Union nurses showed up in full force Monday for the second day of a weeklong strike at the Kapi‘olani Medical Center for Women & Children.

They wielded signs that said “Patients Before Profits” and “Safe Staffing Matters!” in front of the hospital, while clanging bells and whooping as passing cars honked in support. More than 100 striking nurses occupied Punahou Street around the corner to Bingham Street, where a sign near the parking garage entrance said “Burnout Caused This Turnout.”

The Hawaii Nurses Asso­ciation OPEIU Local 50, representing about 600, and Hawaii Pacific Health, which runs Kapi‘olani, have been unable to see eye to eye on nurse-to-patient ratios as they try to iron out a new three-year contract.

The strike comes as hospitals on Oahu, including Kapi‘­olani, are at their busiest due to a high patient census and bustling emergency rooms.

Gidget Ruscetta, Kap‘iolani’s chief operating officer, reassured the public that the hospital is operating smoothly despite the strike, with the help of hundreds of temporary nurses.

“Our nurses are here and they are working,” she said. “They are skilled, focused and showing great compassion towards our patients and family. They are working really well with our physicians — our physicians have been pleased.”

Within a 24-hour period, Kapi‘olani has delivered 16 babies, received four ambulance patients, handled two critical care transports for one premature baby and one child for the neonatal and pediatric intensive care units, and performed four emergency operations.

She said skilled temporary nurses are filling in from top institutions such as Boston Children’s Hospital and the Children’s Hospital of Philadelphia, among others, but declined to give an exact number or cost.

Some patients, however, are being moved due to noise from the strike on the street below, she said. The hospital is also offering small, noise-canceling headphones to help babies rest.

Nurse-patient ratios

The main point of contention between the two parties remains a proposed nurse-to-patient ratio determining the maximum amount of patients a nurse can have at one time.

Rose Agas-Yuu, HNA president, said these ratios — not pay — are the highest priority for the union and that it is part of a national push that already has taken place among nurses in Michigan and New York.

Kap‘iolani nurses are taking a stand for nurses across Hawaii, she said, and pushing to be the first in the state to get these nurse-to-patient ratios written into their contract as many continue to handle a higher workload and burn out on the job.

The striking nurses at Kapi‘iolani have received support from colleagues joining in from The Queen’s Medical Center, Straub and Kaiser, she said, with more flying in from Wilcox Medical Center on Kauai.

The doctors and community also have been expressing their support, she said. An online petition launched by the union garnered more than 88,000 letters of support for the nurses as of Monday evening.

Marcella Kopa, an NICU nurse at Kapi‘olani for 18 years, said she felt she had to take a stand because current guidelines are not enforced.

“There is a shortage of nurses willing to work here because we consistently have higher patient ratios,” she said. “We currently have guidelines, but they aren’t followed because there’s no accountability.”

In intensive care, the nurse-to-patient ratio is usually 1-to-1 or 1-to-2, she said, but she has had to deal with three or four patients at a time.

“I really wish it didn’t come to this,” she said. “I really wish I was taking care of all my patients, but at a certain point we have to take a stand for the future of our patients and for the future of quality of care at Kapi‘olani.”

Kapi‘olani management, however, contends that mandating patient staffing ratios is not the answer to shortages.

In an editorial that ran in the Honolulu Star-Advertiser, HPH system chief nurse executive Amy Thomas said that evidence from California, the only U.S. state to have comprehensive staffing ratios in place, shows they have not helped to ease workforce shortages.

“This is because mandated staffing ratios don’t address the underlying issues causing staffing shortages,” she wrote. “They don’t produce more nurses and, if implemented, would further strain the overburdened health care infrastructure across our state.”

Studies have shown the unintended consequences of the ratios, she said in the editorial, which include reduced access to care and added costs passed on to patients.

Kapi‘iolani is also concerned these fixed ratios would affect management’s flexibility while serving the needs of patients on a case-by-casis basis as they ebb and flow.

“Being the only full-service women’s and children’s hospital in Hawaii and the Pacific Basin,” said Ruscetta, “we have a big responsibility to our community, and this is something we have never taken lightly.”

The union has rejected Kapi‘iolani’s offer several times to use a federal mediator to resolve the issues, she said, along with the proposed creation of a new council that would include unionized nurses to discuss how to update staffing levels.

“We offered across-the-board wages that would make our experienced nurses among the highest paid in the state of Hawaii,” said Ruscetta, including annual salaries of between $121,000 and $151,000.

Hospitals, meanwhile, continue to be very full, according to Hilton Raethel, president and CEO of nonprofit trade group Healthcare Association of Hawaii.

Statewide, the average number of patients per day is at about 2,440, which is higher than it was pre-pandemic.

“We thought that the increased census was as a result of the pandemic,” said Raethel, ”and that after the pandemic, things would go back to normal. Well, that has not happened.”

While local universities and hospitals have been ramping up their training programs to bring in new nurses, they cannot keep up with the pace of the demand. Over the past 12 to 18 months, some 400 to 500 traveling nurses per day have filled the gap and supported local nurses.

“Traveling nurses are very expensive,” he said. “You have to pay airfares, hotels and all the costs of bringing in travelers.”

While other initiatives, including the use of technology, could help, hospitals across the U.S. continue to struggle with staffing shortages.

Negotiations between HPH and the union began in mid-September, and the Kapi‘olani nurses have been working without a contract since Dec. 1.

The current strike ends at 6:59 a.m. Sunday. Two additional bargaining sessions have been scheduled for Jan. 31 and Feb. 1.