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.

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

Pen Point 37

Trade in health services, especially the migration of healthcare professionals (HCPs), is continuously growing.  As such, developing countries such as the Philippines, export healthcare professionals to other countries (mostly developed countries). The liberalization of trade in health services, espoused by the ASEAN Integration, has further promoted this migration of health professionals. Since the “world price” of nurses is higher than the “local price”, the Philippines has a comparative advantage in producing nurses, and gains by producing and exporting more. Obviously, one of the favorable effects of nurse migration is the considerable remittances sent home by theses nurses each year. Unfortunately, these remittances will not be able to offset the loss of skilled nurses due to migration, leaving behind an already disadvantaged health system.

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. The mushrooming of nursing schools in the Philippines, however, has relieved concerns on potential domestic shortage of nurses due to exportation. Another negative effect that the Philippines experience is the loss of educational expenditure. When government-subsidized nurses migrate to another country, the PH do not only lose a HCP but also the money invested in their education.

 

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

Does this kind of trade in health care promote the realization of self-interest or social interest? Who really gains and loses from this trade? Do the losses, if any, exceed the gains? Is this kind of trade not only motivated by the desire for revenue, but also by the desire to cope with overproduction and lack of opportunities for nurses in the Philippines?

A Day in the Life of a Neuroscience Nurse

2019_0101_07144600

There is no typical day for a nurse. No, really, there isn’t. Every day or shift has the potential to be exhausting, challenging, inspiring, or everything combined. On any given day, nurses often see patients (and their families) at their weakest and most vulnerable, but sometimes at their strongest.

Nurses usually spend more than 8 hours in the hospital tending to the needs of their patients. For neuroscience nurses, 8 hours might not even be enough to do everything that you want and need to do for your patients. Almost all the time, neuroscience nurses handle patients diagnosed with cerebrovascular disease or stroke. However, there are times when patients with autoimmune diseases (i.e. Guillain-Barre syndrome, multiple sclerosis, chronic inflammatory demyelinating polyneuropathy) are admitted in the hospital. These patients warrant almost the same level of care as stroke patients.

It is almost impossible to write about a typical day for a neuroscience nurse given the fact that healthcare workplaces vary and the actual work differs from shift-to-shift depending on the type and number of patients a nurse needs to care for. The following is a broad outline of what a workday might be for a neuroscience nurse in the Philippine General Hospital during an 8-hour morning shift.

Early Bird

A nurse’s day often begins even before the sun is up. Most nurses have taken a bath and / or eaten breakfast before other healthcare professionals even hit their alarm’s snooze button. Those who do not live within the vicinity of the hospital often ride a bus, jeepney, or train to get to the hospital. You are lucky if the commute only lasts an hour or less. On a usual weekday, travel time doubles and sometimes even triples.

Some nurses arrive as early as an hour before the actual shift starts. The time is spent preparing for patients’ medications. Some oral medications (tablets) need to be crushed as they will be given to patients with dysphagia (inability to swallow as a consequence of stroke) via nasogastric tube. A tray will often be filled with vials of antibiotics that are diluted at least 30 minutes before they are administered to patients. Ampules of paracetamol, dexamethasone, and furosemide are immediately broken and aspirated into a syringe one after the other.

Sometimes, a nurse will do a quick round in the ward to see how many are intubated and connected to a mechanical ventilator. He/she then proceeds to prepare materials for tracheostomy or endotracheal tube care which will commence after the handover.

Handover

A hospital isn’t like any other workplace where one shift ends before another begins. Morning, afternoon, and night nurses usually work as a team ensuring that patients receive seamless care. This is made possible through nurse-to-nurse endorsements (handoff of information) at the start of every shift. The morning shift nurses get information from night nurses about what happened overnight, as well as other pertinent patient information or needs that are essential for the next shift. Depending on the number of patients, handovers usually take 30 minutes.

It is also during the handover when nurses check for supplies and inventory to make sure they have enough for their shift. The code cart (emergency cart or e-cart) is typically used for emergency cases such as when a patient goes on cardiac arrest. The e-cart contains essential emergency drugs, including epinephrine, used during cardio-pulmonary resuscitation (CPR). Hence, in the neurology ward (where a high-stress situation could easily arise), it is a-must for nurses to check the supplies contained in the e-cart every shift as one wouldn’t want to run low on supplies during emergency situations.

Morning Rounds

Average days or routine work doesn’t happen when you’re dealing with many patients, especially those in the neurology ward. Mornings are often busy for nurses. A lot can happen during and in-between shifts. Much of the hours in the morning are spent on hourly assessing the condition of patients, taking their neurologic vital signs (blood pressure, heart rate, respiratory rate, temperature, GCS, & pupil size and reaction to light), and monitoring blood sugar of patients with diabetes.

Neurologic diseases often affect cognitive as well as motor/muscle function. As such, more than half of the patients are highly dependent on the nurses. During the morning rounds, nurses often position these patients on high back rest. This is in preparation for various morning care routine and the subsequent tube feeding.

The actual work starts by administering Salbutamol through a nebulizer followed by suctioning of secretions (i.e. sputum, saliva). The ward has only one nebulizer and three cheap portable suction machines that are used for 18 patients. Suction machines use ‘suction’ to pull out pooled secretions in the patient’s tube or mouth to remove obstruction in the airway. Unfortunately, some of these machines have worn out, unable to effectively suck thick, frothy secretions. As a result, some of the patients’ relatives often take the initiative to buy their own machine/s.

After routine morning care and bathing, both oral and intravenous medications are administered to patients. Some patients have multiple antibiotics which are run for 1-2 hours each. Others are given hypertonic saline solution ranging from 150 mL to 400 mL depending on the latest serum sodium of a patient.

Oral medications are mostly given via a nasogastric tube before or after (depends on the medication) tube feeding with osterized (blended) feeding or milk. Patients are left on moderate to high back rest positions after feeding, and observed for drug-related adverse reactions.

Noon

Patients’ vital signs are continuously monitored throughout the shift. Other explicit and implicit needs of patients (e.g. suctioning, bed turning) are also addressed throughout the shift.

Some doctors ask for blood, urine, and sputum samples from their patients to be tested at the hospital laboratory. Neurology nurses often take these samples at or before noon and are eventually collected some time after by a laboratory aide.

Other procedures such as x-ray, ultrasound, and CT scan have varying schedules and these procedures should be taken into account when planning the care of patients. Routine care can be disrupted by these procedures especially when they are ordered stat (medical abbreviation for ‘immediately’ or ‘urgent’).

Some patients who are ordered to be discharged from the hospital are assisted by nurses in accomplishing hospital billing clearance. Most patients in the charity wards go home without paying a single centavo as they are required to enroll in Philhealth (the Philippines’ national health insurance provider). When a patient’s hospital bill is beyond the case rate determined by Philhealth, he/she is automatically referred to other government institutions (e.g. DSWD, DOH, PCSO) for financial assistance.

Patients who are to be discharged are also referred to the hospital’s Dietary Department for nutrition-related lecture conducted by a nutritionist/dietician. Patients with diabetes who are already insulin-dependent are taught by nurses about diabetes and insulin administration prior discharge.

As most days are busy, nurses will often try to take some time for lunch in the middle of the day. This doesn’t always happen though. Sometimes, a ‘lunch’ would be whatever you could grab in-between nursing tasks. Nothing’s guaranteed for nurses, especially a decent mealtime (and even toilet time). Having the time to eat can be a luxury when you’re dealing with an endless list of patients who have immediate needs all day.

Afternoon Rounds

Much like the morning rounds, afternoon rounds kick off by checking if any patient’s status has changed since the last rounds. Some patients require strict hourly monitoring especially when their blood pressure readings are erratic. A patient may be given nicardipine (to decrease BP) or norepinephrine (to increase BP) which is titrated hourly to maintain a specified blood pressure.

By the afternoon, some patients could have been discharged or released but several more will have been admitted in the interim. Nurses can often find themselves managing new patients and administering any medications that need to be given at that time. And of course, during this time, most nurses catch up on charting/documenting nursing care and carrying out doctors’ orders.

The afternoon also include visiting hours. Nurses often use their ‘people skills’ during this period. Nurses are often tasked with updating family members on a patient’s condition. They also educate new patients (and their families) about their diagnosis, treatment and nursing care plans, as well as unit/hospital rules and regulations. Nurses will have to answer patient questions and ensure that both the patient and his/her family have adequately internalized what they need to know.

Handover

Despite the toxicity, one may consider it a good day if no patient went on cardiac arrest or had to be intubated.

Before going home, a neurology nurse will have to make sure that everything has been properly documented. Nurses will have to double-check patient charts and update handover notes for the next shift. Nurses need to make sure that the transition to the next shift goes as seamlessly as it was in the morning so that patients are getting consistent care.

When the afternoon shift nurses arrive, morning shift nurses (usually the charge nurse) will brief them and leave the care of their patients to these nurses with equally capable hands. After the final ward rounds, morning shift nurses go home, enjoy their hard-earned rest, and start again the cycle after 16 hours.

End Notes

There is no typical day for a nurse, especially a neurology nurse. No matter what a nurse does, or where he/she does it, there is always the unpredictability of how a day will start and end. It is an incredibly demanding field, but it can be a rewarding and fulfilling one.