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The Philippines is fast losing its skilled nurses to the world’s
developed economies at a serious cost to the quality of its own
health-care system.
Turnover rates on a national scale have reached
40 percent to 60 percent annually, said Dr. Marilyn E. Lorenzo,
director of the Institute of Health Policy and Development Studies
and professor at the UP College of Public Health.
This means that of a hundred nurses, 40 to 60
leave every year. Partial results from a continuing survey among
government hospitals show nearly half of a hundred nurses leave
every year, said Lorenzo.
Compounding the outflow is an internal migration
where nurses in the rural communities and in primary and secondary
hospitals flock to the urban areas and tertiary hospitals to get the
hospital experience needed to be hired abroad.
As a result, an already inadequate delivery of
health services in rural and remote areas is further compromised,
affecting the poor and vulnerable population groups.
Impact in Mindanao
Southern Mindanao has 42 towns and 4 cities. The
region comprises the provinces of Davao Oriental, Davao del Sur,
Davao del Norte, Compostela and Davao City.
Rural health teams perform primary health-care
functions for communities. These teams provide technical assistance
and carry out programs on immunization and disease prevention and
control. Each team is composed of a doctor, nurse and midwife.
The ideal ratio is one doctor for every 40,000
residents, but the actual ratio in the region is one doctor for
80,000 to more than 100,000 residents. Dr. Dolores C. Castillo,
regional health director for Southern Mindanao, said a third of the
region’s 42 towns have more than 40,000 residents. These areas
obviously need more than one doctor, she said.
“But with more doctors shifting to
nursing so they can work abroad, where do we get doctors?”
Castillo asked. This school year there was already a
significant drop in applications to medical schools. One such school
saw a 20-percent drop in enrollment, she said.
Nurses who work in rural health teams have not
been leaving in significant numbers, said Castillo. “What keeps
them here are the exam requirements for work abroad and the costs of
complying with them. But as soon as recruiters offer to subsidize
these costs as part of their package, our nurses will leave,” she
said.
“We also expect to lose our midwives, who will
work as caregivers abroad. If we start losing our rural health
unit teams, who will take care of the barangays?” she asked.
Crippled operations
From tertiary hospitals in Manila to rural
hospitals in Southern Mindanao, the situation is the same. The
steady exodus of skilled nurses is crippling the country’s
hospital operations and lowering the standards of quality health
care.
Specialized procedures such as open-heart and
cancer surgeries in some of Metro Manila’s big hospitals have been
delayed because there aren’t enough skilled nurses to man
operating tables, said Maria Linda Buhat, president of the
Association of Nursing Service Administrators of the Philippines.
Buhat, who is also assistant director for
nursing services at the Philippine Heart Center, declined to name
these hospitals.
At the San Pedro Hospital in Davao City, the
surgical intensive-care unit was closed down for lack of nurses to
man it, said Elsie Tee, dean at the San Pedro College of Nursing.
The hospital has since merged the unit with another ICU.
To illustrate the drain of key health-care
professionals, a survey of eight hospitals in Southern Mindanao from
1998 to 2001 showed a dramatic rise in the percentage of nurses who
resigned to work abroad. The proportion rose to 28.75 percent in
2001 from 4.74 percent in 1998.
In a survey done by the Davao Regional Hospital
late last year, about 82.5 percent, or 63 of 118 respondents, said
they plan to work abroad. “This is alarming because we have about
91 nurses doing direct nursing care and of that, 52 are leaving,”
the report noted.
The Davao Medical Center, Mindanao’s leading
government tertiary hospital, reports that at least two nurses leave
a month. In 2000 the average was five resignations a month, said Dr.
Gerardo D. Cunanan, its chief.
At Davao Doctors’ Hospital, a private hospital
in Davao City, the figures are higher–5 to 20 nurses leave in a
month. Dr Herminio A. Villano Sr., its president, gets requests for
urgent replacements on his desk every day.
At a regional hospital in Southern Mindanao, 3
of its 12 head nurses–as well as half of its team of 12
operating-room nurses–have left to work abroad.
Ruth Danganan, chief nurse of Brokenshire
Hospital in Davao City, said the head nurse of the hospital’s
emergency room has left, and his replacement is also leaving. The
head nurse of the operating room also left for the US last year and
her replacement is also leaving.
Danganan, an experienced ICU nurse herself, is
also leaving for the US in six to eight months.
The impact on those who are left behind can be
demoralizing, said Vilma Comoda, chief nurse at the Davao Medical
Center. “Sometimes our nurses are forced to work 16 hours
straight. Taking leave is a luxury,” she said. Nurses are made to
take care of 20 to 25 patients in critical-care wards. The ideal
ratio is 1:1.
“Fewer nurses mean less care for patients to
the point of jeopardizing their lives. They also mean that the ones
who are left have to work harder and harder and harder,” noted a
2002 report by the nursing staff at the Davao Regional Hospital in
Tagum City.
Procedural lapses
When nurses with 3 to 10 years’ experience
leave, and are replaced by nurses with zero to one year of
experience, the result is a deteriorating quality of health care.
Patients often complain of procedural lapses
like delays in giving medicine. Danganan said patients often ask her
about the young, new nurses: “Marunong ba ’yan? [Are they she
knowledgeable?]”
At Iligan City’s government hospital, 16
of the 40 regular senior nurses have left, and 8 of them were
replaced by young, inexperienced nurses, said Dr. Angelo H. Manalo,
director of medical education at the Mindanao State University’s
College of Medicine.
Some of the nursing duties have been turned over
to midwives and attendants. Senior nurse supervisors and others in
administrative positions also fill the gap. Off-duty nurses are also
required to go on duty, added Manalo.
“The quality of health care has definitely
deteriorated–charting is often missed, medications are given by
the patient’s watchers and monitoring done by midwives. This
makes the system prone to errors,” he said.
Quality care has also slipped in private
hospitals, said Villona in Davao City. “Experienced nurses have a
better clinical eye and have a better assessment of the patient’s
condition. But inexperienced staff lack critical thinking and
decisions” are delayed.”
Inexperienced nurses also don’t know how to
triage–give importance or priority to patients who demand
immediate attention, and what kind of attention, said Dr. Romulo A.
Busuego, chief of hospital, at the Davao Regional Hospital in Apokon,
Tagum City.
Danganan notes with concern a marked difference
in the general attitude among new nursing graduates, especially
among the “second coursers,” or those who take nursing as a
second profession.
She and several hospital officials note that the
new graduates aren’t “service-oriented, do not seem dedicated
and are intolerant of the workload.”
“They look at the profession merely as a
steppingstone to a better-paying abroad. Most of them stay with us
from six months to one year while waiting for their papers,” said
Danganan.
Quality care begins from one’s training in
school, but even here the quality of training is also slipping, said
Tee at the San Pedro College of Nursing in Davao City. The school is
one of the country’s centers of excellence in nursing.
She said the education system has not kept pace
with the increased demand for nursing education. Most teachers lack
hospital experience and academic qualifications. She noted no
incentive for teachers to take postgraduate courses, since most of
them are biding their time and intend to leave.
“With that kind of training, what kind of
service will nurses give to their patients? Our head nurses in the
hospitals are getting older,” said Tee. “When they’ve had
enough, who will train the new nurses? More important, who will
propagate the culture of quality care?”
Conclusion
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