It was bad when the Washington Hospital Center fired 18 nurses during last winter's blizzards. It got worse when the nurses union and management failed to negotiate a new contract in the summer. Then last week, the hospital effectively cut take-home pay for most nurses. As WHC nurses voted overwhelmingly Tuesday night to join the largest nurses union in the country, labor relations at the area's biggest hospital were tense. 'People are really angry,' said one veteran nurse, referring to the way hospital officials forced through a plan that increases base pay but cuts shift pay for working evenings, nights and weekends - action that the hospital said it took only after more than 100 proposals and counterproposals and two months of silence from the union. The labor dispute reflects growing rancor across the country at a time when the role nurses play in the country's evolving health-care system is set to become more critical then ever: The success of the sweeping health-care legislation will depend heavily on primary-care givers, such as nurses, whom President Obama has called 'the beating heart of health care.' The country's more than 3 million nurses already make up the largest segment of the health-care work force. Millions more will be needed to take care of the 32 million additional people who are estimated to get health insurance coverage in 2014. The quality of care nurses provide will also be crucial as hospitals will increasingly be paid for how well they take care of patients rather than how many procedures and tests they perform. Better nurse staffing and work environments are linked to fewer hospital readmissions, hospital-acquired infections and bedsores, experts say. 'Our research has shown that nurses are the single most important factor in how satisfied patients are with hospital care,' said Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. But during a recession, with their salaries being targeted, nurses across the country are unhappy: In Minnesota 12,000 nurses from 14 hospitals narrowly averted the biggest nursing strike in U.S. history in July after a dispute over staffing and benefits. In Philadelphia, 1,500 nurses and health-care workers had a 28-day work stoppage at Temple University Hospital in April over benefit cuts. In Oakland, Calif., nurses at Children's Hospital Oakland voted last month to authorize a strike to protest efforts to reduce their health-care coverage. For nurses, changes in the delivery of and payment for care are occurring at the same time that patients are sicker than before and the use of sophisticated technology is increasing. Coupled with chronic understaffing and high turnover, the pressures on nurses are enormous. In the WHC pulmonary step-down unit where many patients go after leaving intensive care, one nurse often has to care for four patients on respirators, said nurse Blondina Mays. That's double what it used to be when she started at the hospital 11 years ago. In labor and delivery, two nurses are supposed to be in attendance for every delivery, but 'we do it when we can, it just depends,' said one veteran nurse who did not want to be identified. Many teenagers having babies for the first time need teaching and support, but nurses often only have time to do the minimum, taking vital signs and checking medications. 'I feel like I'm not doing the job I want to do,' said the nurse, who has more than 20 years experience in labor and delivery. 'I'm not doing a good job of taking care of them, of meeting the emotional needs.' Sometimes, that can be as simple as holding a patient's hand, or helping brush their teeth. When she squeezes that in, patients are so grateful. 'It just breaks my heart,' she said. Nurses say the contract dispute has accelerated turnover. In April, 27 nurses left, followed by 27 in May, 30 in June, 35 in July and 18 in August, according to hospital data. This year's annual turnover rate is 17 percent, up from 14.4 percent the year before. Beth Pruski, 36, left in August. She was a staff nurse who took part in a 47-day strike in 2000 at the hospital. As primary breadwinner, Pruski didn't want to take any chances this time. 'I need a full-time job. I needed health benefits,' said Pruski, who found another nursing job. It's unclear what happens next for the 1,600 nurses at the 926-bed hospital center. The hospital's action to impose its wage plan angered nurses, who turned out in record numbers to vote to affiliate with the national nurses union, said Stephen Frum, chief shop steward for the local Nurses United union. Voting ended Tuesday night with 1,121 in favor of joining National Nurses United, 66 against, and three abstentions. The national union, formed in December with about 155,000 members, has been actively organizing across the country. WHC nurses say they hope the affiliation will give them more clout. Executives at Washington Hospital Center, part of the $3.8 billion nonprofit Medstar Health system that is the region's largest health system and also owns Georgetown University Hospital, say they are under enormous pressure to trim costs. Because of the recession, patients continue to delay or forgo care because budgets remain tight. Patient admissions at Washington Hospital Center, like elsewhere, were down last year. Most patients have little or no insurance, so cost-cutting is essential if the hospital is to survive, said Janis Orlowski, the chief medical officer. Under the plan imposed last week, most nurses will get an increase in base pay of 4.5 percent to 6.75 percent over three years, she said. But most will have take-home pay cut because of cuts in pay for shifts. Last year, the union said the average nurse earned $74,000; managers say it was $93,000. 'We have tremendous respect for our nurses. This was a business management decision,' Orlowski said. (Optional Add End) The hospital is also committed to safe staffing levels; more than 200 new nurses will be on board by Oct. 18, and another 200 and 70 more patient care aides are to be hired by next June, officials said. Although they acknowledge that patients are generally sicker than before, the overall number of nurses has increased since 2004 while hospital admissions have decreased. Earlier this year, the two sides agreed to a staffing matrix that sets goals for the number of nurses needed for each shift. But Tonya Washington, who heads nursing, said goals aren't always met. More important, the labor dispute has prevented this critical measure from being put in place as policy. At the moment, the recession has made for an unusually tight market for nurses. But the health-care overhaul is expected to change that. New health-care organizations, where doctors and hospitals team up to provide total care for patients, will mean more jobs for nurses outside hospitals, their traditional workplace. 'Health reform will create a lot of opportunities for nurses, and this is just going to put competitive pressure on hospitals to attract and keep nurses,' said the University of Pennsylvania's Aiken. 