The agreement, which came after federal negotiators intervened, resolved a labor dispute that had prompted a rare lockout of about 600 nurses following a strike and detentions of demonstrators accused of blocking the facility’s driveway.

Nurse-to-patient staffing ratios had been the Hawaii Nurses Association’s biggest complaint. Throughout negotiations, which started in September 2023, the union said that nurses were being overworked by having too many patients under their care.

The new three-year contract includes mandatory minimum staffing ratios that are consistent with nationwide standards like those set by the Association of Women’s Health, Obstetric and Neonatal Nurses.

It also establishes a formula for determining how many nurses are needed per patient, according to a statement from Kapiolani Medical Center. Previous staffing ratios — which vary according to specialty, patient condition and experience levels — didn’t have to align with those standards.

To make the changes more feasible for the hospital, the union agreed to a gradual implementation and allowed more travel nurses to be hired, union president Rosalee Agas-Yu said.

Nurses also got a raise in their base pay range to $133,000 to $160,000 for a three day workweek with 12 hour shifts. Advocates said that plus better staffing ratios will allow the facility to compete with private practices and clinics that are drawing away talent by offering more standard work schedules.

The nurses, who had been locked out for more than two weeks, will return to their jobs on Sunday.

Agas-Yu said the staffing ratios were an important victory because of the need to make bedside environments like Kapiolani Medical Center attractive enough that workers don’t leave for other jobs.

“We’re happy with that,” she said. “It gives us time to work with these ratios and see where we’re at before the next contract negotiations.”

While the hospital requires 24/7 staffing, places like urgent care clinics or private practices can boast a more appealing work environment with more regular hours.

Hawaii has a lot of licensed nurses, Agas-Yu said, “they just don’t want to work at the bedside.”

And eventually, as burned-out nurses leave for other jobs, more work is left behind for the remaining nurses to cover, sparking a vicious cycle, she added.

As nurses pushed for stricter staffing ratios, the hospital said that implementing them would reduce flexibility.

This proved to be an impasse. The unionized nurses held a one-day strike in mid-September, and the hospital responded by locking them out and busing in replacement travel nurses. At one point, police detained 10 protesters accused of blocking the hospital’s driveway.

With tensions high, federal mediators were brought in again last week at the request of Gov. Josh Green. A tentative agreement was reached Tuesday, and the nurses overwhelmingly voted to approve it on Wednesday.

The hospital said the raises would be applied to every nurse, with an average of 3.5% annually over about four years.

The contract also stipulates that a council of nurses and nurse leaders that will meet monthly to review the staffing ratio spreadsheet and discuss staffing and commitment to programs for recruitment and retention, according to Kapiolani Medical Center.

Nurses around the country are bargaining for better staffing ratios. In New Jersey, about 900 nurses and 500 other health care workers at the main teaching hospital for Rutgers New Jersey Medical School threatened to strike for a better mandatory staffing ratio, northjersey.com reported.

Younger generations seem more willing to push for better working hours and conditions, and the Covid-19 pandemic exacerbated those demands after overwhelming hospital staff, president and CEO of the Healthcare Association of Hawaii Hilton Raethel said.

“It’s not just health care. It’s a whole generational shift,” he said.

After California, hospitals in Hawaii pay registered nurses the second-highest average incomes in the country, at about $120,000 per year. In contrast, places like West Virginia and Mississippi pay their nurses only about $75,000 per year.

Agas-Yu said that Hawaii’s salaries are offset by a much higher cost of living and the fact that many households are multigenerational, meaning that one income might have to support more people.

Agas-Yu said she hopes that other health care workforces in the state can follow suit.

“It’s kind of like a landmark in Hawaii,” she said.