Stepwise Approach to Address the Nursing Shortage in Critical Care Settings

With limited manpower and resources, hospitals can only do so much in a pandemic. Sadly, the country is still in the pandemic phase of the COVID-19 outbreak and more cases are expected to be confirmed in the following weeks. The Department of Health (DOH) has recently identified six areas in the Visayas as emerging COVID-19 hotspots. This includes Cebu City, Cebu province, Ormoc City, Southern Leyte, Leyte, and Samar. As of June 29, there are more than 7000 confirmed cases in Central Visayas, with Cebu City having the highest number of confirmed cases in the country.

Patients with COVID-19 sometimes develop severe and critical conditions that will warrant admission in the intensive care unit (ICU). The effective management of critically ill patients infected with COVID-19 is dependent upon the efficient provision of evidence-based nursing care. Notably, Eastern Visayas has only nine ICU beds while Central Visayas has 111. More than 50% of ICU beds in Central Visayas have already been occupied. Interestingly, the DOH, in consultation with the Philippine General Hospital, has recommended a 1:1 nurse-to-patient ratio for ICUs. Maintaining appropriate staffing in health care facilities, particularly ICUs, is essential to providing a safe work environment for health care workers and safe patient care. With the current state of local health systems in the Visayas, this “ideal” ratio will be hard to comply with, risking quality care and patient outcomes.

Early into the pandemic, the government was quick to anticipate this and published a call for nurse volunteers who are willing to provide their services to the designated COVID-19 referral hospitals. While this policy has the potential to increase the supply of health workers, particularly nurses, this might not be enough when we reach the peak of 75,000 COVID-19 positive cases expected to occur in the next few months.

The Cebu Medical Society has raised its concerns over the city’s exhausted and overwhelmed health system citing health workforce shortage and scarcity of medical equipment. More than 130 health care workers in Central Visayas have been infected with COVID-19 as of June 15. Some hospitals have forced their nurses to undergo home quarantine after being exposed to positive cases. Consequently, this left the hospitals with a skeleton staff that is just enough to keep essential services running.

The surge of confirmed cases leading to an increase in demand for nursing services has significantly strained local health care systems. This expected surge of confirmed COVID-19 cases will now require the restructuring of policies to address the nursing workforce shortage in hospitals, particularly in intensive care units. Therefore, it is imperative for the government to seek ways on how to increase the capacity of the health care system, primarily by improving nursing resource management in hospitals. A combination of national- and hospital-level policies could be the key to solving this workforce problem.

Despite the efforts of the Department of Health to increase health workforce supply through volunteerism, there is a great potential that the program will not be able to adequately address the growing demand for nursing services, specifically intensive care nursing. Therefore, there is an urgent need to look at other policy alternatives that can complement this program alongside other policies.

POLICY ALTERNATIVES

The increase in service demand should be coupled with an increase in service supply. The government must ensure that hospitals are adequately staffed with competent nursing personnel that can deliver quality care to the people. Policies to make the necessary arrangements to ensure adequate staffing needed to respond to the increased demand for nursing services should now be taken into consideration. The recommendations provided below could hopefully give the government and nursing administrators a new perspective on how to address the imminent workforce shortage.

Status Quo: Emergency Hiring and Redistribution of Existing Staff
Current policies for managing the current issue on localized nursing workforce shortage are limited to the redistribution of existing staff from various sources and the temporary employment of volunteer nurses. Earlier this year, the DOH announced that it is hiring health personnel in select hospitals and other health facilities to expand the country’s response to the COVID-19 pandemic.

As of July 1, DOH Central Visayas has deployed 270 nurses across different facilities in Cebu City. Meanwhile, the Armed Forces of the Philippines has deployed nine nurses as a response to the shortage. In addition to this, nurses under the Nurse Deployment Program were also redeployed to DOH- and LGU-operated hospitals. Some NDP nurses, however, were retained in their original areas of assignment to help implement public health measures to prevent and control the spread of infectious diseases.

Alternative 1: Issuance of Temporary Licenses to Graduate Nurses
Through the Professional Regulation Commission and the Board of Nursing, with the recommendation of the Secretary of Health, the government can issue temporary professional licenses to nursing graduates and be classified as Graduate Nurses (GN). Similar to policies in the United States of America, the issuance of temporary licenses will permit Graduate Nurses to render nursing services to patients in non-COVID units. This will allow professional nurses to be deployed to critical care units flooded with confirmed cases of COVID-19.

Temporary licenses will only be given to individuals who have been conferred the degree of Bachelor of Science in Nursing by a reputable institution of higher learning in the Philippines. Individuals applying for temporary licenses may or may not have taken the nurse licensure examination; provided, that no applicant must have taken the licensure examination for more than three times. Successful applicants will be assigned to hospitals that have requested additional staffing complement due to shortages.

Alternative 2: A Tiered Staffing Policy for Pandemics
The government can direct public and private hospitals to adopt a tiered staffing strategy. This staffing strategy, adapted from the Society of Critical Care Medicine and the Ontario Health Plan for an Influenza Pandemic, can help address the need to staff inpatient and ICU beds by making use of existing nurse clinicians. This can be supplemented by other clinicians assuming new roles, students who were given temporary licenses, and resigned or retired personnel returning to work.

In this model (Figure 1), a registered nurse who is trained or experienced in critical care and who regularly manages ICU patients oversees the care of two to three groups of three to four patients each. A non-ICU nurse who has some ICU training or experience but does not regularly perform ICU care is inserted at the top of each triangle. This non-ICU nurse extends the knowledge of the ICU nurse while working alongside other members of the team without ICU training and experience. The tiered staffing policy can be an effective strategy to incorporate non-ICU-trained staff to augment the trained and experienced ICU staff.

Tiered Staffing v1

Figure 1. Tiered staffing model for critical care units

Less-skilled staff will have to assume roles previously performed by critical care nurses under the direct supervision and support of the latter. Nursing tasks may need to be delegated to less specialized workers such as nursing aides and ward assistants. Allowing this approach will reduce the responsibilities of the critical care nurses but it does not remove the accountability from these nurses. Critical care nurses remain responsible for any task delegated to lower-level cadres or non-critical care staff under their supervision.

POLICY ANALYSIS AND MATRIX

Status Quo: Emergency Hiring and Redistribution of Existing Staff

Public and private institutions have recruited retired, resigned, and unemployed nurses to help in the management of probable or confirmed cases of COVID-19 admitted in hospitals. This was supplemented by the redeployment of nurses from the military and those under the Nurse Deployment Program of DOH. These strategies effectively increased the number of available nurses for hospitals in the Visayas.

These strategies were economically efficient in that the government did not incur additional costs except for the health worker benefits prescribed by the Department of Health and the Bayanihan to Heal as One Act. Moreover, these strategies were easy to administratively implement as they fall within the mandate of local government units and the DOH. Further, these strategies enjoy political and social acceptance as they can address problems with coverage and access to health services, particularly nursing services.

These strategies, however, may not be enough to maintain the adequate supply of competent nurses with experience and training in critical care. Not all nurses will have the skills and knowledge needed to care for patients in ICUs. These strategies fall short in this aspect of the workforce shortage. Currently, no data is available on how many of the recruited and redeployed nurses have training and experience in critical care nursing.

Alternative 1: Issuance of Temporary Licenses to Graduate Nurses

DOH Department Order No. 2020-0169, which allows medical graduates to engage in the limited practice of medicine as deputized physicians, sets a precedent for this policy alternative. Moreover, R.A. No. 11469 vests in the President the power to engage temporary Human Resources for Health to complement or supplement the current health workforce. However, the issuance of nursing licenses and certificates of registrations falls under the jurisdiction of the Board of Nursing as stipulated in Republic Act No. 9173 or the Philippine Nursing Act of 2002. Only the Board has the authority to issue, suspend or revoke certificates of registration for the practice of nursing in the Philippines. As such, this alternative will require a stringent policy process that will take time before a sound policy can be considered. Nonetheless, this should not hinder the government from considering this policy option when the worst scenario is bound to happen.

This alternative can be effective in increasing the number of available nurses that can render health services. Reallocation of program budgets will be required to finance the compensation of Graduate Nurses as well as in instituting licensing procedures. A salary amounting to Php22,316/month, which is equivalent to Salary Grade 11, can be considered adequate compensation for a Graduate Nurse. Should the government decide to hire at least 100 nurses to maintain a 1:1 ICU nurse-to-patient ratio in Eastern and Central Visayas, the government will need to allocate 2.2 million pesos/month for salaries alone. The table below shows the direct costs associated with hiring a Graduate Nurse in varying durations of engagement with government hospitals.

Screen Shot 2020-07-24 at 7.07.38 PM

While this can be an efficient and effective strategy, hiring Graduate Nurses to assume the roles of Registered Nurses in hospitals is not very popular among patients and their caregivers, especially when complex procedures are involved. Past experiences, however, show that Filipinos are more accepting of student nurses and graduate nurses practicing basic nursing skills such as bed bath, wound care, and health teaching.

Alternative 2: A Tiered Staffing Policy for Pandemics

As opposed to other strategies, a tiered staffing policy will not result in an absolute increase in the number of nurses in hospitals. While the level of care may not be the same as in the typical ICU in non-crisis times, having care directed by trained and experienced critical care nurses is an effective way to maximize care for large numbers of critically ill patients. This approach with critical care nurses supported by additional staff members would increase a hospital’s capacity for care of critically ill patients. The use of this approach can help achieve or maintain a safe nurse-to-patient ratio in both general wards and critical care units.

With this alternative, no additional costs will be incurred by the government. Rather, it will only require the reorganizing of hospitals’ staffing management, particularly for nurses. It is technically and administratively feasible as this policy veers closely with the team-based approach which nurses are very familiar with.

This alternative may not need to go through the usual policy process engaged in creating national policies. The policy can emanate from the Centers for Health Development or local government units. Patients and their caregivers do not see this policy option as a hindrance to quality care. Rather, the policy sets a mechanism to improve access and coverage in critical care services while ensuring patient safety and quality of nursing services. Currently, no law or statute prohibits the institution of this kind of policy. It can serve as a quick fix to the local nursing shortage.

POLICY RECOMMENDATIONS

Cebu remains a high-risk area, which means that the SARS-CoV-2 is still spreading in the province. A study conducted by some professors of the University of the Philippines projects 15,000 cases in the province by the end of July. However, relaxing quarantine measures may cause an escalation of up to 30,000 cases by July 31. The occupancy of beds in Cebu City alone, where the majority of hospitals in the region are situated, is more than 70% while occupancy of ICUs is more than 60%. More than 4% of nurses in the Central Visayas region still cannot render services because they were either admitted to the hospital or quarantined in their homes or other health facilities.

Given this, the following stepwise recommendations based on this policy analysis should be considered to augment the required staffing patterns in intensive care units / critical care areas in Central and Eastern Visayas. The government should continue the emergency hiring of health workers which will result in an absolute increase in the number of available nurses. Because not all nurses have adequate training or experience in critical care nursing, this should be supported by a policy on tiered staffing. Such a policy will maximize the skills of critical care nurses while ensuring the delivery of quality nursing care to more patients. Lastly, should human resources for health become severely depleted due to sickness, death, and other reasons, the government should explore the option of issuing temporary licenses to graduate nurses.

  1. Issue a policy on tiered staffing

The government should enact local policy that will designate nurses with training and experience in critical care nursing as interim unit heads overseeing the care of two to three groups of critically ill patients. Each group of less specialized staff (i.e. nurses with inadequate ICU training and experience, nursing assistants, graduate nurses) will assume roles previously performed by critical care nurses. Moreover, hospitals should allow task shifting to less specialized health workers such as nursing aides and ward assistants to reduce the workload of registered nurses.

Additional training for less specialized workers in areas of potential increased service demand should be provided to ensure staff competency and capacity, especially when deployed to critical care areas. Procedures for supervision and monitoring of performance should be established to ensure the quality of services delivered.

  1. Continue hiring nurses from various groups

Retired, resigned, and unemployed nurses should be continuously recruited to help in the management of probable and confirmed cases of COVID-19 that are admitted in hospitals. Training and orientation should be provided to meet the needed minimum skill sets. Moreover, procedures for credentialing newly recruited staff, specifically looking at training and experience in critical care nursing, must be developed.

The government can also tap nursing organizations such as the Association of Private Duty Nurse Practitioners of the Philippines whose self-employed members are hired to care for private individuals and/or their families. More nurses from the military and police services can be deployed to civilian hospitals. NDP nurses should remain in their original area of assignment to help in the implementation of public health measures.

  1. Issue temporary licenses to graduate nurses

The Board of Nursing can issue temporary licenses to Graduate Nurses within a prescribed period (e.g. 90 days or until the pandemic is controlled) that will allow them to care for patients in non-COVID units. This will allow the reallocation of trained and experienced nurses to critical care units. Graduate Nurses can work under a tiered staffing approach where they are supervised by competent registered nurses.

Procedures for credentialing, training, and performance evaluation should be developed in consultation with members of the academe and nursing service administrators. The Board should also develop procedures for revocation of temporary licenses that can be done at a time the government deems the pandemic is under control or until hospitals are at the level of or below their surge capacities.

CONCLUSION

The role of nurses has been considered crucial in managing this pandemic, most especially in implementing strategies to #flattenthecurve. While this is the case, shortage in the nursing workforce will not make the management of the pandemic any easier. Hence, the government and hospital administrators need to plan ahead of time to address pending problems such as nursing shortage and to increase the capacity of the health system to cater to the growing needs of the population.

Effective nursing workforce management is essential to ensure adequate staff capacity and competency during a pandemic which substantially increases the demand for nursing services. The recommended stepwise approach can be a promising solution to the local nursing workforce shortage. However, these recommendations are interim solutions to a possibly chronic nursing workforce shortage in the Philippines. A national investment in the nursing profession will be vital to address this shortage. Such investment will require significant political will, support, and financial investment.

REFERENCES:

1.    Aguilar, K. (2020). Gov’t allows ‘limited practice’ of medical graduates in COVID-19 response. Retrieved 5 July 2020, from https://newsinfo.inquirer.net/1258334/govt-allows-limited-practice-of-medical-graduates-in-covid-19-response
2.    COVID-19 FORECASTS IN THE PHILIPPINES: NCR, CEBU and COVID-19 HOTSPOTS as of June 25, 2020. (2020). Retrieved 5 July 2020, from https://www.up.edu.ph/covid-19-forecasts-in-the-philippines-ncr-cebu-and-covid-19-hotspots-as-of-june-25-2020/
3.    DOH RELEASES INTERIM GUIDELINES FOR EMERGENCY HIRING OF HEALTH PERSONNEL Press Release/12 April 2020 | Department of Health website. (2020). Retrieved 5 July 2020, from https://www.doh.gov.ph/doh-press-release/DOH-RELEASES-INTERIM-GUIDELINES-FOR-EMERGENCY-HIRING-OF-HEALTH-PERSONNEL
4.    DOH TO DEPUTIZE MED GRADS TO ASSIST IN NAT’L COVID-19 RESPONSE | Department of Health website. (2020). Retrieved 5 July 2020, from https://www.doh.gov.ph/press-release/DOH-to-deputize-med-grads-to-assist-in-nat%E2%80%99l-covid-19-response
5.    Duque: 22 more doctors to be deployed to Cebu City. (2020). Retrieved 5 July 2020, from https://www.sunstar.com.ph/article/1862123/Cebu/Local-News/Duque-22-more-doctors-to-be-deployed-to-Cebu-City
6.    Einav, S., Hick, J. L., Hanfling, D., Erstad, B. L., Toner, E. S., Branson, R. D., … & Christian, M. D. (2014). Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest146(4), e17S-e43S.
7.    Emerging Health Workforce Strategies To Address COVID-19 | Health Affairs. (2020). Retrieved 5 July 2020, from https://www.healthaffairs.org/do/10.1377/hblog20200414.197056/full/
8.    Goh, K. J., Wong, J., Tien, J. C. C., Ng, S. Y., Duu Wen, S., Phua, G. C., & Leong, C. K. L. (2020). Preparing your intensive care unit for the COVID-19 pandemic: practical considerations and strategies. Critical Care24, 1-12.
9.    Halpern, N. A., Tan, K. S., & SCCM, V. T. (2020). US ICU resource availability for COVID-19. Society of Critical Care Medicine, March25.
10. IN NUMBERS: What hospitals need to treat COVID-19 patients. (2020). Retrieved 5 July 2020, from https://www.rappler.com/newsbreak/in-depth/256133-numbers-what-hospitals-need-treat-coronavirus-patients
11. Nonato, V. (2020). Not Enough Beds, Healthcare Workers To Address COVID-19 Cases In Case Of Surge – UP Research | OneNews.PH. Retrieved 5 July 2020, from https://www.onenews.ph/not-enough-beds-healthcare-workers-to-address-covid-19-cases-in-case-of-surge-up-research
12. Phua, J., Weng, L., Ling, L., Egi, M., Lim, C. M., Divatia, J. V., … & Nishimura, M. (2020). Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. The Lancet Respiratory Medicine.
13. Shang, Y., Pan, C., Yang, X., Zhong, M., Shang, X., Wu, Z., … & Sang, L. (2020). Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China. Annals of Intensive Care10(1), 1-24.

NOTE: This is an abridged version of an academic paper submitted to the faculty of the Department of Health Policy and Administration, UP College of Public Health.

Nurses’ professional and moral duty

Nurses have 5 fundamental responsibilities:
-to promote health
-to prevent illness
-to restore health
-to alleviate suffering
-to assist towards a peaceful death

Inherent in nursing is our duty to perform these responsibilities especially in the context of a pandemic. It is hard for many of us to turn our backs on our patients simply because we have pledged our whole lives in the service of the people.

However, times like this also beg the following questions:
Do nurses, and other health care workers, have a duty to care for patients when doing so exposes the nurses themselves to significant risks of harm and even death? More importantly, in the face of serious infectious disease, is there a duty to treat?

Our health system does not have the capacity to handle a pandemic. And this was made apparent in the previous weeks. Let me cite some experiences from the frontline (these ones I got from personal communications with nurses on the ground from various locations).
-Because of their duty to treat, some nurses were forced to perform CPR without adequate personal protective equipment or PPE on a patient with unknown COVID status.
-Some nurses left their sick family members because they were asked to report to duty.
-A nurse did not leave the patient room because her patient was unstable, unresponsive and drowning in his own urine and feces. Without any help, the nurse stayed with the patient and changed his diaper 3 times.
-Some nurses chose to stay inside patient rooms so they can properly monitor their patients because the hospital lacks proper surveillance equipment and has inadequate nursing staff. This despite hospital protocol saying that nurses should only stay in patient rooms for a maximum of two hours in an eight-hour shift.

These are some of many instances where nurses felt responsible to perform their duties despite knowing risks of harm and death. Truth be told, nurses will continue to perform their duties despite the risk of dying or acquiring the disease because many of us feel that it is our professional and moral duty to do so.

Recommendations to Address the Potential Local Nursing Shortage Amid the COVID-19 Pandemic

The role of nurses has been considered crucial in managing this pandemic, most especially in implementing strategies to #flattenthecurve. While this is the case, shortage in the nursing workforce will not make the management of the pandemic any easier. We recommend an integrated approach comprised of some or all the recommendations mentioned in this policy brief. However, these recommendations are interim solutions to a possibly chronic nursing workforce shortage in the Philippines. A national investment in the nursing profession is needed to address this shortage. Such investment will require significant political will, support, and financial investment.

Thank you Neil Roy Rosales for writing this with me. Please feel free to share with your colleagues.

Link to full policy brief: Recommendations

Foster collaborative relationships

Immediately after the news broke that three doctors died due to COVID-19, people took their frustration to Twitter and were quick to blame patients for their failure to divulge accurate health and travel history. For many, this alleged ’lie’ caused the life of an unsung hero who was at the frontline battling the pandemic.

A patient withholding facts and misleading health workers is no laughing matter. Physicians cannot appropriately diagnose and treat patients unless the latter share information freely. Thus, the feelings of anger, hatred, and frustration felt by many doctors last week were all valid. These feelings make them human after all. But, this is more than a simple case of dishonesty. To directly equate a person’s death to a lie, whether intentional or not, is a bit overstretched. Alternatively, our frustration directs us to question what could have possibly gone wrong between the patient-physician relationship.

Patients also fear for their lives, much like the rest of us in the field of health care. Some patients are intimidated, only to share their whole health history after their first conversation with a health worker.  Truth be told, it is sometimes difficult to share private information to our friends and families. What more to people you barely know? Unfortunately, this is not an excuse for patients to deliberately lie about their health status.

Although motivations for withholding the truth vary from patient to patient, options to address this problem are rooted in one concept: a collaborative patient-health worker relationship. It is important, I suppose, for our patients to feel that we trust them and that they, too, can trust us. Let us allow our patients to freely verbalize their thoughts and feelings. Let us take time to listen to them so that they can put their trust in us.

Conversations with patients are almost always difficult. But given the gravity of what’s at stake, we are encouraged to find ways to expand and make better the existing lines of communication. We are encouraged to find ways to make patients more comfortable to admit embarrassing behaviors, and facts about themselves. Finally, we are encouraged to create a trusting environment embedded in the system to allow and support collaborative relationships between patients and health workers.

The frontline

As a nurse, waking up each day is a struggle knowing that there is a high risk for us to acquire the disease. However, we are constantly reminded of our duty to the people. That it is our duty and responsibility to help those in need, especially the poor, weak, and vulnerable.

Times like this make us realize that effective communication is key. Sadly, the field of health has failed to do it well in many instances. Today, more than ever, I fervently ask our leaders to first show TRANSPARENCY. Make things clear for us. Make us understand how things will be managed, coordinated, and disseminated. Make us feel that you are on top of this and that processes are as clear as they can be.

Second, I ask for CONSISTENCY. We are tired of hearing conflicting statements, especially those from the higher ranks. Such conflicting statements create confusion which in turn causes panic. Let there be a single message from a single source.

Finally, I ask for INTEGRITY. Let us not fool each other. Again, kabaro mo na. Sana hindi ka na isahan pa. Tayo-tayo dapat ang nagtutulungan. Hindi dapat nag-gugulangan. Let us be honest to each other so we can all work well together. After all, we all aim for one goal – the end of this crisis.

The coming weeks will show how resilient and responsive our health care system is. The circumstances will test how our current systems will adapt and change according to the pressing needs of the people. Our experiences during this pandemic will surely change how we will implement the UHC law in a bigger scale in the following years.

Please pray for everyone, especially those in the frontline. It is a scary, scary world and we have nobody to save us but ourselves. Ingat!

DISCLAIMER: There is no way this post pertains to a particular individual, hospital, or organization. Before you try to twist whatever I said in this post and send complaints, please clarify them first with me. Send me a message. It’s free.

Nudging in health care

We saw a dramatic change in people’s behavior brought about by information (and misinformation) regarding the worldwide spread of COVID-19. People began clamoring for more health information and others started wearing surgical face masks to protect themselves. Following advice from the Department of Health, several organizations cancelled their scheduled conferences and conventions this year.

What surprised me, however, is the fact that many food, retail, and service companies started providing hand sanitizers not only to their employees but also to their customers. Schools, hospitals, and shopping malls did the same, and even placed posters at entry and exit points to inform the public on infection control measures that should be observed within their premises. The placement of posters, the availability of and accessibility to alcohol or hand sanitizers created a positive reinforcement that influenced individual and group decision-making leading to a change in behavior. In behavioral science, this is best explained by the “Nudge Theory”.

The reaction of the Filipino community to this actual health threat is a manifestation of how the theory works. Based on observation, some people who saw hand sanitizers and alcohols on counter tops actually rubbed some on their hands. To an extent, the mere presence of these alcohol-containing preparations ‘nudged’ people to make the right decision which is to practice hand hygiene. Studies in other countries such as the UK have been successful in providing empirical evidence to support the use of nudging to influence behavior in health care settings. Such practice, however, has not been extensively explored in the Philippines.

While we focus on containing the local transmission of COVID-19 in Metro Manila for now, health care professionals and policy makers can take this opportunity to review existing policies on hand hygiene, infection control, and even outbreaks. We have been accustomed to using the rational choice model to create policies influencing people’s behavior. Using this model, we assume that humans are rational beings and given adequate information, they will rationally act on their own self-interest. Sadly, this approach does not work well in real life. Fortunately, the nudge theory, introduced by Nobel-prize winner Richard Thaler and law professor Cass Sunstein, provides policy-makers with another approach to influencing behavior. This theory suggests that we cannot stop people from being irrational because much of instant decision-making is influenced by context and environment. We can, however, seek to influence decision-making impulses to produce outcomes that are beneficial both at the individual and societal levels.

At the moment, we are pleased and thankful for the initiatives of private companies to educate their employees and customers on proper hand hygiene, and providing the necessary facilities to practice hand hygiene procedures. In the future, we should hope to see how the government will use nudging techniques to influence people’s behavior. As the theory can be applied even in realms outside health, nudging presents a low-cost and effective policy option that can perhaps complement or replace traditional regulation with nudges to influence people’s everyday choices without restricting their freedom of choice, and imposing penal charges or taxation.

Call for fair and adequate hazard pay

How much is the price of upholding the rights of nurses in the country? For some, it costs nothing.

Nurses are at the frontline of the health care delivery system. They become the first and last health workers in contact with patients and their families. As such, nurses are exposed to low- and high-risk hazards during their working hours. Exposure to these hazards could result in discomfort, illness, and even death. It is imperative, therefore, to provide additional compensation to nurses performing their jobs in hazardous work areas.

Through Republic Act No. 7305 or the Magna Carta of Public Health Workers, the State recognizes the need to provide extra compensation to nurses for performing duties that expose them to potential health hazards. However, recent reports slap us with the reality that some nurses in the country receive little to no hazard pay.

We aspire for fair and adequate hazard pay for nurses in the Philippines. Fair in the sense that all nurses are well-compensated considering the health risks associated with the nature of their work. Adequate in the sense that it follows the rates set forth by the law. Fair and adequate hazard pay ensures the protection of nurses who relentlessly offer their lives to the service of the people. Fair and adequate hazard pay puts premium on the lives of both the health care workers and the patients they serve.
While we recognize the financial limitations being experienced by many local and provincial government units, this should not restrain the government from exercising its lawful duty to protect health workers from the dangers associated with the delivery of health care.

I call on the Department of Health (DOH) to look at the undocumented issues surrounding the non-payment of hazard pay experienced by nurses in various parts of the country. Moreover, I call on the local and provincial government units to (1) review its annual budgetary allocation and bring back health at the top of its priorities and, (2) ensure that nurses are compensated hazard allowances equivalent to the appropriate percentages as specified by the law. Finally, I call on Congress, DOH and the Department of Budget and Management to revisit the Magna Carta for Public Health Workers, specifically the provisions on salaries, hazard pay, and other forms of allowances.

The right to health is not limited to a privileged few. The government carries the burden of ensuring that this right is upheld as a human right equally enjoyed by all Filipinos. The promises of universal health care cannot be realized when the primary drivers of the health care system, our health care workers, are left at the brim.

Alagaan ang mga tapag-alaga

PNA National Day of Protest | 8 November 2019 | Kartilya ng Katipunan

Minsan. Minsan kahit katatapos lang natin sa trabaho ay iniisip na natin ang susunod na araw. Kumusta na kaya ang pasyente kong si Juan? Nainom na kaya niya ang mga gamot niya? Kumusta na ba si Maria? May kirot pa kaya siyang nararamdaman?

Madalas. Madalas iniiwan natin ang trabaho natin na mistulang post-apocalytic scene sa isang pelikula. May mga pasyente na nagsisiksikan sa iilang kama. May mga pasyente na walang mainom na gamot dahil walang pera. At may mga nurse na kayod kalabaw pero kahit pagod, gutom at ihing-ihi na, nakangiti pa ring nakaharap sa mga pasyenteng sinumpuan niyang paglingkuran. Kahit gaano man kahirap gampanan ang mga responsibilidad ng isang nars, paulit-ulit pa rin nating pinipili na maglingkod sa bayan.

Bakit nga ba tayo gumagawa ng ingay? Bakit ba paulit-ulit ang ating panawagan? Iisa lang ang sagot – dahil hindi sila nakikinig. Gusto natin alagaan ang ating mga pasyente nang husto at may dignidad. Gusto natin magtrabaho bilang mga nars na nirerespeto at binibigyang halaga. Gusto natin muling ipakita ang ligaya sa likod ng natatanging pag-aalaga. At, gusto natin na umuwing panatag na maaalagaan din natin ang ating mga sarili at pamilya.

Tunay nga ba ang kabataan ang pag-asa ng bayan? Ngunit, paano tayo aasa sa isang bulok na sistema? Para sa mga kabataang nars na gaya ko, napakahalaga ng pagtitipon na ito. Ito ang araw na minarkahan natin ang simula ng mas marami pang aksyon mula sa nagkakaisang mga nars na naglilingkod para sa bayan. Ito ang simula ng pagpapanday ng isang mas magandang bukas para sa aming henerasyon at sa mga susunod pa. Ito ang nagsisilbing katibayan na may pag-asa pa. May pag-asa pa para sa isang mas maayos, tuwid at makatao na sistemang pangkalusugan.

Hiling ng mga kabataan na tulad ko ang isang bukas na hindi perpekto ngunit malapit sa uliran: sapat na sahod, regularisasyon at hindi kontraktwalisasyon, makatwirang nurse-to-patient ratio, at ligtas at maayos na lugar ng trabaho.

Alam natin na hindi rito nagtatapos ang laban. Alam din natin na mahaba-haba pa ang lalakbayin. para sa mga inaasam. Pero kaming mga kabataan, lubos na umaasang ngayon kami ay tuluyang pakikinggan. Sa huli, iisa lang naman ang ating panawagan: alagaan din ang mga tagapag-alaga.

SG15, ipatupad!

Sahod ng nurses, dagdagan! Dagdagan!

Advocate for equal pay for both government and private sector nurses

This is in response to Maristela Abenojar’s letter titled “Pass law on nurses’ minimum base pay” (Philippine Daily Inquirer Opinion, 14 October 2019).

I am one with the Filipino Nurses United (FNU) in their call for higher wages for nurses in both the public and private sectors. However, pushing for a P30,000 minimum base pay for nurses in both sectors will not result in the equality that the proposed policy is aiming for. Currently, Salary Grade (SG) 15 is equivalent to P30,531. Thus, nurses in the public sector are already receiving a base pay higher than what is being proposed.

When Congress decides to change the law, it usually does so prospectively. Therefore, rather than setting the minimum or base pay at P30,000, it might be more beneficial (for private nurses) if we lobby for equal pay for both private and government nurses. Equal pay would mean pegging the salary of all nurses, whether in private or public sector, at the base pay set by the law for government nurses which is SG 15. Hopefully, in the long run, any increase in the base pay of government nurses based on the Salary Standardization Law and General Appropriations Act would mean the same increase for those in the private sector, creating an equal footing for all nurses regardless of the sector they are working in.

While this is a far-fetched policy alternative, with possible resistance from private health care institutions, it will guarantee private nurses with salaries at par with salaries of government nurses. I call on FNU, the Philippine Nurses Association (PNA) and Bayan Muna partylist to review House Bill No. 3478 and look at other policy alternatives that will ensure Filipino nurses’ right to just compensation.

Filipino nurse: a global good?

Do we cast Filipino nurses as “global goods” rather than “domestic providers” of health care? Do we implicate them as sources of remittance income rather than for their potential contributions to the local health system?

Trade in health services is continuously growing. There are four ways based on the General Agreement on Trade in Services (GATS) by which the Philippines can take advantage of. In particular, Mode 4 (Movement of Health Professionals) offers possibilities for the entry and temporary stay of health professions in a foreign country in order to supply a service. Two forms for the international trade in health services exist: (a) temporary movement of health professional to provide services abroad, and (b) short-term health consulting assignments. As such, developing countries including the Philippines, export health care professionals to other countries most especially to the developed ones.

The ASEAN Economic Community promotes different forms of trade in health services. It ranges from exportation of cross-border health care to migration of health professionals, and direct foreign investment in the health sector. The liberalization of trade in health services, espoused by the ASEAN Integration, has further promoted the migration of health professionals.

The Philippines is known to be among the countries with the highest labor exports. Since the “world price” of nurses is higher than the “local price”, the Philippines has a comparative advantage in producing nurses, and substantially gains by producing and exporting more. According to the Commission on Filipinos Overseas, 4.3 million Filipinos were living outside the Philippines under temporary, work-related residence programs. Many health professionals are among those living outside the country for work-related reasons.

The majority of deployed health professionals are nurses, which is estimated to be around 87,000. These nurses are deployed mostly in the Middle East. Destination countries for temporary residents include Saudi Arabia, United Arab Emirates, Kuwait, Hong Kong, and Qatar. For permanent residents, the destination countries include USA, Canada, Australia, United Kingdom, and Japan.

Several reasons push nurses to leave the Philippines. The main push factor identified by nurses is low salary. Other push factors include poor work environments and lack of employment opportunities. On the other hand, nurses are primarily attracted to better working conditions and higher remuneration offered by other countries, which is about five times more than they would receive in the Philippines.

The movement of health professionals from low-income to high-income countries somehow improve economic efficiency. For receiving countries, migration helps alleviate shortages of domestic health professionals observed in middle- and high-income countries.

In a way, migration tends to ease the sending country’s problem with unemployment by allowing unemployed and underemployed health professionals to take on jobs that are available for them abroad. More importantly, one of the favorable effects of nurse migration for the sending country such as the Philippines is the considerable remittances sent home by these nurses each year. In the case of Filipino nurses, a significant share of their earnings is usually remitted home. The remittances of these health workers help finance the health care needs of the local population.

Unfortunately, these remittances will not be able to offset the loss of skilled nurses due to migration, leaving behind an already disadvantaged health care system. How do we balance competing interests in overseas health professionals’ remittances and the need for qualified health workforce in our weak health system extremely affected by the uneven distribution of health workers?

The migration of HCPs has the potential to create an imbalance in supply and demand of health workforce in both the home and destination countries. So far, the migration of nurses from the Philippines has not led to any domestic shortages unlike in Indonesia and Malaysia where migration exacerbated shortages of nurses. The mushrooming of nursing schools in the Philippines has relieved concerns on the potential domestic shortage of nurses due to exportation. However, concerns with the quality of education provided by new nursing schools have been raised in recent years.

Another negative effect that the Philippines experience is the loss of educational expenditure. When a government-subsidized nurse migrates to another country, the Philippines do not only lose a health care professional but also the money invested in his/her education. However, if nurses return home after a number of years, they will be bringing back with them new knowledge and skills. In contrast, permanent migration risks substantial human resource or capital losses with expected long-term effects on social and economic development.

Clearly, trade in health services creates both opportunities and risks. At the end of the day, it is important that we ask who truly gains and loses in this kind of trade. Do the losses, if any, exceed the gains? Is this kind of trade motivated by the government’s desire for revenue? Or is it motivated by the desire to cope with overproduction and lack of job opportunities for nurses in the Philippines?

References:

Arunanondchai, J., & Fink, C. (2007). Trade in health services in the ASEAN region. The World Bank.

Dayrit, M., Lagrada, L., Picazo, O., Pons, M., Villaverde, M. (2018) The Philippines health

system review. World Health Organization Regional Office for South-East Asia. Retrieved from http://apps.searo.who.int/PDS_DOCS/B5438.pdf

Lorenzo, F. M., Galvez-Tan, J., Icamina, K., & Javier, L. (2007). Nurse migration from a source country perspective: Philippine country case study. Health services research, 42(3 Pt 2), 1406–1418. doi:10.1111/j.1475-6773.2007.00716.x

Rodolfo, M. C. L. S., & Dacanay, J. (2005). Challenges in Health Services Trade: Philippine Case (No. 2005-30). PIDS Discussion Paper Series.

Sriratanaban J. (2015). ASEAN integration and health services. Global health action, 8, 27199. doi:10.3402/gha.v8.27199