Hundreds of union nurses that showed up Saturday morning at the entrance to Kapi‘olani Medical Center for Women & Children to defy management’s lockout were turned away as expected.

Just before 7 a.m., the nurses, some in full scrubs, gathered on the front lawn and marched in a procession toward the doors to return to work the day after striking, but were met midway by Troy Branstetter, Kapi‘olani’s vice president of general services, informing them they could not enter due to the lockout.

There were no skirmishes or takedowns — and Honolulu police were present but did not interrupt the procession.

“We’re ready to work,” declared Rosalee Agas-Yuu, Hawaii Nurses’ Association president. “We want to go up there to our patients, but if Kapi‘olani states that they don’t want us in there, we wanted to hear from your mouth personally because these nurses are dedicated to their patients. They are dedicated to this hospital.”

Agas-Yuu continued with, “I want you to tell us to our face and you say, ‘Thank you very much,’ that you do not want us in there to take care of our patients who need us, who we know to this moment need us.”

She was referring to an emailed letter she received Friday evening from Kapi‘olani CEO David Underriner, repeating that the lockout would occur at 7 a.m. Saturday unless HNA unconditionally accepted the contract offer presented on Monday.

This had been communicated on multiple occasions over the past nine days, he wrote, adding that any direction by HNA to have nurses report for work “would be misleading, intentionally disruptive, and would serve no legitimate purpose.”

Agas-Yuu thanked security for not taking her down, emphasized that the attempt was “about the people” and that the nurses are not violent.

The nurses then walked back to the street to hold what the union called a demonstration, a gathering to wave hand-held signs, most of which said, “Illegal Lockout.”

Some of the nurses were visibly emotional and tearful as they walked. Some wielded their smartphones to record and stream the historical moment on social media.

Kapi‘olani Chief Operating Officer Gidget Ruscetta said the hospital had reached out to the union early this morning, prior to the lockout, to express again that it is willing and available to meet.

“This is a difficult situation for all of us here at the medical center,” she said. “We want our nurses to be back at the bedside with their patients. We always have. Again, the union has the power to end this lockout and it’s in their hands.”

She said the union has not yet responded.

Historic lockout

Friday’s one-day strike was the second time this year that about 600 Kapi‘olani nurses represented by HNA walked off the job. In January, they staged a weeklong strike.

That strike in January had been the first held at Kapi‘olani in nearly 50 years, and nurses were welcomed back to the morning shift after its conclusion. This lockout, according to labor unions, is an unusual and unheard-of move in Hawaii history.

Agas-Yuu acknowledged that the conflict has evolved into what she called a “different battle,” potentially impacting all union workers in Hawaii.

“It’s not just about Kapi‘olani nurses any more,” she told the Star-Advertiser. “It’s the workers of Hawaii. Every worker that now goes through negotiations, it brings up the question if this is acceptable.”

Friday’s strike was held to protest an unfair labor practice, she said, which was management’s retaliation against nurses who were filling out safe-staffing forms. It was also to push back against management’s alleged bullying tactics, she said.

Management denies any retaliation or bullying.

Since the strike was held to protest an unfair labor practice, HNA is alleging that the lockout is illegal and has filed a complaint with the National Labor Relations Board. A decision by the board, however, is still pending.

Furthermore, the union decried the imposition of an indefinite lockout — basically an ultimatum — until a contract is unconditionally accepted, particularly when they are pointing out unsafe nursing practices.

Nurses have also learned their employer health-care coverage would end if they do not return to work by October.

In a pep talk to union nurses after being denied entry, Agas-Yuu said there was strength in numbers and that, “money will not win this, heart will win this.”

Friday marked one year since negotiations began between Kapi‘olani and HNA. The union has been working without a contract since December, and the lockout applies to all HNA-represented registered nurses with contracts that expired Nov. 30.

Kapi‘olani executives said that during the lockout, a temporary workforce of skilled nurses will keep the hospital fully staffed.

Staff-to-patient ratios

The union and hospital management continue to clash on proposed nurse-to-patient ratios, with the former saying there must be limits to how many patients nurses are assigned at a time, particularly for intensive care units.

The conflict is playing out across the U.S., as nurses’ unions push for these limits, saying they are overburdened, and that these measures are necessary for patient safety.

There has been a chronic shortage of nurses, exacerbated by an exodus during the COVID-19 pandemic, across the nation. By some estimates, America will be short of more than 78,000 full-time registered nurses in 2025.

Hospital executives have pushed back, saying fixed ratios have not solved staffing shortages, do not allow managers to adapt to the changing dynamics of patients’ needs, and come with unintended consequences such as closures.

Hospitals are absolutely committed to patient safety, said Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, a nonprofit trade group.

Nurse managers are already making decisions on patient-staff ratios on a daily basis, he said. These decisions are based on the severity of patients’ illnesses, availability and experience of staff, and numerous other criteria. A “fixed ratio” does not adapt to all of these varying factors.

“There’s a wide variety of factors,” he said. “You cannot just look at the number of patients, and say it’s “x,” then “y.” It’s not how hospitals work, and it’s not how care works.”

Paul Silva, a registered nurse at Queen’s cardiac ICU, disagreed.

Silva, who joined the demonstration Saturday to support Kapi‘olani nurses, said he’s seen their effectiveness in California, where they are mandated.

“We’ve also been negotiating about patient ratios,” said Silva, who is on HNA’s negotiation team for Queen’s, representing about 2,000 members. “We want to see that in our contract, and Queen’s does not.”

Nurses there are burdened with too many patients at one time, he said, and are advocating for dedicated break nurses so they can actually take their breaks without passing their patients on to fellow nurses. Breaks are often skipped.

“Unfortunately, Queen’s management is very similar to Kapi‘olani’s,” he said. “They aren’t budging. We want to take care of our patients safely. That’s it.”

Negotiations have been ongoing since mid-April. HNA’s contract expired June 30.

According to Chartis, a health care advisory firm, more states are passing legislation on hospital staffing in an effort to improve patient safety and reduce nurse burnout.

At least three states — California, Massachusetts and Oregon — have some sort of mandated nurse-to-patient ratios, and a handful of other states are also considering them.

Some 15 states such as Washington have laws on staffing requirements, whether it be the establishment of a nurse-driven staffing committee or public reporting requirements on staffing. Some individual hospitals may also have nurse-to-patient ratios in place.

A Senate bill introduced at the state Legislature this year to establish nurse-to-patient ratios, with specific numbers for the ER, ICU and other departments, did not survive.