PBN asked hospital and university leaders how they’re trying to solve Hawaii’s health care labor shortage.
Readers are well aware of the fact that Hawaii has a critical shortage of health care workers. PBN has been reporting, for years now, on the physician and nurse shortages in particular.
To help readers understand the scope of the problem, and the solutions underway, we thought it would be enlightening to bring together three hospital administrators and three higher education representatives to tell us what they’re doing to staff up health care in Hawaii — the workers they need, how they’re teaching them, and the challenges they face in training them once hired.
The conversation was held virtually on May 13, highlights here are edited for length and clarity.
We opened the conversation by asking our hospital administrators what kind of workers they need. Physicians and nurses, certainly, but it turns out the overall labor picture in Hawaii has them short on everything from lab techs to housekeepers to administrative support.
Chang: I think the most obvious one is in the nursing areas, and this was even pre-Covid. We were all struggling to find enough nurses.
But I think that problem has been exacerbated over the last two years and it’s increasingly more difficult to find nurses and retain nurses at affordable rates. We also have needs in physician assistants, nursing assistants, imaging technologists and all the physicians, as well.
Roche: Certainly, nursing has been a significant challenge, but I would also say that for [Kaiser], ultrasound techs, cardiovascular techs, some of the specialties where there’s limited or no training on-island has really been a challenge as well.
And then unlicensed personnel, hospital aids, have been a challenge and we’ve been working hard to try to partner to fix that problem.
Underriner: I would agree with all those areas, and just to even go further, also medical assistants, nurse aids, clinical aids. We’re down in support staff and that really taxes our nursing.
So I would just add that and then [in the] clinics, the patient services reps. That [lack of] front office personnel is really constraining the ability of our physicians to have the throughput they need to have. Support staff are critical and in high demand.
I’d also say surgery techs, instrument techs, these folks that really make that place work well, When you get those folks short, the systems have to work very hard to be effective.
And so we’ll talk about some of the solutions to it, but it’s been hard to get those positions filled and kind of hard to bring travelers in because they’re not the highest paying. But they are critical to the work we do right now.
Chang: We have some areas that are very specialized, and like Dave said, you can’t find travelers to come in with these very specialized skill sets.
So you either have to grow them within or you have to find ways to retain the ones that you have. And that’s what seems to be a big challenge. The other piece is that competition with other industries has become increasingly, I think, a challenge. So our EVS [environmental services] workers, as soon as the hotels opened up, we saw an out-flux of our staff.
Roche: I would echo that and include our supply chain personnel, they’re another group of frontline staff that you really need specialty training for, but it’s really difficult to both hire and retain. It’s on the job training, so it takes a while to get them up to speed.
And I would echo Dave’s comments around surgical techs, OB techs, sterile processing techs. They’re all highly specialized, just difficult to find. And travelers are almost nonexistent in some of those areas.
When we’re talking about the nurses and other positions where you’ve seen a lot of attrition through Covid — has that been retirements? Has it been a cost-of-living issue where people are leaving Hawaii as opposed to leaving medicine? What are your observations on where your workforce has gone?
Chang: We saw a handful of staff that decided that they were going to retire, and that’s a risk of ours. We have a lot of our employees, a lot of our nurses and frontline staff that were very close to retirement age.
And then the pandemic kind of pushed them over the edge and made them make that decision. And then it’s, how do you backfill with really a limited pool of talent out there, regardless of clinical/non-clinical?
And so I think Covid did have a distinct impact on the rate of attrition. But also, I think that we’ve seen some people decide that, you know, Hawaii was maybe not their permanent home and they decided they were going to get closer to family and leave the Islands.
Some of the military were reassigned and so we saw a little bit of everything. I think the one number that surprised us is that the rate of attrition, the rate of retirement in nursing compared to the national average.
Hawaii was actually well ahead of the national average, so we had less people retire, but still impactful enough that we all felt it.
Babington: I don’t know if people realize it, but the average age of a hospital nurse in this country is 53 years old and 50% are 65 or older. That’s a tsunami waiting to happen.
Roche: The Hawaii Center for Nursing published the report in December 2021. One-third of the nurses are 55 and over in the state of Hawaii, there are 900 fewer registered nurses in Hawaii than there were two years ago when they did the relicensing.
At our hospitals, it’s no different — 20% of our nurses are 55 and older and potentially can retire in the next 8 to 10 years — so we’re rebuilding the pipeline.
Our universities have been expanding their course offerings and growing the number of graduates.
Babington: At Chaminade, we, five years ago, had about 50 students graduate. Now, we have about 120 every year and we’ve continued to ramp that up. We have over 400 nursing students now. We started an accelerated program for people with either bachelor’s degrees in another field, with the science prerequisites, or people finishing all the sciences that moved into nursing versus [other majors]. But I think all of us, HPU and UH, are well aware that the nursing challenges are really significant.
At the graduate level, we have a doctor of nursing practice, family nurse practitioner, psychiatric mental health, and also we’re starting a pediatric nurse practitioner program. But there are other health professions we haven’t talked about [especially in]mental health. That’s an area that Chaminade has many, many programs. We have master’s programs in mental health counseling and marriage and family therapy. We have the only clinical psychologist training program.
We also are opening a couple of new doctoral programs for educational psychologists. This was at the request of the Department of Education. We have a contract with it for several years.
There’s not enough people that do the psychological testing in the school system and in the population at large. We also have a doctorate in marriage and family therapy program. So we have about 200 master’s students and about 100 doctoral students right now in those areas.
Walsh: We’re really excited about a couple of new specialties that are the first in the state of Hawaii. One is the doctor of physical therapy program, which is starting in the first week of July — we are aiming to have 100 students in that program. It’s a hybrid program, so we’re able to enroll students all across the country. But about a third of the students right now are from Hawaii, from the Neighbor Islands as well as Oahu. And the way the program is set up — all of our programs are set up — is short-term immersive programs, which allows students to come in just a couple of weeks a semester and do their in-person clinical work with faculty. But they don’t have to relocate their whole families for the duration of their program.
One of the barriers to entry has been the cost of these launches. It’s three years in the making for that DPT program. We’re also launching a physician assistant master’s program that will start in January of 2024; then in July of 2024 will be an occupational therapy doctorate.
All of them have about a 2- to 3-year onramp to get in line in the accreditation queue. In 2020, we saw that in Hawaii, because it didn’t have these programs, students were going to the Mainland and not coming back. So, we’re hoping to have about 100 students in each of these three programs and they should all be fully enrolled by summer of 2024.
We [also] have a BSN [bachelor’s in nursing degree], so a nurse practitioner. And then we also have masters and DNP [doctorate, nurse practitioner] and post-masters certifications in mental health, acute care and family nurse practice.
Hedges: [At JABSOM,] we bring in 77 students in each entering class, and, depending upon whether they take an extra year or not, because we occasionally have some that’ll take a year to do research to get a master’s in public health or to get an advanced biomedical degree. We may graduate somewhere in the low to mid 70s and other years we’ll have in the 80s. Right now, we’re trying to place 83 [medical] students for their third year of training, meaning that we would be graduating that many the following year.
In the specialized, technical field of health care, getting a degree or certification is just the beginning of joining the workforce. Next comes on-the-job training, and our industry leaders tell us that there’s a self-perpetuating bottleneck they’re working to solve — because of the shortages of physicians and nurses, the industry’s ability to absorb and train new grads is limited.
Hedges: We, of course, partner with multiple health systems, but in particular we have worked with Queen’s Health System and Hawaii Pacific Health to develop additional training opportunities.
One of the things that our physician programs at both the M.D. and the resident level have been facing — and it sort of has a trickle-down effect because we have to look at our our whole approach to health care — [is that] workforce training is a really fragile ecosystem.
Many of the programs that are being developed require some physician faculty involvement. You can’t have a physician assistant program or a physical therapy program without having some associated physician involvement and in-faculty supervision. You can have a lot of the teaching done by other providers, but there has to be, at some point, engagement with the physician population.
Given that we have this deficit of physicians across most specialties and we have only a limited number of specialties that we do offer here — we have 18 different advanced residency programs, about half of those being at a specialty level — creating the physician workforce that will then train not only future physicians, but other health care providers is becoming a very interesting phenomena.
We’re looking very hard at how we can do more Neighbor Island training so we can move additional workforce training not only for physicians, but the advanced practice nurses, the physical therapists, physician assistants and so forth, more into Neighbor Island settings. But it’s a complex arrangement, and we have to be careful that we don’t pull in too many trainees and not have the clinical training that they’ll need.
Part of this deals with the rigor of the accreditation system, and the supervising physicians need to meet some very rigid criteria in terms of their clinical practice skills, but [it’s] also their availability and the effort that they put in to evaluate the learners.
We have probably as many challenges around having the supervising physicians as we have of finding the clinical sites in which they would practice. So we’re trying to build both of those. But right now, the biggest rate-limiting step is the supervising physicians and given the shortage of physicians, obviously they’re stretched, their time is more limited.
Walsh: To Jerris’ point, we’re trying to be very sensitive in some of these programs, too, because we understand how constrained our clinical sites are because of the lack of medical supervision.
Part of the reason for going with the hybrid model is so that we can both accommodate local students with the limited placements that are here, but also, honestly, to bring in the enrollment to make it financially sustainable by having students enroll across the Mainland.
And we have on average about 2,000 clinical partnerships that have to be created for each of these new specialty health care fields — it’s a very heavy lift to get started, but we were again very mindful that we could not depend on all of these clinical sites to come from local sources just because there’s a small population and a lot of competition and a lack of extra personnel to assist.
But we’re also grateful for partnerships with Hawaii Pacific Health and Queen’s, who have been wonderful to work with for our local nursing students. We have some really great partnerships lined up for the DPT [doctorate in physical therapy] cohort that’s starting in July.
Babington: We have partnerships with all three [hospital systems on the roundtable], but we also have been partnering recently with Queen’s for a year-round certified nursing assistant training.
In meeting with some of the nursing personnel at Queen’s, they said that curricula here for licensure or certification in Hawaii is really heavily focused on long-term care so these CNAs come in to your hospitals and they don’t know acute care. So we’re finalizing an add-on to our CNA training to take some of your CNAs and give them the acute care before you hire them.
Roche: I’m relatively new to Hawaii.
I’ve been here two and a half years, so I’ve spent most of my career in the tertiary, quaternary area on the Mainland, mostly East Coast, Midwest, and we’ve always hired new graduates.
When I came here and found out we weren’t hiring new graduates, I was like, wait a second. [A]s we’ve come out of the [pandemic] surges we have [established] a new graduate residency program — we’re actually in our third cohort with new graduates and are planning for a fourth.
So we’ve onboarded 30 new grads in the last nine to 10 months and are planning for, as I said, No. 4. And we’ll continue to get into a cadence of hiring new graduates, in sync with graduations.
We’ve also built new-to-specialty [training, that is] the ability to train internally staff moving to the ICUs, to labor and delivery, to [perioperative], wherever they want to go. We’ve onboarded a number of nurses in new-to-specialty. I think it was Lynn who said, you know, you have to look at the demographics of nursing in the Islands
And as it relates to hospital needs, we partnered with Leeward Community College. They have done hospital aid training for skilled-nursing facilities and that’s where they do their clinicals.
They’re not really prepared to come into the acute care space. So in partnership with the Harriet Trust and Leeward Community College, we now have a program where they are offering specific courses only for aides that are destined to come into the acute care space, and we’re offering that clinical opportunity for them to come in.
And then our hiring them recognizing, you know, we had a gap and we needed to fill that gap, so we partnered to do that.
Chang: At Queen’s, there’s really an evolution in our thinking. Our goal is to be a great place to work, in practice, but our history has not been on-boarding and hiring new grads — very few, maybe 30 a year. We have recently given employment to about 75 [new graduates]and the goal is to have 150 by the end of the year.
Internally it’s making us rethink how we are onboarding. And so you have to have a mentor nurse, a senior nurse, who is going to take some of these nurses under their wing. It’s a little bit different mindset in how you’re going to provide ongoing training. And if it’s new-to-specialty or if it’s just new to acute care, both of them have to be treated in the same way — lots of didactic, outside-of-the-nursing-unit training, but you have to give them protected time to do that. Same thing with your mentors.
They have to have some protected time and you just know there’s going to be a decrease in the productivity when they’re teaching a nurse and educating so that patient care is still safe.
I think you’re going to see a very drastic change in our approach over the coming year. We have to catch up and the partnership with our educational institutions for nurses and other bedside specialties, I think that’s going to have to be an ongoing thing. You know, the more people we can keep people here in Hawaii … I think we’ve recognized that once you let them leave and they get a permanent job somewhere else, it’s really hard to recruit them back. So we have to get ahead and we have to think differently.
How Hawaii is rebuilding its health care workforce – Pacific Business News – The Business Journals
PBN asked hospital and university leaders how they’re trying to solve Hawaii’s health care labor shortage.