KIP AOKI / KAOKI@STARBULLETIN.COM Contract settlements that ended strikes at three of Honolulu's major hospitals in January did not provide a cure for the chronic nurse shortage that is likely to become even more severe in the foreseeable future.
There's no cure in sight as retirement,
poor working conditions and fewer
graduates continue to drain
Hawaii's pool of nursesBy Lee Catterall
lcatterall@starbulletin.comThe consequences are threatening for patients. Recent studies confirm that inadequate nurse-to-patient ratios result in more patient deaths.
"It's very serious," said Kathleen L. Yokouchi, executive officer of the state Board of Nursing. "In the past it wasn't a global shortage. You could always get nurses from Australia or Canada, but everybody's experiencing shortages because of the fact that a lot of nurses are retiring worldwide."
"It's going to get worse," said Christi Keliipio, executive director of the Hawaii Nurses Association.
"This thing is not going to peak even through the year 2010," agreed Richard E. Meiers, head of the Healthcare Association of Hawaii, an organization of hospitals and other medical facilities. "This may go on until the year 2020."
The problem may persist even longer than that. A national shortage of nurses estimated at 126,000 is projected to exceed 800,000 by 2020. The shortage is caused, in large part, by expanded job opportunities for women and the reluctance of men to enter nursing, and is exacerbated by work conditions aggravated by the shortage itself.
The shortage is reaching crisis levels nationally, and the numbers in Hawaii are even more stark. A federal survey in 2000 indicated Hawaii was among the 10 lowest states in the number of registered nurses per capita.
STAR-BULLETIN / 2002
Nurses at St. Francis Hospital walked the picket line in December during the nurses strike.
The ages of nurses on the job in Hawaii are even more ominous. Nationally, only 9 percent of the nursing work force is under age 30, compared to more than 25 percent in 1980; in Hawaii, a survey of the Hawaii Nurses Association members revealed that only 6.2 percent are under 30. The average age of working registered nurses nationally is 45, compared to 48.5 in Hawaii. Many are scheduled to retire as baby boomers reach the age where they will need increased health care.
The shortage contributed to month-long strikes that ended in January at St. Francis, Kuakini and the Queen's hospitals. Issues of more concern than wages to the striking nurses were workplace conditions and being forced to work overtime.
"Nurses work 24 hours, seven days a week," said Keliipio. "It's a labor-intensive, physical job. There are more back injuries in the nursing profession than among construction workers."
Government statistics show there are nearly 500,000 licensed R.N.s in the United States who are not working as nurses. In Hawaii, a survey of one-third of the licensed R.N.s with Hawaii addresses showed that the number not working as nurses rose to 19.5 percent in 2001, up from 14.6 percent in 1997.
Like other states, Hawaii seeks many nurses from abroad, and the Philippines is the favorite recruiting area. Last year, about 60 percent of the estimated 20,000 foreign nurses who took state exams in the United States came from the Philippines. About one-fourth of all hospital nurses in the Philippines left their homeland last year, creating a serious shortage in that country.
More than 1,000 imports from the Philippines now work as nurses in Hawaii, said Tina Salvador, president of the Hawaii chapter of the 32-chapter Philippine Nurses Association of America, which plans its national convention here next year.
"I do know through the years that (Hawaii) hospitals have used recruiters out in those areas," Meiers said. "The Philippines have provided some really good nurses for us."
Societal changes set the stage for the national shortage of nurses. The women's-rights movement of the 1970s led many career-minded women, who previously had been limited to nursing or teaching, to take advantage of other opportunities. If they were interested in health care, many became doctors instead of nurses; nearly half of medical school graduates today are women, compared to just 6 percent in 1960. Meanwhile, nursing schools have failed to attract large numbers of men, who comprise only 5.4 percent of the R.N. work force.
"We see from all that data and reports on the mainland that there is not the interest," said Carol Winters-Moorhead, dean of nursing at Hawaii Pacific University. "That is not so in Hawaii. We have many, many more applicants. There is incredible interest in nursing, not only (among) females but males."
Still, Hawaii's nursing schools are not graduating enough students of either gender to keep up with the increasing vacancies. Hawaii loses about 400 nurses a year through retirement, but only 280 nurses are graduating from nursing schools in the state to fill those positions, said Meiers.
The decreasing number of graduates is caused not only by the emergence of other career opportunities for women but by a shortage of nursing-school faculty. The American Association of Colleges of Nursing estimates that 5,823 qualified applicants were turned away during the 2000-2001 academic year due to an insufficient number of faculty, clinical sites or classroom space.
"We need more faculty," said Winters-Moorhead. "The pool of experienced faculty is diminishing rapidly because of retirement. The number of nurses who are preparing for the faculty has diminished at an alarming rate." Master's degree programs in nursing that have education tracks decreased nationally to only 64 in 2000, down from 112 in 1996, she said.
Winters-Moorhead believes that increasing Hawaii nursing schools' faculty, classroom space and clinical facilities could play an important role in addressing the state's nursing shortage.
"We do have quite an interest (in nursing) in Hawaii, and it's an aberration from the mainland. I think that's because there's still value for the profession," she said. "I think our cultural mix has something to do with the value of nursing as a career choice." Parents in Hawaii value health care as a profession, she said, and children's cultural respect for elders causes them to heed their advice.
Another factor, Winters-Moorhead said, is the military presence in Hawaii. Many medics leaving the military choose to retrain as nurses in Hawaii, which she partly attributes to the 20 percent male portion of HPU's last graduating class.
One of the major problems is the dearth of information about the extent and nature of the nursing shortage. No one seems to know how many people are working in how many nursing jobs in Hawaii, or how many nursing positions are vacant.
"Nobody really knows at this point," Meiers said.
"There's been no place that information has been pulled together in one area," agreed Keliipio.
The Board of Nursing has 12,922 nurses licensed as registered nurses, but Yokouchi said she has no idea how many are actually working as nurses. Many nurses on the mainland maintain their Hawaii licenses as well as the licenses in the states where they live.
"We're not authorized by law to ask them where they work or whether they're full-time or part-time," Yokouchi said. "We license them."
That is why health-care leaders from all quarters are enthusiastically supporting legislation to create a Hawaii center for nursing, quartered at the University of Hawaii, where information could be gathered, culled and used to develop a strategy for attracting and retaining nurses. Thirteen states maintain such centers.
"It's very important, because it provides information to employers, to the public, everybody who would be impacted by nursing," said Yokouchi, who testified at the Legislature in favor of the bill's enactment.
North Carolina was the first state where such a center was authorized, and Brandy Cleary, its executive director, said it proved useful within a short time of its opening in 1991.
"In the mid-'90s, because of managed care, et cetera, there was a perception -- and it was actually true in some areas -- that nursing had an oversupply," Cleary recalled. "We actually surveyed new graduates and found that, in fact, all of them were getting jobs. So we wanted to get that message out so that people weren't assuming that nursing was no longer a good career choice."
The strategy worked. While the number of nurses per capita declined in Hawaii by 4.1 percent from 1996 to 2000, it rose in North Carolina by 8.1 percent.
The North Carolina center can assemble all elements of the health-care profession to develop a strategy for coping with the nursing shortage.
"We need to do a lot of things," Cleary said, "and one benefit of a center is to give you an infrastructure, where you can say, 'Folks, there's no simple solution, so let's come together and put together an array of recommendations so we can attack this problem on multiple levels.'"
