The combination of the changes in the US hospital industry and resulting pressures on the workforce with the relative immobility of hospitals has led to the growth of unions in this industry while unions are losing members in most other industries. Drawing on theoretical work that places changing work experience as a major factor in pro-union behaviour, the article examines how the rise of competition among private hospital systems has led hospital managements to adopt ‘lean production’ methods borrowed from manufacturing. The consequent pressures on the workforce have encouraged workers to join unions. These same forces have shaped the content of collective bargaining and divergent styles of unionism. As the transformation of hospitals are a piece of the broader neoliberal era in which they occur, this analysis should be applicable to certain other industries as well.