Introducing

Underpaid and Undervalued Nursing Crisis at LBJ

About our Project

In a collaborative effort by three bright individuals, the goal of this project was done to develop possible solutions in sustaining healthcare personnel, specifically our local nurses, at our LBJ hospital. Our research will look into factors such as the following: leaders, if policies exist or what policies need to be implemented/enforced, and the management of money at LBJ.

In a collaborative effort by three bright individuals, the goal of this project was done to develop possible solutions in sustaining healthcare personnel, specifically our local nurses, at our LBJ hospital. Our research will look into factors such as the following: leaders, if policies exist or what policies need to be implemented/enforced, and the management of money at LBJ.

The Team

Click on a team member's name to read their reflections on this project.

Major: Liberal Arts

Major: Liberal Arts

Major: Liberal Arts

Age: 20

Age: 19

Age: 19

Explaining the Problem

Being that there is only one working hospital here in American Samoa, there should

be a sufficient amount of healthcare workers there, however, that is not the case.

Our group chose this topic because we feel that it is crucial to have healthcare

providers at the only hospital we have. Lives are on the line and if there is no one to

look out for our people, who will? LBJ hospital has become short-staffed with numbers

of nurses decreasing and leaving. The question is why and how we can take action to

resolve the issue. Due to the nursing shortage, nurses who stayed have been inquired

to work overtime in assisting patients, and unlicensed foreign nurses from Fiji were

brought in to aid our local nurses because Fiji's nursing curriculum was said to be quite

equivalent to the U.S. curriculum than Samoa's nursing program curriculum at the

National University of Samoa.



As promised, local nurses were promised their overtime pay and increment by LBJ's

administration however, the hospital supposedly "did not have enough money" to pay

for their overtime but could afford to hire unlicensed nurses from Fiji in November

of 2022 and pay for their housing and other benefits. In the following month of

December that same year, the same issue was happening to EMS workers with the

hospital refusing to pay for their overtime. In a Samoa News article written by

Joyetter Fa'apouli Feagaima'ali'i, former CEO says in his interview that "they don't pay

for overtime because the hospital does not have any money for OT."




In December of 2022, about 50 nurses went on a strike to grab attention for better-working conditions at the hospital. In a survey we conducted with about 10-12 responses, we asked nurses about the issues with their pay, potential leaders who might be the cause, if they felt undervalued as a nurse, fairness of pay between tenured local nurses and contract nurses, money management, the underdevelopment of the hospital and how it has gotten, where the allocation of the funds is being spent, and possible solutions into resolving this grievance issue. As a part of our survey, we asked nurses if the former CEO was a part of the nurse shortage issue, and 9/10 confirmed that he, and other leaders such as the DON, were indeed part of the problem.
























Former CEO of LBJ, Mr. Moefaauo Bill Emmsley, told Samoa News that the strike

was "uncalled for" and that they should have "been more patient because it was a

part of the plan". Reason being is that Moefaauo told Samoa News a total of $50,000

was paid for all nurses' excess leave and salary adjustments in January 2023. While

salary adjustments and excess leave was paid, it could be said that this did not

happen until the strike broke out while others remained on strike until they were

paid appropriately. The nurses' strike on pay grievances shows that the hospital

administration took action only after the strike happened. It was their wake-up call!

Given the demands this strike has put on his position and the face of LBJ, Emmsley

demanded more from the nurses in terms of their performance. Although research

shows this issue to be recent, our findings reveal that the shortage has been an

ongoing issue spanning more than eight years. This cries for a call for change.







(Click on NAME to read article)

A Facebook post of the Fijian Nurses pictured with the LBJ Board of Administration at a welcoming dinner at Sadies by the Sea, where the Fijian nurses were said to be staying.

“If the hospital can afford to make administrative decisions by hiring overseas unlicensed nurses, we are entitled to our overtime."

Line

"It's not just about the money, the situation with patient care is getting very dangerous."

On September of 2022, the American Samoa Medical Center Authority budget for the new fiscal year outlines an increase of $15 million allocated for salaries. Click here to view article.

Based on the Samoa News article you've just seen, we can see that the nurses' budget is $6.38 million, and according to that budget, not being able to pay nurses their overtime pay and promised increments is questionable. This budget had already been approved by the Fono and was set to start on October 1st, 2022. So, the question is, where are the nurses' money going towards when everything has its/their specific amount of money to their name?


Nurses' salaries depend on their position, whether they are a Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), or a Registered Nurse (RN). According to a Samoa News article, the LBJ nurses' entry level salaries were to be increased and to go into effect on December 6, 2022, by 20%. Certified nurses were to make $9.88 per hour to whereas they were only getting paid $7.86 before; Licensed Practical Nurses were to earn $13.22 per hour from the $10.22 paid before, and Registered Nurses were to make $18.42 from the $15.06 they were making before. This boost is said to be partially funded by the ARPA grant. Unfortunately, that "promised increase" did not show up in their paychecks. It only increased by$.18. Former CEO was informed about this grievance, but nothing was done to address it. The Chairman of the Board was also not aware of this issue until he received emails from KHJ News. See more here.


In an interview conducted with an anonymous nurse of 33 years at LBJ, she claims that the issue starts from the "higher up organizations" - the Government as well as the entire LBJ administration. There is a myriad of problems that lie at the hospital and the pay is one of them. It took 8 years for the administration to raise nurses' pay and it only followed through after the nurses' strike that was held in December of 2022. She also claims that another reason for the nursing crisis is the toxic environment at LBJ, and the best way to resolve it is communication. Because of his poor work ethics, former CEO of LBJ, Mr. Moefaauo Bill Emmsley was removed from his position and Dr. Akapusi Ledua was renamed Acting Chief Executive Officer with a newly hired physician, Dr. Joseph Shumway, called to serve as the Acting Chief Medical Officer (CMO).


Being that LBJ hospital is a government agency under the government, American Samoa Government (ASG) along with LBJ's Board of Directors and hospital administration should be held responsible for this issue with nurses' pay.

The chart presented here provides an overview of the hospital's budget for the fiscal year 2023.

Talk is cheap If their actions don t reflect their words then they didn t really mean it

Examining Alternative Policies

  1. The Payment Policy:

Nurses, just like any other healthcare worker, should be paid their salaries according to their position, years of experience, and education. Being a nurse is not an easy job as it is difficult and challenging when it comes to dealing with the health and wellness of a patient. Since nurses can work in a range of settings and conditions, the time nurses spend with patients compared to doctors and other medical professionals should also be considered. The increase in patients unbalances the patient-to-nurse ratio where there aren't enough nurses covering each department at LBJ.


This is an original policy that would consider paying nurses, and all healthcare workers alike, a guarantee to their overtime pay every pay period. It is by this policy that the government makes sure to prioritize the hospital being that it is a government agency. Pay should be based on their level of degree, years of experience, and the type of work a healthcare worker does. Failure to pay workers their salary will result in the removal of the position of those responsible, and if not paid on payday, the employee may decide to resign and leave the organization regardless if he/she is on contract. Having a clean house would leave those working at LBJ to choose or vote for leaders who will push to keep the hospital up and running. Departments responsible for generating revenue for LBJ include the hospital's billing and collections department, as well as its various clinical departments ( emergency department, surgery department, and outpatient clinics). These departments generate revenue by billing patients, insurace companies, and other third-party payers for the medical services provided by the hospital. Additionally, LBJ may receive funding from the federal government and other sources to help support its operations. These include the Centers of Medicare and Medicaid Services (CMS), the Indian Health Service (IHS), and the U.S. Department of Health and Human Services (HHS). May receive funding from the National Institutes of Health (NIH).


ADVANTAGES:

  • Ensures fair pay
  • Promotes equality among all healthcare personnel
  • Appreciates their line of work
  • Result in a clean house and better leaders for the hospital

DISADVANTAGES:

  • Risk of choosing the wrong leaders
  • Misuse of funds
  • Leaders may be held unaccountable
  • Too many walk-outs if pay is not distributed



2. Open-Door Policy:

The former CEO respects the nurses and their freedom of speech on their strike, but he reminded the nurses about the open-door policy they should have used to their advantage. According to Samoa News article entitled, "Nurses received promised pay raises and excess leave payments", it's just not used every so often. We know that this is an existent policy at the hospital, but it doesn't seem to be enforced according to the former CEO. When implementing the open-door policy, employees have the opportunity to express a complaint/concern, raise awareness for a problem, or even make suggestions for a change. Mr. Emmsley goes on to say reckless statements about the nurses leaving their duties and jeopardizing the lives of the patients, but he forgets to realize the impact working overtime has caused the nurses as more time is spent at the hospital than with families at home. This is where many concerns lie. When every employee, irrespective of their position in an organization, can have an open discussion and share their opinions with the senior members, a culture of equality and empowerment prevails in the workplace. This policy can be an effective tool for gathering feedback and gauging the staff's perspectives regarding job satisfaction and workplace perception. These discussions can provide valuable insights into what the teams think of the business and how to improve work conditions.


To implement this policy, one would need to:

  1. Discuss goals
  2. Invite opinions
  3. Clarify the chain of command
  4. Establish parameters
  5. Prepare a conflict-management plan
  6. Remain open to new ideas


ADVANTAGES:

  • Provides accessibility; helping to improve relationships and can lead to more effective communication, actionable feedback and satisfying results.
  • Promotes healthy discussions between management and personnel.
  • Boosts morale as it motivates team members to commit themselves fully to their duties, responsibilities, and shared goals.
  • Improves working relationships between personnel and managers.

DISADVANTAGES:

  • Can waste management's time and decline productivity where employees may take long hours from manager's schedules to talk about their concerns at work. This results in managers not completing their responsibilities and duties on time and an overall productivity decline.
  • Creates dependency; the policy may make employees too dependent on their managers and it can make employees scared to take decisions and solve problems independently without going to their managers first.
  • Disrupts the Chain of Command as it can make employees feel entitled to consistently go beyond their managers/team leaders and reach higher-level executives.


3. Pay under the Fair Labor Standards Act

  • LBJ Hospital is semi-autonomous from ASG, but both pretty much follow the same laws and abide by the U.S. Department of Labor Laws. Under ASCA Title 32: Labor: (a) No employer may employ an employee in excess of 40 hours a week unless such employee receive compensation for employment in excess of such weekly hours, at a rate not less than 1 1/2 times the regular rate at which he is employed. (b) No employer may employ an employee over 14 hours in any one 24-hour period, except in case of extraordinary emergency.


Advantages:

  • Guaranteed salary for a specific occupation
  • Stable relation between a employer and employee
  • Federal minimum wages are about $7 and 25 cents per hours.
  • Workers paid under a certificate authorizing commensurate wage rates must receive the full fringe benefits listed on the wage determination.

Disadvantages:

  • FLSA does not require vacation, holiday, severance, or sick pay; meal/rest periods, holidays off, or vacations; premium pay for weekend or holiday work; pay raises or fringe benefits; or a discharge notice, reason for discharge, or immediate payment of final wages to terminated employees.



Proposing a Public Policy

The Fair Labor Standards Act for Overtime Pay

The FLSA sets standards for overtime pay, which is generally one and a half times the employee's regular rate of pay for all hours worked over 40 hours in a workweek. However, there are some exemptions and special rules that apply to certain industries in American Samoa. It is unsure if LBJ uses this policy, however our recent research and articles we found is that nurses do no get paid overtime. If an employer, including the hospital does not abide by the Fair Labor Standards Act (FLSA), they may be subject to legal action and penalties. The Department of Labor's Wage and Hour Division in American Samoa, also known as the HR, is responsible for enforcing the FLSA, and they may investigate complaints and take legal action against employers who violate the law. These penalties/consequences include back pay, liquidated damages, civil penalties (can range from $50- $1,000 per violation), criminal penalties, injunctions, and debarment.

Advantages

  • Protects workers; the FLSA establishes minimum wage and OT pay requirements which can help ensure that workers are fairly compensated for their work.
  • Promotes fair competition; By establishing minimum wage and OT pay requirements, the FLSA helps to level the playing field for businesses and promotes fair competition.
  • Provides clarity; The FLSA provides clear guidelines for employers and employees regarding minimum wage, overtime pay, and other labor standards.


Disadvantages

  • Compliance costs; Employers may incur costs associated with complying with the FLSA, such as recordkeeping and payroll expenses.
  • Limited flexibility; The FLSA establishes minimum wage and OT pay requirements that may not be flexible enough to accommodate the needs of all employers and employees.
  • Exemptions and special provisions; The FLSA includes exemptions and special provisions that may make it difficult for some workers to qualify for minimum wage and OT requirements.


Why this policy is Constitutional :

The Fair Labors Standards Act is constitutional because it relates to the federal government's power to regular interstate commerce under the Commerce Clause of the U.S. Constitution and provides uniform labor standards across the U.S. and its territories.

Developing an Action Plan

For a policy to become public, it must first be adopted by the government officials. The policy our group would like to propose or further support is the Fair Labors Standards Act as it requires covered employers to pay non-exempt employees at least the federal minimum age of $7.25 per hour for all hours worked and overtime pay for hours worked over 40 in a workweek. According to the law, a nurse is referred to as a non-exempt employee therefore, nurses should have the right to attain their overtime pay without question. The main difference between exempt employees and non-exempt employees is that exempt employees are not eligible for overtime pay, while non-exempt employees are. However, due to the types of duties nurses perform and the amount of pay they receive may make them "exempt" under the FLSA therefore making them ineligible for overtime pay. To qualify for any overtime exemption, nurse's salary must be at least $455/week.


Some ways to influence the government in further implementing the Fair Labors Standards Act for our hospital is to:

  1. Reach out to our elected officials and express support for the act (Governor Lemanu Mauga and Lt. Governor Talauega Ale)
  2. Share concerns about the current labor standards at LBJ and explain how the FLSA would help improve working conditions for employees.
  3. Join/support advocacy groups that are working/interested to promote the FLSA and raise awareness about the issue.

(American Samoa Medical Association (ASMA), the American Samoa Department of Health (ASDOH), and American Samoa Nurses Association (ASNA): these labor unions/healthcare advocacy groups work to address issues such as healthcare access, healthcare workforce development, public health emergencies, and more.)


One way to develop community support for this policy is to engage with local community organizations, such as labor unions, advocacy groups, and faith-based organizations. We can work in sharing the benefits of the FLSA and the impact it would have on healthcare workers at LBJ. We can also organize public events, such as town hall meetings/rallies, to raise awareness about the issue and encourage community member to get involved. Additionally, we can use social media and other digital platforms to share information such as formulating opinion polls and surveys through the media, generating letter and phone call campaigns, and even writing news articles and blog posts to engage with community members online.


Given that Samoans are known for their strong religious traditions, it may be beneficial to explore faith-based organizations as potential sources for support. There are many in American Samoa that serve a variety of religious communities. Some of these organizations include the Congregational Christian Church in American Samoa (CCCAS), the Roman Catholic Diocese of Samoa-Pago Pago, the Methodist Church of Samoa, the Church of Jesus Christ of Latter-day Saints, and the Assemblies of God in American Samoa (AOG). These organizations provide a range of services and programs to their members and the wider community including religious services, education and training, social and community outreach, and more.

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The implementation of the Fair Labor Standards Act (FLSA) in American Samoa is a complex issue that involves a number of legal and economic considerations. While there is NO set timeline for the process, it typically involves a period of research and analysis, followed by a public comment period, and then the development and implementation of new regulations. It may also be affected by legal challenges, and political considerations, and other factors. Ultimately, it could take several months or years depending on a variety of factors, including the priorities of the relevant government agencies, the resources available for the implementation process, and the level of public support and engagement.

We conducted a survey with two formulated questions and asked about 100 people about the fairness of the policy and whether or not they would further support it within our community.

Eseta Enesi's Reflection

Before this project, I wished I had more knowledge pertaining to the issues of Nurses. The LBJ hospital not only have complications with Nurses employment, but the whole facility has been undergoing shortage of staff. Nurses take care of their patients but its unclear who is taking care of Nurses. Our main focus was to find reason why the promised pay was not initiated. With the amount of problems LBJ is facing it is hard to focus on just Nurse issues. With the lack of time managing and staffs not complying it was tough finding a solid solution. As group we could have evaluated our findings better and work harder. It is unclear whether the nurses will get their promised pay and the new CEO has not shared his plans. We did find that nothing can be helped without the support from the government and new leaders who should be pushing for a cause. Moreover the project was a fun experience as our interactions with Nurses and Staff was somewhat heartwarming. The Nurses who continued to work at the hospital do not have regards on pays, but focus on their number one rule "patients first". Thankful for this experience, and thankful for our Nurses!

Iris Penitusi's Reflection

Through the Project We the People, we were given the role to act as policymakers in formulating our own policies according to our local issue. With that, we were held responsible in making sure that the process of implementing and creating policies are effective as possible. Being that it is a group project, teamwork and communication was crucial in gathering all our research materials and putting it together on this platform. I found this project to be a real eye-opener as it helped me promote my critical thinking abilities and to also become more aware of the policies that exist and do not exist (but should be enforced) in our territory. I've also learned that public policies come with a lengthy process, and I applaud government officials given the role's difficulty. If I were given the opportunity to redo this project again, I would make a planner on what each of our task should be so that each member has a topic to focus on and start researching already. I would also begin my research earlier than the due date so that I have more time to gather my info, manage my time in getting to interview the other potential interviewees we had in mind, and also try to get my hands on real-solid evidence if possible. Although I struggled with my group members in terms of communication, we were able to complete it in the end. Project We The People was the highlight of this semester; all of us tried our best in compiling our information and basing it on this website together, and the results was definitely worth it. It is something I would do again!

Olita Ara's Reflection

Each of us had been given the opportunity to participate in the role of a policymaker through the work or the project “We the People,” creating our own policies in accordance with our issues. As a result, we were expected to ensure that the process of applying and creating policies was successful. Since this is a team effort, I appreciate the worth of teamwork because it was important for making the project done. The fact that they were just a couple of us in our groups. The final semester project plays a key role in helping each other to get ready for the working world. Choosing a project for the final semester that reflects your personality and hobbies and will benefit your future is necessary. I decided to focus on the Policy information and setup. I was hoping to learn new things and put my presentation skills to use with respect to issues discovered in everyday life. Through this project, I learned how to fully understand situations, problem events, and as well as certain challenges that may take place in a real-life environment. In addition to these, I learned a ton of new abilities outside of learning. My group did a great job even though it is a project that requires a lot of hard work, but we still managed to keep the team together and stay focused.



SURVEY RESULTS

Due to the demanding nature of their work, some nurses were unable to fully participate in the survey. The survey received a relatively low response rate, with only 10-12 nurses able to provide feedback. In total, there are 15 questions included in the survey.

The initial set of questions raised additional inquiries that required further clarification from the nurses.

REFERENCES

Advantages of an open-door policy (and how to implement one). (n.d.). Retrieved April 19, 2023, from https://www.indeed.com/career-advice/career-development/implement-open-door-policy


ASCA. AMERICAN SAMOA. (n.d.). Retrieved April 18, 2023, from https://www.americansamoa.gov/legal


Enough is enough, striking LBJ nurses say about pay grievances. Samoa News - Latest and Breaking Sports, Politics, Business, and Samoan News from Pago Pago, American Samoa. (2022, December 21). Retrieved April 18, 2023, from https://samoanews.com/local-news/enough-enough-striking-lbj-nurses-say-about-pay-grievances


FY 2023 budget proposal for LBJ shows a $15m increase allocated for salaries. Samoa News - Latest and Breaking Sports, Politics, Business, and Samoan News from Pago Pago, American Samoa. (2022, September 28). Retrieved April 18, 2023, from https://samoanews.com/local-news/fy-2023-budget-proposal-lbj-shows-15m-increase-allocated-salaries


Hospital CEO publicly scolds nurses in a recent LBJ Newsletter. Samoa News - Latest and Breaking Sports, Politics, Business, and Samoan News from Pago Pago, American Samoa. (2023, January 26). Retrieved April 18, 2023, from https://samoanews.com/local-news/hospital-ceo-publicly-scolds-nurses-recent-lbj-newsletter


Kkhjfm. (n.d.). Most LBJ Hospital Nurses didn't show up for work Friday. Talanei. Retrieved April 18, 2023, from https://www.talanei.com/2022/12/16/most-lbj-hospital-nurses-didnt-show-up-for-work-friday/


LBJ CEO requests that the Treasury pay Ems Overtime. Samoa News - Latest and Breaking Sports, Politics, Business, and Samoan News from Pago Pago, American Samoa. (2022, December 1). Retrieved April 18, 2023, from https://www.samoanews.com/local-news/lbj-ceo-requests-treasury-pay-ems-overtime


LBJ nurses receive a well-deserved and long-awaited raise. Samoa News - Latest and Breaking Sports, Politics, Business, and Samoan News from Pago Pago, American Samoa. (2022, December 13). Retrieved April 18, 2023, from https://www.samoanews.com/local-news/lbj-nurses-receive-well-deserved-and-long-awaited-raise\


Nurses receive promised pay raises and excess leave payments. Samoa News - Latest and Breaking Sports, Politics, Business, and Samoan News from Pago Pago, American Samoa. (2023, January 4). Retrieved April 18, 2023, from https://www.samoanews.com/local-news/nurses-receive-promised-pay-raises-and-excess-leave-payments


American Association of Colleges of Nursing (AACN): The Essentials of Doctoral Education for Advanced Nursing Practice. Washington, DC, Author, 2016


"American Samoa's only hospital at full capacity". RNZ. 28 November 2018.
















After showcasing this website, we received positive feedback, including suggestions to write proper reports on grievances and use digital documentation as an option, given the current digital age. It's somewhat related to the open-door policy where employees can express a complaint/concern, but it is encouraged that if a grievance(s) permits, writing a report or even recording a report would be a necessity in helping to hopefully, make changes around LBJ or other workplaces for that matter.

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