Nursing crisis looms for Hawai'i, nation

By Glenn Scott
Advertiser Staff Writer

•	Ways to increase the supply of RNs Improve the public perception of nursing. Increase enrollment in nursing education. Eliminate stigmas and career barriers facing men and ethnic minorities. Develop ways to keep older nurses in the work force. Allow more foreign-educated RNs to work in the United States. Source: Peter Buerhaus, RN

For now, the popular remedy on the Islands is to supplement the supply of 9,000 working nurses by recruiting highly-skilled RNs who accept short-term contracts for the chance to sample different parts of the country.

Recruiters say Hawai'i is an obvious draw, and virtually all Island hospitals rely to some degree on these traveling nurses, especially for hard-to-fill, high-skill jobs.

But even the supply of eager travelers will eventually be inadequate, experts predict, as the nursing shortage reaches a crisis level in another decade. Driving the trend are a mix of baby boom demographics and new career opportunities for young women, researcher Peter Buerhaus of Vanderbilt University told a Honolulu audience last week.

The average age of registered nurses is increasing at more than twice the rate of the U.S. work force, he said, because boomers dominate the nursing ranks.

The average age in 1980 was 37.9. Today, it's about 43.

Here's the problem: As a significant portion of the nursing population in Hawai'i and elsewhere approaches retirement age, so too do the 78 million boomers. That means, given current trends, that the nurse population will be declining just as the demand for health care shoots higher from a growing population of older Americans.

In another decade, if trends continue, experts say, as many as half of the current population of 9,000 working RNs in Hawai'i will be reaching an age when they'll retire or ease out of the work force.

Traveling nurses represent a relatively small percentage of the Islands' total, said Nancy McGuckin, executive director of the Hawai'i Nurses Association, which tracks hiring trends.

But because the travelers, as they're known, come and go every three to six months, they account for a lot of hiring. Of the 600 registered nurses hired last year in Hawai'i, she said, half were travelers.

McGuckin estimates that, after accounting for the roughly 280 registered nurses entering Hawai'i's work force each year from college, the state remains short 120 positions a year.

Enter the travelers — experienced nurses who contract through placement agencies to go where hospitals need them.

Traveling nurse Laura Kosanovich looks for work in resorts and upscale places like South Florida, Las Vegas and the San Francisco Bay Area. For now, she lives on O'ahu, coping with the daily dramas in the emergency room at St. Francis Medical Center.

Though her skills are in demand in Hawai'i — a supervisor already has tried to hire the registered nurse as a permanent employee — Kosanovich concedes she won't last among the sweet people here she has come to appreciate.

"I'm very comfortable here," says the 50-year-old mother of four grown children. "But I'm just afraid that down the line, that little gypsy in me is going to say it's time to go."

"During times of shortages," says Cathy Tanaka, St. Francis's director of staff support services, "bringing in traveling nurses who are already well-versed in these competencies helps us bridge the gap."

As Tanaka noted, most of the travelers are placed in the critical care units — areas requiring some of the highest skills. Thus, nurses with strong backgrounds and preferred professional experiences are marketing their mobility. Working through a growing industry of placement agencies, they can drop into the action like so many paratroopers wherever needed.

The traveling life is good, says Kosanovich, for those who can adapt quickly and thrive on the unknown.

"I like to work in ER," she says. "Something new's coming through the door all the time ... That's what I like. It's as transient as my lifestyle."

Even travelers and their placement agencies, though, finally are threatened by the demographic trends that researchers say are sure to alter the nursing labor force and threaten the ability of medical providers to offer adequate care.

In the short run, the excess demand for nurses offers travelers favorable conditions, says Buerhaus, senior associate dean for research at Vanderbilt University's School of Nursing. But unless agencies can develop new types of travelers, they too will face problems.

"The same shortage that is affecting employers," says Buerhaus, "is going to affect them."

Stability not possible

Hospitals generally prefer to rely on the stability of permanent employees and to avoid the placement fees, apartment rental contracts and constant turnover that come with travelers. They also want to avoid the mixed signal sent to permanent staffers when short-timers walk right into high-profile jobs.

Lately, that hasn't been possible.

"I would guess that every hospital uses some form of traveling nurses," Tanaka says.

McGuckin says nursing shortages have occurred in eight- to 10-year cycles over the past three decades as interest in the field rises and falls. In times of shortage, employers raise pay.

She agreed with Buerhaus that the current trend is far more extreme and worrisome because it rides the demographic reality of the baby boom generation.

Speaking last week in Honolulu at a conference on critical nursing issues, Buerhaus reviewed Census data suggesting the current shortage, unless addressed, will worsen into a crisis. The average age for registered nurses, he said, has climbed from 37.9 in 1980, after boomers had entered the field, to about 43 today.

In some key areas, the average age is even older. "The average age of an operating room nurse is something like 53," he said. "At that age, they're starting to drift out of the market."

Here's the problem: Nurses aren't the only category of people growing old. As the 78 million members of the boomer generation advance toward retirement, the medical industry is looking ahead at an eventual doubling of the Medicare population. More older patients, said Buerhaus, means more demand for services and, consequently, a need for more nurses.

But younger people are not entering nursing in the same percentages as in previous generations as the traditional pool of candidates — college-age women — are looking at increased career options. Less than 10 percent of the nation's RNs are less than 30 years old.

The overall effect, he said, is that the RN work force will continue to age through this decade and then will start to shrink just as the need for nursing services shoots up.

Bonuses and free housing

It is within the framework of these larger issues that traveling nurses find their calling and their capacity to go where they please.

In many areas, travelers get cash bonuses, free housing and their pick of shifts. That can mean night work and spending days having fun.

"We have a lot of hospitals where the night staff are all travelers and the charge nurses are all travelers," says April Errazuriz, a nurse recruiter for Professional Placement Resources of Jacksonville Beach, Fla., which represents about 200 nurses. "People just aren't staying in the nursing field."

The situation is more settled in Hawai'i, where union contracts ensure travelers get treatment and compensation roughly equal to permanently employed nurses.

Still, some institutions try to reduce use of travelers. The Queen's Medical Center plans to phase out travelers by the end of the year, said Lisa Nishikawa, coordinator of nurse recruitment.

To develop more full-timers, she said, Queen's is bolstering its program to help train graduating nurses from Island colleges and is emphasizing internal training programs aimed at qualifying more nurses for demanding jobs in emergency and operating rooms.

"Job candidates are looking for hospitals that are willing to educate their people internally," Nishikawa said.

Avoiding travelers, though, means giving up on another recruiting method. Tanaka said St. Francis usually has on staff 20 to 25 travelers who work on contracts that extend up to six months. She considers many prime candidates for recruitment.

"We have been quite successful getting RNs to stay," she said.

That was the case with Jennie Gamage of Lexington, Ky. She worked at St. Francis for six months in 1990, during an earlier shortage. By then, she had been traveling for three years, working mostly in southern cities like Winston-Salem, N.C., Charleston, S.C., and Louisville, Ky.

After Hawai'i, she returned home. She came back three weeks later attracted, she said, by the cultural diversity, the Island traditions, the hospital 'ohana.

Today, Gamage is professional development director at St. Francis. She's the one trying to bring Kosanovich aboard.

The allure of the nomadic nursing life, she said, is in its autonomy.

"Normally, you're in and you're out," she says. "You're not involved in the hospital politics. You do your work and you can move around."

Now that she's committed to one place, though, she sees virtue in permanency, in professional development programs and, in the case of this newly married Kentucky native, in immersion into the local culture.

Kosanovich says she won't travel forever, either. But this nurse from an upstate New York steel town says she just can't convince herself to end the travels that take her from one resort area to the next.

The moving, for her, works against the inexorable trend that worries everyone else. "Since I started traveling," she says, "I've gotten 15 years younger."

Glenn Scott can be reached by telephone at 525-8064 or by e-mail, gscott@honoluluadvertiser.com.