April 14, 2022

Episode 68: The unique challenges of nursing on a remote island chain

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Description

Our guest for this episode is Laura Reichhardt, the Director for the Hawaii State Center for Nursing. As the most remote inhabited island chain in the world, Hawaii faces a unique set of challenges when it comes to nursing, including a high cost of living, a diverse patient population, difficulty transferring in nurses from out of state, and access to supplies that can be interrupted by natural disasters and other logistical issues. 

During the pandemic, these challenges became exacerbated and the state’s supply of nurses was severely limited. Laura and her colleagues at the center for nursing worked closely with the state government on their COVID response plan and to enact changes that would facilitate the flow of nurses into the state. 

Today Laura and Dan talk about that work, as well as Hawaii’s nurse residency program, the first statewide residency program in the nation. She also talks about what she sees as the future of the workforce, the need to train more specialist nurses and her advice for nurses who want to get more involved in policy making at the state and local level.

Links to recommended reading: 

Podcast

Transcript

Dan:

Laura, welcome to the show.

Laura:

Thanks so much for having me. I'm really happy to be here.

Dan:

Yeah. So I know we were talking a little bit before we started recording, but I would love to have you retell the synopsis of how you ended up in the Hawaii nursing workforce.

Laura:

Yeah, I'd be happy to. So I'm actually born and raised in Arizona. I grew up on the US-Mexico border, and that community is, like Hawaii, very unique, very rural, and we have our own very specific community. I ended up going into public health and I got a degree that emphasized in border health. All of my practicums were on the US-Mexico border. And I worked for the US-Mexico Border Health Commission immediately after graduating, but life took me to Hawaii. And finding myself uprooted, I thought that I was applying to a small nonprofit, and ended up applying and getting hired at our largest health insurance organization in Hawaii, doing HEDIS quality improvement measures, helping stand up some of their Medicare plans, learning about provider payment transformation. And at the end of the day, I was doing still public health work. I was doing healthcare administration, really focusing on patient quality outcomes, working on helping providers understand their patient panels.

Laura:

But I ended up realizing I wanted to be a clinician, and I really didn't want to keep on working in the system that put these pressures coming down from insurance companies, when I really felt the strongest potential for impact and change was at that patient provider level. And so, I became a nurse. I looked into all of the different professions, and felt that nursing matched my core values the most. And I already had a French Bulldog in Hawaii. French Bulldogs don't travel well, so I knew that I needed to find a program in the state. So I went to nursing school in Hawaii, and I graduated. Me and my dog were ready to go, but there were no jobs in nursing at that time, but there were jobs in health policy. And so I started doing health policy in my graduate work, or while I was a graduate student, and then immediately thereafter. And that took me and my French Bulldog to the Center for Nursing, and that's how I joined the state in this capacity. And now I get to say that my population that I care for are nurses, which is such an honor.

Dan:

That's awesome. Yeah. I think caring for our caregivers is a huge mission of mine as well, and so we align there. And can you talk about some of the unique challenges of Hawaii? One of the things that, when I was at Kaiser Permanente, we found, and this was working with some of the physician groups, was it was really easy to recruit physicians there. But when their families came, they found it hard to integrate with the community, and find their niche and some of that belonging. So, I'd love to hear your perspective on some of those unique challenges.

Laura:

Yeah. That sense of belonging is really important here, and that's something... Being from the US-Mexico border, has helped me transition. I never felt displaced, but a lot of people, when they are transplants, they feel displaced. They feel like they get what we call rock fever or island fever, where you feel the need to get to the mainland or travel elsewhere. And I've always found that to be really comforting. Oh, but some of the unique things about Hawaii, we are the most remote inhabited is chain in the world, and we also have an incredible amount of natural disasters that can come our way. A couple years ago, we had a hurricane, I think we had an earthquake, we had a tsunami threat, and then we had a power plant have troubles, all at the same time. So, all of these different natural disasters coming our way all at once.

Laura:

And so it really makes you feel the remoteness of where we live. If the ports close down, it can take weeks to get another barge coming our way. Or, if there's a storm in the Pacific that makes boats have to reroute, that really changes the availability of resources. We have to prepare for food and other dry goods, other sundries, for two weeks. Because if the ports get shut down, that's how much time we need to have in our emergency preparedness response. So we're remote in a way that really doesn't capture the awareness or the plausibility in other areas. You might be remote, but you're still a couple hour drives away. In terms of island to island, there isn't a, "Drive away." The only way to get from Maui to Oahu or from Big Island to Kauai is by a plane or by a boat, and there really isn't the ferries across islands like there were in the past.

Laura:

And so we're talking about expensive travel. Just by plane. You can't just get in the car and drive away, so you really have to plan or have the financial resources to do so. That really came into play when the pandemic hit, because it affected access to nursing students becoming licensed. Our only testing site was on Oahu, and it became very difficult to travel from island to island at that time. And then we have our culture here. Hawaii is the land and the place of native Hawaiian people, and we have their culture that is very present in our lives. And we're very fortunate that this is a strong part of our place here in Hawaii. And we also have a lot of other people who have come to Hawaii and have pretty predominant populations. Japanese, Chinese, Filipino populations. We have Puerto Rican populations that are very strong and prevalent as well. And those populations and our mix of different cultures is really different than any other community in the United States or, really, in the world. And so when we bring everyone together and look at that culture, the mix, and our own unique culture but all of those individually, really is different in terms of how we engage with each other, what patients need in terms of their care and understanding, and even just the cultural norms.

Dan:

Yeah, definitely a lot of unique challenges there, both culturally and from just a physical location piece. One thing that I noticed during the pandemic is, a lot of travel nurses like to go to Hawaii, which is probably also another challenge in the workforce, because that premium labor can be very expensive. And if you don't have a pipeline on the island, it can create some of those dynamics. So, what's the current state of the nursing workforce within Hawaii?

Laura:

That topic, I think, I spend 95% of my time on these days. We have the first statewide nurse residency program collaborative in the nation. So we were the first state where our hospital employers got together, through the Center for Nursing, and said, "Let's all do a nurse residency program. Let's all pick the same curriculum. Let's get our new grads into the hospitals, and let's train them." And for 10 years, we were really focusing on med-surg nurses. And in 2021, we started also using nurse resident programs to train up to 31 different specialty areas. And fewer, I mean, really, functionally, fewer are happening, because they're the highest in demand. But what's happening, and what has been happening in our state, is that we have a great entry to practice pathway for med-surg nurses and acute care, but we don't have a great pipeline to either train or develop our own nurses in specialty areas.

Laura:

And so when the pandemic hit, we needed the OR nurses, we needed the ED nurses, we needed the ICU nurses, critical care nurses. And we weren't able to develop them ourselves, particularly at the rate that they were really being utilized in the patient care settings, because those were the areas that became so high in demand. The acuity of all inpatient patients just increased dramatically. And so we became incredibly reliant on these specialty nurses during COVID, more so than normal. And then we also saw a lot of our nurses from our state who got sick and realized, "Oh, I really want to be closer to my brother or my mom and dad," and so they were leaving to the mainland. Or, who took travel jobs on the mainland. And so that decreased the availability of highly specialized nurses in our state. I think a lot of our states, we've recognized that we might have similar or the same license numbers, but the availability of nurses in terms of people and positions has just dissipated.

Laura:

And it's even more challenging in longterm care and home health and these other settings. And so we have been bringing in traveler nurses more than ever before, really in those specialty areas. Concurrently, we're looking at how to develop more training programs. And not just for new grads, but also incumbent nurses into these specialty areas, because we realize that we have to be self-reliant. When you have a two-week wait for toilet paper if things go down, or when you have delays in license processing time because all workforces have been impacted by COVID, you realize that you can't just rely on the resources of the nation, which is intangible and imprecise. We have to be able to have a strong grasp on all of our needs in our state. And that's from the beginning of nursing education all the way through expert nurses.

Dan:

Yeah. That's something that I've been really interested in, too. And I'm on a few committees with AACN and ANA, and I've been trying to push to say, "Our schools have been set up to create generalists, but the market is demanding specialists." And so when I was at Trusted Health as one of the clinical leaders there, we saw jobs across the entire country. In the pandemic, it wasn't a need for necessarily med-surg as the highest piece, it was ED and ICU, it was Level 4 NICU nurses. And we just don't prepare new grads to enter those specialties very well unless you have a really, really robust transition-to-practice program. And so I think we have to flip both the school model, and like you said, that residency model sounds amazing, where you can actually help people transition to, number one, the specialty that they're passionate about. Because you'll have more engagement and people stay, instead of being forced into something that they're told to do. But also, you create this pipeline of specialty that fills the needs of some of those longterm issues that we're seeing shift within the healthcare space.

Laura:

Exactly. And I think the challenge is that there's just not time or space in the clinical care environment to develop your own program. I mean, it really is most efficient when there's a great curriculum that can be applied. But then also, the way we fund nursing. We're a cost center. And so ultimately all of this training, it comes at a cost. And it's, "How do we value that cost?" Obviously, we know that these roles are critical. They are necessary. They are not replaceable, but we have to re-envision how we set up this whole continuum of lifelong learning, and infuse it correctly into these various settings. Whether it be schools of nursing or workplaces, because the construct that we have been working on is ultimately flawed and it does not allow for us to actually do the things that are necessary for patient care.

Dan:

Agreed. And at the fundamental basis of it, it's a supply and demand problem. And the supply is not meeting the demand. And my concern from a nursing standpoint, I don't know if you have opinion on this or have been in conversations around it, is if nursing doesn't evolve the way it produces new talent into the profession, then what's going to end up happening is we'll continue to chronically be short on nurses. And someone's going to have to fill in that gap, and the health systems may not look to nursing to do that work anymore. And so, our profession really needs to evolve or it may be at risk for being sidelined.

Laura:

I think you're right. I also think... We talk so much about acute care. In our state, only about 50% of jobs are acute care jobs in nursing. And then the other 50% are in longterm care and in home health, and in public health nursing, school nursing. And in all of these other roles, going back to the value of nursing, these roles are so valued by community members, by the patients and families who are receiving the care from nurses, but the salary is really inequitable. And the resources that are supporting nurses in acute care often don't exist, because they're smaller facilities, smaller organizations. So you don't have a residency program, you may not have a medical library or all of the teams and work groups that are working to push quality. You might be the only nurse on your floor or unit.

Laura:

And so, that can be isolating. And so I think we also have to support the nurse and the system that the nurse works in, in all of these other settings, because we're driving nurses only into acute care because of the more resources they get. And we know that the future of nursing isn't just in a hospital, and in Hawaii we're already living that. How can we balance that? Because that affects wellbeing for the nurse. So often, though, the nurse, particularly in our state, they're the breadwinners and they're providing for their families. And so we need them to be healthy and strong and well, and well-supported in these areas that they feel passionate about and they're doing a good job in. How can we do better for them?

Dan:

Yeah, I love that too. And really pushing nursing out into the community where we have the skillset to make outcomes change and lower the cost of care, which I think is a huge opportunity there. And I know there's lots of opinions and opposition to things like that, but I think, truly, that's where we're headed in the future. Talk to me a little bit about how the workforce in your organization's shifted as the pandemic started. Hawaii locked down, and really no one was allowed in and out except a certain set of essential workers, which must have been a shock to the system in itself. But how did you guys really sit down and start planning how to respond to this? And what are you proud of?

Laura:

We have so many things that we really can be proud of in our state. And I'm fortunate that we are able to serve in some of that capacity at the Hawaii State Center for Nursing. When we shut down in November, the governor, as you mentioned, shut down travel, except for essential workers. So some of the challenges that that created was when nursing students graduated, they were no longer students and that was umbrella'd under essential, and they were not yet healthcare professionals. They weren't licensed nurses. And so there was this bubble that they had to get through, which included for neighbor island nurses traveling to Oahu to take their exam, and also just accessing the exam. We had a six-month wait at one period. So one of the first challenges that we worked through was how to get new grads available to work in their communities.

Laura:

And we worked with the governor's office and the Department of Commerce and Consumer Affairs, which includes and oversees the Board of Nursing. And we worked very closely with the Board of Nursing, as well as employers and schools of nursing, to create and language in the governor's proclamations, to waive the licenses for any nursing student who graduated May 2020 or after. And so, our governor's proclamation is set to end in two days. We'll see what happens, but it's continued since that time. So any student who has graduated after May 2020 has been able to start working immediately. And that buys them time so they can get access to the NCLEX, but also start contributing to their local community's nursing workforce needs immediately.

Laura:

Another challenge that we have had is that we've had COVID surges. And we really didn't have large COVID surges until the end of 2020, and then really they were still what we would consider mild until Delta and Omicron, which really impacted us to a greater extent. What was happening is that we had some organizations reporting a third of their workforce falling out or having nearly a thousand employees out on sick, and that decimates your ability to provide patient care in the way that you were providing patient care before. So something we stood up with Delta is that we started weekly meetings with our CNOs, just for brainstorming, and even just providing emotional support amongst that level of CNOs. But at the beginning of Delta, we realized that we had a huge overturn of CNOs in our state. And all of the CNOs who used to know each other, worked together for years, had all retired. Or, many of them had retired, I should say, and that we needed to recreate this community amongst them to enable leveraging their resources amongst each other, validating approaches and responses, and assessing if their plans were on par. And that really helped. Initially, in Delta, we had a couple CNOs who were like, "I've ran out of ICU nurses," and other CNOs were able to say, "Well, I have somebody who's available. Let me see if they can be sent over."

Laura:

And so there was immediate human resource sharing. But also, when we started talking about crisis standards of care or resource limitations that were critical, they were able to develop plans, ensure that they had strategies to train their nurses and other healthcare team members on what those plans were, and manage the implementation in a way that was consistent across the state. And so we weren't seeing inequities or differences that fundamentally could, I think, cause more trauma or harm to the nursing population as they were working in these very dire circumstances. I think that they have done really great work, lending resources to each other. And that's one of the things that our state does so well, is that we don't keep our cards close. When we're at a table with our colleagues, everybody's sharing. Everybody has their cards on the table, everybody is leaning in, supporting each other, and sharing their knowledge.

Laura:

At the beginning of the pandemic, we actually started that initiative as well, between our clinical placement partners and our schools of nursing. And we've had that sustained committee since March of 2020, which really was critical in ensuring that nursing education continued, which I think was a topic of conversation everywhere. In our state, it took a really long time for nurses to be allowed back into clinical settings. And so there was also a lot of collaboration amongst the schools about how to do virtual simulation and how to stand up alternate learning structures. And then we started partnering with the Department of Health, who said, "Well, we know that we're going to need help with testing centers and vaccine sites." And so we got all the schools of nursing collaborating with the Department of Health and all of these different testing sites. So we were piecing things together as we go, but we did it always on a collaborative front so all of our partners were at the table all at once.

Dan:

Yeah. I think that's one thing that I've noticed in my multiple visits to the islands, and also working in some of the facilities there too, that this sense of family and collaboration is a really, really strong piece of the culture. And I suspect in the nursing world they're very much the same, that it's all hands on deck because there's really no other choice. You can't just go to the state next door and go say, "Hey, can we get some of your people over here?" Like you said, it takes weeks or hours and logistical challenges to move resources around. So, that spirit of working together is exemplar for other states, California and others that could really learn from. So, I think that's awesome. As we emerge out of the pandemic, what will you never go back to, that may have started in the pandemic that you found is a way better way than what we've done in the past?

Laura:

Gosh, I feel like I'm still processing that. What I can say is that our nursing schools have become more challenged in providing nursing education at a time when we have never needed nursing education more. We have such challenges recruiting nursing faculty, having the faculty size that we need. We have so many vacancies. And we know that we also need to grow, and then we also need more instructors. And so what I hope and what we're working on in that realm is getting more resources from the state. We have a bill right now for our state schools of nursing to increase instructor lines. We know that we're going to need to increase faculty lines. And what I hope for is that we can start thinking about how to innovate the dual faculty appointments with our academic and clinical providers. We need to do that better. We know that we need working nurses who are elbow deep in their work, teaching nursing students.

Laura:

And we can do that in a better way so that it's not a resource constraint or a challenge. We've been working, white-knuckling it for many years, well before COVID, and I think we can break out of the shell and do that better. We're also looking more collaboratively at nursing professional development once they're in their careers, for incumbent nurses. Thinking about how to develop our own for-specialty nurses is really, really exciting. I think we're going to have to think about the finances for that. I think we're also going to have to think about how that affects the continuum of care. Because when longterm care isn't accepting patients, which we're experiencing right now, all of those patients are staying in the hospital and we can't discharge them. And what are the reasons why? When we look at the nursing, not just the environmental perspectives, or COVID with safety and infectious disease, but what are the opportunities to create a stronger continuum between these settings?

Laura:

And I think that has a really exciting potential. We can definitely address that through specialty development and lifelong learning. We can also develop that through more collaborative working groups like we have with the CNOs and we have with nursing education, because that works so well in our state. And we do have nurses that represent organizations outside of acute care on our CNO group, and they really help inform and guide the conversation. So, those are some things that I'm excited about. I also think that we have started looking at our origins and our core values and the reasons why we do things again. We're being reminded about why we are nurses, and that's always important.

Dan:

Yeah, I agree. And I love those initiatives coming out. And again, I think the academic-practice partnership is going to be the key to moving much of our profession forward. So, exciting that you guys are charging the path there. What are some of the innovations happening within nursing in Hawaii? What would you say are the bleeding-edge aspects that you guys are working on?

Laura:

Strengthening our nurse residency programs, we're doing it in a bigger way that we ever have. It's not necessarily innovative. We know that this is necessary, but the fact that we're doing it and we had almost a 300% growth in new graduate program, hiring into new graduate program. So more facilities are offering new graduate support, as well as more facilities are hiring new graduates. But that volume is so large now, so we have moved from it being a nice-to-have to a need-to-have. And I think that pretty soon we're going to move from a need-to-have to a, "Have we ever done it differently?" It's just become a cultural norm now. I think that's really important because, as we all know, nurses are well known for... We say that we eat our young, and the chicken pecking order, or however you want to describe it.

Laura:

And I think we're working to erase that in our state, and I'm very excited. There's really big interest and concern about nurses' wellbeing. And a lot of organizations are doing a lot of things, and it's all being done differently. There's not consensus yet on the approach, but what I'm excited about and what I'm hopeful for is that when we focus on a nurse being healthy and well... Again, we're moving away from nurses eating their young or thriving off of the, "Suck it up, buttercup," model. Saying the, "Oh, you have to earn your dues." If we think about it as investing into the empowerment and wellbeing of nurses, we know that collaboration amongst healthcare team is going to get better. We know that patient care is going to get better. We know that retention is going to get better. But all of those are ancillary outcomes, and it's really centered on the nurse. And so I'm excited that this is a topic of conversation, because it's really going to drive our state in a direction that we've never been before.

Dan:

I love all of that. And I think the next generation, and the incoming workforce of nurses graduating and entering the workforce, they're not going to put up with that, "Suck it up, buttercup," anymore. And they know they have the feet to move them to other organizations if they want to and they know that there's not enough, and so they can really write their ticket. And if organizations still has that sort of archaic culture, they're not going to be around long, or they'll at least not have enough nurses. So, it's awesome that we address it, and I think addressing it head-on is really important. I want to wrap up on one last topic, which is, even recently, a lot of nurses are starting to realize the path forward has to involve policymaking. But we take a policy course in many of our programs but, at least in my experience, it doesn't resonate with, "What can I do today?" Or, "I'm more focused on clinicals at the moment," so it's sort of, "Make it through the policy course." But how are you engaging nurses at all levels into policy changes, policymaking, so that they can design the future of the profession?

Laura:

When I talk about policymaking and informing change, particularly when I'm talking to nurses, I try to emphasize our roots and our beginning. And we all learn the nursing process, that's the first thing we learn. And the first step of the nursing process is to assess. So often we hear the solution without fully understanding what the lay of the land is. What has been tried before and failed, why it failed. What are all of the other factors involved? What are other professions that have these same needs or don't? Assessment is so key. And I think that we really fail to lead with assessment in policymaking. But when we do lead with assessment and we find the solution because we've done proper assessment, we are so successful. This is our training. This is how we do it. This is what we do. And so when we're able to engage in policymaking at the organization level, at the profession level, at the state level, and even at the federal level, when we're able to carry things through, our work is strong. Our work is repeatable. Our work is relevant. And all of that helps us build clout and rapport, and so we will be able to have more colleagues who will be willing to work with us again and know that we will deliver. And the nursing process is what gets us the ability to deliver time and time, and time again.

Dan:

Yeah, I love that. I was in a conversation today where we were talking about a quote that was in one of our books, which was, "Innovation is building the future you want." And the way you build your future is to set up the structures and the rules, and all those things that govern our work. And the only way to do that is through getting involved in some sort of policy conversation. Whether it's local policies on your unit, all the way up through government and national, and even international policies. So, I love the way you framed that. We like to end our chats with the handoff. So, that one nugget that you want to share with the group. From our conversations, a takeaway for them to run away with and go change their workplaces for the better. What would you like to hand off to our listeners?

Laura:

Share your concerns and your successes broadly.

Dan:

I love it. And we don't even have to unpack it, because I want to leave it there so that people can just ponder that for a little bit because I'm sure it means something different to everyone. But I love it. So, Laura, thank you so much for being on the show. If people would like to learn more about the Hawaii Center for Nursing and some of your work, where can they find you easily?

Laura:

Our website is hawaiicenterfornursing.org. I'm also on LinkedIn. My name is Laura Reichhardt. And I have a very difficult spelling, so make sure you add all of the Hs and all of the DTs. I'm on LinkedIn. I'm available. My email and phone number is also on the website, hawaiicenterfornursing.org.

Dan:

Awesome. Thank you so much for being on the show. We'll make sure we put those in the show notes. And we'll have to have a Mai Tai next time I'm out in the islands.

Laura:

Yeah. Now you know how to get ahold of me and give me a call.

Dan:

Yeah, for sure. All right. Thanks so much, Laura.

Laura:

All right. Thank you.

Dan:

Thank you so much for tuning in to The Handoff. If you liked what you heard today, please consider leaving us a review and subscribing on Apple Podcasts, or wherever you listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Doctor Nurse Dan. See you next time.