Category Archives: Nursing in Hawaii

Welcome to Nursing in Hawaii blog

I don’t often add to this blog these days. Most often I blog at and I invite you to go there. That other blog is pretty much focused on health care and nursing in Nepal (and by extrapolation, South Asia). And even there I go through fits and starts of activity. As you may guess, I am more active when I am actually in Nepal. Interacting and having dialog with my colleagues there provides inspiration for new commentary.

When I was more active I tended to write about issues faced by new graduates when entering the workforce, from the perspective of being a faculty member who was sending them forward with great pride and hopefulness.


I loved Hawaii during the ten years I lived there, and I wish every nurse could have gotten the positive reception I did. The spirit of Aloha is real. I think people from Da Mainland expect that somehow everyone is happy-go-lucky… some sort of cartoon stereotype of what it means to be “native.” But the spirit of Aloha is something you can adopt as a hard-working member of the community.

One of the big surprises is the intelligence and work ethic of the average nurse or health care worker in the Aloha State. Hawaii is a model of how to have a diverse society for the rest of the USA.

Books, did you say?

I also have written two books, on the subject of health care in Nepal, and these can be obtained via Amazon. There is a separate blog for the second book, The Sacrament of the Goddess. I have been asked when the third will come out. Usually the question comes from a person who has no idea what it entails to write a book, (even a book as humble as mine). The answer? I don’t presently think I have it in me to devote that kind of obsessive effort.

Right Here, Right Now

I am back on the mainland USA, this time in Florida where my relatives have established a beachhead. I teach nursing to – “beginners.” This is the most fun level at which to introduce what it’s like to do this work. I am fortunate to share my job with colleagues and administrators I respect and enjoy.


Feel free to browse this blog!


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Filed under Nursing in Hawaii, Uncategorized

Escape the cold with a Nursing Job in Hawaii Jan 8 2014

note: you are missing the boat if you don’t click on the hyperlinks – the colored text. Click here to see how some Americans live

Two phenomenon:

a) record cold in the mainland USA – colder than it’s been in decades due to a “polar vortex


b) a small surge in hits on this blog with the title “Nursing in Hawaii

Q: are they related? or a coincidence?

A: darned if I know! But – it’s no accident that there is always a TV show about Hawaii…..

Fact is, this blog has four or five entries that directly address the nursing job situation in Hawaii, and they have taken an uptick in hits for the last month or so, really noticeable this past week.

The first is:  Read This Before You Move to Hawaii to get a Nursing Job.

Next: It’s Official Hawaii has an “Oversaturated” Nursing Jobs Market

then there is: Hawaii Nursing Jobs Update Oct 2013

and: part One Guide to Hawaiian Culture for the Travelling Nurse

along with: Part Two Guide to Hawaiian Culture for the Travelling Nurse

finally, there are special aspects of culture here, and while this one may seem like a stretch, you can have more fun if you approach it this way: Twelve Steps to Prepare for Global Nursing. If you come here, get off the beach and explore. You will find a wonderful mix of Asian cultures here. There is also something called “local culture” which I love love love.

Humbly, I recommend all of the above. When I lived in rural Maine, we spent winter evenings by the woodstove curled up with a cup of tea of cocoa and reading the seed catalogs. (studying the seed catalogs is more like it.)  I suppose the Youth of Today are curled up by the woodstove with their iPad or laptop (does anyone use a laptop anymore?) surfing the Nursing Jobs Board for Hawaii.

This is not new.

In World War Two, the US Government was desperate to promote nursing as a contribution to the war effort. As part of the marketing campaign, there was a series of books based on the adventures of Cherry Ames, a fictional nurse from Hilton, Illinois ( a fictional town; but I bet it’s cold there today!). The third book of the series was “Army Nurse” published in 1944, and the book opens as Cherry Ames, RN is celebrating Christmas in Panama under the palm trees.  Now, everybody knows she was actually in Hawaii but the information was classified.

What is the answer?

Should you move to Hawaii or – no? Well, if you ask me it’s too late for this year. By the time you get here it will be springtime! The vast majority of nurses working here are from here, and we have excellent schools of nursing. There is a steady stream of military nurses who come through here, as well as spouses of military. In past days when the job market was a bit more inviting, Hawaii was a must-stop for young nurses who wanted to use their profession to work/travel around the USA.  (it used to be, if you had a nursing license and walked into a hospital, you could get a job quickly. Not so much these days).  Alas, we do not presently have an acute shortage.

If you should decide, I invite you to read all my other blog entries to prepare. I have truly loved being here. It’s a special part of America, and the beauty of it extends beyond the climate and scenery.


Filed under Honolulu, Nursing in Hawaii, Uncategorized

teaching delegation and the Nurse Practice Act, part 3 Jan 1 2014

Third in a series.

Background: How did I get involved with the topic of delegation?

Yes folks, I have fifteen years of critical care nursing  experience, and I am a former ACLS Instructor and ACLS Regional Faculty. I love those subjects, they are exciting and fun.

By contrast, delegation is boring, a sort of grind-it-out, eat-your-spinach-and-take-your-medicine area of nursing.  At least, up until the time you get in trouble with it somehow.

In 2002 I took a faculty job at a school of nursing on the east coast where they were having a low pass rate on the NCLEX exam for first-time takers. At the time of hire I was tasked with re-evaluating course content for the leadership and management class I would teach, to strengthen the NCLEX first-time takers pass rate. (I detest the idea of using in-class time to do review questions.)  After researching this, I found the resources I list here in these blog entries. And by the way, that school on the east coast had a timely and gratifying increase in our pass rates once we gave proper attention to this material.

The first part of the this series dealt with a way to conceptualize the definition of nursing in a way that makes “delegation” easy to understand, using a short YouTube video;

The second part dealt with how a teacher can use certain in-class simulation exercises to show a practical way that nurses implement the Nurse Practice Act every day at work. Summary: give them a list of patients on an imaginary ward and have them make out the nurse’s assignment. then discuss and critique. this takes the content beyond a dry lecture about styles of ward organization. In that blog I recommended the resources from Ruth Hansten, RN PhD, especially her YouTube videos.

Today – the third part of the puzzle. Working With Others from the NCSBN.  This is a 40-page FREE publication of NCSBN that goes into the subject of delegation-  in detail. Originally published in 1998 and updated in 2005.

The next piece from NCSBN is one I recommend highly. it is a package. First a video“Delegating Effectively: Working Through and With Assistive Personnel,” and also a set of overheads. It costs $299. If you click on the hyperlink with the title above, you can see the video broken into five-minute clips on the website. Now I hate to criticize, but the video(s)  are not the most exciting ever. It’s the accompanying overhead package that is valuable. I used to omit presenting the video and go straight to the overheads.

I always preface it with the following disclaimer:

“This is not the most exciting. in fact, it is as boring as things get. BUT, the material comes straight from the NCSBN, and they are the ones who dictate the content on the NCLEX exam. It says in the exam map that 20% or more of the content of NCLEX is “delegation.” If you wanted to do well on the exam, doesn’t it make sense to go to NCSBN, find out what teaching materials they have provided, and then incorporate those exact teaching materials into this curriculum?”

Usually that short speech creates student buy-in.


In the Working With Others paper, there is a section on interpersonal skills, in which the point is made that “the best set of delegation rules will not be effective if the RN lacks the interpersonal and conflict-resolution skills to carry them out.” (sic).   and so the Working With Others paper has a lot of emphasis on communication and interpersonal skills. This is excellent, very practical. In the package with the overheads and video, you will find a set of seven suggested role play exercises dealing with conflict arising out of delegation. These are pure gold. I always use them. they provide excellent fodder for in-class discussion of delegation.

Cultural comfort with perceived aggressive behavior?

As a complete aside, while in Hawaii I volunteer as a guest lecturer for NAMI and friends, a group in Waipahu that works with newly arrived immigrants from the Philippines who attended nursing school there and now wish to prepare for the USA NCLEX. I always provide this content for that group. When I do the role-plays with recent immigrants in the class, they invariably have difficulty showing assertive behavior. There seems to me to be a cultural component in the reluctance to deal with conflict.  this is in sharp contrast with the more-acculturated students of Asian descent who are educated here in USA.

There are also generational implications for this. If the RN is fresh out of school, they may be in a situation where everybody they supervise is older than they are. but that is subject for another blog entirely…..

I have one more entry in this series. why not subscribe to this blog and be sure you won’t miss it?


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Filed under foreign nurses in USA, NCLEX, nursing education, Nursing in Hawaii

It’s Official – Hawaii has an “oversaturated” market for nurses

Update: As of October 30, 2013, the job market seems to be easing.  click here to get to an updated blog.

note: be sure to click on the hypertext links, they are either underlined or else in a different color, and BTW you can also find the surprise

Is this really news?

The Honolulu Advertiser Sunday April 28th, 2013  edition included an article on page D-1 titled Nurses Wait for Jobs. (as of 2014 this is a year old…)

The subtitle?  recent graduates end up competing for a few positions in an “oversaturated” market.

Here is the link, but there is a warning – The Honolulu Star-Advertiser will ask you to buy a subscription in order to read it. Bummer. It is well-written though.

In summary, the Honolulu article describes the recent closure of Hawaii Medical Center East & West, the number of currently registered nurses who are working in jobs that do not a require an RN, the predictions of the Hawaii State Center for Nursing, and the statistic from one of the major hospital groups that they now have 150 recently-graduated RNs on the payroll in non-nursing positions. This latter effort is admirable but it makes you wonder how long it can be sustained.

The article tries to end on a hopeful note, saying that in a year or two things will be better.

National Student Nurses Association

It’s important to get a feel for whether this is just a collection of stories or not. Here is some data.

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at

There is a quarterly publication of the National Student Nurses Association named “Dean’s Notes” and their Jan 2013 issue focused on the results of a nationwide survey of new graduates that showed a lot of info about this very subject. click here to find the URL – go to “Jan 13 issue” and it will appear by magic.

UPDATE May 17 – one of the Universities is offering a refresher course in clinical skills this summer for those RNs not employed in the RN role. I think this is a great idea for keeping skills sharp.

I am very curious to know my reader reactions on this subject. please feel free to comment.


Filed under nursing education, Nursing in Hawaii

Never Doubt the power of nursing

If you want to read about a country where health care is not a right or a privilege, buy my book.  would you want to get health care there?

The key to this entry is the hyperlinks. when there is an underlined piece of text or it’s in a different color, it leads to a video. Click on those.

thought for the day

watch this video. It shows Gabby Giffords leading the Pledge of Allegiance. bring a tissue.

Congressperson Giffords was severely injured in a shooting. She received first aid at the scene and was rushed to a hospital where doctors and nurses stabilized her. She was on a ventilator in an ICU for weeks. I don’t know the details of her hospital stay, but she was on  a mechanical ventilator and received excellent care if you ask me. Her husband made a video journal of her progress.



It didn’t stop in ICU.  She got excellent physical therapy and speech therapy.  I would be remiss if I did not mention those disciplines. I can see it by looking at her gait in the video of the Pledge.

Here is the punchline

Every one deserves that level of excellent, compassionate care.

Never doubt that national trends affect you when you work as a nurse at the bedside. When Romney and Ryan say they are going to cut health care costs, and roll back Obamacare, they mean it. For me, I have seen the cause-and-effect every time we elect a Republican. The war on Women is not limited to control of reproductive rights. It extends to a lack of care about occupations that are traditionally thought of as “Women’s Jobs.” Yes folks, that includes nursing, whether you are a male or a female nurse.

Here is the opinion of the American Nurses Association

don’t think “My congressperson is okay it’s the other congresspeople who are the problem”

we need to do more to elect people to congress who are likeminded. In some cases, the local voters figure “yes, congress is bad and they aren’t getting anything done, but my guy is okay”

No. If your guy is voting against women, voting against nurses, voting against health care, and trivializes the effect of sexual assault on women, then he’s not okay. Your guy is not helping.

Every family in America has something at stake in this election.  Every nurse knows the need to fund health care.

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Filed under Nursing in Hawaii, Obamacare

Nurses, nursing and unions – Happy Labor Day!

from a site on FB called ” the other 98%” – I have this idea that the person who made this won’t mind, but I don’t know who that was.

For a nifty poster about team work, feminism, solidarity etc, go to Syracuse Cultural Workers and get their catalog.

How nurses get their groove back…..

In the Year of Our Lord 2000,  I was elected the President of the Maine State Nurses Association. My tenure there was rocky, which is a whole ‘nother story. At the time we had 1,800 members, the vast majority of whom were rank-and-file unionized nurses. Prior to being President of the organization I had never visited some of the unionized hospitals around the state, so I decided to do so ( I was a faculty member at a college at the time.)

“And how did you get the union, here at this place?”

I always asked this question. At one particular place, I got the answer below. Here is the  true story of the nurses union at a small Maine hospital. The names of the hospital and the name of the administrator and the name of the nurses, have been changed.

A small hospital (about sixty beds) in the state of Maine was having financial problems. The CEO of the hospital was concerned about the amount of money being spent on the payroll. To use the management euphemism “labor costs” were going up.  this particular CEO had no clinical background. He decided that he would show some “leadership” in controlling costs.

Fair enough; that’s what we expect administrators to do.

I suppose he thought he was “innovative.” He adopted a tactic of walking through the building every day between nine in the morning and noon. At each nursing station, he would look to see if nurses were sitting down. If they were, he would come up behind them, tap them on the shoulder, and tell them to sign out on their time sheet, because if they were able to sit down it must mean that they were done for the day. And send them home.

Nurses protested that they needed to “chart” – to document their care’ and to do such things as checking doctor’s orders, etc, but to no avail. Spending part of each day sitting down and doing book work is part of the job. The Director of Nursing was a pleasant older lady who was not willing or able to stand up for the nurses.  The medical staff of the hospital was supportive but they couldn’t do anything right away.

Within two weeks, there were enough union cards signed to force an election. Within two months, the CEO was gone.  So was the Director of Nursing.

The nurses didn’t get the union right away, but when they did, they thought of naming their local after the (now gone) CEO, because as one nurse put it “He did more to bring a union there than any fifty organizers could ever have done.”

Since then

Since then, the hospital has still struggled with finances, and yes, there was a round of layoffs along the way and a new emphasis on cost containment. The union was not able to prevent those mega-trends from affecting the nurses jobs.

But the union was able to establish that reductions-in-force would be conducted fairly. Along with  a lot of other things that stabilized the employment scene. and most importantly, things that contributed to better patient care.


which leads to the moral of the story. Within the realm of people who organize nurses into unions, there are proverbs. And this story illustrates a few general conclusions.

1) Nurses will not vote for a union so much as they will vote against their manager

2) nurses will not vote for a union because of promises of more money, but they will always vote for a union if they feel that patient care is threatened.

3) if the administration wishes to prevent a union from forming, the best step is often to fire the managers who are being unresponsive.

4) a union can not promise results such as better wages or working conditions or job stability; but the union can promise a framework within which the union members can bring their concerns to management so they can at least be heard.

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Filed under Nursing in Hawaii, Uncategorized

In Defense of the living, breathing professor – and patient

link to an article in the Wall Street Journal, titled “In Defense of the Living, Breathing Professor” . In brief, he is saying that there is flawed thinking when we measure college education by “output” as if we were making widgets on an assembly line.

The author makes the point that human contact is the key element of education. He’s a physics teacher.

Nursing education certainly needs to incorporate active coaching on a one-to-one level as we impart the process of patient care. Nowadays we are more likely to use simulated learning ( “Sim-Man”). We are more likely to develop sophisticated scenarios such as the Heart Association has used in ACLS classes for thirty years. This is all well and good,  but it reminds me that I  have been meaning to write something similar to my esteemed colleague from Williams College. My own essay would be titled “In Defense of the Living, Breathing Patient.”

Does this apply to clinical?

you bet it does.I do think that the faculty need to be actively involved in assessing and caring for every patient assigned to their students, particularly at the beginner level, and that faculty need to model a level of engagement that promotes the idea of how to change the plan when you go “off script.”  For this, faculty need to be experts in clinical practice.

Nursing faculty shortage?

This takes careful planning. I think we have a national infusion of new faculty who are uncertain of this role. Those of us who are older faculty members need to find the means to share what we know if we are to create the best environment.

I think I will write future blogs on the subject of technology and the human element. In the meantime, welcome back to school!


Filed under Nurses Brain, nursing education, Nursing in Hawaii

Nurse Burnout, Reality Shock, Marlene Kramer

note: all words or phrases that are underlined lead to hyperlinks – be sure to click on them and see what happens ;-)

The B word?

In my recent blog about adrenaline junkies, I got a private message reply asking for advice: What if you were an adrenaline junkie now verging on burnout?

Well, naturally my first reaction is to tell that person to go to Amazon and buy my book about nursing in Nepal. One basic premise of the book is to explore what happens when you are a lifetime adrenaline junkie and you finally get to a problem so big, so overwhelming, that God can’t even deal with it. Yes, such problems exist, and yes, God has a special way to address them over the course of time. There is an answer – but you will have to read all the way to the end.

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at

you could also buy my second book. see picture of the cover at left.

Marlene Kramer,RN, PhD

I read a lot of papers written by nursing students on the topic of burnout when I teach the senior-level leadership, management and issues classes. I always check to see whether the person was diligent enough to find the book “Reality Shock: Why Nurses Leave nursing” by Marlene Kramer. This one is old by now – written waaay back in the 1970s – but it was such a classic that it still deserves to be studied and cited. (note: On Amazon there are only three used copies, and the minimum price is $199.50… go figure…). In fact, one Google source indicated that it has been cited 743 times in subsequent scholarly work. Dr. Kramer is now retired but had a long distinguished academic career. Her work on reality shock and burnout created a national dialog at the time which led to the work of Patricia Benner and others.

Kramer and Magnets

There were many who thought that Kramer portrayed nursing in a highly negative way, and this reaction produced a result that is still evolving today. The argument was “Okay, you have showed us what is wrong but why can’t we focus on the good things that are happening?”  Which is of course, what a reasonable person would ask.  Nursing advocacy, the heart and soul of what nurses do, is based on righteous indignation and the desire to make things better, and so Dr Kramer was firmly in the tradition started by Florence Nightingale herself.

Magnet Hospitals

The reaction to Dr Kramer caused the American Nurses Association to promote the studies about magnet hospitals – places where the new nurses were being nurtured and developed. and from there to the whole Magnet Nursing Service movementThere is now an independent non-governmental agency which evaluates hospitals that voluntarily apply for Magnet Designation.  Can we agree that this is a good thing? We still have a long way to go, and the budget climate is not helping us, but an argument could be made for saying that Kramer gave the entire profession the wake up call that led to this work. She got the ball rolling. Every hospital should have a Magnet Nursing Service.

Return to wallowing in negativism

back to burnout. There are four phases.

the honeymoon. This is where the new nurse is still being oriented and everything is wonderful. The preceptor is so smart! The staff is amazing! The paycheck is HUGE! we all love to be around such a person and delight in the innocence of youth.

crash and burn. the onset of this is hard to predict, but usually about the six-month mark. Takes place when the nurse starts getting feedback from every direction, not all of it is easy to take because people are telling him or her that they are not perfect. The nurse is now saying “These people are jerks. This hospital has its priorities wrong. nobody is listening. Why did I ever want to be a nurse?”  This person can be angry and depressed.  Nothing is wonderful anymore. The road has a fork in it. One choice is to leave; the other choice is to stay.  When the nurse  leaves (regardless of where they go), it  causes the cycle to repeat with new nurses.  Turnover of this nature is expensive for all concerned. The National Council of State Boards of Nursing has recently recognized that up to 25% of staff nurses who do get a job, leave their first position within a year, which has caused the NCSBN to work on what they call “Transition to Practice” issues. In this way, we wonder if anything has changed since the 1970s……

recovery.  This is a phase of letting go of anger and depression, characterized by the return of a sense of humor. The preferred outcome of crash and burn.  The nurse wakes up and realizes that some things are good, some are bad and not everything is perfect. Or Burnout the nurse quits the job and goes to another job (to enjoy another honeymoon!) or maybe leaves bedside nursing altogether.

and resolution. where the nurse develops a sense of perspective and is able to contribute effectively.

The Care Plan for the Nurse?

The key is to assess yourself and those around you, and adopt some specific interventions.

the honeymoon? keep the new nurse grounded in reality. No, it’s not as perfect as you think

crash and burn? similar to above. No, it’s not as bad as you think. Hang in there and keep working at it!

recovery? find new ways to be productive now that the new nurse has been around the block.

and resolution? find joy and happiness in leading your life, with nursing being just a part of it…

Water over the dam

There’s been a lot of work on related topics since 1975. For example, the whole “codependence” thing came and went – the more codependent the nurse is, the more likely they are to experience burnout.  Closely related to this is the idea of OCD, and I gave my two cents on this in a prior blog. We have had periods of cost-cutting when a new wave of managers rejected efforts to nurture and  mentor new nurses through their role transition issues. Sometimes it feels like all the negative and positive trends are now stewing in the same pot…..

The Bottom Line

Probably the most important lesson is that you may go through these phases by yourself, but you are never alone. Use your peer-group resources. Each nurse has to start by assessing themselves as to where they lie on the four-phase continuum. Keep your sense of humor, and keep your self open to sharing with others.


Filed under nursing education, Nursing in Hawaii

Nurses have a lot at stake if Obamacare is repealed or the Ryan Budget is enacted

August 22nd Update: is there anybody left who thinks the GOP is not waging a “war on women?” If so, click on this link.

Please share this widely. here is the link to this blog:

In the interest of full disclosure, I am a partisan Democrat. Have been all my life. I am committed to defending the underdogs of society.

Last spring I wrote a blog on the subject of Obamacare, saying that we need to keep it. I quoted an NPR radio piece where the economic specialists described how it seems as though health care is pitted against spending money on building roads.  Road-building is “men’s work” – somehow this means it is more valued by legislators than “women’s work????” – I just don’t think so. I am old enough to remember the Reagan Recession of 1982 in which households where the main breadwinner was a single woman were inordinately affected. I know lots of nurses who are single parents….. let’s think of a better way….. ( and by the way – Reagan was not such a great president….)

Then I left for the summer. The Supreme Court ruled in favor of the Affordable Care Act.


But the last shot has not been fired. Nobody should relax and think that the provisions of reform are safe.

The latest thing is The Romney/Ryan plan to replace Medicare with a voucher program. Ugh. Please do click on the link!!!!

Here is a YouTube Video from the Obama campaign, which every nurse needs to see:

We have a problem with vouchers. In brief, they are highly unlikely to cover enough of the costs, and people will be responsible to pay out-of-pocket. Paying out-of-pocket serves as a means of forcing people to self-ration the care they receive.

I know many senior citizens who are committed to never be a burden to their children, and who will go without needed services before asking their kids for money.

I also know many adult children who are caregivers for a frail elderly parent, and who spend a lot out-of-pocket even though they now have Medicare.

I have met women who have put off care for breast lesions because they were hoping it wasn’t cancer – and when it turned out that it was, they suffered needlessly because it was too advanced to treat. Metastatic breast cancer is not a happy way to die.


The reality is that money doesn’t actually cure anything; it’s the nurses and doctors and drugs and treatments that do the curing. All these things will disappear when the money dries up. Nursing agencies including home care, will close. Hospitals will close or cut back.

Here is a place where nurses need to educate the public as to the effects of cuts. Please share the video link widely.

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Filed under Nursing in Hawaii, Obamacare

Choosing a new name for this blog – “Nursing in Hawaii”

This goes out to all my loyal subscribers. THANK YOU for reading.

The blog was formerly named “Honolulu 2011-2012” to distinguish it from Kathmandu Summer 2011, but I will soon be back on Oahu, and writing once again. I had a great summer backpacking on the mainland.

I think I climbed up and over about two hundred of these…. it sure feels that way!

Q.  Where was I?

A: Hiking the Appalachian Trail in the mountains of Tennessee, North Carolina, and Virginia. I hiked about 330 miles.

yes, on foot.

Summer break will soon be over

and it is time to get to work. I will be on the east coast for two more weeks and arrive on Oahu Aug 13th.

New catchy name for the blog?

the new name will be “Nursing in Hawaii” which is broad enough to encompass many topics. please pass along the link to all your friends and encourage them to subscribe. I hope to continue to share advice for the nurses new to the workforce.

I will write about other nursing topics as well. Role socialization has been a favorite; such things as organizational behavior, health policy, etc.

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Filed under Honolulu, Nursing in Hawaii