 for the people. I'm your host, Manara Mordecai. The show is dedicated to unveiling pressing issues that are facing Hawai'i today, attempting to identify policies that will provide effective solutions. Today on the show, we are discussing the growing aging population in Hawai'i and its impact on the nursing profession. My guests are Ina Chang, who has practiced as a nurse in Honolulu for over a decade, and Sam Fulmer, a nursing student at UH Honola. Welcome, Sam and Ina. Let's begin with you, Ina. I know that you've been in geriatric care for almost the entire time you've been a nurse. Could you tell us about your work and what type of care do you provide right now? Currently, I am a hospice nurse, so I provide nursing care to most of my patients who are at home, allowing them the comfort to be at home and treating them to be comfortable at home pretty much. Previously, I was working in long-term care, skilled nursing, slightly different, but still taking care of our kupuna and their aging needs and just their health care, though. Yeah, so that was really one. Thank you. So tell me, how does working with kupuna and specifically geriatric care, how does it differ for nurses from that? Does it require special training? We don't really have like a special, like say like for labor and delivery or PDA. If you don't really have, I would say in general, it is very different than what nurses would want, would think of doing like stay in a hospital or an ER. We have to think about a lot of issues that are surrounding the patient. So beginning with their health, of course, they have a lot of comorbidities, meaning they have a lot of other illnesses that surround them. It's not only one issue. Some people go to the ER for one issue, like they hurt their head and they need staples. And that's something pretty, you know, kind of textbook standard, okay, stick you up, go home. This one you might have like people with diabetes and then like COPD or some heart failure all together. And it, you know, you have to manage to care with all their issues physically. And also they could have psychosocial issues. A lot of times they have Alzheimer's dementia. And there's another interesting aspect that I don't feel like they really tell you in nursing school is the family, their support systems. So they also have the support systems that you have to help support and guide because in the end, they're going to be the ones to take care of them. And then it all is kind of that pretty much all-encompassing. And it's a lot just talking about it in action. It's even more. But it's a really rewarding, it's a very rewarding scope of nursing, I think. And it really teaches, it really teaches a caregiver how to really think of health and healthcare in a different perspective, in my opinion, as a nurse. I think every new nurse should be a geriatric nurse at least once, even if they don't really want to be one. You'll probably end up being one anyway. That actually is a good transition to my next question is, do you think there are enough nurses in Hawaii who are trained to provide geriatric care or who are working in geriatric care? You know, so again, like I left nursing school for a while. When I first started nursing school, I didn't know anyone. I really wanted to be a geriatric nurse in my school. And there was a class of, I think, about 80. All of them just were set to go somewhere. None of them were geriatric. So no, I don't think there's enough emphasis on it, the need and the benefits and also the training. I think it should be highlighted more, not only in Hawaii, but all over probably. But I feel like we don't have enough nurses in general. I feel like that are locally working, I think. I think a lot of our nurses are transported here for many reasons. But I think that we have enough nurses who work in the geriatric that just couldn't maybe find their dream job, whatnot. And then, you know, they stay for a while until they, it's basically, geriatric nursing is mostly a stepping stone for a lot of nurses. So would you say the salaries and the benefits for geriatric care for nurses is comparable to other fields? So I have always been a geriatric nurse. So as far as benefits, I'm pretty sure it's really just based on what company you go with. As far as salary, I've always known that we get paid significantly less than the main nurses. And that significance could be like $20 less an hour, which is very significant. And I'm not talking about just my profession. I'm talking about like in, like, every scope of nursing, like 10 to like 20. I can, I noticed that, like, when I was curious to look up stats before, and I was like, think about like half a year when I was like, wow, we're still there. And actually, I think, because this is me, but he had been voted to be one of the worst states to work as a nurse before. Like what I saw, it was hardest, not worse, but hard to work. Because it's just a lot less paid than I mean for a nurse if you're not attached. We see a lot of nurses leaving for the mainland because of that. I do have a lot of nurses in my class that have less. A lot of them, but they're not necessarily nursing reasons. They're more likely like, like, like kind of financial reasons, which I guess kind of ties with their nursing because that's their career. But there's just more opportunities out there in some ways. And they, again, they strive for different things. So if they want to be in like a burn unit, you know, we don't have really burn units here. They have especially want to pursue, they need to go in the mainland. So. So how do the facilities are dealing with the shortage of nurses specifically in geriatric care? Are they recruiting from other places? Or what do you see happening? If anything, or are you just overworked? I think all nurses are overworked in general, not only for geriatrics, just an opinion of mine. But from past, I know that we have contacted agency nurses a lot. We either, but we don't always like to contact agency nurses because I think it's an uncertainly amount of money that is just hurt the company a lot to try to hire a nurse from outside the company come in. They would rather have their own calls, pick it up, or yeah, like, someone wants to do an extra shift or, you know, more money because it's going to be over time, then they'll probably do that. Or where it comes that is you just kind of end up finding people covering half shifts to half shifts or, you know, just maybe just kind of like that just pulled together somehow, but it's never something that's likely planned in my dream. And you say that you've at least around you, you see nurses being overworked. What does that look like? Is it too many hours, too many patients? Tell me, describe it day to day. How do you feel like you could have more support or resources to help you do your job well? I think the nature of geriatric nursing is that it is not very predictable and acute things can emerge and acute instances kind of emerge. Therefore, it makes it hard to plan out your day. A typical nurse in geriatrics will have about 16 to 18 patients. So that's skilled and long-term mix. So if nothing happens, that's great. If everything happens, then, you know, then you get really burnt out. You have to stay longer in a facility. It just means that you would just spend more time at the end of your shift following up on the care. Because you always have that next shift to come and support you to, you know, go on the floor, but you still have to finish what you, you know, happened during your shift. For me as a hospice nurse, that just means I would spend a lot of time, you know, adjunctly like documenting and helping with care. I have gone over time at the patient's house before very long just as a situation. And it just means that you just have to have a longer day. You are just very compounded with a lot of documentation. No one really mentioned that in nursing school for me. Maybe if they did, it would have changed my life a little bit. But good amount of your day spent doing paper charting and paperwork. Yeah. And I believe that's because that's how we get reimbursed in this system is we have to be very careful and we have to be very mindful of how we document. And we still have to do the patient care, which a lot of times I feel the patient care takes, you know, it should take forth. But when you have the pressure of your own life to, I haven't even started talking about people, nurses having a life, but we do. And then having to document a day of work and happening and having to balance just being care of your patient, it becomes a lot. It becomes, you know, somehow it becomes a marathon every day. Yeah. Well, thank you for that. Sam, let's transition to you. I know you've done some work with the elderly as well. Tell us about your experience caring for kupuna in Hawaii. Yeah. So before I started my nursing program, I was working as a certified nursing assistant in a skilled nursing facility. So that's not, it's not an acute hospital, but like a subacute is what they would call that. So I would take care around like a patient's a day. A majority of them are geriatric. And I would be assisting nurses like Ina helping her with her care. And she's, the nurses are basically like seeing either like our boss. And so we're kind of their extension for the patient. So we're helping them with their, yeah, what we call like active daily living skills, bathing, getting ready for therapy, helping them throughout their day, whatever those needs may be. So yeah, it's a really hands-on job. It's rewarding. It's very difficult. It's not easy work, very physically demanding job. But it's immensely rewarding. And I think that's the draw to nursing is that you get such an award from the work that you're doing, such meaning instantly. So yeah, it's definitely I think one of my goals to pursue, advance myself in a nursing degree too. So when you were doing that kind of work, did you see, did you find that there was a short or the nurses were overworked or they're the shortage of nurses? What was your experience looking at as an assistant? I think for me, it depends on kind of how you know, saying different days, you might have where we talk about like acuity, where they might have some, something might progress and might need a little bit more attention. And so you can't go and reach another patient that might need your demands, you know, you have two patients asking for your help simultaneously at the same time. And so that can kind of get difficult to manage. Safety wise, you know, in nursing, we're always about quality, effective care, safety, like those are really horrible hallmark principles that we try to guide whatever action that we're doing. I think, I think this narrative about nursing shortages, I think it's kind of, it's kind of hard because I know a lot of when I'm looking at the job market right now as a prospective nursing graduate, I'll be graduating this August and I get a sit for my end collect this fall. A lot of the jobs that are being offered are, you need a couple years of experience under your belt before you can even apply. So there's kind of this gap between once I got my degree, now where can I get training on hand, like at the hospital in the clinic setting to make myself more competent. So I think that's where there's some issues in, I guess, in that transition from nursing education to being a nurse. Okay. So it has been, the transition hasn't been streamlined at least. So this actually, what I'm hearing is that the training or the type of care that you're going to provide to geriatric patients, it does require some specialization. As Inna mentioned, there are multiple issues that can come up. Inna said in her class, there wasn't a lot of specialized training. So this was over 10 years ago. You're a nursing student now at UH Manoa. Do you see that there's increased focus on providing specialized training in geriatric care in the nursing program? I would say yes. We got to participate in this really cool program this spring semester, where I was called the Geriatric Interprofessional Panel. And we actually got a case study and we met with students from the medical school, pharmacy students, students in dietetics. We all got together and we got to collaborate together because a lot of nursing care is in interprofessionals. So you're working with PT and OT, physical therapy, occupational therapists, dietitians, medical doctors, nurse practitioners, physician assistants, all of these different professionals that have certain skill sets. And then we have to like synthesize together and create effective care plans for Kapuna. And then we kind of had that opportunity to work it out as students. And that was great because I kind of got to see different expertise like listening to a social worker talk about at-home care programs, coordinating those things that me as a nurse, I don't have a lot of training in that, but that's her expertise. So I think overall the dealing with our aging population is that we have to be coming together and then strategizing together because we all have different points of view and expertise to deliver like effective care to them. Are you learning about the increase in the growing aging population in Hawaii as well and what type of demands there will be coming forward in the next two decades or so? Not. I didn't learn forecasting for that population yet. We talk about it in class, but it's not specific per se. It's more because you have to like learn the theory of nursing and then we kind of discuss aspects of different disease processes and how those will present in different populations. So we always are talking about like, okay, what is the geriatric patient different versus a pediatric patient with heart disease? Those are two different patients, right? Or then you have a patient with hypertension and is pregnant as well. So how do you deal with that patient? Each one of those are going to be dealing with something different, even though the disease may be the same. We also understand to most of my courses that I've been taking, I've been fortunate that a lot of our professors always highlight geriatric population when you're dealing with them. Here's some unique features that you have to kind of take into consideration and then kind of deal with those dignity aspects like trying to empower them to make correct choices. Kind of those challenges of geriatric populations when they get a hip replacement or something and then it starts limiting their mobility. Psychologically, how tough is that? You know, when they're trying to be compassionate and understanding how people, you know, it's hard to experience not like in illness, you know, psychologically, it's hard. And then how do you be compassionate as nurse providers? And I think when nurses are stressed and they're not feeling like they're being supported by their employers or the institutions that they are working for, we can see that correlates with like not as effective of care that is being provided. And so then it's kind of talking about, okay, how can we make this, how do we improve this? You know, can we do it at the state level? Can we do it at, you know, or can we create incentives within the state for employers to employ more nurses or to allow them to do it as like a tax benefit or something? I mean, we have to start coming up with more creative ways instead of just letting it build up because it is going to become more and more of an issue. You know, like they talk about the nursing age, I think right now is 49. A few years ago, that average age was 54. So it is going down for a nurse, but that's a high age. So in the next 20 years, a large percentage of the nursing staff is going to retire. It'll be interesting what next year, because of COVID, how many nurses were still working, got maxed out from that COVID dealing with the pandemic, you know, that stress and then being like, okay, I'm done. I'm gonna, I can retire now. So it will be an interesting adjustment, I think in this upcoming year is what we'll determine what where our outlook will be going in the nursing field. So do you feel like one, there's definitely a need to maintain the type of data and kind of evidence to help us plan ahead, right? Like seeing how many nurses are retiring in any given year and how do we feel that you feel like in the nursing profession, this is a question for both of you that the data that we're keeping to make sure that we are not finding ourselves in a critical shortage, is it sufficient? Do you feel like the state is up to date in maintaining good numbers, good statistics and what the nursing profession looks like in Hawaii? Either one. Yeah. I mean, I've been using this a lot this whole year. It's like, we just been through a pandemic. So I really feel like, no, not because of, you know, that we don't care, but it's just we, we have gone through a lot this year. And I think it's a good and it's not to be over optimistic, but it's it caused attention to a lot of things that needed to be called upon. So my hope is, as Sam said, like in the future, we do, like from here on, then we do think of that. We do think of considering more of the statistics of what we need for a component, because I think there was, I believe, at least here, I feel that they do realize our geriatrics are the ones that would hit the hardest here. And the care that was needed to coordinate, definitely needed some fine tuning, I think, probably. So I think it's good to be mindful, but I wouldn't, I don't think we have that much of a focus on statistics right now. I think everything is very COVID geared, very prevention geared, very population kind of a pandemic viewed geared. So in essence, it could, I think it just take the right person to like introduce it. And then like, oh, yeah, that's a great idea. We'll do that too. So I think I'm hopeful about that. So yeah. Sam, do you have any comments? Yeah, I think for the like specifically, we're talking about the state of Hawaii in different states and their departments of health, I think overall, they do have a pulse on it. You know, I think a lot of the time when we think about shortcomings or shortfalls within the health care system, we kind of pinpoint it onto people or maybe even a profession. You know, at the time, it's a function of the system itself. So when errors or shortfallings happens, it's the system that is at fault. So meaning structurally how we built it up to allow certain events to happen or to not happen. So structurally, what is unique to Hawaii? We have a really high cost of living, you know, land space is super limited. Do we have enough housing facilities for a kapuna to go into? Do we have enough long term care facilities for them to go into? Do people have to retire and go to the mainland? You know, do they have to leave their home? You know, native wines are being pushed out of their homelands here. They're not able to survive in this very expensive state and it's going to become even more expensive. It's not going down. So can the state come together with other health care institutions, major hospitals and health care teams work together to try to resolve that? You know, those are some of the more interesting aspects of care that we need to consider, you know, and then it's going to be start pushing for the cheaper, you know, right now it's kind of like the race to the bottom, where's the cheapest labor is going to be, you know, the nursing profession makes up 90% of health care, you know, where the foundation of health care at the end of the day, the nursing profession is that so how are we empowering our local community and nursing profession to meet the need of our capuna? Great question. I'm going to bounce that right back to you. You have the experience, you are a student, you experience both the educational aspect of it and the profession itself. Let's say you are the decision makers table, what policies would you put into place or would you recommend to encourage more people to join the nursing profession and to enable them to be successful on their job? So how do you create that culture? Let's start with you, Sam. Okay, I have a few ideas. Okay, so in 2019, no, I looked this up. So in 2019, there was 624 nursing degrees awarded in the state of Hawaii in one year. That's a huge population. There's not 624 job openings in the last year. I don't think so. It could be wrong. What? Right? So can we incentivize, like, what if they didn't get tax or tax exemption program for training new grad nurses at your facility, you know, give them that 12-month program hands-on, kind of like your preceptorship you get in your last year of your nursing program, they continued on with that to get you really get you on the ground running and then to incentivize businesses and healthcare institutions to employ them to become part of their staff, you know, and if it's not there then somewhere else or it can be like loan forgiveness programs that the state can start implementing, you know, there are available at the federal level but we are we're considered rural medicine. We can tap into resources here that bridges those gaps and then our care institutions like, you know, UH Manoa, you have an entire faculty staff that are trained professionals in the nursing teaching discipline, right? How can they be employed by the long-term care facilities that need nursing? They need nurse staff. So how can they join together and build a program? I think for me that's what I would love to see is them teaming up together, creating these programs for the new grads that are coming out. We're local individuals or graduating in nursing degrees and we don't know the exact next step. There's only so many new grad programs available to us right now and I would be to expand that in every type of nursing career. Great. This is exactly why I have the show is so we can hear about policy recommendations from people who are on the ground. So, Ana and I, you and I have had conversations about empowering families to care for their kupuna. Tell me more about that. I want to hear your ideas of how we can do that and being innovative in that kind of care. Yeah, so I really like FAMS. I agree with that 100%. By the way, I also feel that there is need of more people to be more programs to involve family caregivers to be a part of and not just when things happen. Just throughout, just I wish like, you know, their family hospitals or, you know, public health would just be like, hold events like, hey, you know, like, this is how you take a blood pressure, you know, like, and this is when you not that you need to know everything, but just know enough to feel confident to know when it is to contact a healthcare profession and when it is to not run to the ER or, you know, just and they don't feel supported and in turn, their patients, which is their loved ones, my patients will feel that as well. I also feel that they because I'm a mother, think they need to give just a little bit support to family nurses who have families because I feel like that's where nurses feel the burnout when, you know, it's rewarding and we love it. We wouldn't be doing it. We wouldn't be working if we didn't. But the truth is, we also have, you know, a family and I don't see that. I really would like to see companies come on. That's not only a nursing profession thing. I know it's an all over America kind of needs to think about, you know, kind of like mother kind of maternity leave kind of a thing or if they just need, I think that's a good incentive to have for keeping nurses, you know, engage education nurses. I've known a lot of nurses who are seniors, which are my helpers, as Sam said, rise up because they have the support and thought enough encouraging nurses around them to become a nurse themselves. I source that nurses become nurse practitioners. I've trained a lot of nurses become nurse practitioners right now. So it's very, it's just a bit, it can be very thriving, but it really needs to grow and support. So I love it. Thank you so much for both of your ideas. This has been a great conversation. I'm so happy we got to do this. Thank you. I hope somebody takes to heart all the suggestions that you've made because you are on the ground doing this important work. Thank you. And Aloha, take care. Thank you, Benara. Thank you, Sam. Thank you. Thank you.