Nursing schools peddle dreams

Nursing schools peddle dreams

By RN

Conclusion

SMACK in the heart of downtown Manila and around the Professional Regulatory Commission can be found the country’s export processing zone for nurses. There, a dozen or so nursing schools and training centers have somehow converged and are thriving, mining the dreams of those aspiring to work overseas.

In one of these schools, students called upon to recite are admonished by the teacher to speak in English. “How can you work abroad if you can’t even answer in English?” the teacher tells them.

Soon, the same school will also introduce a new subject: Trans­cultural Nursing, which will teach students how to practice their profession in countries whose culture and environment differ vastly from the one they had always known.

Throughout the country, nursing education is being retrofitted to meet the demands of the global market. A surge in demand for nurses among health institutions overseas—particularly in the United States and the United Kingdom—is fueling a boom in nursing schools. But as in any other boom, quality has suffered as the numbers increase, in large part because of skewed priorities.

In the 1970s there were 40 nursing schools in the country. Today there are about 350, including many that are focusing more on reaping profits from people dreaming of high-earning jobs overseas than on preparing students for an exacting profession that provides care for ailing patients and technical support for doctors.

Many of these schools lack up-to-date facilities, qualified faculty or affiliation with a hospital, all of which are supposed to be in place before these institutions are allowed to operate.

Yet instead of attending to these problems, many nursing schools have busied themselves adjusting their requirements to fit the needs of a new type of students: middle-age professionals seeking a new career. Called “second-coursers,” they include doctors as well as accountants, clerks, teachers, journalists, government employees and secretaries. All of them hope to become nurses, preferably in a foreign land. More often than not, such students enjoy a shorter term since their basic science subjects in their first course are credited.

But Rita Tamse of the Technical Committee on Nursing Education of the Commission on Higher Education (CHED) urges students to first scrutinize a school’s credentials and past performance before parting with their often hefty tuition. She notes, for instance, that 23 of the current number of nursing schools have failed to meet the requirements set by the government for them to operate. These schools are supposed to have until this month to stop operating and start transferring their students, but they have appealed to CHED to let them continue for one more year. They have also sought the help of congressmen to avoid closure.

To help students avoid the duds among the schools, CHED has issued a list showing the performance of various schools in the Nursing Board Exam. CHED divided the schools into five categories, with those that have 90 percent or more of their examinees passing the Board in the last five years classifying as institutions that had “outstanding performance.” The bottom category is for “very low performing” schools, or those with 29 percent or below of their students passing the exams. (Check out www.pcij.org for the list of schools.)

Very low performers made up 21 percent of the total schools listed by CHED. The bulk, or 36 percent, of the total belongs to the “low-performing” category, or schools that saw 30 percent to 49 percent of their students passing the Board.

Only 12 nursing schools—a mere 6 percent of the total—made it to the outstanding category: University of the Philippines-Manila, Saint Paul College (Iloilo), Silliman University, Saint Louis University, Mindanao State University-Marawi City, Saint Paul College (Dumaguete), Paman­tasan ng Lungsod ng Maynila, Saint Mary’s University (Bayombong), Saint Paul College (Manila), and University of the East Ramon Magsaysay Memorial Medical Center.

Of the 94 schools that had less than five years of Board performance, 42 had zero passing rates, meaning none of their graduates passed the national exam.

Under the law, a nursing school must have a passing rate of 5 percent to be able to continue operating. CHED wants to push the rate up to 30 percent, a level that could close down many of the nursing schools.

To certain schools, CHED might appear to be a villain. But the government and even recruiters know that in the end, having high-quality graduates is the best way the country could stay in the business of exporting nurses.

Requirements not being met

For almost a year CHED’s technical committee monitored nursing schools for their compliance with five requirements: adherence to the nursing curriculum, availability of facilities, ratio of faculty to students, affiliation with or existence of an active tertiary hospital to serve as base for students, and a qualified faculty.

Tamse notes that many schools “are really having trouble with the last three requirements.” Depending on the year level of the students, a school is supposed to observe a teacher-student ratio. In the subject on Related Learning Experience, for example, there should be one teacher for just eight students.

A school must also have a dean—a requirement that seems reasonable enough but which nursing schools find hard to meet. “It’s very easy for them to have facilities because they have lots of money,” says Tamse. “They can build a school, put up air-conditioned classrooms, a nursing laboratory and all that.” But one apparently cannot buy something that’s simply not available, such as qualified teachers and a dean.

Base hospitals are also a problem. “We have too many nursing schools for the number of qualified training hospitals available all over the country,” says Tamse. Not just any hospital can qualify as a base. It has to have the major departments—surgical, obstetric-gynecological and pediatric wards. It should be a tertiary hospital accredited by the Department of Health. And it must have an occupancy rate of 80 percent, which means it is an active hospital where students can be exposed and properly trained.

In addition, some schools want to offer classes in trimesters or quartermesters, a suggestion that would fast-track the course but inevitably lead to half-baked students. “In many health sciences, exposure is important because that is where skills are honed,” says the CHED consultant. “If you shorten that, you come up with graduates who are half-baked. And when they get to the hospitals to work, they’re dangerous. Talagang makakapatay [They can really kill people].”

Diploma mills

The overwhelming number of students wanting to become nurses obviously contributes to the desire of many schools to have as many graduates as they can. According to CHED, nursing schools had a total of 80,000 enrollees last year, among them “second coursers.” The steep cost of the course apparently did not faze them, perhaps because they expect a quick return in their investment once they land a job overseas.

“Nursing is not a poor man’s course,” admits a social science major, who has decided to change professional gears. He ticks off his expenses: tuition per semester is P40,000. Other costs include reading materials, about P5,000 (for books, both bought and photocopied); stethoscope, P850; white shoes, P1,500; white shoe polish, P500; food and lodging, P25,000.

For students who could not afford the full semestral payment, an installment plan is available. A down payment of P10,000 is required, with the balance paid in three “gives,” each to be given before the three major tests: prelims, midterm and finals. Inability to pay at any point would mean dropping out from class, repeating the semester and paying up once more. In the end, the poorer the student, the higher the costs incurred.

There are already schools that turn down enrollees for sheer inability to accommodate them. Far Eastern University, for example, reportedly rejected 5,000 applicants last year. In the same period, the UP College of Nursing admitted only 70 students out of 11,000 who applied. That number for admission will not increase even as 14,000 applicants have already asked to be taken in for the coming school year.

No to second-coursers

At the same time, some nursing schools do not admit second-coursers, including doctors, in their classes. The demand from regular students appears to be enough to make up for any financial gain that is given up.

Dr. Rusty Francisco, a nurse with a doctorate in nursing education and an owner of a training center for nurses bound for abroad, says many students are deluded into thinking that enrollment in a nursing school is a guaranteed passport to a job abroad.

“Passing all examinations does not make them competitive,” he says. Not many Filipino nurses are familiar with the medical equipment being used in US hospitals, he points out. Neither do they know how to operate in an environment where patients are more assertive and aware of their rights. That is why in his training center, Francisco emphasizes what Filipino nurses should expect when they are in the United States.

He adds that while Filipinos are still the preferred health workers, they may soon be facing stiff competition from the Chinese and the Indians who have come to realize the financial windfall from the export of nurses to developed countries.

Changing values of nurses

Although Filipino nurses are known for being compassionate and caring, these qualities appear to be disappearing because the goals for taking up nursing have changed. From desiring to be of service to another human being, nursing students are now primarily motivated by the need to make money.

Francisco argues that even a high-standard school may not be able to change the mindset of those already determined to earn dollars above anything else. “A school curriculum,” he says, “does not automatically turn a person into a caring, compassionate nurse with the ability to be assertive and articulate.”

Tamse agrees with the observation. “Some of them don’t even have the heart for it,” she says. “They’re just there because they know it’s a good passport for going abroad. . . . Nursing is about caring and being compassionate. It’s difficult to be compassionate if your only purpose is to earn.”

But it is also difficult to deny the validity of the economic reason behind the decisions of many who leave. At the Philippine General Hospital, says Tamse, “99 percent left because they have to finance the schooling of their brothers and sisters, the husband is unemployed or underemployed, the children need to be given quality education and so on.”

She says many of the nurses cry and tell her, “I don’t want to leave naman ma’am, eh. It’s just that I have to do it.” In one exit interview, a nurse underscored the words, “Pera lang po [It’s only the money].”

But the likes of Tan are unwilling to take all these sitting down. In a rather controversial scheme, Tan suggests the enactment of a National Health Service Act that would require health sciences education graduates of state colleges and universities to serve the equivalent number of years of study in the country. Since the state has subsidized the education of these health science graduates, he reasons, they should pay back the favor by serving in the country for a few years.

Pros and cons of mandatory service

Several bills have been filed in Congress imposing mandatory service for nurses. Predictably, these have been opposed by nurses’ organizations that say the practice is discriminatory and oppressive.

Tan believes otherwise. He points out that the current health crisis warrants compulsory service by health workers for a specified period. He also notes that countries like Indonesia and Malaysia require their medical and health science graduates to work in the country before going abroad. In fact, Tan says, the Philippines is the only country in Southeast Asia that does not have a National Health Service Act.

Dr. Irineo Bernardo of the Philippine Hospital Association, for his part, says, “We need to look at a problem from many angles.” Instead of dreading the loss of more nurses, doctors and other health workers, he suggests working harder to improve the health condition of Filipinos.

“The government keeps talking about having a strong republic,” he says. “Why not have healthy Filipinos so we can really have a strong country?”

The country’s health status

Up to now, Bernardo says, the government has not established the health status of the country. “How healthy or how sick are we?” he asks. “If the number of health providers goes down, will that make more people sick? No!”

But if the government fails to look after the health of its people—such as by making it easy for cigarette companies to sell their products—then Filipinos will get sick, he says. Educating the people on how to take care of themselves could do more to improve public health rather than having a big number of health providers, he says. Points out Bernardo: “Sickness comes from our lifestyle, from what we take in. We need food, not medicine.”

Although the disappearance of doctors and nurses is indeed a problem, Bernardo suggests taking good care of those who stay behind. “Recognize the competence of nurse anesthetists, for example, and pay them as well as a doctor,” he says. After all, surgery would be impossible if no anesthesia is administered.

There is in fact a boon for those who will remain in the country: they would now have a bigger market for themselves, since they will have fewer rivals. “There will come a time when things will not be good,” concedes Bernardo. “But they will become better. Many hospitals will close down but they will be replaced by new players. We will change.”

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Posted on Monday, March 21, 2005

Nurses lack hurts healthcare system

By RN

First of two parts

LANI, a radiology technologist in a government hospital in Que­zon City, remembers the time when she moved among the best in her department. “We used to have good senior nurses here,” she says.

Then, almost suddenly, her coworkers started leaving. “That whole year, I kept seeing resignation papers,” recalls Lani. Even the aides were disappearing, going off to London or the United States or elsewhere for good. Today, out of the 40 staff members that she had originally worked with in the department, only four have stayed behind. But even they—including Lani—have either applied or are planning to apply for work abroad.

This month, some 20,000 nursing students will graduate from 350 schools in the country. As the global health industry opens itself up to more migrant health workers, many of the new graduates will be making a beeline for jobs overseas. But many more of them will not pass the qualifying exams for nurses, thanks to a boom in nursing schools that has led to a decline in the quality of education and also of students being accepted into nursing programs. In the last few years, less than half of those taking the nursing board exams passed.

The best among the graduates, however, are often bound for abroad, many of them skipping the one- or two-year experience required by hospitals. In the last 10 years, the Philippines sent close to 90,000 nurses overseas. Today it is exporting more qualified nurses than it is producing, leading to a nursing crisis that has already diminished the quality of hospital care and even forced the closure of a number of hospitals.

A study by the National Institute of Health (NIH) describes migrant health workers (nurses, physical and occupational therapists and midwives) as generally young, from 20 to 30 years old. Migrant doctors are between 31 and 40 years old. But these figures can deceive. Now and then, hospital staffers would speak of doctors who have retired or are about to retire and taking up nursing. Age is not a hindrance to working abroad, especially in the United States where one can work for as long as one wants to.

Although the number of male nurses has been observed to be on the rise, the migrant health workers are still predominantly female, meaning more families are losing their traditional caregivers—the wives, mothers and sisters. According to a 2004 Asian Development Bank report, 65 percent of Filipino workers overseas are women.

The NIH study also warns that because the migrating nurses are usually the ones with training, experience and skill, patients in hospitals and other health institutions in the Philippines can expect a higher incidence of cross-infections, adverse events after surgery, accidents, injuries and even increased violence against the staff.

With the best among nursing students often leaving as soon as they graduate, the less skilled are taking the place of senior or relatively more experienced nurses who have also left for other shores. In a year or two, they too would be gone. The void would be filled once more by fresh graduates who would repeat the same cycle: get a few years experience in a local hospital, apply for work abroad and then leave. It is, say many health professionals, a cycle that leaves local hospitals in a state of perpetual displacement—and patients in constant danger.

Next to India, the Philippines is already the largest source of doctors in hospitals abroad. The country also supplies 25 percent of all overseas nurses worldwide. Not surprisingly, about 10 percent of the Philippines’ 2,500 hospitals have closed down in the past three years because of the loss of doctors and nurses to jobs overseas.

As more nurses leave and as fewer are qualifying for the job, the situation in hospitals can only deteriorate. But to Rita Tamse, deputy director for nursing of the Philippine General Hospital (PGH), “that worse situation is happening right now.”

The exodus continues

“Our problem is unskilled, untrained nurses,” says Dr. Irineo Bernardo, executive officer of the Philippine Hospital Association and owner of a primary-care community hospital in Tanay, Rizal. He notes that the turnover of nurses has been particularly high in the last five years.

“In a small hospital, we’d expect one or two to leave for abroad in a year,” says Bernardo. “Last year, we had five who left.”

Even the PGH, the country’s premier government hospital, is also seeing an exodus, with up to a quarter of its 2,000-nurse work force leaving in the last few years.

The preferred country of destination is the United States because of the possibility of acquiring US citizenship and all its privileges. But 57 percent of Filipino nurses abroad are in Saudi Arabia and only 14 percent are in the United States; 12 percent are in the United Kingdom.

But that may soon change. Figures vary but the United States is said to need about a million nurses over the next few years; Canada, 10,000; the Netherlands and the United Kingdom, 7,000; other countries, 27,000.

In 2001 the Philippine Overseas Employment Administration (POEA) reported that 13,536 Filipino nurses went overseas, almost double the previous year’s exodus of 7,683 nurses. The 2001 figure is the highest ever recorded. The same year, only 4,430 students passed the Nursing Board Examination.

The pattern would be repeated in 2002 when 11,911 nurses chose to work abroad as against a much smaller number of nursing students—4,228—who passed the board. Clearly, the country has been exporting more nurses than it was producing.

Falling standards

Tamse, who is also a member of the Technical Committee on Nursing Education of the Commission on Higher Education (CHED), notes that the latest Nursing Board Exam in December registered its lowest passing rate ever at 43 percent. Of the about 12,000 students who took the board, only about 5,000 made the grade.

Thus, although the PGH used to accept only the top graduates of the country’s nursing schools, it can no longer afford to stick to such standards, says Dr. Jaime Galvez Tan, vice chancellor of the University of the Philippines in Manila that is in charge of the hospital. So long as a nurse makes the minimum passing grade, an apparently desperate PGH will take the applicant.

Bernardo points out that the shortage of skilled nurses compromises the quality of patient care. He says, “It takes years for a new graduate, even for someone with good grades, to be trained.” It is not enough that a nursing graduate knows the theories, says the doctor, adding that “he or she must know the culture inside a hospital as well.”

Skilled and trained nurses are a requisite of proper health care. In some towns, small hospitals are run by nurses, not doctors. Bernardo says that if the only nurse available “is an idiot, then better not open the ward altogether. You’ll be putting the patients at risk.”

One need not even go to distant barangays to find unskilled nurses. In a top hospital in Metro Manila, Tan recalls asking for a spittoon for a patient. “The nurse,” he says, “came back with a urinal.”

I also witnessed a nurse at a government hospital using her cell phone’s calculator to compute the intake and outflow of fluid of a patient, only to come up with the wrong numbers, which were recorded in the patient’s chart. Doctors base their diagnosis and course of treatment on the patient’s chart and wrong data could lead them to make wrong conclusions.

But even doctors are fast disappearing. On the fifth floor of a busy hospital in Manila, for example, hundreds of doctors congregate from Friday to Sunday in the early evening to “learn nursing.”

Tan says that 5,500 doctors are now enrolled in 45 nursing schools in courses that were tailor-made for them. Two thousand doctors have already taken up the Nursing Board Exams, topping the test in 2003 and 2004. Last year, the topnotcher in the medical board exam announced his plans to work overseas as a nurse.

Dropping employment

Thus, even as more nursing schools pop up each year, medical schools are getting less popular. Of the 39 medical schools in the country, three have ceased operating because of steeply declining enroll­ment. One report says that only six medical schools out of 25 that it studied registered an increase in enrollment. The highest increase in enrollment, registered by Mindanao State University, was 29 percent.

This, however, is hardly encouraging compared with the decline in enrollment experienced by most schools. The Iloilo Doctors College of Medicine, for instance, reported a 74-percent decrease in enrollees. Except for the University of Santo Tomas, nearly every medical school covered by the study reported a shortfall in its enrollment quota.

Among the reasons cited by health workers bound for abroad are political instability, corruption and the need for political backing to get a job or a promotion. They also deplore the long hours of work required of them. The most common reason they give, however, is economic.

Tamse recalls that one nurse came back from the United Kingdom with P500,000 after just six months there. For those bound for the United States, there is even a signing bonus of anywhere from $2,000 to $10,000.

Paltry salaries

These figures, she says, are “a far cry” from what nurses are paid here. Those in the provinces, for instance, get as low as P2,000 a month. Ironically, government hospitals pay more than private hospitals. Nurses in public hospitals receive at least P9,000; in private hospitals, it could go down to P4,000 a month. Under the Nursing Law of 2002, an entry-level nurse should get about P13,300 a month.

“It’s such a small amount and yet the government is unable to give that,” Tamse says, citing “unavailability of funds” as the constant reason being given by the Department of Budget and Management. In the meantime, a contractual nurse without experience gets P9,930 a month; with experience, the pay goes a bit higher at P12,000.

Even recruiters are handsomely paid for every nurse they bring to a foreign-health institution. Tan says a recruiter once offered him $7,000 for every nurse that he could find for a US hospital. When the disbelieving doctor finally got the chance to talk to staff members of that hospital, he was even more surprised.

“They denied it!” cries Tan. “They weren’t giving $7,000 for every nurse. They were giving $14,000!”

Tan worries that doing nothing to stop the flow of Filipino doctors and health workers to other countries could only lead to a “health human resources disaster.” Based on the results of a project he has been conducting in the last several years, he thinks the lack of good role models is partly to blame for the exodus of health workers. Some teachers, he says, tell their students there is no hope in this country.

Grades, not values

The medical curriculum, he adds, gives premium to grades and competencies rather than values. Globalization of labor has also contributed to a materialistic attitude even among those whose profession is supposed to serve others.

Yet Tan says that medical students generally start off with the right attitude and values. But somewhere on their way to becoming doctors, something seems to happen to them, changing their goals and plans, he says.

Over the years, Tan has been monitoring the attitudes of medical students, asking them three questions: How do you describe yourself? How do you see yourself 10 years from now? What country do you want to serve?

During the first and second years, he says, a medical student would usually describe himself as “compassionate” and “humane.” The student would also see himself working in public health, community medicine, or with a nongovern­mental health organization. Those years also see all medical students replying that they would like to serve in the Philippines.

Change, however, comes by the third year onward. With students invariably describing themselves as “competent” and “skilled,” many now want to become super-specialists. And by the time they graduate, only 25 percent said they would stay.

But Tan says the outward flow of health workers, however strong it is right now, can be “tamed” and lead to a “win-win situation” for the Philippines and the importing countries.

He suggests the initiation of bilateral negotiations with countries that import Filipino health workers that would lead to the allocation of development aid or compensation to the Philippines in exchange for sending health workers abroad.

He also advises the government to create a national commission to oversee the planning, production, deployment, retention and development of health professionals. He deplores the fact that there is no single body taking charge of these matters, which explains why figures concerning health matters vary depending on which government agency is consulted.

For now, however, Filipinos who fall ill will find less skilled professionals attending to them.