The year was 2002. Gathered together in a small Asian diner in Hawaii, the board of the Asian American/Pacific Islander Nurses Association (AAPINA) was discussing whether or not their young organization had enough membership support to hold a national conference. Who would attend and why? What would be the criteria for determining whether the event was a success?
Back then, the board, consisting of 14 members, didn’t have answers to these questions. But today AAPINA has held four successful national conferences in different cities across the country and is preparing to hold its fifth annual conference, “Achieving Health Parity for Asians and Pacific Islanders through Practice, Research and Education,” on May 22-24 in Las Vegas.
The national conferences have given AAPINA members the opportunity to come together in one place to network, gain support and mentorship, and discuss issues facing Asian/Pacific Islander (API) nurses. This in-person camaraderie is important, because many members have little interaction with other API nurses in their day-to-day working lives.
“I didn’t feel like I had a political voice in any other nursing organization,” says SeonAe Yeo, PhD, RNC, FAAN, associate professor at University of North Carolina at Chapel Hill School of Nursing and immediate past president of AAPINA. “I felt that it was critical to bring our voice to the nursing profession.”
The idea of holding a national conference was implemented during Yeo’s presidency. “Prior to that, the association mainly communicated with its members through newsletters,” she explains. “Now that we have an annual conference, members get to see each other at least once a year. That’s one reason why membership grew during my tenure to about 200 members. When I began my presidency in 2001, we had less than 20. And it continues to grow.”
According to its mission statement, AAPINA has four main objectives:
• To identify and support the health care needs of API people in the United States and globally;
• To implement strategies to act on issues and public policies affecting the health of APIs;
• To collaborate with other interdisciplinary health and professional organizations; and
• To identify and support professional and nursing concerns of API nurses in the U.S. and globally through active networking and empowerment.
“We try to appeal to nurses working in different areas of the profession, including clinical, research and administration, and we’ll continue to do that,” says Yeo. “But what I’ve found is that this type of organization is particularly attractive to many international Asian graduate students [studying in America]. If you look at any major nursing school in the nation, about half of the graduate students are from various countries in Asia. These students are typically isolated. I’ve also found that many API nurse clinicians working in hospitals in staff or administrative roles are more isolated in their work environments and feel the glass ceiling effect more.”
Yeo notes that these nurses often have impressive titles and have earned graduate-level degrees and certifications, yet cannot advance to higher levels in hospital settings. “AAPINA provides them with a way to start thinking in terms of asking why they can’t get on a career path the way [majority nurses] are doing,” she says. “We’re [helping them address] the language barriers and cultural isolation that API nurses face. We also provide connections to other Asian and Pacific Islander nurses.”
Laying the Foundation
Compared to some other minority nursing associations, such as the National Black Nurses Association and the National Association of Hispanic Nurses, which have been in existence for more than 30 years, AAPINA is a relatively young organization. It was founded in 1991.
“That year, several of us [founding members] were attending a conference for ethnic minority nurses. This was the first time I had ever seen a group of Asian American nurses together in one place,” says Kem Louie, PhD, RN, CS, FAAN, associate professor at William Paterson University Department of Nursing in Wayne, N.J., and a past president of AAPINA. “We were all very concerned about [diversity in the nursing profession and creating more leadership opportunities for] minority nurses. So before we left the conference, I suggested that we stay connected, not realizing that this would be the impetus for forming AAPINA.”
AAPINA began with a group of 14 members who were committed to being advocates for Asian American and Pacific Islander nurses. These founding members represented a variety of geographic areas, from Hawaii to the East Coast. The fledgling association established bylaws and set out to bring the diverse voices of API nurses to the forefront of professional nursing issues.
Louie points out that one of the reasons why an association like AAPINA didn’t form earlier is because the API population is very diverse, encompassing many different ethnic subgroups. But even though, for example, the health care needs of Native Hawaiians are different from those of immigrants from Southeast Asia, “we are trying to [address the health concerns of the overall API population] and health disparities in particular,” she says.
Adds another AAPINA founding member, Mi Ja Kim, PhD, RN, FAAN, professor and dean emerita of the University of Illinois at Chicago College of Nursing, “Since we serve such a diverse population, language barriers can be a problem. English isn’t always [patients’] primary language.”
Over the years, AAPINA has been involved in several initiatives that have made a major difference in increasing national awareness of API health disparities and advancing health policy agendas that benefit the API population. In the late 1990s, under Louie’s leadership, the association worked with a coalition of other groups, such as the Asian and Pacific Islander American Health Forum, to get President Bill Clinton to establish a White House Initiative on improving the health status of API communities. Prior to this, the API population had been falsely stereotyped as a “model minority group” with few health problems. Therefore, they were rarely included in federal minority health programs or government-funded health disparities research studies.
There had already been many federal initiatives aimed at improving the quality of life for underserved African American, Hispanic and Native American communities, Louie explains. “It was quite exciting to be part of this movement that was saying, ‘Look, Asian Americans and Pacific Islanders would like some recognition that we, too, face great health disparities [and that we need more federal resources directed toward this problem’]. As president of AAPINA, I was invited to be a part of these important discussions.” President Clinton signed the executive order authorizing the API Initiative in June 1999.
Two years later Louie, representing AAPINA, published a landmark white paper on the health status of Asian Americans and Pacific Islanders in the journal Nursing Outlook. “The white paper was a review of API health disparities, what we need to do to remove them and recommendations for research,” she says.
Louie’s article noted, for example, that “Asian Americans and Pacific Islanders exceed other groups in health disparities in the areas of tuberculosis and hepatitis B, whereas cancer and cardiovascular diseases are leading causes of death within the Asian American and Pacific Islander populations.”
Sharing a Common Vision
In much the same way that AAPINA was established from a common bond among like-minded API nursing professionals, the National Coalition of Ethnic Minority Nurse Associations (NCEMNA) grew from discussions among leaders of several prominent minority nursing organizations. These dialogues revealed that the individual associations all shared a common goal—advocating for equal opportunity in nursing and better health care for communities of color.
“We decided to work together as a single unified force instead of each association separately competing for funding when we have such common missions and goals,” says Louie, who holds the position of secretary on NCEMNA’s board of directors.
NCEMNA, incorporated in 1998, serves as the umbrella organization for five associations: AAPINA, the National Alaska Native American Indian Nurses Association (NANAINA), the National Association of Hispanic Nurses (NAHN), the National Black Nurses Association (NBNA) and the Philippine Nurses Association of America (PNAA). Collectively, NCEMNA gives voice to 350,000 minority nurses and to the lived health experience of a constituency marginalized from mainstream health delivery systems.
Being part of the NCEMNA collaborative has enabled AAPINA to receive federal funding that an association of its size would have difficulty obtaining on its own. Each year, through a grant from the National Institute of General Medical Sciences (NIGMS), a different NCEMNA member association receives funding to support its annual conference. AAPINA is the 2008 recipient.
“The grant has helped in getting keynote speakers and panels for the conference,” says Jillian Inouye, PhD, APRN-BC, AAPINA’s newly elected president. “[On a broader level], it is stimulating research and development of minority nurse scientists.” NCEMNA is also using the $2.4 million NIGMS grant to fund the Nurse Scientist Stimulation Program, a five-year initiative to increase the number of minority nurse researchers who can investigate the causes of health disparities and develop culturally appropriate interventions.
“When we incorporated all the minority nurse associations through NCEMNA, it gave AAPINA a lot of energy and financial support to become more organized,” continues Inouye, who is a professor and graduate chair at the University of Hawaii at Manoa School of Nursing and Dental Hygiene. “Kem Louie was the association’s driving force throughout the early years. Now, [thanks to our involvement in the coalition], more people have become interested in AAPINA. We have more members, we’ve gotten our Web site up, we’ve started to hold conferences. And through NCEMNA’s Aetna Foundation grant, we’re able to offer scholarship opportunities to pre-doctoral or even master’s students. That has really helped draw more people to our organization.”
The annual Aetna/NCEMNA Scholars Program is another NCEMNA project designed to introduce nurses of color to careers as nurse scientists and socialize them into the research agenda to eliminate health disparities. Each year, the program provides financial and mentoring support to 10 nursing students—two from each of the coalition’s five member associations.
Mentoring is also an important part of AAPINA’s mission to support and empower Asian and Pacific Islander nurses and students.
“I’ve served as a mentor through AAPINA as well as through NCEMNA,” says AAPINA president-elect Oisaeng Hong, PhD, RN, associate professor, Department of Community Health Systems and director of the Occupational Health Program at the University of California San Francisco School of Nursing. “Our mentees are mostly doctoral students who are matched with a mentor based on areas of interest, research topic and target population. We spend one to two years together, but we don’t have to be in the same city. Communication happens through phone calls and email. We get face-to-face time during our annual conferences.”
Onward and Upward
With membership on the rise and the success of the national conferences firmly established, AAPINA’s leaders are setting goals to ensure the association’s future growth and sustainability while continuing to increase its value as a resource for Asian and Pacific Islander nursing professionals.
“One of our most important objectives at the moment is to expand our efforts in growing our membership and to reach more API nurses,” says Hong. “It’s hard work because we have no hired staff.”
Inouye says that implementing a strategic plan is one of her goals during her presidency. “I also plan to update our mission statement and Web site,” she adds. “Now that we have some funds, we’re able to hire an attorney for the first time to update our bylaws. I’d also like to expand our board of directors and [create more opportunities for our members to get involved as leaders in the association]. Currently, we only have an executive board, which includes the president, president-elect, secretary, treasurer, past president and the chairs of the membership and newsletter committees. So I’d like to create a board aside from that to help manage AAPINA. It’s a slow process, but it’s working.”
The strategic plan will also focus on establishing local AAPINA chapters in various parts of the country. “We currently have a student chapter in San Francisco and one that’s starting in Chicago. These are things that will be fleshed out as we develop the plan,” says Inouye.
Of course, AAPINA will continue to promote the expertise of Asian American and Pacific Islander nurses as culturally competent advocates who can play a crucial role in improving the health of API populations. “The health care issues that we [APIs] face are similar to those of other ethnic minority groups,” says Inouye. “These include diabetes and obesity. It may not seem that obesity is a problem for APIs, but their BMIs are increasing, which puts them at risk for cardiovascular disease and cancer. Our Native Hawaiian population is at risk for every kind of disease. They have very poor health outcomes.”
The association keeps its members abreast of key API health issues through its newsletter, Web site and workshops at the national conference. In 2005, AAPINA was one of several nursing associations that received grant funding from the national Nurse Competence in Aging (NCA) program to disseminate information to its members about the health care needs of minority elders. As a result, AAPINA was able to add a new section to its Web site focusing exclusively on gerontology/geriatrics issues and resources.
These successes are only the beginning of what AAPINA will continue to achieve through its dedicated and determined leadership. “In the future, I would like to have more [API] scholars and clinicians united in voice so that we can promote the AAPINA organization and our mission,” says Kim.
For more information about the Asian American/Pacific Islander Nurses Association, visit www.aapina.org.
On January 12, 2011, little seven pound, 10 ounce, 20.5 inches long Carson joined the Samantis family after a fairly easy pregnancy and uncomplicated delivery. Until Carson was born, both his mother, Kristen, an interventional cardiology nurse at Massachusetts General Hospital in Boston, and father, C.J., worked full time. Until four days before Carson was born, Samantis, now 31 years old, was working.
In the 1980s and 1990s, over 80% of women ages 25–34 years old were working, according to the U.S. Bureau of Labor Statistics. Before the Family and Medical Leave Act (FMLA) passed in 1990, around one-third of women never worked while they were pregnant, one-third quit their jobs, and only one-third took a maternity leave that often lasted under a week.1 For employers and employees, today’s culture of working mothers elevates work-family relationships to a high priority. The FMLA allows employees who have worked at least 1,250 hours to leave their jobs for 12 work weeks in a 12-month period, without pay, to give birth and care for a newborn child.
But nurses face particular stressors when they return from maternity or paternity leave, and the Massachusetts Nurses Association and other unions say these benefits could be better. While all working mothers (and fathers) have a difficult time reacclimating to work, nurses generally face grueling 12-hour shifts, so they are away from home for longer periods of time and may feel especially drained by the nature of the work they do caring for patients.
Samantis decided to start a family only after carefully considering the economy and her job. She waited to have Carson until she had earned enough time off to take the full 12 weeks of paid maternity leave. While she has worked at MGH as a nurse for over two years, she has worked at MGH for a total of nine years, with a previous position in health education.
The days when every mom was a stay-at-home mom are a distant memory. New mothers are returning to work in large numbers, and nurses are actually more likely than other moms to return to work full time. According to the U.S. Department of Labor, 20% of nurses work part time, and most of those women are married with young children. At Massachusetts General Hospital, where Samantis works, nurses represent 15% of the hospital’s overall maternity and paternity leave, but most of the new parents return to the full-time 36- to 40-hour workweek, according to the hospital’s human resources department.
“This is where the recent economy has had a larger impact on nurses and this trend [of working mothers],” says Steve Taranto, Director of Human Resources at the Knight Nursing Center for Clinical & Professional Development and the Yvonne L. Munn Center for Nursing Research at Massachusetts General Hospital. “Especially in today’s economy where fewer people have jobs and more nurses are supporting unemployed spouses, this is the career that the marriage or family will turn to as the reliable source of benefits,” he said.
After Carson was born, the Samantis family decided they didn’t want to put the baby in daycare, so they agreed that Kristen would work part-time. How that reduction in income from her career would affect their new family’s lifestyle troubled her.
“I was a nervous wreck when I had to go back to work,” says Samantis. “I kept thinking about it as each week of maternity leave passed by.”
While hospital administrations have streamlined adjusting schedules when nurses take paternity or maternity leave and return, nurses find returning to work particularly stressful because of their own schedules. Nurses often work nights on already minimal sleep as new parents, and they are balancing a baby’s sleeping patterns with long hours and/or night shifts at the hospital.
“Since I was going back to work mostly nights, I was sad that I wouldn’t be the one putting him to bed each night,” Samantis says. C.J., her husband, was handling nightshifts with the baby on his own, and little Carson wasn’t sleeping through the night. C.J. would stay up all night with the baby, then return to work in the morning, and Kristen would work nights, then stay awake most of the day taking care of Carson.
According to research published in Health Affairs in 2011 by Project Hope: The People to People Health Foundation, job burnout or dissatisfaction among nurses is a big problem in hospitals because of risks to patients, work disputes, and turnover.1 The research found much higher levels of burnout with nurses working in hospitals and nursing homes, where lower patient satisfaction levels correlated with more dissatisfied or overworked nurses.
What’s best for you and your family
“There are fewer jobs out there, so the nurses, even if they have just had a baby, have more of an incentive to pick up more hours as they adjust back into work, where their career is often a large source of income for their family,” says Taranto.
While Samantis originally thought she would sleep when the baby took naps during the day, she discovered that Carson napped less as he got older, which didn’t allow her to sleep like she planned. “That makes for a cranky baby and mom!” she says. Immediately after returning from maternity leave, Samantis worked 36 hours a week, but she has since dropped that number to 28. “We are not superheroes!” she says.
Communicate with your supervisor
The nature of nurses’ schedules when taking maternity leave, versus other roles in a hospital, may actually be advantageous. Nurse managers have more freedom and flexibility to adjust schedules to meet a new parent’s needs by offering more hours to part-time workers and per diem nurses.
Before and during her leave, Samantis closely communicated with her supervisor and still does. When she needed to cut back her hours after Carson was born, her supervisor was supportive and checked in periodically to see how things were going. Her manager recently gave Samantis the option to cut back to 24 hours a week, which the new mom is considering now that Carson is five months old and sleeping less while she is at home with him during the day.
Although cutting back working hours is a big decision, as fewer hours means less income, Samantis would only need to be at work two days a week instead of three, a schedule worth considering for a family not using daycare.
According to the Human Resources department where Samantis works, most nurses return from maternity leave at the 36- to 40-hour workweek level, while only a few come back at the 20- to 24-hour workweek level. They attribute this trend to the economic stresses of the past three years. Like Samantis, nurses who are new parents are working on limited sleep and would prefer to be home more often with their babies, but taking cuts in their hours means cuts in their paychecks.
“Mass General’s flexibility with nursing schedules is what leads to the greatest success with regards to retaining nurses post-maternity leave,” Taranto says. The hospital was named a “Working Mom Institution” in 2005 by Working Mother, scoring particularly high in child care options, parenting and child care workshops, and benefit policies that allow mothers flexibility around part- or full-time employment. MGH has a job vacancy rate of 1% and a turnover rate of 3.1%, which represents return for education, nurses becoming stay-at-home moms, or family situation changes. Communication between supervisors and nurses about schedules is key to keeping MGH working mothers happy, Taranto says.
Mark your calendar
According to the Mayo Foundation for Medical Education and Research, returning to work at the end of the week or on a weekend eases new parents back into the work routine. Nurses have the flexibility as well to not schedule themselves two days in a row at first, so they only need to get through one day of work before they can return to their babies.
Of course, returning to work also presents an emotional challenge for new parents. For moms in particular, postpartum hormones are still fluctuating 12 weeks after giving birth, so being back at work may be that much more stressful.
“You haven’t had a chance to wrap your head around taking care of a baby yet,” says Samantis, who says she felt “out of sorts” when she returned to work after her maternity leave. According to the Mayo Foundation, for all new parents, nurses or otherwise, calling to check in with your baby and whoever is taking care of him or her is important for your peace of mind and to stay connected with a shift in your life that is still so new.
Recruit reinforcements for baby and you
Leaving your baby in someone else’s care is one of the most important decision new parents can make. Finding reliable childcare is also one of the most challenging aspects of being a working parent. While MGH provides childcare for their workers 10 minutes away from the hospital, as well as onsite daycare centers for emergencies, the Samantis family decided they didn’t want their baby in daycare but had no one to call to stay at home with him. Working their careers around alternating days and nights at home was the best decision for her family, Samantis says. In this way, her schedule options allowed her family to work through this.
Breastfeeding can also complicate the return to work. Some babies have trouble latching, and it takes time to develop a routine. Once moms are back at work, sticking with this schedule becomes even harder.
According to the World Alliance for Breastfeeding Action, for the first six months back at work, employed women should receive support from their workplace to provide private breastfeeding options. Hospitals today have lactation rooms set aside for their working moms, but the commitment presents daily challenges. Finding time during your shift to sit in a lactation room is one thing; you then need coworkers to care for your patients while you’re pumping. But many still make it work.
At MGH, Human Resources and the Employee Assistance Program have been monitoring and keeping track of numbers in the hospital’s lactation rooms, which have been adjusted and their numbers increased based on their volume of use.
“Pumping while back at work is a huge commitment,” says Samantis, who shifted to baby formula for Carson when they returned from the hospital, even though she originally planned to breastfeed until she went back to work. “With that being said, many of the moms I work with do it and are successful!”
Baby yourself and stay positive
Maintaining regular bed times, cleaning out unnecessary commitments, and maintaining a positive attitude are all keys to balancing your work and home life.
The Samantis family has found good routine now, and Kristen says Carson “is sleeping like a champ through the night.” She still doesn’t work two days in a row unless it’s the weekend, so she says her lack of sleep at home doesn’t affect her work too much. She is thankful she can be home with Carson to watch him play and grow while still maintaining her career.
“I’m just now feeling like I can balance everything—home, life, relationships, work. It’s still hard being a working mom, but everyday I feel like it’s getting a little easier!”
“Kuleana means having a sense of place in society such that each person has a right to basic necessities needed to sustain oneself—security of housing, food, health care, transportation, safety, and justice—and in turn has a responsibility to contribute to the sustenance of society,” Boyd says. She likens this sentiment to “client rights and health care ethics” in the Pathway program.
A contrast to the vacation resort paradise with which the continental 48 are so familiar, Hawaii actually experiences a great deal of socioeconomic instability. Pathway out of Poverty helps the impoverished, particularly native Hawaiians, build self-reliance and guides them toward a career in nursing.
Teaching since 1998, Boyd is currently an assistant professor at University of Hawaii, Windward Community College in Kaneohe, in addition to serving as Director of the Pathway out of Poverty program. In her own words, the program is “a curriculum based in Hawaiian values and traditions of healthy living that leads underserved community college students through a nursing pathway from Nurse Aide (NA) to Licensed Practical Nurse (LPN) to Registered Nurse (RN), with inherent increases in wageearning potential.”
Boyd won the Robert Wood Johnson Foundation Community Health Leaders award in 2011 for her commitment to improving health care in her community while overcoming immense personal obstacles. She received $20,000 for personal growth and a $105,000 grant for the Pathway program. The grant’s mission? “To support and sustain the capacity of individuals who demonstrate creativity, innovation, and commitment to improving health outcomes at the community level.” This mission was well served in honoring Boyd’s life and work.
From the ground up
When her guardian grandmother died, Boyd found herself in a much darker world. “My grandmother instilled in me that I was a precious blessing on earth. After she died and I went to foster care I was told that I was fortunate to have food on a plate or a roof over my head,” she says. “I was given old tattered clothes while foster parents bought new clothes for their own daughters. I was made to scrub toilets while other kids played outside. It sounds Cinderella-ish, but it’s true.
Boyd accepting the Robert Wood Johnson Foundation Community Health Leaders award in 2011
“I was warned that if I didn’t surrender I would be put on the street,” Boyd says. “I found myself 13 and pregnant. After my early childhood with my grandmother I was never again told in my youth that I was a blessing. I knew inside that my blessing was to help others.” Through this experience, Boyd says she learned “society treats the havenots as want-nots,” casting them aside. But she convinced her social worker she could live as an independent, and went on to complete nurse training and education up to her Ph.D.
“I was fortunate to have come across folks in my own path out of poverty that held knowledge about supports for have-nots: orphaned, teen mother, impoverished, minority,” Boys says. One of the folks was Kathryn L. Braun, Dr.P.H., Boyd’s Ph.D. mentor and a professor of public health at the University of Hawaii. They met through Braun’s work with `Imi Hale, The Native Hawaiian Cancer Research Training Network, and Braun also served on the University of Hawaii’s dissertation committee throughout Boyd’s doctoral studies.
“I have always been inspired by Jamie, who overcame many obstacles to get where she is today,” Braun says. “The road was difficult, but it has motivated her to help others ascend the path out of poverty through education and service.”
From the early days, when Braun was helping her mentee obtain research funding from the National Cancer Institute, to now, where they support each other’s professional pursuits and even room together at public health conferences, the two women forged a close, supportive relationship. “As a Native Hawaiian I could not have completed my Ph.D. training without her dedication to mentoring NH [native Hawaiians] and other Pacific Islanders,” Boyd says of her mentor. Braun also notes that Boyd is one of the state’s first Ph.D. nurses to come from an indigenous background.
“She declined a [University of Hawaii] research position in favor of [Windward Community College], so she could reach Hawaiian and other disadvantaged students,” Braun says. Originally charged with developing a health curricula that would help get students “done and out,” Boyd recognized the deficiencies and disparities plaguing her vocational students. “They are not eligible for federal financial aid or student health insurance, WCC provided no graduation ceremony for NA graduates, and there were no supports to transition graduates to living-wage jobs,” Braun says. “She worked to convince WCC to approve a ‘pathway’ approach, helping transition NAs to the Associate Degree in Nursing. She worked nights and weekends to secure financial and in-kind resources to reduce barriers facing students, which won WCC and community support.” Boyd also steered the WCC’s administration toward indigenous teaching models.
“I always had the capacity to give and would have to work very hard to earn resources to experience the privilege of helping others,” Boyd says. “I learned that every individual who presents as a ‘have-not’ may hold within the potential to make lasting positive change.”
On the Pathway out of Poverty
Native Hawaiians seem to have the deck stacked against them: they are more likely to hold low-paying jobs, lack health insurance, suffer from chronic disease, and drop out of school. According to Boyd’s 2007 article “Supports for and Barriers to Healthy Living for Native Hawaiian Young Adults Enrolled in Community Colleges,” “in 2000, 72.5% of Native Hawaiians were overweight, 54.4% met national recommendations for physical activity, and about 10% enrolled in college.” They are underrepresented in areas that count, like amongst college students and health care practitioners. Because of these disparities and others, Boyd is taking action.
At the crux of Boyd’s efforts to improve the health and socioeconomic livelihood of indigenous Hawaiians is the Pathway out of Poverty program: “A Values-Based College- Community Partnership to Improve Long-Term Outcomes of Underrepresented Students.”
Boyd points to a snowball effect in native Hawaiians’ achievement levels: students do poorly in the K–12 levels and cannot gain entrance to public universities. After years of insufficient grade school support, and consequently poor achievement, they’re also unprepared to enter fields like nursing. “But we naturally give so much to community and have a natural aloha to care for the sick,” she says. “We need for Hawaii universities to stop social exclusion behaviors of our early colonizers and allow Native Hawaiians to selfdetermine entrance criteria to nurse training in Hawaii.” The alternative? “Allow me to create the first Indigenous School of Nursing that is inclusive of Native Hawaiian values and cultural practices.”
Boyd reports 135 students, or 90%, of those who have participated in the first three and a half years of the program graduated and became certified nurses assistants; 77 of those individuals went on to higher education, including 33 entering nursing programs.
“Her vision is to reduce poverty and increase representation of Hawaiians in nursing,” says Braun. “Toward that end, she secured critical partners and more than $1 million to build . . . Pathway out of Poverty.”
What nurses can do
“There are big gaps between resources that slow people’s potential to heal themselves,” Boyd says from experience. “My motivation is to eliminate gaps and create a steady, continual path out of poverty.”
It’s not about handouts, Boyd says. It’s about education. “Don’t give childcare; provide centers for child care co-ops,” she says. “Don’t give food; protect land to grow food or designate certified kitchens where [the] disadvantaged can feed each other.”
To that end, Boyd recently secured funds and began developing a “Seed to Plate” curriculum, says Braun. “Pathway students use the garden as a healthy foods ‘lab.’ Recognizing Jamie’s success in nursing and Hawaiian educational approaches, she was asked to join with faculty in botany and nutrition to build cross-disciplinary learning communities that aim to impart Western knowledge while honoring Hawaiian traditions for healthy living.”
Boyd’s Ph.D. dissertation defense. Committee members (left to right): John Casken, R.N., M.P.H., Ph.D.; Kathryn Braun, Dr.P.H.; Boyd; (chair) Chen Yen Wang, A.P.R.N., Ph.D., Lois Magnussen, A.P.R.N., Ed.D.; Bee Kooker, A.P.R.N., Dr.P.H.
Boyd says those who are working diligently should be awarded with “change credits,” like those given to her by the Robert Wood Johnson Foundation. Boyd’s life’s work, her ultimate goal, is to reduce poverty and health disparities amongst indigenous and minority populations. She intends to do so through education, advocacy, and tapping into native teachings. Her solutions draw upon economic and cultural research. In the end, these people will have brought themselves out of poverty. “Through my volunteerism, peer mentorship, publication, and dissemination I help other underserved, and together we pull ourselves up and in turn again pull up even more.”
Lisa Zick-Mariteragi, A.P.R.N.-R.X., M.S.N., M.P.H., an advanced practice nurse practitioner in internal medicine, worked with Boyd at Waianae Coast Comprehensive Health Center in 1998– 1999. “Jamie was a NP student at the time and knew that I took students who had a vested interest in improving health outcomes for indigenous populations,” Zick- Mariteragi says, who agreed to mentor the eager student. “She had a very clear picture in her mind of where she wanted to go professionally and what she needed to do to get there.” Zick-Mariteragi says Boyd, even then, was focused on the bigger things beyond the horizon of her graduate studies.
“Based on, among other things, the Native Hawaiian principles of ‘Ohana, Aloha (appreciation), Laulima (work), Lokahi (unity), and Malama (service), Jamie has been able to create a venue and provide access for disadvantaged individuals to improve their own lives by addressing their social, cultural, educational, familial, and fiscal needs through her programs,” Zick-Mariteragi says. “She demands commitment from them to pay back— not to forget where they came from—and forward-extend a hand to those in greater need than themselves.”
Sharmayne Kamaka, C.N.A., experienced that demand firsthand. She was one of the first Native Hawaiians to join Boyd’s Pathway program. The two met at Windward Community College, where Boyd served as Kamaka’s CNA instructor. “My first impression was that I thought I couldn’t meet her expectations. She was very strict, yet loving at the same time,” Kamaka says of Boyd. “I felt a magnetic pull toward her ‘mana.'” But over the four years they have known each other, that intimidation gave way to deep admiration and a strong mentoring relationship.
“Without Jamie, I wouldn’t be where I am today,” Kamaka says. A divorced mother of five when she met Boyd, Kamaka couldn’t afford to begin her CNA training, but Boyd helped her do the legwork needed to secure funding. “Four years later, I am on the dean’s list, a Phi Theta Kappa member, and a KCC Practical Nursing Student [graduate],” Kamaka says. “Without all the countless selfless hours of Jamie writing grants and securing contracts and community partnerships, I would have given up. It was always a dream of mine to become a nurse. Jamie is making it possible for my dream to come true.” But Boyd says Kamaka is “fulfilling her own dream….She hasn’t gotten anything she didn’t work very hard for.”
Visions of the future
Zick-Mariteragi says she imagines Boyd will continue to grow the Pathway program; to surprise her colleagues with her unstoppable energy; and to make her kupuna (ancestors), her keiki (children), and her mo’opuna (grandchildren) proud. “All that she is, all that she’s done, she’s truly fought hard for. Determined, focused, passionate, humorous, pressed to improve the outcomes for native peoples by creating models of personal and community development—quite literally from the ground up,” Zick-Mariteragi says. “Though I was her mentor before, she could be mine now.”
Braun says she also imagines Boyd simply continuing her current trajectory: reaching out to the community to engage students and administrators, health care providers and funders alike.
Kamaka imagines Boyd establishing Hawaii’s first indigenous nursing school, with buildings named after her. “She is definitely a community leader and should be recognized as such,” Kamaka says.
And what does Jamie Boyd imagine for herself? Her ultimate goal is, indeed, to create a school of nursing for indigenous peoples, she says, combining traditional healing with cutting-edge medical technology—and social justice training to boot. She hopes the disparities affecting native Hawaiians and other underserved populations become a non-issue.
Yet, as long as they persist, and perhaps simply because they persist, disparities and deficiencies make so many people feel helpless—particularly the people living them. Then, someone fights back. Though disparities often prove stubborn, when confronted with individuals determined to eradicate them, they can topple. Jamie Boyd is one such fighter, armed with her cultural roots, her resolve, and her Pathway out of Poverty program.
“For every gain I experienced, I promised to turn back and pull up 10 just like me,” Boyd says. “I’ve already pulled up 10, and I’m still going strong.”
“Before we were Westernized, Native Hawaiians were very healthy, lean people,” says Suzette Kaho’ohanohano, RN, health educator and clinical supervisor at Hui No Ke Ola Pono, a health care center for Native Hawaiians on the island of Maui. “We were fishers, we had land.”
Today, few Native Hawaiians own land, much less cultivate crops or catch fish offshore. Often unable to afford fresh vegetables or fish, they eat an Americanized diet of fast food and are the world’s number one consumers of Spam, the canned meat product high in saturated fat, sodium and cholesterol.
Unhealthy eating and a sedentary lifestyle have translated into big health problems for Native Hawaiians. Three-quarters of them are overweight, according to the Hawaii Department of Health. While Hawaii has the third lowest overall obesity rate in the nation (20.6%), the rate for the state’s Native Hawaiian population is 39%—much higher than Mississippi, the most obese state, at 31.4%.
The outlook is similarly grim for other Pacific Islanders living in Hawaii, most of whom are immigrants from Samoa, Guam and Micronesia. Nafanua S. Braginsky, MSN, RN, a Samoan American nurse who is a lecturer at the University of Hawaii at Manoa School of Nursing, treats many Samoan patients at a clinic in Honolulu.
“We see a lot of big women,” she says. “When we ask them to work on losing some weight, they say: ‘But I don’t want to lose weight.’ It’s a culture where [you’re not supposed to] be too skinny.”
Too Little, Too Late
Obesity is only one of the many serious health problems Native Hawaiians and Pacific Islanders (NHPIs) are grappling with. They have high incidences of diabetes, hypertension, infant mortality and mental illness, to name just a few. Pacific Islanders also have high rates of tuberculosis and Hansen’s disease (leprosy).
In contrast, NHPI women have comparatively low rates of breast and cervical cancer. But because they are much more likely to be diagnosed late, when the disease is already in an advanced stage, they have disproportionately high mortality rates, according to the American Cancer Society.
Lack of early detection and preventive care is a problem across the health spectrum for Native Hawaiians and Pacific Islanders. They have unusually low rates of cancer screening, immunizations and visits for prenatal care. A variety of studies has found that they visit the doctor less frequently than their Caucasian counterparts, seek care late in the course of a disease and are more likely to accept a serious disease as fatal, rather than try to fight it.
Yet in most cases, this low utilization of health care services is not due to lack of access. With the state’s mandate that employers provide health insurance for all full-time workers, only 4.1% of Native Hawaiians are uninsured—lower than the rate for Hawaiians as a whole, the state health department reports. Unemployed Hawaiians can qualify for the state’s Medicaid managed care program, Hawaii QUEST. But many do not apply and application processing can take months.
This long list of health disparities breaks the hearts of veteran Native Hawaiian nurses like Mary Frances Oneha, PhD, APRN, director of quality and performance at the Waianae Coast Comprehensive Health Center. The center provides health care services and outreach primarily to disadvantaged Native Hawaiians on the west coast of the island of Oahu. In her 17 years at the center, she says, “there has been an increase in screenings and more outreach, but I’m not sure they have resulted in better outcomes. I can’t think of a significant health care indicator that has gotten better.”
But Oneha has by no means given up hope. She is currently working on several research projects to improve Native Hawaiian health, including one that focuses on infant mortality risk reduction factors among pregnant women.
Asked to explain the poor health outcomes and underutilization of medical services, Native Hawaiian nurses at the front lines point to cultural trauma. Every Native Hawaiian is familiar with the events of 1893, when American and European plantation owners and missionaries, assisted by the U.S. Marines, invaded the palace of Queen Liliuokalani and seized control of the Hawaiian government. Hawaii was annexed by the United States five years later.
Mary Frances Oneha, APRN, PhD
Like most Native Hawaiians, Kaho’ohanohano’s ancestry comprises a mixture of races and ethnicities. Her background includes German, Polish, Irish and Russian heritage, but she feels the closest affinity with her Native Hawaiians roots. She says the near-destruction of the traditional Hawaiian culture has thrown Native Hawaiians off balance and had a devastating effect on their emotional and physical health, a process called “cultural wounding.”
“Native Hawaiians [sank into a collective] depression when we lost our land, our culture and our language,” she explains. “We turned to alcohol and tobacco. To me, it’s a lot like what happened to the American Indians.”
Now Native Hawaiians are a minority in their own land, unnoticed by tourists in the beachfront hotels. According to the most recent U.S. Census, there are only about 260,000 Native Hawaiians in the state, or about 15% of the population. That’s fewer than the number of Japanese Americans living in Hawaii and only slightly more than Hawaiians of Filipino descent.
Oneha, whose ethnic background reflects successive migrations to Hawaii (English, Scottish and Chinese), agrees that Native Hawaiians’ poor health “has to do with the history, the historical trauma that we’ve been through. There is a cumulative experience that people bring with them [from generation to generation].”
A Patchwork of Cultures
Pacific Islanders have also experienced the impact of Western influences on their traditional way of life. But unlike Native Hawaiians, their small island societies have managed to hold on to their languages and much of their culture.
Thanks to wide-open borders between these islands and the United States, some 28,000 Pacific Islanders have migrated to Hawaii. So have thousands of people from the U.S. territories of Guam and American Samoa, who have no entry restrictions because they are U.S. citizens. There are currently 16,000 Samoans and 4,000 Guamanians living in Hawaii, the Census Bureau reports.
Suzette Kaho’ohanohano, RN, screens a patient for hypertension.
America’s borders are also open to people from the former U.S. trust territory of Micronesia, some 8,000 of whom now live in Hawaii. While one part of this territory, the Commonwealth of the Northern Mariana Islands, remains American, the rest has spun off into three independent nations: the Federated States of Micronesia, the Republic of Palau and the Republic of the Marshall Islands, where the U.S. conducted extensive nuclear weapons testing from 1946 to 1958. Under treaties with these nations, called the Compacts of Free Association, their citizens can enter the United States without visas or time limits.
Unlike Native Hawaiians, who share a common language and culture, Pacific Islanders in Hawaii are a fragmented population who speak many languages and come from many different islands with totally different customs and cultural beliefs. As many as 20 different languages are spoken at health centers in Hawaii.
All of this adds up to frustrating challenges for Hawaiian health professionals trying to provide care to Pacific Islander patients. In an article published in the California Journal of Health Promotion, researchers from the Hawaii Department of Health and the University of Hawaii noted that “health care providers [in Hawaii] almost universally regard Micronesians as ‘difficult’ patients.” Not only are there cultural barriers, they wrote, but many of these patients change residences frequently and go back to their homelands, making screening and follow-up “problematic.”
Under the Compacts, Micronesians are eligible for Hawaiian Medicaid, which has spent an estimated $100 million on health care for them over the years. Prodded by state health officials, the federal government finally agreed in 2004 to pay the Hawaii Medicaid program $10.5 million for Micronesian care, but the contribution falls short of the full $18 million their care actually cost.
Not surprisingly, Native Hawaiian and Pacific Islander nurses are at the forefront of the state’s efforts to improve health outcomes for NHPI patients and communities. Many of these nurses are involved in interventions that tap into Native Hawaiian cultural traditions—traditions that patients are in many cases reconnecting with.
For More Information About Native Hawaiian and Pacific Islander Health Hawaii State Department of Health http://hawaii.gov/health Native Hawaiian Health Office of Minority Health–Native Hawaiians/Other Pacific Islanders Profile Papa Ola Lokahi www.papaolalokahi.org Asian and Pacific Islander Health Forum www.apiahf.org Nutrition and Well-Being A to Z–Diet of Pacific Islander Americans www.faqs.org/nutrition/Ome-Pop/Pacific-Islander-Americans-Diet-of.html National Minority AIDS Education and Training Center–Native Hawaiian Fact Sheet CDC National Center for Health Statistics—Health of Asian or Pacific Islander Population www.cdc.gov/nchs/fastats/asian_health.htm
To break down barriers and establish trust, nurses take advantage of Native Hawaiian concepts like ohana (close connections to family and friends). Patients are encouraged to bring family members into examination rooms, which actually improves compliance. Similarly, patients are urged to draw on their shared cultural values to help each other stay healthy. A study conducted in the 1990s found that when groups of Native Hawaiian women used traditional Hawaiian values like kokua (proactive helping), aloha (compassion) and pili (bonding as family), more of them sought screening for breast and cervical cancer.
This emphasis on providing culturally competent care is epitomized by the Native Hawaiian Health Care Systems, a group of wellness and outreach centers created under the Native Hawaiian Health Care Act of 1988 and partly funded by a grant from the federal Health Resources and Services Administration (HRSA).
“Native Hawaiians have often felt that the Western health system did not understand or value their beliefs and practices,” says Dianne Ishida, PhD, MA, MSN, RN, an associate professor at the University of Hawaii at Manoa School of Nursing. “That’s why it was important to create a Native Hawaiian health system.”
Each of the five main Hawaiian islands has a separate system. Hui No Ke Ola Pono, the system for Maui, offers disease prevention and health promotion programs, nutritional education and counseling, wellness classes and community health screenings.
Janice Fernandez, RN, a Native Hawaiian nurse who runs a hypertension and stroke program at the center, says some patients do not readily accept her recommendations. “Sometimes Native Hawaiians are really hard-headed,” she explains. “If they are not ready [to make the necessary lifestyle changes], they’re not going to accept it.” Some patients, she adds, have dropped out of the program, then reappeared a year or two later.
Hui No Ke Ola Pono also offers traditional Hawaiian healing methods, including lomilomi, a form of massage, and hooponopono, family conferences in which relationships are set right through prayer, discussion, confession and forgiveness.
Kaho’ohanohano, the lead clinical supervisor for the Maui system, says the nutrition courses try to accommodate Native Hawaiian tastes. “For example, they should not be eating Spam, but if they insist, we show them how to cook it healthier. Instead of frying it, they can steam it.” Participants are also given opportunities to taste healthy foods and are taken on shopping trips to grocery stores.
Given Native Hawaiians’ distrust of Western medicine, it makes sense to take small steps. Rather than impose a strict diet, Ke Ola Mamo, the Native Hawaiian Health Care System for Oahu, helped middle-aged and elderly patients lose 5% of their body weight through lifestyle modifications, such as taking walks. Participants wanted “to do things their way,” says Donna Palakiko, RN, MS, programs administrator for the Oahu system. “We [Native Hawaiians] don’t really take well to being told what to do.”
She adds that Native Hawaiians often keep their opinions to themselves, so nurses need to pick up non-verbal cues, such as a patient making a face.
Nurses Reaching Out
Pacific Islanders are also eligible to receive care from the Native Hawaiian Health Care Systems, but many of them don’t take advantage of this opportunity. So the Maui system is reaching out to them by partnering with local churches and other trusted organizations in the PI community. When Fernandez provided health screenings to 125 Micronesians at a church-sponsored outreach event, she found that more than half of them had high blood pressure or diabetes and most had not signed up for Medicaid. Even by NHPI standards, “it was very disheartening,” she says.
Church-based outreach programs have been very successful in raising community awareness about health issues, Hawaiian nurses report. For example, Samoan pastors have been trained to present cancer as a palagi (white man’s illness) to differentiate it from a Samoan spiritual illness, which cannot be cured.
At the Waianae Coast Comprehensive Health Center, nurses are reaching out to homeless Native Hawaiians living on the beaches. Partly due to a lack of affordable housing, an estimated 2,000 people live on beaches and other unsheltered areas on Oahu alone.
The nurses bring hygiene products, blankets and donated clothes. “We try to meet their needs and their goals,” says Yvette Budoit-Alop, RN. “In the short term, that means food, shelter and clothing. In the long term, it means being ready to get off the beach.”
Being Native Hawaiian herself helps her establish rapport with them—at least to some extent. She uses “talk story,” an informal way of conversing using Hawaiian pidgin slang. One person will share a story, and the others corroborate or add to it. But the homeless people are still wary. “It takes a while for them to trust us,” Budoit-Alop says. “We saw one mother with kids out on the beach for a year before she requested shelter.”
Even though there is a great need for more nurses like Budoit-Alop who can provide culturally knowledgeable care to the NHPI population, very few Native Hawaiians enter nursing. To try to increase Native Hawaiian enrollments, nursing schools like the University of Hawaii at Manoa on Oahu are doing their own community outreach, sending representatives into local high schools to develop students’ interest in nursing, help students become academically prepared for nursing school and find financial aid for them.
Outside of Oahu, it is difficult for Native Hawaiians to pursue their education. Kaho’ohanohano says she earned her associate’s degree in nursing from Maui Community College, but then had to get her BSN degree online through the University of Phoenix, because there were no such programs on Maui.
She believes Native Hawaiian nurses can make an important contribution to improving the health outlook for her people, because “we are actually the bridges between the traditional Hawaiian culture and the Americanized world. We are trying to incorporate the Hawaiian culture into Western medicine.”
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