Hawaii nurses change the conversation on safe staffing

After years of being told that nurse staffing was a collective bargaining matter-something to be worked out between workers and management behind closed doors-nurses in Hawaii got the Legislature on record: We hear you.

"This is an issue for all nurses," says Terilyn Carvalho Luke, president of Hawaii Nurses and Healthcare Professionals, AFT Local 808, one of the AFT's newest affiliates. "It's not isolated to collective bargaining; it's not isolated to one union or another. It's our profession that's under fire right now."

This year, after years of organizing, educating lawmakers and bringing bedside realities into public view, the nurses succeeded in changing that conversation. It's the result of a yearslong campaign by a coalition of nurses and community advocates-crossing union and nonunion lines-to pass meaningful staffing legislation in the state.

In May, the nurses secured a formal legislative resolution, an official acknowledgment from Hawaii's lawmakers that they understand what's at stake for patients and communities and know the issue demands continued attention. While legislation establishing stronger staffing standards has yet to become law, a resolution is recognition of the importance of safe staffing and the need for continued action-and a sign that lawmakers are finally hearing what nurses have been saying for years.

Acknowledgment matters

For Carvalho Luke and the coalition of healthcare workers behind the campaign, that acknowledgment matters.

"Even though we didn't get the bill passed, we're going to keep trying because we know it has more teeth," she says. But "the resolution acknowledges that the legislative body has heard us. They know how important it is to the community."

The campaign has been years in the making. Nursing unions had proposed staffing legislation before, but advocates quickly realized that passing a bill would require changing how lawmakers-and the public-understood the issue.

"When lobbying lawmakers, we had to stress that it is not a collective bargaining issue because legislators kept saying we needed to bargain for it," Carvalho Luke says. "But this is about our people, patient safety and our community. It's bigger than just us. Not only do the nurses pay the price, but the patients we care for pay as well."

The coalition began building support across the healthcare profession, bringing together union and nonunion nurses around a common goal. They also recognized another challenge: Much of what happens inside hospitals remains invisible to the public.

"We discovered that part of the solution was letting people know what they don't know [is happening] behind the doors of hospitals," says Carvalho Luke. "They keep things under wraps and do settlement agreements so that people don't know how bad things really are."

To change that, nurses launched a grassroots community campaign while continuing to educate lawmakers about what staffing shortages mean for patients, families and healthcare workers.

A strategic shift

They found allies in the Legislature who encouraged them to rethink their approach. Initially, advocates considered pursuing staffing ratios similar to those used in other states. But legislators unfamiliar with healthcare often deferred to hospital executives and lobbyists when debates became centered on numbers alone.

"We actually met with legislators who told us we needed to approach it from an angle of legislators who are not informed about healthcare," Carvalho Luke says. "When it comes down to what goes on behind closed doors in those buildings, they listen to the hospitals. They are businesses."

The advice led to a strategic shift. Instead of centering the legislation on fixed staffing ratios, the coalition grounded the bill in evidence-based standards developed by professional nursing associations. "We took the recommendations to heart," says Carvalho Luke. "We switched [our focus] to the professional association standards."

Those standards already exist to help hospitals ensure safe patient handling, safe patient care and better outcomes. "They've done all the work," she says. "We were just handing it to the legislators to look at."

The approach offered another advantage. Rather than requiring lawmakers to revisit the law every few years, the legislation could evolve alongside professional standards and emerging research. "The legislators were not interested in having to revise a bill every few years," Carvalho Luke says. "They wanted something that would be a living bill." The strategy also helped neutralize arguments over specific staffing numbers.

"Code Red showed us the importance of having an enforcement mechanism," says Carvalho Luke, referring to the AFT's campaign to help its healthcare affiliates secure safe patient limits and other crucial protections to improve the quality of care. "If you don't create a penalty, the hospitals aren't going to do anything."

The proposal gained attention. "We might be one of the first states that tried to change the bill in that way," she says. "A lot of heads turned."

A coalition of nurses and community advocates, including the Hawaii Nurses and Healthcare Professionals, worked together to push for safe staffing legislation in the state.

Stories are a powerful tool

As the campaign grew, so did public support. More than 200 nurses submitted testimony in support of safe staffing legislation, sharing stories about conditions inside Hawaii hospitals and the impact staffing shortages have on patient care.

For Carvalho Luke, those stories remain the campaign's most powerful tool.

"We're having a lot of issues within the hospitals just in regard to staffing alone," she says. "The message I told our members was simple: The stories you're telling me, and you're telling management, need to be told out there to our whole community."

She wants nurses and healthcare professionals to understand that their firsthand experiences carry more weight than statistics ever could. "I want them to know that their voice means the most," she says. "I tell them: It means so much more when it comes from you directly. What a bad night you had. What happened. What patients were endangered. It just hits home so much more when you tell your truth."

The realities nurses describe are familiar across the profession. Hospitals acknowledge that patients are arriving sicker and requiring more complex care than in years past. Yet staffing levels have not always adjusted to match those changing needs.

"There are sicker patients coming in, but they haven't adjusted the number of nurses that they need," Carvalho Luke says. "If you've got more things that are happening to that patient, you need a patient load to be lower in order for you to adequately care for the patient."

The consequences can ripple throughout an entire unit. "So many times nurses have a load of five or six patients, and they're given less than 10 minutes every shift to take care of a patient, and that includes charting," she says.

Patients and families often experience the effects without understanding what's happening behind the scenes. "You're there with a loved one in the hospital, and they need something, and they hit the call light, and if the nurse doesn't answer within 10 or 15 minutes, you're going to complain," says Carvalho Luke. "Patients and their families don't understand that on that floor someone else needed their care or was in a critical moment that now the nurse needs to prioritize."

Unsafe staffing also affects healthcare workers themselves. Carvalho Luke recalls an emergency room nurse who was assaulted on the job and spent months recovering from post-traumatic stress disorder.

"The employer is not usually proactive and doesn't connect the dots until bad things happen," she says. When incidents occur, nurses are often asked by management what they could have done differently. That question can be frustrating. "You almost want to throw it back in management's face and say, well, what could you have done differently to prevent this from even happening?"

Staffing is about more than wages

For Hawaii nurses, that question remains at the heart of the staffing debate. What could be prevented if hospitals consistently staffed units according to evidence-based standards? The legislative resolution doesn't answer that question. But it does represent progress. The national wave of healthcare worker organizing and strikes has helped lawmakers understand that staffing concerns are about more than wages.

"The strikes really opened their eyes," says Carvalho Luke. "Nurses and healthcare professionals are not just striking for pay. We've told the employer that over and over again. It's not about pay. These are our patients' lives."

The coalition's work is far from finished. HNHP, which represents more than 1,300 healthcare professionals including nurses, nurse practitioners, respiratory therapists and laboratory professionals, continues to advocate for stronger staffing protections while implementing workplace improvements already secured through bargaining. And the union itself continues to grow. Recently, laboratory professionals reached out, seeking to join HNHP because of the organization's reputation for advocacy and member engagement.

"Being part of the AFT has made a difference, and I think our members truly see it. It was such a privilege to have somebody say they want to join us because of our values and our mission and how we treat people," says Carvalho Luke. "We're really advocators for what's right."

That growth has translated into increased member involvement, with more than 50 stewards now helping represent workers throughout the organization. "People want to be part of making the change and the difference," she says.

For a union that has existed for just over five years, that's a sign that something larger is taking shape. "When we formed this union, we felt we needed to be more adequately represented. We needed to have more of a voice," says Carvalho Luke. "We are on the path of achieving that."

[Adrienne Coles]