GUAM is an unincorporated territory of the United States. With a population of more than 167 000 individuals, Guam has a total land mass of 544 square kilometers.1 The island is located in the Western Pacific, approximately 3700 miles southwest of Honolulu; 1500 miles southeast of Tokyo; and 3100 miles northeast of Sydney, Australia.2 There are several U.S. military bases on the island, which are considered to be strategically important for the United States in the Pacific region.1 This geographic location, and the affiliation with the United States, positions Guam as a regional hub and bridge between the continental United States and the Asia and Pacific region. The Chamorros (indigenous people of the Marianas archipelago) account for 37.3% of the population, with 26.3% Filipinos, 7.1% Caucasians, 7% Chuukese, 2.2% Korean, and other Asians and Pacific Islanders making up the remainder of the island's residents.1
THE FREELY ASSOCIATED STATES
The US Congress established the Compact of Free Association in 1985 with the Federated States of Micronesia (FSM) and the Republic of the Marshall Islands. In 1994, the Compact was expanded to include the Republic of Palau. The Compact enabled citizens of the Freely Associated States (FAS) to reside in US territories and possessions freely, without the mandate to follow the Immigration and Nationality Act's visa and labor certification requirements.3 Guam has experienced an increase in migration of Micronesians from the neighboring countries, in particular, from the FAS. Between 1995 and 1996, the Micronesian migrant population in Guam was 190 persons. This number has been dramatically increasing, with 898 migrants listed in Guam from 1987 to 1989, and 5446 migrants enumerated in 1998.4 In 2010, the number of FAS citizens who migrated under the Compact of Free Association rose to 22 086 persons.5 The migration of Micronesians from the FAS has significant implications for the health care system in Guam. In part, this is due to the health disparities faced by this group. In addition, the current failing of the health care infrastructure is exacerbated by a critical nursing workforce shortage. Guam and the FAS islands also have Health Professions Shortage Areas (HPSAs) for Primary Care, and are categorized as Medically Underserved Areas (MUAs) by the US Department of Health and Human Services Health Resources and Services Administration (HRSA).6
HEALTH STATUS INDICATORS AND HEALTH DISPARITIES
Health disparities in Guam and the Micronesian region are striking and are creating challenges due to limited health resources, coupled with a nursing workforce shortage. Table 1 illustrates several key indicators of health, comparing the US indicators with those of Guam and the Micronesian region. Infant mortality is alarmingly high, with rates more than double or triple those of the United States. Infant mortality in the Marshall Islands is 19.30 per 1000 live births, while the US rate is 5.8 per 1000 live births. Life expectancy is as much as 11 years shorter in the Republic of Palau than in the United States.7
Health disparities in other areas are just as striking. The tuberculosis incidence rate for the United States was 3.1 per 100 000 population in 2016, while the rate in Guam was 53 per 100 000 population. The FSM rate was 177 per 100 000; Palau had a rate of 123 per 100 000; and the RMI rate was 422 per 100 000.8 Epidemics of other infectious diseases such as dengue fever, cholera, and measles are commonplace. The prevalence of infectious diseases remains a significant issue in the FAS. In addition, the emergence of noncommunicable diseases (NCDs) in the last several decades has led the Pacific Islands Health Officer Association to declare an NCD crisis. The combined problem of infectious and NCD significantly taxes an already fragile health care system in the FAS.
As the residents of the other Micronesian islands migrate to Guam, they experience disparities in health and socioeconomic status, which further burdens the weak Guam health care system. Higher rates of poverty have been documented among FAS migrants on Guam. In 2003, 45.2% of Compact migrants lived below the poverty level, with 81.6% living below 185% of the poverty level.9 With the high rates of infant mortality in Guam and the region, it is important to note that, in 2004, 46.8% of the women on Guam who did not receive any prenatal care were from the FSM.10 Cancer disparities among Micronesian migrants on Guam have been well documented through the Guam Cancer Registry.11 , 12 Incidence rates for liver cancer among Micronesians was 39.4 per 100 000 compared with the US rate of 5.2 per 100 000. Micronesian incidence rate for lung and bronchial cancer combined was 111.5 per 100 000, while the US rate was 70.1 per 100 000.11 Micronesians also had higher mortality rates for liver cancer (43.5 per 100 000). The US mortality rate was 4.9 per 100 000.12
Cancer incidence data from a 2014 Guam Community Health Assessment revealed that the incidence of lung cancer in Guam from 2003 to 2007 was 88.4 per 100 000 for Chamorros, 174 per 100 000 for Micronesians, and 34.0 per 100 000 for Filipinos. Disparities in diabetes were also evident. The diabetes mortality rate on Guam was 39.9 per 100 000 compared with the US rate of 22.3 per 100 000 in 2010.13
NURSING WORKFORCE SHORTAGE ON GUAM
Guam has one public, government-run hospital, the Guam Memorial Hospital Authority (GMHA), and one private hospital, the Guam Regional Medical City (GRMC), which opened in 2015. GMHA has 158 acute care beds and 40 long-term-care beds. GRMC has 136 beds. Both hospitals report nursing vacancies ranging from 20% to 40%, with over 100 registered nurse (RN) positions available between both facilities. These vacancies do not include RN vacancies in the island's primary care settings. This critical shortage impacts the health care delivery system on Guam and requires collaboration among nursing leaders to develop creative approaches for improving the situation. Nurse leaders on the island, and in the region, have been actively working to find solutions to the shortage, and to the issue of health disparities. There are several notable efforts underway, involving nurse administrators and faculty of the University of Guam and other nurse leaders on Guam and the Micronesian region.
Faced with a growing nurse vacancy rate in both medical centers, the University of Guam has partnered with the Guam Memorial Hospital Authority and the Guam Regional Medical City nurse administrators to propose a novel approach for easing the shortage. Nurse administrators identified over 50 BSN prepared staff working at the hospitals in various non-RN roles, such as technicians, nursing assistants, and licensed practical nurses. These BSN prepared staff had not passed the NCLEX examination to obtain their RN license. Some of the staff members had not attempted to take the examination; some had previously taken but not passed; and a majority were foreign-trained BSN graduates from the Philippines. The Guam Department of Labor (DOL) Special Projects Coordinator became aware of the serious nurse shortage issue and recommended the nurse administrators submit a proposal to address this to the DOL for funding. A ground-breaking and innovative plan has been proposed and approved to provide an NCLEX review course to 42 selected candidates. The intent is for the hospital to place these individuals into vacant RN positions when they pass the NCLEX and obtain Guam RN licenses.
Although several NCLEX program participants are not current hospital employees, both GMHA and GRMC have agreed to employ all participants who successfully obtain their RN licensure. This partnership is a $100 000 commitment to upskill these potential RNs and to provide the hospitals with much-needed staff. The project includes a clinical refresher course led by the University of Guam School of Nursing and Health Sciences. The refresher is vital to the success of the program, as employers and nurses alike want to ensure the participants are competent and up-to-date in their basic nursing skills. Due to the dedication and creativity of nurse leaders, and the partnership with the Guam DOL, this project began on July 2, 2018. It will result in more RNs for the workforce by September 2018. If successful, the project may become an annual program for further addressing an ongoing nursing shortage.
Nurse leaders must continue to take actions that result in the improvement of the existing health infrastructure while pursuing workforce development. The Guam Nurses Association has advocated for nursing leadership, and through the Commission on Nursing Leadership (CNL), has been instrumental in providing a venue for nurse leaders across the island to collaborate. The CNL was established to serve as the collective body for advocacy and expertise in many areas of nursing education, practice, and other areas of concern in health care. This body is composed of the nurse administrators and leaders from a broad range of health care agencies and organizations. Nurse leaders from the private sector, local government, military, nursing regulatory board, and professional nursing organizations meet on a regular basis to collaborate on critical issues affecting the profession. There are many examples of issues addressed by the Commission on Nursing Leadership, which have resulted in improvements to the workforce, or the health system. For example, the CNL established a task force on nursing education in 2004. This has resulted in recommendations leading to the establishment of the first, and only, nursing program for practical/vocational nurses on Guam. This was a critical step toward addressing the nursing shortage. Nursing salaries and wage structures are a continued area of interest and advocacy. In the past, the CNL provided key leadership in achieving increases in nursing salaries from the Government of Guam. These increases led to the private sector also increasing wages in order to remain competitive. The CNL remains a strong body for advocacy and advancement of the profession.
Another important organization that promotes the advancement of nursing practice and improvement of standards of care in the US affiliated Pacific Islands is the American Pacific Nursing Leaders Council (APNLC). The APNLC was founded by nurses in 1978 and celebrated its 40th anniversary at the annual conference held in Guam in June 2018. The APNLC is composed of nurse leaders who work and reside in the US Affiliated Pacific Islands (USAPI): American Samoa, the Commonwealth of the Northern Marianas Islands, the FSM (Chuuk, Yap, Pohnpei, Kosrae), Guam, the Republic of the Marshall Islands, the Republic of Palau, and Hawaii.14
The mission of the APNLC is to “provide a unified voice for nursing in the USAPI for the purpose of improving professional nursing practice, education and service in order to inform policy that supports the health of all peoples of the Pacific.”14 The purposes of the APNLC are to provide a communication mechanism for nursing leaders; examine issues affecting the USAPI; explore education needs of nurses in the USAPI; develop and implement strategic plans to improve nursing and health care within the USAPI jurisdictions; and to take a leadership role on health issues in the USAPI jurisdictions.15 The profession of nursing provides the common ground for the nurses in the USAPI in spite of the diversity in ethnicity, language, and culture.
The APNLC annual meeting brings together hospital, public health, professional nursing organization, and nursing education leaders. There is much work accomplished in this face-to-face meeting, with limited additional work done during the year. As nursing staff shortages have become critical, travel to and from the meeting has become more challenging, and attendance has declined. However, the 40th anniversary conference was attended by delegates from all but one jurisdiction. The APNLC continues to be an important mechanism and venue for advancement of the nursing profession in the region.
One important outcome of APNLC annual meetings is the work done by the Nursing Education Committee. Nursing education leaders are composed of educators from the Northern Marianas College (Commonwealth of the Northern Marianas Islands), Palau Community College (Republic of Palau), College of Micronesia (FSM), and College of the Marshall Islands (Republic of the Marshall Islands) with associate degree programs, and the University of Guam (Guam), with the only USAPI BSN nursing program west of Hawaii. In 2010, through the efforts of the US Department of Health and Human Services Region IX Nursing Consultant, a Robert Wood Johnson grant was secured. This opened up the opportunity to use face-to-face and alternate communication modalities to meet between APNLC conferences. As a result, the Pacific Island Network of Nursing Education Directors (PINNED) was born. Regular meetings have allowed more in-depth discussion of the nursing education issues facing the region. The program directors share their goals, successes, and challenges. Consequently, there has been a realization that each director does not have unique challenges. The additional discussions have allowed a sharing of thoughts, solutions, best practices, and overall growth for all participants and their programs. Also through the grant, money was secured to acquire simulation models and mannequins for each of the nursing programs. These simulation mannequins allow the faculty and students to work through clinical situations in a safe environment where mistakes can be corrected and discussed without fear of harm to patients. PINNED member's collaboration has resulted in the development of an associate degree in nursing program to be established at the College of Micronesia/FSM. Through a supplemental Area Health Education Center (AHEC) grant awarded to the Guam Micronesia AHEC, development of the program was supported along with other initiatives for nursing education and faculty development.
The nurse leader communication facilitated by relationships built through APNLC has led to opportunities for improvement of health in the Pacific region. The University of Guam (UOG) has partnered with the Perinatal Rescue Network to become providers and trainers for Helping Babies Survive and Helping Mothers Survive initiatives. The mission of the Perinatal Rescue Network is to empower communities to effectively manage perinatal emergencies and reduce newborn and maternal mortality in settings with limited resources.16 These initiatives are specifically designed for areas with few resources, and should serve the developing nations in the USAPI well. A work-in-progress UOG is now providing the Helping Babies Breathe program to nurses from Pohnpei State Hospital and faculty from the College of Micronesia/FSM. Efforts to expand these offerings to other jurisdictions are in the planning stage. Strong partnerships and effective nursing leadership have led to this important program, which has the potential to impact the quality of health care in the region and combat the disparity in infant and maternal morbidity and mortality.
The AHECs are also important partners for improving education, practice, and workforce development. The US Department of Health and Human Services, Health Resources and Services Administration funds the Guam/Micronesia AHEC with Centers on Guam, at the College of Micronesia-FSM, and the College of the Marshall Islands. The Hawaii AHEC includes Centers in American Samoa, the CNMI, Yap, Hawaii, and Palau. The work of these 2 centers covers the 10 USAPI jurisdictions. The University of Guam is the Program Office of the Guam/Micronesia AHEC (G/M AHEC). The overarching goal of the G/M AHEC program is to improve health outcomes for the underserved Pacific Islander populations in the jurisdictions served by the Centers. The purpose of the program is to increase diversity of the health care workforce, improve the workforce distribution, and promote transformation of practice to improve health outcomes. Through the work of the G/M AHEC, nursing education in the region has been strengthened. The University of Guam has played a key role in the development of simulation training at the educational institutions in the RMI, FSM, and on Guam. The Associate Degree program at the COM-FSM graduated the first nursing cohort in 2014. Prior to the establishment of this program, nursing education was only available on Guam, Hawaii, the RMI, Palau, or the CNMI. There was no locally available program to produce nurses for the FSM.
The AHECs also contribute to the quality of the workforce through continuing education and professional development opportunities. A goal of continuing education is to decrease the sense of professional isolation that can be experienced due to the vast distances separating the island jurisdictions. Training and professional development opportunities include trauma nursing, palliative care, mental health, breast feeding, cultural awareness, and other topics relevant to the region. The AHEC in each jurisdiction works collaboratively with the nursing workforce leadership to identify training needs. For example, an innovative training program for Health Interpreters was developed and implemented with AHEC support. Prior to 2017, there was no training available for those who provide services as medical or health care interpreters. The training will be sustained and institutionalized at the Guam Community College through the ongoing support of the G/M AHEC. The AHEC directors on Guam have participated in the Culture and Language Access Service Partners (CLASP) Coalition and have advocated for implementation of the Interpreter Training. CLASP seeks to address the issue of disparities by supporting equity for all individuals through cultural and language competency. The Coalition has been working with policy makers to advocate for services that will meet the needs of our diverse community. This is an example of the important role nursing plays in the health care issues facing our increasingly diverse and global community.
OPPORTUNITIES TO STRENGTHEN NURSING IN THE USAPI: A CALL TO ACTION
There are many challenges facing the USAPI, but there are also many opportunities to strengthen the nursing profession. Continued examination of nursing scope of practice and standards of care in each jurisdiction is important. The global health issues of migration, epidemics, NCDs, infectious diseases, and climate change effects require strong leadership and collaboration. The work that continues through various nursing and health organizations in the region are commendable and must be supported. Collaborations must be strengthened and expanded due to the limited resources available on Guam, the CNMI, and in the developing nations of the Micronesian region. Nurse leaders must play a role in policy development and in the development and implementation of strategies to address the many issues facing our islands. The continued health disparities, poor health care infrastructure, and limited workforce require the combined efforts of all stakeholders. There is a sense of urgency that has spurred a call to action among nursing leadership. Continued successes as a result of strong nursing leadership are key to reaching the goal of eliminating disparities and improving the health of the people of Guam and the Micronesian region.
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