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Licensed practical nurses, the workers who are a central cog of care at long-term care facilities, are leaving the workforce in droves, raising serious concerns about who will provide hands-on care for Hawaii’s disabled and elderly in coming years.

These are the workers responsible, and , for administering medications and performing treatments that doctors and higher-level nurses have prescribed, including replacing bandages, cleaning wounds, handling IVs and changing catheters and colostomy bags. They are normally a common sight in nursing homes, pushing carts laden with meds through the halls and stopping to talk to each patient to make sure they take each pill on the right schedule.

While registered nurses are key administrators who oversee medical care and respond to health crises, LPNs are the point people who daily address the health care needs of sick people living in care facilities.

In 2019, , according to statistics from the state Department of Commerce and Consumer Affairs, which administers professional occupational licenses. But when license renewal time rolled around this summer, even before the delta variant hit, .

More than 1,000 of these nurses, about 39%, have fled the field in Hawaii.

Other kinds of licensed health practitioners have also headed for the exit in the past two years but at nowhere near the same rate as LPNs. There’s a , according to the American Health Care Association and National Center for Assisted Living.

This is occurring as numerous studies have highlighted the fact that America’s aging population means that many more workers who specialize in the care of the elderly and disabled will be needed, not fewer. The decline of LPNs in Hawaii means that the shortfall will be even greater than people had anticipated.

What Happened To Hawaii’s LPNs?

Where Hawaii’s LPNs went and who is doing the work in their place is something of a medical mystery. Officials at the state Board of Nursing say that they only became aware of the decline when the new statistics on license renewals were released late last month, and that administrators and health-industry professionals are still in the process of analyzing the data.

Officials at , the health care industry trade group, have found it puzzling and worrisome.

“We don’t have all the answers on that one,” said Patrick Harrison, the association’s senior director of post-acute care, whose work includes keeping an eye on long-term care facilities in the state.

Harrison said a variety of factors are coming into play simultaneously, including the aging of the LPN workforce, the stresses imposed by the Covid-19 pandemic and changing student tastes, with more people entering health care preferring to become registered nurses and to skip over the sometimes-transitional role as a licensed practical nurse.

There has also been a public failure to adequately fund nursing training to provide faculty to teach local students who will become the next generation of licensed practical nurses. Many more instructors are needed, he said, but programs have been put on hold rather than expanded. Kapiolani Community College, the only place the training had been available on Oahu, no longer has an LPN instruction program, he said. LPNs typically receive one to two years of specialized training.

“We need to overproduce LPNs to ensure a robust future for quality care in Hawaii,” Harrison said. There is “absolutely” a need for LPNs, he said, noting that it is increasingly obvious that more support and resources need to be directed toward educating and retaining LPNs.

A captured a snapshot of Hawaii’s LNP population in a survey of all nurses licensed at that time. Historically, LPNs have been a mostly stable workforce, with about a third of them having worked at the same place for 10 years or longer. The survey found that LPNs were eight years older than the average state resident, with a median age of 47, and that 31% of them were at least 55 years old. About 88% were women. About 45% were Filipino, with the next biggest group, about 23%, identifying themselves as being of two or more races.

These older workers were particularly vulnerable when the epidemic hit, and to continue working in health care, particularly in long-term care facilities.

“Covid is a big factor,” said Bob Gahol, a retired registered nurse and executive at Tripler Hospital, now vice president of . “They are an aging population and concerned about exposure to the virus. They are a high-risk population. A lot of them retired or they got other jobs in the medical field.”

Some, he said, began operating private care homes where they could live and operate in “a more safe environment,” he said.

Others who had higher-level qualifications but who found it difficult to get hired at hospitals in Hawaii in the past may have moved into RN positions now, Gahol said.

Many nurses in Hawaii come from the Philippines because the country has invested heavily in high-quality nursing-school education, and the failure of other countries to do so means there is a big market for nurses from that country in Europe, Saudi Arabia and in the United States, including Hawaii, he said.

A Dwindling Workforce Before The Pandemic

The authors of the 2019 nursing study were already worried about the steady disappearance of LPNs in Hawaii, noting that the state had lost 17% of its LPN workforce between 2015 and 2019. At that time, signs of disaffection with the field were already evident, with about 14% telling the center they planned to leave the nursing workforce within five years.

These were the growing tensions even before Covid hit.

“LPN wages are a pittance and the job source is long-term care,” said Hawaii island resident Jacqueline Gardner, a former LPN who eventually became a nurse practitioner, and now serves as Hawaii island ombudsman for the state Office on Aging. “You’re busting your ass and you are busting your ass for pennies.”

Hawaii’s hospitals, which pay higher wages than long-term care facilities, began declining to hire LPNs some years ago because there was a ready supply of local registered nurses available and shorter, more intense hospital stays required higher-skilled nurses. In many cases, hospitals have been able to hire RNs as LPNs and pay them at the LPN rate, several nurses said.

Most LPNs have ended up working long hours for low wages at nursing homes, they said, with LPNs earning only about $50,000 a year despite Hawaii’s high cost of living. These facilities operate 24 hours a day, seven days a week, and workers are frequently asked to work overtime and double shifts.

“Then they pass around a slip of paper asking you if you want Thanksgiving, Christmas or New Years off this year, when you want them all,” Gardner recalled.

Many prospective students have soured on LPN work, said Karla Kibayan, a secretary at the nursing program at Hawaii Community College in Hilo. Word has circulated among young people that “LPNs are getting overworked because they are cheaper to hire,” she said. Kibayan said that many health care facilities are paying LPNs at low rates but expecting them to also do the work of registered nurses.

Why Not Become A Registered Nurse Instead?

Many younger licensed practical nurses are in the process of making the shift to become registered nurses by seeking advanced education, the health executives said.

There’s a shift underway in the workforce, said Suzy Schulberg, president and chief executive officer of Arcadia, which operates two senior care homes, 15 Craigside and Arcadia. “What you’re seeing with LPNs is that it’s a transitional position,” she said. “The goal is to become an RN for more earning potential.”

For all these reasons, once the pandemic arrived, the LPN exodus turned out to exceed even the greatest fears of the authors of the nursing center report. LPNs had even more reasons to be unhappy during the Covid pandemic, when low-paid workers caring for nursing-home residents were blamed when their patients started getting sick and dying. The work has always been sad and challenging, but news about Covid deaths caused workers in some health care facilities to be treated like criminals.

Another factor in the nursing workforce deficit appears to have been that health care facilities have long hired a lot of LPNs from the mainland rather than employing local nurses. When Covid hit, many seem to have decided to go home. The state licensing statistics show that in 2019, there were 733 LPNs here listed as having mainland addresses but by last summer, there were only 292.

On the other hand, there has been considerable flux in the workforce in the past two years and it’s not entirely clear what the mix of workers is now. Some LPNs may be working here without being licensed in the state. Under , out-of-state nurses were not required to obtain a license in Hawaii if they worked under the supervision of a state licensed practical nurse or registered nurse. For that reason, it’s possible that the nurses who left were replaced by other contract nurses from the mainland.

In addition, health care facilities were allowed to hire (distinct from a regulated group known as certified nursing assistants), if they “demonstrate competency in skills and techniques necessary to care for residents’ needs.” These unregulated workers are helping care for patients by bathing them, feeding them and providing other support care, health officials said.

This all raises some concern about what is happening inside nursing homes now. Some people are wondering about the quality of care patients are receiving, particularly because the lockdowns that protect frail elderly from Covid also serve to keep family members out and unable to serve as outside eyes and ears to conditions inside.

“We have no ability to monitor and investigate,” said Lydia Hardie Hemmings, an advocate for the Hawaii Disability Rights Center. “In the era of Covid, it’s very hard to get behind the closed doors of facilities to see what’s going on. We can’t get in there.”

She called the situation “very scary.”

Harrison, though, pointed out that Hawaii’s long-term care facilities have had some of the lowest rates of Covid infections among the states.

“Our long-term care providers have been working diligently,” he said.

Vaccination mandates may cause more LPNs and other health workers to leave, . Statistics from the U.S. indicate that of 43 nursing homes in Hawaii, the staff is 100% vaccinated at only five, though as of October 3, most had vaccination rates solidly in the 90s.

Vaccination reluctance has been tied to misinformation, political alienation between Republicans and Democrats and reluctance to take newly developed medications that some federal scientists have been slow to fully approve. There has also been a fissure in the anti-abortion movement because some of the treatments were developed with . Many anti-abortion church leaders, , have opted for vaccination and urged their followers to do so as well.

But devout Catholics and evangelical Christians are disproportionately drawn to elder care as a form of ministry to the sick and needy, and some of them may be more prone to refuse vaccination because of the fetal tissue issue.

Harrison and Gahol, both of whom are strong vaccination advocates, said they believed Hawaii could lose more health workers for this reason, particularly as .

“It’s a legitimate fear,” Harrison said.

“Could some workers go? Definitely,” Gahol said.