Our Disappearing Nurses

A nursing shortage looms on the horizon, not just nationally, but also here in Hawaii. Can the problem be fixed before it's too late?

Hob Osterlund is a nurse, one of those essential professionals we tend to take for granted, since they’re always around when we need to have our wounds dressed, our babies delivered, our hearts bypassed.

But Osterlund, like so many Hawaii residents, stands on the threshold of retirement: She turns 60 in September. Therein lies the rub. Just as the baby boomers are entering their golden years in mass numbers — a time that coincides with a greater need for medical care — the nurses who do so much of that caring are getting older, too.

Osterlund, a registered nurse with a master’s degree, lives on Kauai and travels to Honolulu to work three 12-hour shifts at The Queen’s Medical Center. It’s a job she especially values because the hospital has worked hard to make a national name for itself in her specialty: pain and palliative care. She’s been a nurse for 30 years, and still loves it, although her commute is becoming increasingly expensive and the physical, social and economic ills of her patients have gotten more complex. Still, she has no plans to retire just yet.

Many of her colleagues across the nation are retiring, however, and their departure is contributing to a nursing shortage of serious—and snowballing—proportions. The AARP anticipates the nation will be short some 1 million nurses by 2020. In Hawaii, the deficit of 960 nurses recorded in 2006 is expected to grow to 2,700 nurses over the next 12 years—about a quarter of the projected need.

The shortfall is especially significant because nurses perform the majority of our health-care services, says Barbara Mathews, executive director of the Hawaii State Center for Nursing, which was established by the Legislature in 2003 specifically to address the nursing shortage through recruitment, retention and research initiatives.

“I think we are certainly going to have a severe nursing shortage in Hawaii,” Mathews says. “Is there still time to act? Absolutely.”

The solution, however, isn’t as neat as enrolling more young people in nursing school, or getting more trained bodies into the diverse settings where nurses tend patients. “It’s very complex,” says Sandra LeVasseur, the center’s associate director of research and an associate professor at the University of Hawaii’s School of Nursing and Dental Hygiene. “It’s not just one factor.”

For starters, Hawaii’s nursing programs currently turn away qualified applicants, and will continue to do so, because they can’t handle major expansion. Why? Nursing faculty are also aging: 60 percent are age 50 or over, and perhaps 20 percent of them will retire within five years, LeVasseur says. Since this is a nationwide trend, Hawaii won’t easily be able to recruit teaching staff from elsewhere, either.

Although the Legislature recently provided funds to increase enrollment in the state’s nursing programs, LeVasseur predicts “we’re still not going to be able to produce enough nurses to replace and fill the vacancies that will be present in 2020.”

The problem is further compounded by an astonishing 60 percent of new nurses nationwide quitting their first job within the first year, Mathews says. The center is conducting a study to determine how Hawaii fits into that national trend. It’s unclear whether nurses who quit are leaving the field entirely or moving into other jobs, she says. But it is clear that steps must be taken to smooth the transition between nursing school and the work world so that nurses stay on the job.

Robin Tanner, an Oahu registered nurse who specializes in intensive care, says new nurses tend to be overwhelmed by the many demands of the profession, especially those who graduated from a two-year registered nursing program “where everything is so speeded up, they get on the job and think, ‘Oh, my gosh, this is so much more than I thought.’ You’re walking miles every day, doing things you never imagined you would be.”

Meanwhile, the seasoned nurse who is charged with helping new graduates perfect their clinical skills is busy with her own patient load and duties, and often has no training in how to be a teacher or mentor, says Tanner, who bases her observation on 30 years of nursing experience and involvement with the American Nurses Association. “The stress levels are incredibly high,” she says. “New nurses often go home in tears.”

Kauai resident Andy Parks, who was the first male to graduate from Kauai Community College’s two-year registered nursing program, but left the profession more than a decade ago, agrees.

“Even though most professions are different than what they taught you in school, nursing is one of the worst. Very little of the perfect way they taught you is present on the job.”

The stress is exacerbated, Tanner says, because “unlicensed personnel,” including various aides and therapists, have replaced nearly all of the licensed practical nurses and some of the registered nurses who used to work in local hospitals. Even new graduates trying to learn their own jobs have responsibility for the unlicensed personnel beneath them, she says.

The cost-cutting trend toward compartmentalizing a nurse’s duties, then training unlicensed personnel to do some of those tasks, adds to burnout among seasoned nurses, too, Tanner says. This is partly due to the increased responsibility they have for other workers, and also because nurses often no longer perform such direct care services as bathing or massage, where they can conduct their own careful assessment of a patient’s condition. “My license covers that unlicensed personnel, not the [hospital] managers’,” she notes. “I have to be sure they can do what they’re supposed to do and come back to me with a problem. Many of them are very good at their jobs, but it’s a task. They don’t understand the implications for the patient as a whole. I worry about my license, and I worry about my job satisfaction.”
 

Recalls Parks: “It’s really scary when you’re the RN in charge of 10 or even 20 patients and you realize you’re on your own. Everyone is looking to you to make decisions and you’re relying on a team of everyone from aides to housekeeping for the information you need, and you’re so bogged down with paperwork you end up cutting corners, and you’re doing that with people’s lives. There’s a point when, unless it’s a ‘calling’ rather than a job, it’s just not worth it, no matter how much they pay you.”

In a poignant piece published by Portland Magazine, Osterlund wrote about a nurse who arranged to have an inmate brought from prison—handcuffed, shackled and escorted by four guards—to his dying mother’s hospital bedside, because the nurse had intuited, quite correctly, it turned out, that the woman needed to see her son before she could pass on.

“I don’t think the general public recognizes the independent thought and talent it takes to be a nurse,” Osterlund says. “Nurses have to be physically strong, emotionally astute, intellectually bright and technologically savvy. What other profession requires such a combination of skills?”

Mathews agrees, noting that nurses function as “super communicators,” who are able to deal with doctors, patients, families and the ubiquitous computers that are an integral part of modern healthcare.

Nurses today also are required to do more documentation and must be aware of numerous government regulations that have been added to the field, especially in long-term care, says Sally Ishikawa, Oahu region chief nurse executive for Leahi Hospital. They’re also expected to be business savvy “because the reimbursement really drives the success of the healthcare institution you work for,” she says.

In short, nurses keep getting more duties, leaving them with less time to perform the direct patient care that often prompted them to enter the field. Part of this is caused by the tremendous role that technology now plays in healthcare, and Ishikawa says it has been difficult for some of the older nurses to adjust. Nurse-patient interaction now frequently involves a computer, which demands that information be entered at specific times, and patients are often hooked up to an array of bedside machines equipped with alarms that create a continuous cacophony, contributing to the overall noise and intensity of a modern hospital.

Some patients have even accused nurses of “surfing the Web” because they spend such an inordinate amount of their shifts entering data into the computer. Observes Tanner: “If I’m a patient, I want the nurse taking care of me, not the computer.”

Adds Ishikawa: “For nurses to survive in these high-stress environments, they need a very nurturing environment that’s supportive.”

The stress level for both new and seasoned nurses is exacerbated by other dramatic changes in healthcare that have brought about shorter hospital stays and more outpatient surgeries, Mathews notes.

And patient needs are becoming increasingly complex, as both hospitals and long-term care facilities see more patients with a host of physical, emotional and mental issues. In one such case, a young man who suffered severe injuries during a methamphetamine episode that left him nearly helpless kept up a continuous howl and had to be restrained both for his own safety and because he liked to hit nurses whenever he had an opportunity. He ended up staying on a regular hospital ward far longer than was necessary, adding to the trials of nurses there, because it was so difficult to find a long-term-care facility that would to take him.

Ishikawa says such scenarios are becoming increasingly frequent, due to both a scarcity of beds in long-term care facilities, which serve the elderly, chronically ill and disabled, and the nursing shortage that already exists in those areas. “There’s quite a lot of stress because of the [low staffing] numbers. Because they’re working short in so many areas, the nurses are experiencing burnout.” She attributes the staff shortage to the pay disparity between nurses employed by hospitals, where the reimbursement per patient is higher, and those who work in long-term care and other community settings.

LeVasseur says there’s another factor at play, too. Studies show that young nurses “have a lot of interesting expectations,” she says. “Many want to go into the high-profile areas of nursing, such as critical care, emergency, intensive care and surgery. Very few now want to go into long-term care or geriatric nursing.”

This troubles Ishikawa, who notes: “I think the highest priority is care of our elders because that’s what’s facing us now: an aging population in Hawaii. I’m afraid there might not be settings for them in the future to take care of their needs.”

Adds Mathews: “We need to look at how to meet the needs of people with not only medical problems, but vast and complex social problems. And much like the nursing crisis, these are issues that need to be addressed by the entire community. You see a microcosm of the culture within a hospital or long-term care facility.” Recent societal changes, such as “greater tolerance for a lack of civility, more abusive communication and behavior, more violence, gets translated into the healthcare profession. Nurses want to be treated more respectfully.”

More respectful treatment by doctors, administrators and even those who design the equipment nurses use and the facilities where they work could help resolve some of the conditions that are prompting nurses to leave the field, Tanner says. “It’s about empowering nurses to fix the problem. Nurses need to have a say in how a unit is run, how it’s staffed, where supplies are kept, when discharges are done, even the layout of the buildings.”

Mathews says the high attrition rate for new nurses might best be stemmed through “more robust internships and even residency programs” that would give nurses direct clinical experience as part of their training, as well as increasing the use of “simulators” in the classrooms. This past May, the center  also started the first phase of a program that is intended to create a standardized program for training and supporting the seasoned veterans, or “preceptors,” who work so closely with nurses during their first months on the job.

Meanwhile, the center is trying to entice veteran staff nurses to stay in the profession through leadership development training, more flexible schedules and nontraditional educational programs that allow them to earn advanced degrees while continuing to work—a necessity for most, Mathews says—or live in rural areas. The goal is to improve their job satisfaction and opportunities for advancement, with the idea that once some of these nurses earn graduate degrees, they may even move into teaching.

While nursing advocates are taking some steps toward addressing the looming shortage, they agree that new partnerships with business and philanthropic organizations on both the local and national levels are key to resolving the problem. Such relationships can provide additional funding, as well as insights into new models for management and other best practices.

Tanner thinks it’s time for Hawaii hospitals to implement rules that improve nurse-patient ratios, noting that when California lawmakers mandated that approach several years ago, “the nurses came back. They flocked from other states to California, because do you want to work in a facility where you’re taking care of 10 patients, or five or six?”

She also believes that registered nurses need to be recognized as the college graduates with high professional standards that they are. “That would attract more people to the profession. People want respect in their jobs. It’s too bad when patients don’t know who is the nurse and who is the nurse’s aide because we’re all wearing the same scrubs.”

The public can help push that shift, Tanner says, noting that some patients admitted to local hospitals actually record who is providing the bulk of their care. Families also have begun serving as watch dogs, actively questioning those who are providing care. “That’s making the healthcare facilities take notice,” she says. “It’s patient complaints, people saying ‘we want good care,’ that will bring about changes.”

Kauai-based freelancer Joan Conrow is a frequent contributor to HONOLULU Magazine. She also worked on “24 Perfect Pupu,” in this month’s Restaurant Guide.