A bill introduced in the state House of Representatives that would require nurse staffing standards for Hawaii hospitals statewide has been shelved, but debate is expected to continue.
The bill, introduced by state Rep. Sean Quinlan (D, Waialua-Haleiwa-Kahuku- Kahana) and backed by three unions representing more than 5,000 nurses, sought to establish minimum nurse-to-patient staffing ratios, placing a limit on how many patients nurses care for at a time. It also would have required hospitals to create nurse staffing committees, with an appropriation of funds to the state Department of Labor and Industrial Relations for enforcement.
But after 90 minutes of testimony earlier this month, House Bill 1244 Opens in a new tab was deferred by the House Committees on Health and Labor chaired by Reps. Gregg Takayama (D, Pearl City-Pacific Palisades) and Jackson Sayama (D, St. Louis Heights-Palolo-Kaimuki).
Hawaii Nurses’ Association President Rosalee Agas-Yuu said the union was deeply disappointed because the deferral shut down the democratic process of bringing the bill to a vote.
“Safe staffing is a fundamental issue that affects all of us, and by refusing to allow a vote, policymakers are turning their backs on the very professionals who are the backbone of healthcare,” she said in a written statement. “Nurses are the experts in patient care, and (their) voices deserve to be heard as they advocate for the community who are their patients, your constituents.”
A companion bill, Senate Bill 424, was never scheduled for a hearing. A similar bill was also shelved early in the legislative process last year, but a resolution resulted in a detailed study on nurse staffing.
That study, “Time for Triage,” was recently published, and both nurses and hospital management have cited it as reasons for why the staffing bill would and would not benefit the state.
Nurse-to-patient staffing ratios are an issue that union nurses have brought up time and again during lengthy contract negotiations with hospitals over the past year and a half, with stalemates triggering several strikes, a lockout at Kapi‘olani Medical Center for Women and Children, and a near strike at The Queen’s Medical Center.
The debate is still playing out in current contract negotiations and is expected to be back again next year.
A constant divide
HB 1244 proposed minimum nurse staffing standards for registered nurses statewide, saying it would reduce turnover and “ensure that patients receive the safe, timely care they deserve.”
It outlined enforceable staffing ratios of 1-to-1 or 1-to-2, depending on the stability of patients, for intensive care units, neonatal ICUs, and neurological critical care and burn units.
For emergency departments, it proposed a 1-to-1 ratio for trauma or critical care patients; one nurse to no more than four patients over a 12-hour shift; and one nurse to no more than five patients at a time.
Ratios are also laid out for other units ranging from labor and delivery to psychiatric units, among others. Hospitals that do not comply would be fined, but would also be able to seek a variance.
The measure was supported by HNA, Hawaii Nurses and Healthcare Professionals, UNAC/UHCP and many other unions, including United Public Workers and the University of Hawaii Professional Assembly.
Supporters said chronic understaffing compromises safety, delays critical care and places stress on both patients and their families. They said studies have shown better staffing ratios lead to better patient outcomes, fewer medication errors and fewer readmissions.
Dozens of individual nurses from Kaiser to Queen’s sent written testimony sharing stories of how they were overburdened with too many patients and stretched to their limits, saying that in their experiences, hospitals are not following promised national standards.
These standards need to be implemented statewide instead of through individual collective bargaining sessions, they said, particularly for nonunion nurses.
HB 1244 was staunchly opposed by major hospital organizations, including The Queen’s Health Systems, Maui Health and Hawaii Pacific Health-affiliated hospitals, including Kapi‘olani, Straub Benioff Medical Center, Pali Momi Medical Center and Wilcox Medical Center on Kauai.
Linda Beechinor, vice president of the Hawaii chapter of the American Nurses Association, urged support for the bill, saying that the nursing workload is a wellness issue, directly impacting the ability to retain nurses.
“I implore you to listen to nurses who are telling you that their work conditions are untenable and we are advocating for patients, which is our professional, ethical duty,” she testified before lawmakers. “Hawaii-ANA respectfully requests that the committee members work with us to advocate for nurses and health workers’ safe working conditions, and conditions that promote safe and optimal patient care.”
Hawaii-ANA represents 17,000 registered nurses living and working in the state.
Those opposed said rigid patient-to-staff ratios would not solve the workforce shortage and that the “cookie cutter” approach would also make it difficult for hospitals to adjust to the dynamic and constantly shifting needs of patient care in every unit.
Furthermore, they said many hospitals already follow national guidelines for appropriate staffing levels, and that these issues should be, and have been, worked out in collective bargaining agreements.
The state DLIR opposed the bill, saying it lacks expertise on hospital staffing matters, and that this was an issue between employer and worker.
Potential consequences
Hospital management opposing the bill said potential consequences include delays in care, turning patients away or even closures of certain units.
Joan Kanemori, Kapi‘olani chief nurse executive, said that as the state’s only full- service newborn, maternity and pediatric hospital, it does not turn patients away.
“The bottom line is that strict adherence to the staffing ratios outlined in this bill will lead to delays in moving patients within the hospital and patients receiving the care they deserve,” Kanemori testified in person. “There will be longer wait times in the emergency department, backups for surgical recovery rooms and delays for patients from the neighbor islands when they require care within the hospital, including intensive care.”
Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, whose members include acute-care hospitals, skilled-nursing facilities and other health care providers, said experience in other states has shown rigid patient-to-staff ratios do not solve the nurse workforce shortage.
“We’re very concerned that the current federal administration and Congress will further cut spending for nonprofit and safety net hospitals,” he testified in person. “Unlike private businesses, hospitals cannot readily raise prices to offset labor costs.”
Instead, the state Legislature can continue to invest in programs at public high schools, community colleges and universities to boost the health care workforce.
Mike Robinson, who testified on behalf of Straub Benioff, said “fixed ratios do not magically create the workforce that’s needed” and would be challenging to establish in a fluid hospital setting.
During the deadly New Year’s fireworks explosion in Aliamanu, for example, Straub’s burn unit, the only one in Hawaii and the Pacific, admitted 10 patients within an hour’s time, and fixed staffing ratios would make responding to that kind of tragedy more difficult.
Unions disputed this, however, saying nurses have, and always will, step up when emergencies like the fireworks explosion and Maui wildfires arise.
Still negotiating
HNA and Wilcox, meanwhile, are still in negotiations over a new contract, weeks after about 160 nurses there held a three-day strike protesting unfair labor practices.
The main point of contention, according to HNA, is staffing ratios, with nurses wanting a ratio of one nurse to five patients for the medical-surgical unit, which would be closer to standards on Oahu, rather than a 1-to-6 ratio.
Negotiations between the two parties began in early May and the contract expired Aug. 31.
The Kauai County Council supported the nurses with a resolution earlier this month urging the Legislature to implement safer nurse-to-patient staffing requirements for hospitals, the Garden Island reported.
Catherine Sataraka, director of patient safety and quality at Wilcox, opposed the bill.
“As Wilcox is in the process of negotiating its labor contract,” she wrote in testimony, “the introduction of statutory provisions during these negotiations would establish an inappropriate precedent that would have far reaching implications across the continuum of care in our state.”
HNA also began negotiations recently with the North Hawaii Community Hospital run by Queen’s in Waimea on Hawaii island.
Agas-Yuu said the unions will continue their advocacy for a statewide staffing bill.
“A lot of heart and soul went into it by a lot of people,” she said. “I see the positive as each year goes by because more people are starting to understand it. Now we have communities rallying for it.”
