California State Nurses Association (CSNA) and once remarked that at one time or another, she’d served “on nearly every district or state committee.”

Her priorities were patient care and nurses’ welfare. She felt (as recent studies have confirmed) that the two are not in conflict and in fact are inextricably linked: Better conditions for nurses result in better outcomes for patients. The hard part, of course, is that trying to reach a balance is often a battle.

Collective Bargaining

It was due in large part to the leadership of Alford and then Executive Director Shirley Titus that the CSNA first sought to improve working conditions for nurses through collective bargaining back in 1942.

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At the time, nurses’ salaries averaged about $140 a month (roughly $2,200 today), but some hospitals paid as little as $90 a month (less than $1,500 in today’s dollars). Many hospitals would not hire married women or allow a pregnant nurse to continue working. Hours were long, split shifts common and retirement plans nonexistent.

After the California Hospital Association refused to adopt proposed minimum salary standards, CSNA members empowered their organization to act as their bargaining agent. In 1943, the War Labor Board, concerned about wartime nursing shortages, authorized a 15 percent pay increase.

The CSNA’s position led to conflicts with the ANA (of which the CSNA was then an affiliate) and with the non-nursing CIO affiliate of Alameda County, which also sought to represent nurses. CSNA leaders stood firm, eventually dropping “State” from the organization’s name and splitting from the ANA. (Today, CNA is affiliated with National Nurses United.)

Nurses on Strike

Alford’s work on improving the quality of care led to her appointment in 1952 as the first director of the National League of Nursing’s Department of Hospital Nursing. In that role, she built alliances and fostered cooperation with other organizations. “I see the urgent need for nurses to work with all others so nothing pertaining to nursing will go on without our participation,” she said.

In 1956, her success led to her appointment as CSNA’s executive director, succeeding Shirley Titus. During Alford’s tenure, the organization moved away from confrontation, instead supporting the creation of “Professional Performance Committees” as liaisons between nurses and hospital representatives.

Nursing Education

In 1966, however, Alford supported a major shift in the association’s strategy: an abrogation of the previous “no-strike” pledge. The move was prompted by the mass resignation of thousands of Bay Area nurses in protest of low wages, which resulted in a job vacancy rate hovering around 30 percent and unprofessional patient care in local hospitals.

The result was the first strike by registered nurses in the nation’s history. The willingness of nurses to strike is still very controversial, but Alford saw it as necessary to secure both nurses’ economic security and patient welfare.

She lauded a new generation of nurses who “refuse to compromise their ideals” or to accept “a pattern in which the motives of industry are smothering the basic human ideal of giving quality nursing care.”


Why the ANA has an annual award honoring Shirley Titus

No discussion of nurses and collective bargaining would be complete without mentioning Shirley C. Titus, RN (1892–1967).

Titus, an alumna of the University of Michigan, became director of nursing services at the University of Michigan, Ann Arbor School of Nursing in the 1920s and dean of Vanderbilt University School of Nursing in 1930. After moving to the San Francisco Bay Area, she became executive director of the California State Nurses’ Association (CSNA) in 1942.

Throughout her 14-year tenure as CSNA executive director, Titus was a powerful advocate for higher pay and better benefits for registered nurses. In a landmark 1943 article in the journal Modern Hospital, she advocated collective bargaining as a vital means of securing nurses’ economic security, a position endorsed by the American Nurses Association in 1946.

In later years, the ANA honored her work with the annual Shirley Titus Award. Currently, Titus is one of three nurses honored with the ANA’s annual Advocacy Award.

ELIZABETH HANINK, RN, BSN, PHN, is a Working Nurse staff writer with extensive hospital and community-based nursing experience.

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