Op-ed: Why an inaccurate 'overworked nurses' report poorly reflects Hawai'i's nursing efforts

In Hawai'i, nursing strives to and prides itself in evidence-based practice and data-driven nursing workforce policy and recruitment and retention programs. In 2003, nursing, healthcare leaders and policymakers established the Hawai'i State Center for Nursing with a mandate to promote quality practices and best outcomes in nursing and conducting research on the current and future status and trends of the nursing workforce. Today, we at the Center for Nursing remain stalwart in our efforts to fulfil this vision.

In late June 2018, a report from Medicare Health Plans stated that Hawai'i has the fewest nurses per capita in the nation. This is both false and a poor contribution to workforce supply and access to care discussions. The report underreported the nurses who work in Hawai'i by 80 to 87 percent, depending on if you refer to our state labor or licensing data. In numbers, the report only included what is equivalent to the licensed practical nurse workforce, and entirely omitted what is equivalent to every single registered nurse in Hawai'i. When the report used data stating that we have only 2,700 nurses, instead of roughly 13,000-19,000 that our state labor or licensing data reports, respectively, the accuracy of the report is going to be very, very wrong. Recognizing that the data used in the report were inaccurate, I contacted the data source immediately. The data were taken down and work efforts are underway to correct this issue. Unfortunately, the developers of the report have not yet retracted their report or issued any public notice to organizations, groups, and/or individuals that have read the report. This is not evidence-based reporting. Instead, it is harmful, inaccurate, but eye-catching reporting. We don't need meritless alarm in an era of healthcare access insecurity, healthcare provider burnout, and ever shifting benchmarks for care.

Moving on, let's get the story straight. Per capita is a poor method to analyze capacity to care. The Healthcare Workforce Technical Assistance Center notes in their Health Workforce Analysis Guide (2016 Edition), that assessing the true need for healthcare workers is difficult, as healthcare is so rapidly changing. Additionally, demands for healthcare are multifaceted and ever-shifting with changes to the healthcare delivery model, population health emphasis, integrated service delivery systems, payment reform, and team-based care all having impacts on the number, and the type, of healthcare professions needed to provide safe, high-quality, and timely care. Beyond this, different populations have different needs. It is well recognized that populations with poor social determinants for health have higher healthcare needs. Though Hawai'i is incredibly expensive, and we have our own health inequities, we have continuously lead in well-being across the nation, according to Gallup. These influences are more impactful than a general count of nurses per person.

There are other factors that influence access to care and quality of care. As a member of the National Forum of State Nursing Workforce Centers, the Hawai'i State Center for Nursing utilizes the Forum's Nurse Supply Minimum Dataset to assess our existing workforce. The Hawai'i State Center for Nursing 2017 Nursing Supply Survey indicates that nurses are well distributed. This tells us that we don't have a distribution problem. This is good, primarily for our rural and neighbor island populations, because it tells us that nurses are in their own communities, ready to care for the people who live in them. Additionally, the majority of nurses are employed in a single full-time nursing position that requires 37-40 hours per week. Nurses are not reporting the overwhelming workload that this study suggested, based on the hours worked and jobs held.

Nurses are a stable workforce and are consistently a high demand profession. According to the Hawai'i State Center for Nursing 2017 Survey, over 80 percent of our nurses intend to stay in their position within the coming year, and 90 percent intend to remain working as a nurse for at least the next five years. A stable workforce has performance stability, organizational and clinical knowledge and experience that is critical for maintaining high quality care. That we have a stable workforce should be lauded as a success!

One of Hawai'i's greatest healthcare strengths is that our nursing population is one of the most highly educated nursing workforces in the nation, with 72 percent of our registered nurses holding a bachelor's degree or higher in nursing compared to 54 percent of the nation. At nearly 18 percentage points higher than the national average, this gives our nurses additional skills and resources for patient care and navigating the complex healthcare system. Across the state, we see working associate degree prepared registered nurses selecting to deepen their nursing knowledge and skills through additional education. We are seeing nursing students choose to either immediately transfer into a bachelor's in nursing program or select a bachelor's program from the outset. Our nurses are investing in themselves and choosing lifelong learning as a commitment to caring for the people of Hawai'i and achieve improved outcomes. 

That we have a stable, highly educated, and geographically well-distributed nursing population does not imply that there are no inequities in care. Rather, it is meant to convey the complexities of assessing if our current workforce is meeting the demand for healthcare services. It recognizes our strengths, which can be leveraged to enable our state to address gaps in healthcare needs and unique characteristics. With this state-specific information, we can better respond to the unique needs of our state relative to the healthcare delivery system, payment methods, social determinants of health inequities, as well as our unique, island influences on healthcare delivery and wellness. Hawai'i is not the "worst," nor the "most overworked." Further, I caution using these wash-terms on the national level, and instead encourage readers to find the state healthcare workforce researchers, policymakers, and planners to help validate and clarify national data that can only be done when the local conditions are well known, and considered.

Laura Reichhardt, MS, APRN, AGNP-C, is the director of the Hawai'i State Center for Nursing and an adult-geriatric nurse practitioner. She advocates for nurses through national, state and local initiatives and through partnerships with schools of nursing, nursing employers, healthcare partners and policy makers across Hawai'i.

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