A Senate bill before the state Legislature addresses the primary point of contention between unionized nurses at the Kapi‘olani Medical Center for Women & Children and hospital management.
Senate Bill 1580 — carried over from 2023 — seeks to establish safer staff-to-patient ratios, a top issue cited by the hundreds of nurses who went on strike at Kapi‘olani in January in protest.
It also would require hospitals to create staffing committees, ensure certain meal breaks and place limits on overtime for health care workers, with civil penalties for violations.
The Senate committees on Health and Human Services and Labor and Technology on Monday held a public hearing for the bill and approved it, with amendments.
The Hawai‘i Nurses’ Association, which represents about 600 at Kapi‘olani, is urging legislators to pass the bill, saying hospitals need to hire enough staff to adequately care for patients — not only for patient safety, but to better retain nurses.
SB 1580 is also supported by the Hawaii Workers Center, United Public Workers and Democratic Party of Hawaii Labor Caucus, among others, and many registered nurses who shared personal experiences of burnout from caring for too many patients at a time.
“The recent nurses’ strike at Kapi‘olani Medical Center for Women and Children helped to draw attention to the need for nurse-to-patient ratios to improve patient safety and health outcomes,” said HNA President Rose Agas-Yuu in a statement. “We had hoped management would see how this could benefit patients from our community and improve the quality of care in the hospital. We appreciate the support of our legislators who saw the urgent need to bring this issue to the forefront, which was introduced in last year’s session.”
The bill is opposed by Hawaii Pacific Health, which operates Kapi‘olani, along with Ohana Pacific Health, Liberty Dialysis Hawaii, and the Healthcare Association of Hawaii. The Hawaii State Center for Nursing provided comments on the bill.
Those opposed say mandating fixed ratios could lead to high costs and delays in care and even mean turning away patients if minimum staffing ratios cannot be met.
Talks between HPH and the nurses union resume Thursday — the fifth scheduled meeting since the weeklong strike in January.
The nurses at Kapi‘olani have been working without a contract since Dec. 1.
The ratios
The Senate bill outlines specific minimum staffing standards for various units, which are 1-to-1 ratios of 1 registered nurse to 1 patient for critical care patients in the emergency department, ICU, neurological critical care unit or burn unit.
For a medical-surgical unit, it requires 1 nurse to 5 patients, and for a skilled nursing facility, 1 nurse to 8 patients.
As written, the bill allows health care facilities to apply for a variance if the minimum staffing would not feasible.
HNA says prior to the strike, nurses at Kapi‘olani were assigned too many patients at a time and subjected to mandatory 16-hour shifts. The union said this was because the hospital “prioritizes saving on labor costs over quality patient care.”
But HPH says mandating ratios comes with unintended consequences without alleviating nurse shortages.
“In Hawaii, the impact of forcing fixed staffing numbers will likely result in irreparable consequences to those most at risk in our community,” said Amy Thomas, HPH System chief nurse executive, in written testimony. “Mandated ratios affect access to care and the health care organizations’ abilities to provide services.”
This includes longer wait times for patients, and costs associated with fixed staffing ratios that get passed along to patients.
In California, where staffing ratios have been in place for decades, she said, there is still a shortage of up to 36,000 nurses.
Furthermore, she said, the impact of the ratios in Hawaii would be “exponentially greater” on smaller hospitals, long-term care facilities and rural hospitals where challenges are most prominent — and where they might be forced to turn away patients or close some units.
HSCN said research does not support the legislation of nursing staffing rules or minimum nurse-to-patient ratios.
“A study of 665 hospitals in four states found that increasing nursing staff on a shift did not materially improve patient outcomes in facilities with average or poor working environments,” wrote Laura Reichhardt, HSCN director, in written testimony.
The Healthcare Association of Hawaii also opposed the measure, saying it would create “dire fiscal circumstances” for health care organizations that are already struggling.
The COVID-19 pandemic created a serious crisis for the workforce, according to the trade group, and the latest study shows a statewide shortage of about 1,000 registered nurses. Hospitals, meanwhile, are caring for an average of 400 more patients a day than in pre- pandemic times.
Due to the pandemic and increased costs, the state already lost a nursing facility at Wahiawa General Hospital and Oahu Home Health, a home health agency, in 2023, while others are on the brink of closing.
“The implication of this measure is that hospitals are currently understaffed and will not be in a position to comply with the ratio requirements,” said HAH President and CEO Hilton Raethel in written testimony. “Thus, hospitals would be penalized for circumstances over which they have no control.”
HAH said any staffing ratio requirements will inevitably cause fewer beds to be available, and the likely closure of more nursing homes when the ratios cannot be met.
Although the nurses at Kapi‘olani are the first in Hawaii to strike over staffing ratios, several other nurse unions have done so before them in other U.S. states.
Following a three-day strike in January 2023, about 7,000 nurses at Mount Sinai and Montefiore ratified historic contracts that include enforceable nurse-to-patient staffing ratios, according to the New York State Nurses Association.
The debate has been ongoing in Michigan, where proposed state legislation — the Safe Patient Care Act — is still pending, according to the Michigan Nurses Association.
The group has since 2021 been pushing for this act, which sets nurse-to-patient ratios, curbs excessive mandatory overtime and requires hospitals to disclose RN-to-patient ratios.
The Michigan Organization for Nursing Leadership opposes the act, saying ratios are an ineffective solution that would put hospitals in an impossible situation, risking their ability to stay open and deliver care.
Even without the act, some nurses who have rallied together — including the union nurses at McLaren Lapeer Region Hospital in Michigan — have secured contracts with staffing ratios and fines for administrators that do not follow them in place.
Nurses at McLaren LaPeer last summer held an informational picket and authorized a strike, but agreed to the new contract before holding an actual strike.
Senate Bill 1580
>> Introduced by state Sen. Henry Aquino (D, Waipahu-Pearl City)
>> Companion, House Bill 1378
>> Establishes minimum staff-to-patient ratios for hospitals, care homes, dialysis facilities
>> Establishes certain meal breaks, rest breaks and limits on overtime
>> Appropriates funds to DLIR for implementation and enforcement
Proposed ratios in bill
>> 1 RN to 1 critical care patient in an emergency department, ICU, neurological critical care unit or burn unit
>> 1 RN to 3 mother-baby pairs (6 patients)
>> 1 RN to 3 patients in pediatrics
>> 1 RN to 5 patients in a medical-surgical unit
>> 1 RN to 8 patients at a skilled nursing facility
>> 1 dialysis nurse to 8 patients
Correction: The Hawaii State Center for Nursing provided comments to the Legislature on Senate Bill 1580 but the group did not oppose the measure, as was reported in an earlier version of this story.
