NHS workers in England have voted in favour of striking over pay.
Two-thirds of Unison members, which include nurses, healthcare assistants and porters, said they were prepared to take action.
Three other unions - the Royal College of Midwives, GMB and Unite - have also balloted their members. The results are expected in the coming weeks.
Ministers have given NHS staff a 1% increase, but not for those who get automatic progression-in-the-job rises.
These are designed to reward professional development and are given to about half of staff and are worth 3% a year on average.
But the decision by ministers went against the recommendation of the independent pay review board, which had called for an across-the-board rise.
'Demoralised workforce'Unison general secretary Dave Prentis said: "This government's treatment of NHS workers has angered them and this anger has now turned into action.
"We know health workers don't take strike action lightly or often. The last action over pay was 32 years ago. But we also know a demoralised and demotivated workforce isn't good for patients.
"If we move into industrial action we will work with NHS employers to minimise the impact on patients."
Unison is now expected to wait for the outcome of the other ballots before deciding what action to take and when.
Some 68% voted in favour of a strike and 88% for industrial action short of a strike.
Unison has 300,000 NHS members, but when the other unions are taken into account the numbers top 400,000. It is the first time in their history that midwives have been balloted.
In Scotland, the recommendation was agreed to in full. Wales is doing the same as England, but has given extra money to the lowest paid.
Gill Bellord, of NHS Employers, said the vote was "disappointing" and would "concern thousands of patients who rely on its services".
"I would strongly urge unions to take patients out of this dispute and instead continue constructive discussions, exploring ways to come out of this period of pay restraint in a sustainable way."
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