If you want to understand the state of health care in Hawaiʻi, don’t start in Honolulu. Start in Hāna, Kaʻū, Lānaʻi City, or Hālawa Valley. Start where a single clinic may serve an entire district, where a medevac can take hours, and where the only consistent health care professional is often a nurse or nurse practitioner (NP). Rural nurses and NPs are the backbone of care in our Islands — and right now, that backbone is under strain.
Hawaiʻi’s rural communities face some of the most persistent health disparities in the state. The Department of Health’s Office of Primary Care & Rural Health reports that rural residents experience higher rates of chronic disease and significantly longer travel times for basic services. Many live miles from the nearest hospital. Some rely on clinics that operate with only one or two providers. And in too many cases, the person who keeps that clinic running, who knows every patient by name, who responds to emergencies without immediate backup, is a nurse or NP.
Rural nurses and NPs are not just caregivers. They are first responders, health educators, cultural translators and community anchors. They stabilize trauma patients when no physician is available. They manage chronic conditions for kūpuna who cannot travel. They coordinate telehealth visits, deliver babies, prescribe medications, and provide preventive care in places where the health care system is stretched thin. They do all of this while navigating the realities of isolation, limited resources, and the high cost of living.
Nursing is not simply a set of tasks — it is a profession grounded in rigorous education, clinical judgment, and ethical responsibility. NPs, in particular, complete advanced graduate training and are licensed to diagnose, treat and prescribe independently in Hawaiʻi. In many rural communities, NPs function as the primary care provider. Their work requires the same level of expertise and respect we afford to any other health care profession, yet too often their contributions are treated as interchangeable or secondary.
Yet despite their essential role as highly trained professionals, rural nurses and NPs remain undervalued and under-supported. The 2024 Hawaiʻi Physician Workforce Assessment shows that the state is short more than 1,000 physicians — and the shortages are most severe on the Neighbor Islands. When a nurse or NP leaves a hospital in Honolulu, it’s a staffing challenge. When one leaves a clinic in Kaunakakai, it can shut down services for an entire community — a stark reminder that professional nursing expertise is not easily replaced.
The state has begun to take steps to strengthen rural health infrastructure. Telehealth expansion, mobile health units, behavioral health services, and digital connectivity are all part of the plan. These investments matter. But they will not succeed without a strong rural nursing and NP workforce to anchor them.
Technology cannot replace trust. Broadband cannot replace bedside care. A mobile clinic cannot run itself.
If Hawaiʻi is serious about improving rural health, we must put rural nurses and NPs — as professionals, not stopgaps — at the center of the conversation. Research from the National Rural Health Association shows that students from rural backgrounds are two to three times more likely to return to rural practice, a clear argument for expanding local training pipelines.
It also means recognizing that rural health is not a niche issue. It is a statewide responsibility. When rural communities suffer, the entire state feels the impact — in preventable hospitalizations, in higher emergency costs and in the erosion of the local workforce that keeps our Islands functioning.
Rural nurses and NPs are doing everything we ask of them and more. They are caring for families who have nowhere else to go. They are showing up in the face of shortages, burnout and isolation because they believe their communities deserve better.
The question now is whether we believe it, too.
Hawaiʻi has a chance to build a rural health system worthy of the people who depend on it. But that future will only be possible if we invest in the people who make rural health care possible in the first place. It’s time to stop treating rural nurses and NPs as a backup plan — and start treating them as the foundation they already are.
At Hawaiʻi Pacific University, our Bachelor of Science in Nursing (BSN) program includes a community health course that immerses students in the realities of rural health nursing. Students rotate through communities such as Wai‘anae and Waimānalo, where they collaborate with local partners to identify needs and develop meaningful solutions. Many of our NP students and graduates also come from rural areas, and they are deeply committed to giving back by serving the very communities they call home.
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