A majority of unionized nurses at the Kapiolani Medical Center for Women &Children — 96% — recently voted to authorize a strike, with staffing ratios being the top issue of concern.

The vote to authorize the strike Friday occurred after dissatisfaction with the progress of contract negotiations, according to the Hawaii Nurses Association OPEIU Local 50, which represents about 600 members.

While no strike has been called yet, the option is now on the table. The nurses have been working without a contract since Dec. 1.

“The nurses made every effort to negotiate in good faith to avoid any disruptions to patient care,” said Rose Agas-Yuu, HNA’s newly sworn-in president, in a news release. “We had hoped the hospital management would have learned from the past, approach negotiations differently this time, and reach an amicable agreement in an expeditious manner.”

Hawaii Pacific Health, which operates Kapiolani, the state’s largest specialty hospital for women and children, has made numerous efforts to boost its staffing through active recruitment and creative workforce development training programs.

“While the Hawai‘i Nurses’ Association’s decision is disappointing, we still have meetings scheduled for Jan. 10 and 11 as we continue to work toward an agreement,” said Gidget Ruscetta, chief operating officer at Kapiolani, in a statement. “We are committed to caring for our community and will always prioritize our patients, as we have for more than 100 years.”

But Agas-Yuu said Kapiolani nurses feel it’s time for a change, with the top priority being the establishment of nurse-patient ratios in order to provide the best care for patients.

Since the start of the COVID-19 pandemic, nurses say they have been overwhelmed with the number of patients they are caring for, and the result has been burnout, along with an exodus of nurses who have opted to work elsewhere or to retire.

“The nurses try to make it work, but you can only do it for so long,” said Agas-Yuu, a longtime critical-care flight nurse at Kapiolani. “It’s not sustainable and that’s why you have burnout. You come into work, you’re going to have an overload of patients and you’re frustrated and giving them just-to-make-it-by-this-shift care.”

The ratios, which set the maximum number of patients a registered nurse can care for at any given time, must be set in writing, she said, and not just verbal promises. It was the No. 1 issue that union members brought up.

In response to the issue of staffing ratios, Ruscetta said, “Kapi‘olani has proposed staffing guidelines that adjust to the needs of our patients. We consistently evaluate how many patients we have and how sick they are. These guidelines allow us the flexibility to bring in more nurses to care for our patients. In addition, our proposal also gives our nurses a more active role in staffing assignments and enforcement.”

Agas-Yuu said having enforceable staffing ratios in a contract would be a first for the state and that Kapiolani nurses are taking a stand for nurses as well as patients statewide.

“Whenever you hear nurses talk about their patients, they’re so passionate,” she said. “They tell me, ‘We’re fighting for our patients because we’re not able to give them as much care as we want to.’”

Standards have been set by the nonprofit Association of Women’s Health, Obstetric and Neonatal Nurses, she said.

In California, staffing ratios are mandated by law and vary according to specialty. In Michigan, ratios are not mandated by law, she said, but hospitals there have implemented the ratios.

“It takes a big lift,” she said. “Striking is something we don’t want to to do, but the nurses feel it’s very serious. That’s what they say they’re willing to do.”

The American Nurse Association supports enforceable, minimum nurse-to-patient ratios “as an essential approach to achieving appropriate nurse staffing,” saying studies have shown they improve patient care outcomes.

But some hospital groups and executives oppose ratios, saying they increase costs and come with unintended consequences.

The District of Columbia Hospital Association said the “one-size-fits-all approach” in mandated staffing ratios fails to address the complexity and diversity of all health care environments. In a fact sheet, the association cited instances in which hospital leaders reported difficulty finding specialty nurses, along with increased costs and budget cuts.

But supporters, such as Agas-Yuu, say staffing ratios will help improve retention.

Other issues of concern at Kapiolani include mandatory overtime, which have been in place since 2020, resulting in 16-hour shifts.

Though hospitals have far fewer COVID-19 patients now than during the height of the pandemic, the burden of an increased workload has not eased with the return to “business as usual,” she said. She said she is also seeing a growing number of patients with higher acuity, or more severe illness, increasing stress and demands.

Nurses are also increasingly concerned with safety as incidents of workplace violence rise.

“We do have instances where nurses are getting injured,” she said, “either physically or traumatized by having a parent coming at them and full-on verbalizing.”

The vote to authorize a strike follows an informational picket that Kapiolani nurses held in early December. Negotiations for a new, three-year contract have been underway since mid-September.

The nurses and HPH management resume talks Wednesday and Thursday. If a strike is called, Agas-Yuu said it would be due to unfair labor practices. A 10-day notice would be issued to Kapiolani.­