Hawaii’s Covid-19 crisis has laid bare the serious shortage of nurses in the state, with thousands departing the profession and only a relative handful arriving to replace them.

Although Hawaii has the second-lowest Covid case count in the country and the second-lowest death rate, following only Vermont, the state’s health system remains under severe strain. Citing the ongoing dire situation, on Friday Gov. David Ige extended his emergency proclamation for two more months, continuing limitations on travel and restaurants and the ban on large gatherings, including sporting events and big weddings.

Pressed by reporters at a news conference to explain why Hawaii must continue its restrictions, Ige pointed to Hawaii’s remote location, which makes it hard to get medical help from elsewhere. While he defended the state’s health-care capacity as “good enough,” Ige acknowledged the state doesn’t have enough nurses available in the islands to meet its own needs.

“Clearly in the health care field, we don’t have sufficient employees,” he said, adding that hospital administrators are working hard to add more staff. The state has been dependent on bringing in some 650 health workers who are preparing to depart now, leaving the state once again relying on its own resources.

Nurse hold signs protesting fronting the Kapiolani Womens and Childrens hospital.
Nurses are burned out from double shifts and mandatory overtime under stressful conditions, union representatives say. Cory Lum/Civil /2020

The local staffing shortfall predates the arrival of the coronavirus.

“The shortage of nurses is a long-term problem in Hawaii,” said registered nurse Linda Beechinor, executive director of the Hawaii American Nurses Association. “It’s not arisen because of the pandemic but it has exacerbated the crisis. This has been ongoing for many years and not been addressed.”

But Covid made things worse. The islands’ nurses are exhausted and burned out, many of them working double shifts with mandatory overtime, said Daniel Ross, a nurse at The Queen’s Medical Center and president of the Hawaii Nurses Association.

“Covid just exacerbated it; it made it deteriorate faster,” he said. “But it had been in the works a long while. This just pushed it over the edge.”

For the past 20 months, news reports have speculated about a possible exodus in the health profession. New statistics confirm those anecdotal reports: According to the state Department of Commerce and Consumer Affairs, almost 5,000 nurses left the field between 2019 and mid-year 2021, shrinking the total active workforce from 33,410 in 2019 to 28,548 now. The number of registered nurses and licensed practical nurses fell sharply.

“We’ve lost people we would have had for years to come or maybe just for a few more seasons,” said Laura Reichhardt, an advanced practice registered nurse and director of the Hawaii State Center for Nursing. The shrinkage is increasing as people buckle under the strain, she said.

Some had children at home to care for when the schools closed. Some aging nurses believed that Covid posed too high a personal risk. And some had become frustrated with the overwork and pressure they felt on the job, nursing experts say.

Fewer people have been left behind to handle the increased workload, Reichhardt said, resulting in a “lot of intangible loss” for the remaining workers, she said.

More nurses may depart as federal rules requiring mandatory vaccinations are rolled out. In early September, President Joe Biden announced that all health care workers must be vaccinated at facilities that receive funding from Medicare and Medicaid, with a draft rule for the order expected to be finalized this month. Some health workers around the world have resisted vaccination for philosophical, medical or religious reasons. Most hospitals in other places that enacted similar mandates have lost some employees. The same thing may happen in Hawaii.

“Some will choose to forgo employment rather than get vaccinated,” Reichhardt said. “I believe there will be a further strain on the nurses who stay.”

Nurses, their advocates and hospital officials generally agree on the reasons for this imbalance — but with some differences in emphasis.

Ross, the union president, said he blamed high-paid hospital administrators who made short-sighted decisions.

“A lot of fault lies with our own hospitals,” Ross said. “Before the pandemic was upon us, we were already short-staffed in our facilities. They weren’t hiring to save money. They staffed to the bone. It’s very expensive to have employees. They wanted to keep as few on board as they could, so when it hit, we had no reserve to bring nurses back on board.”

Hilton Raethel, President and CEO of Healthcare Association of Hawaii.
Hilton Raethel, President and CEO of the Healthcare Association of Hawaii, said hospitals were collaborating with nursing schools to increase the number of nurses when the pandemic hit. Cory Lum

Hilton Raethel, chief executive officer of the Healthcare Association of Hawaii, the trade group that represents hospitals in the state, said that retention of skilled nurses has been a great challenge. He said that although hospitals pay high salaries — the average annual pay for a registered nurse in Hawaii is second-highest in the nation, at $104,060 — many nurses chose to leave the state because of the high cost of living.

In 2018, Raethel said, health industry officials began looking for solutions, including deeper collaboration with nursing schools in the state, but that work was only beginning when Covid hit. He acknowledged that, in the past, hospitals had been reluctant to hire younger nurses who were recent graduates because it was time-consuming to train them. Hospital care has become more complex, with patients requiring more specialized care than in the past, he said. That left them in a bind as the crisis arrived.

Reichhardt and Raethel said the state has enough general nurses to meet its needs but lacks the specialized practitioners — operating room and critical care nurses, for example. Another area where there is an acute crisis is among licensed practical nurses, the people who provide supportive care in hospitals and in nursing homes.

There are many potential recruits. Thousands of young people in Hawaii are eager to pursue nursing training. But most are turned away each year because the state’s nursing schools aren’t funded well enough to educate them, and because the aging workforce has left too few nursing instructors to train them.

Once again this year, many students who were qualified applicants were denied admission. Among the 1,393 people deemed qualified to enter the programs, only 636, or less than half, were admitted for nursing instruction, according to a recent survey by the state nursing center. Only 556 ended up enrolling.

In other words, despite the crisis, about 800 prospective students were rejected for admission in Hawaii this year. At the University of Hawaii Maui College, for example, there were 94 qualified applicants but nursing school administrators were able to admit only 24.

“We’re down three faculty and there’s been a hard hiring freeze at UH,” said Anne Scharnhorst, a professor of nursing and allied health department chair at the Maui campus. “You can’t train students without teachers.”

The shortage of nurse faculty is a nationwide problem, Raethel and others said. He said that skilled nurses who work in specialized units make more than college professors and they find it more lucrative to work in the field than to teach.

Maui Memorial Medical Center hospital. 3 aug 2016
Several years ago, Maui Memorial Medical Center chose to hire out-of-state nurses rather than locals. Cory Lum/Civil Beat/2016

Some years it has been even worse. In spring 2015, UH Maui College admitted no nursing students at all because there were no available jobs for them upon graduation. Maui Memorial Medical Center was in financial distress and had turned to traveling nurses instead of local employees to save money on benefits and pension costs. Scharnhorst said hiring has improved since Kaiser Permanente took over the hospital in 2017 and made it a priority to employ local nursing students.

“Kaiser said we’ve got local talent; we want people to live here and stay here,” recalled Scharnhorst. The campus graduated 37 students in May and they found jobs quickly.

“The entire graduating class on Maui was picked up last year,” Raethel said.

He said that local hospitals are trying to hire more local students than they did in the past.

“We’re trying very, very hard to grow more of our own,” he said. “The chances of them staying in Hawaii are better if they come from Hawaii.”

But getting into the field remains challenging. Jasmine Sagaysay, 25, graduated from the nursing program at Hawaii Pacific University in 2019. The year she graduated, no local hospitals came recruiting, she recalled.

“People say Hawaii is short of nurses, and I say, ‘Yeah, but Hawaii wants to hire people with experience,’” she said.

She and her fellow students were delighted when recruiters from St. Josephs Medical Center in Tacoma, Washington swept in and hired many of them on the spot, even those who were caught unprepared, wearing crop tops and torn-up jeans on the day hospital officials visited campus. The hospital took them as registered nurses at $36 an hour, Sagaysay said. At least 10 students left Hawaii, found affordable housing there and didn’t come back.

“They hired almost our whole cohort,” she recalled.

Sagaysay stayed in Hawaii, living with her parents, working for lower pay at a nursing home and then as an aide at The Queen’s Medical Center. She was recently hired as a registered nurse at Queen’s, two years after she graduated from college.

“I had to wait,” she said.

Students who graduated in 2020 — a year when they were vitally needed — encountered another unfortunate barrier. To become licensed to work, they must pass special examinations, known as “boards” — tests administered by a Chicago-based nonprofit, the National Council of State Boards of Nursing. A for-profit testing company, Pearson Vue, administers the tests on the council’s behalf. Pearson has only one nurse testing facility in Hawaii, located in Honolulu.

When Covid hit, the ban on interisland travel made it difficult for new graduate nurses on the neighbor islands to get to Oahu and secure lodgings, according to Scharnhorst and Reichhardt. They were not yet employed and so were not deemed “essential” workers.

Operating under local social-distancing restrictions, Pearson Vue was slow to expand its workspace to accommodate the students’ testing needs. Between travel restrictions and testing-space shortages, some students were forced to wait three months or more to get tested, which added to the new graduates’ stress and anxiety.

Dawn M. Kappel, a spokeswoman for the national nursing council, said that testing delays were caused by “reasonable safety restrictions imposed on the testing contractor due to the pandemic,” and the 67% seating capacity mandate was imposed by the state. She said Gov. Ige helped ease the bottleneck by allowing graduates of accredited programs to work for up to 180 days without taking the exam.

Nursing advocates and health officials lobbied hard to bring Pearson, the national council and the state and city governments together to ease what many called a frustrating logjam.

“It had an impact on the nursing pipeline,” Scharnhorst said.

There’s one silver lining, however. Given the desperation of the crisis, many more recent-graduate nurses have been hired in the islands than in previous years. Nurse advocates and hospital officials say they are working together more cohesively than in the past and looking for ways to fix the system.

“There has been a concerted, collaborative, multi-island, statewide effort to boost retention and make people feel valued, valuable and well-supported in their jobs so they stay,” Reichhardt said.

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