In this article, the need for selected health education programs in Hawaii will be discussed. Changes in the health care system, population and provider population impacting supply are identified. Health trends in Hawaii are highlighted and strategies needed to assure that Hawaii's demand for health professionals in social work, dental hygiene and nursing are suggested

Harrigan, Rosanne C.

Kooker, Barbara Molina

eVols at University of Hawaii at Manoa

Health Education Needs in Hawaii: SocialWork, Dental Hygiene and NursingRosanne C. Harrigan EdD, APRNBx, FAAN andBarbara Molina Kooker DrPH, APRN, RNCAbstractIn this article, the need for selected health education programs inHawaii will be discussed. Changes in the health care system,population and pro viderpopulation impacting supply are identified.Health trends in Hawaii are highlighted and strategies needed toassure that Hawaii ‘s demand for health professionals in social work,dental hygiene and nursing are suggested.IntroductionHealth trends. current and projected health care system changes,population and provider factors, and supply and demand issuesdriving the need for education of selected health professionals in theState will be discussed in this article. In addition, the difficultiesassociated with recruiting qualified health professionals are presented. Economic leverage and research and service contributionsare offered as strategies undertaken by the University of Hawaii atManoa School of Nursing to address workforce supply and demandissues.Social WorkThe School of Social Work at the University of Hawaii at Manoa hasthe only MSW and PhD programs in social work in the Pacific. Italso has the largest B.S. program. Social work is among the fastestgrowing profession for the next ten years and the School providesgraduates to meet the need. These graduates are educated to understand the specific concerns and values of Hawaii’s multiculturalpopulation. They are prepared for the workforce needs of the State,for example in child welfare, mental health, and services to olderpeople.In addition, the School is a leader nationally in producing researchon Asian Americans and Pacific Islanders. The research generatesknowledge needed to develop policies and programs within ourState. The School brings in an annual amount larger than its generalfund budget in training and research funds. The MSW program isranked 29th out of 150 by US News.’Dental HygieneStatistics indicate a continued need to provide oral health care.prevention and education services to the people of the State ofHawaii. The Department of Health reports that on screening of70.000 public school children, the dental health of Hawaii ‘s schoolchildren is poor and among the worst in the nation. Some ethnicgroups and island communities in Hawaii have disproportionatelyhigh rates of dental disease. Ninety-four percent of 6-year- oldsnationally are caries-free compared to 18% of 6-year-olds in Hawaii. Five percent of mainland 5-year olds have “baby bottle toothdecay” compared to 15% of5-year-olds in Hawaii . The highest ratesof this type of tooth decay are among Native Hawaiians (2 1%),Filipinos (32%) and residents of Molokai (33%).Several areas of the neighbor islands are designated as “dentallyunderserved.” In 1992.71 % of dentists surveyed indicated there wasa shortage of dental hygienists in the State. A large percentage ofdental offices have no dental hygienist due to the chronic low supplyof hygienists. Hygienists are needed on the neighbor islands andOahu.The Dental Hygiene program at University of Hawaii at Manoais the only dental hygiene education program in the State of Hawaii.The program parallels the entry-level educational goal (baccalaureate) of the national professional organization. the American DentalHygienists’ Association. The program is accredited by the American Dental Association and 100% of graduates pass National andState Board Dental Hygiene Examinations on their first attempt. Theprogram ranks 47 of 212 or in the top 25% of national performanceranking by the National Board of Dental Hygiene Examiners. Thisprogram is attended primarily by women who are often heads ofhouseholds and have a need to access educational opportunities onisland.The Program also operates a clinic that provides low-cost oral careas well as dental health education to students and residents (elementary schools, skilled nursing facilities, community rehabilitationprograms, Special Olympics, etc.) of Hawaii. Casts are also madefor University of Hawaii athletes in order to fabricate theirmouthguards. Career education is also provided at various highschools and University of Hawaii affiliates to recruit students fromdiverse backgrounds.NursingIn order to meet the health care needs of the citizens of the State ofHawaii, adequate numbers ofnurses are essential. Demographic andeducational characteristics of nurses in the nation and Hawaii havean influence on the supply of practicing nurses as well as the supplyof nursing faculty. This section describes these characteristics andaddresses the approach used by the University of Hawaii School ofNursing to address these issues.DemandDespite a wave of managed care changes such as mergers, consolidations, and briefer lengths of stay that saw hospitals trim their ranksof inpatient RNs by 6% between 1992-1996, the number of employed RNs nationwide grew by its highest annual rate ever — anaverage of more than 3% a year, to 2.1 million in the same period,according to the latest figures from the Division of Nursing, U.S.Department ofHealth and Human Services.2Even as many hospitalscut their inpatient RN staff, nursing employment boomed in otherhospital areas between 1992 and 1996, up 25% in outpatient andlabor and delivery units, up more than 15% in emergency rooms, andrising nearly 10% in surgical facilities, federal figures show. In thesame period, the number of RNs in community health centers rose42%, nearly triple the growth in the previous four years, and climbedby 32% in long term care facilities.2The increased hiring of RNs has spurred multiple factors including: (1) the mounting health care needs of increased numbers ofelderly; (2) a growing population of hospitalized patients who areolder, more acutely ill, and in need of more skilled RNs per patient;(3) the rapid expansion of front-line primary care to many sitesthroughout the community; and (4) technological advances requiring more highly skilled nursing care. A related factor in hiring trendsis the aging of RNs. In 1996, the average age of RNs in the U.S. wasHAWA MEDOAL. JOURNAL, VOL 59, FEBRUARY 200067j._._RNs LPNS ——-APRNs —APRN-Rxs44, up from 40 in 1980. Only nine percent of RNs were under 30years of age.3 In 1997, the mean age of RNs in Hawaii was 4493Since high levels of retirement are projected in the next 10- 15 yearsfor the majority of the RN workforce, the significance of preparingreplacements for them in the face of increasing demand is staggering.Federal figures project that if current trends continue rising,demand will outstrip the supply of RNs beginning approximately2010. By 2015, says the Federal Division of Nursing, 114,000 jobsfor full-time equivalent RNs are expected to go unfilled nationwide.Presently, in an expanding number of markets, hospitals and otheremployers are struggling to meet a rising need for RN care and havestepped up recruitment.SupplyThe majority of RNs in the U.S. hold associate degrees or diplomasin nursing. Although 31% of RNs in the United States in 1996 heldbaccalaureate degrees (41% in Hawaii), 32% held two-year associate degrees (31% in Hawaii), 27% held diplomas (18% in Hawaii),9% had a master of science in nursing (10% in Hawaii), and fewerthan 1% had obtained the doctoral degree (less than 1% in Hawaiias well). This disproportionate supply of nurses with associatedegrees and hospital diplomas has led many policymakers to call forthe closure of significant numbers of these programs in favor ofaccelerated production of baccalaureate and graduate preparednurses. The National Advisory Council on Nurse Education andPractice, an advisory panel to the federal Division of Nursing, hasrecommended, as a policy target, that at least two-thirds of the basicnurse workforce hold a B.S. or higher degree by 2010.2 A recentreport by the Pew Health Professions Commission (1995) urged theclosing of up to 20% of associate degree and hospital diplomaprograms and more concentrated production of nurses from baccalaureate and graduate programs.5 The nurse supply in Hawaii isdescribed in Figure 16 A steady decline over the past five years canbe noted.The health care system’s complexity requires nurses who (1) arecapable of more independent clinical decision making in less structured environments, (2) are prepared broadly in basic as well asbehavioral and social sciences and management, (3) can communicate effectively, and (4) are oriented more to health promotion,maintenance, and cost-effective coordinated care. The B.S. in nursing curriculum provides such preparation, including education andtraining in community based primary care, not typically a part ofassociate degree or diploma programs, and gives nurses a foundationto enter graduate education for advanced practice and management roles.At increasing numbers of health systems nationwide, B.S. prepared nurses are practicing in ways that recognize their differenteducational preparation and competencies from other entry-levelRNs. In these differentiated practice models, B.S. nurses not onlyprovide more complex types of patient care but also design andcoordinate a comprehensive plan of care for the entire length of apatient’s stay—from pre-admission to post-discharge, supervisenurses aides and other unlicensed assistive personnel, design teaching plans for patients, and collaborate with physicians, familymembers, and other hospital departments and research staff. Associate degree prepared nurses function primarily at the bedside in lesscomplex situations and provide additional care such as teachingpatients how to maintain care after discharge.7Faculty ShortageFaculty recruitment problems are emerging nationally and in Hawaii. As the demand for nurses increases, the professors simply willnot be there to educate the workforce on which the state and nationdepend. We are facing serious barriers to attracting the faculty weneed.Tight budgets have allowed only modest increases in nursingfaculty earnings. Full-time nursing professors at four-year collegesand universities earned $66,132 in the 1998-99 academic year, up2.7% over 1997-98. The salary of a middle range full professor at theUniversity of Hawaii is $64,872. Average salaries for UH ManoaNursing faculty are $35,160 for instructors, $41,768 for assistantprofessors, $58,186 for associate professors, and $74,300 for professors. According to College and University Personnel Committees, assistant and associate level faculty pay tallied fairly evenlywith other disciplines while full professors trailed, especially atprivate institutions. This makes recruitment very difficult in light ofthe fact that cost of living in Hawaii is about 30% more.The American Association of Colleges of Nursing reports manyfaculty are opting for early retirement packages or resigning forgreener clinical or administrative positions.8 Some schools aresupplementing faculty practice plans or share salaries throughoutappointments with clinical agencies.In 1998, 411 people graduated from doctoral programs in nursing.5Only 43% had an employment commitment to serve as nursingschool faculty. Seventeen percent accepted non-academic positions. Filling faculty posts has become a problem. Many candidatesdo not have a program of research defined or they lack teachingskills. Others know research is the name of the game and do not wantto teach.Faculty life presents a harder road than private practice or administration. Clinical faculty in particular have long arduous workingHAWAII MEDICAL JOURNAL, VOL 59, FEBRUARY 2000Figurel. Nurse Supply in Hawaii, 1994- 1999Nurse Supply in HawaiiU,C,In-JC-)‘SI.C,Ez94-95 95-96 96-97 97-98 98-99Fiscal Year68hours. Increased patient acuity has decreased the number of nursingstudents that can be safely accommodated in a clinical setting.Faculty may be responsible for 10-14 patients as well as their 8 - 10students in a complex clinical area.Quality and accreditation requires faculty have at least a degreehigher than their students. The new PhD in Nursing Program, nowfunded by the Division of Nursing. is a substantive, coordinatedeffort to increase the number of doctorally prepared nurses who alsoare prepared for an academic career.Strategies Used by the University of HawaiiSchool of NursingEconomic LeverageThe School of Nursing has generated more than $2.4 million inresearch and training grants. The amount of extramural fundsgenerated by the School have increased by more than 600% over thepast three years. All graduates get jobs and pay taxes supporting theeconomy of the State. Most graduates remain in the state. Nurses inprimary care roles have demonstrated the ability to achieve qualityprimary care outcomes at lower cost. Advanced practice nurses arethe least expensive primary care provider to educate.Research ContributionNurses in PhD programs are the only health discipline specificallyeducated to do clinical research with human subjects. Nurses havethe potential to develop evidence-based practices and reduce wastein the delivery system. Nurses also monitor quality of health careservices.Service ContributionNumerous activities occur within the School of Nursing that provideservice to the community. Health outreach education is provided forexample through Dr. Wang’s clinic in China Town for diabeticpatients. Care is also provided for the elderly through specialprograms, clinics and partnerships. Complementary care is offeredthrough the Healing Center at the School of Nursing. Community-based education is the basis of the curriculum and all students learnwithin community sites addressing the needs of the diverse population in the State. Diabetes management is provided through numerous service and research projects. Dr. Kadohiro has a leadership rolein the American Association of Diabetes Educators. Faculty alsoserve as Pro Bono primary care providers in community healthcenters. Faculty and students provide health education for studentsand the community. Health screening is also provided for childrenthrough the Keiki Gold project. All levels of programs are deliveredusing distance delivery methods to neighbor islands. Faculty arefunded through the Community Initiative on Nursing to conductnursing workforce analysis and forecasting studies for the entireState.ConclusionNumerous challenges remain to assure that the State’s demand forsocial work, dental hygiene, and nursing professionals is met. Ashealth care needs of our residents and health care systems change,it is imperative that the State’s educational systems are ready to meetthe challenge. Economic resources are well invested in these pro-grams which assure health and safety of the public and maintain ourquality of life.References1. U.S. NewsOnhine. (March 1998) America ‘sBestGraduate Schools, [online]. Availablefrom: URL: http:/Iaw.usnews.com.usnewsIedu/beyondIbcrank.htm.2. National Advisory Council on Nurse Education and Practice. (October1996). Report to the Secretaryof the Department of Health and Human Services on the Basic Registered Nurse Workforce [REPORTTO THE SECRETARY], pp. 16, 48, 53. Washington, DC: U.S. Department of Health and HumanServices, Division of Nursing.3. Community Initiative on Nursing of Hawai_i. (1997). A Survey of Individual Nurses: Hawaii NursingWorkforce Demand Questionnaire. Honolulu, HI: Author.4. Division of Nursing. (March 1996). The Registered Nurse Population: Findings from the NationalSample Survey of Registered Nurses [RN SAMPLE SURVEY], pp. 8-33 Washington, DC: U.S.Department of Health and Human Services, Bureau of Health Professions.5. Pew Health Professions Commission. (November 1995). Critical Challenges: Revitalizing the HealthProfessionsforthe Twenty-First Century, p.51. San Francisco, University of California-San Francisco,Center for the Health Protessions.6. Hawaii State Board of Nursing. (1999). Personal communication,7. American Association of Colleges of Nursing. (1995). A Model for Differentiated Nursing Practice, pp.26.29. Washington, DC: Author.8. American Association of Colleges of Nursing. (1999). 1998-1999 Enrollment and Graduations inBaccalaureate and Graduate Programs in Nursing, p.12. Washington, DC: Author.Why We Need Laws to Protect Patientsfrom Their Health PlanRichard S. MillerProfessor of Law Emeritus,The William S. Richardson School of Law,University of Hawaii at ManoaLegal Consultant to Hawaii Coalition For HealthThe Hawaii Coalition for Health knows that members of the healthindustry are continuously interacting with members of the Legislature, building good will, and putting forth their views of what theworld of regulation should or should not include. Unfortunately,few on the consumer side have the resources or bodies to put forthsuch time and effort, and most of what we do in the Hawaii Coalitionfor Health is either unpaid or poorly paid. We are essentiallyvolunteers. Furthermore, while we share wide agreement withhealth care providers about the problems of managed care, ourloyalty is to the health care consumer and not to the physician. Thevast majority of our members are patients, not professionals, and thedues of these ordinary people are negligible. They, however, are theLegislature’s primary constituents.Here is why patient-protective legislation is important:1. Several years ago, the Legislative Reference Bureau studiedthe status of Hawaii’s health care system and reported that competition was healthy. Unfortunately, the situation has changed dramatically since then. Today, competition is not working in Hawai’ito provide the best choices of health insurance for health careconsumers. For all practical purposes, the competition that doesexist is only between HMSA and Kaiser, and it manifests itself inefforts by HMSA to reduce the “bottom line” in order to reducepremiums to employers. If HMSA is successful in this competition,it could force Kaiser out of business. Then HMSA will really havea monopoly of health care business as well as a “monopsony “- - theonly buyer of providers’ services left in Hawaii — and HMSA willHAWAII MEDICAL JOURNAL, VOL 59, FEBRUARY 200069

Health education needs in Hawaii: social work, dental hygiene and nursing.

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Health education needs in Hawaii: social work, dental hygiene and nursing.

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