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Nurses going abroad: We train, they gain

Nurses going abroad: We train, they gain

By Francis Cueto

First of two parts

A fortnight from today, 35-year-old Esperanza Reyes Alvaran will be boarding a flight that will take her to San Francisco. From there, it will be a short bus ride to Daly City, where a nurse’s job awaits her.

And although the mother of two has had to step down a couple of rungs in the career ladder (she was a teacher at a Quezon City nursing school until last June), the compensation package her new job offers is more than enough to justify her not-too-painless decision. She will be earning five times her present income.

Mrs. Alvaran says she has only one overriding motivation behind her part in the current Philippine diaspora: Her family.

“Who would want to be separated from their children and husband?” she asks. “They are your family.” Her eldest child is 10.

“But I simply can’t let this opportunity pass us by.”

Before her teaching job, Mrs. Alvaran worked as a nurse at a hospital in Mandaluyong City. She started teaching in 1999.

She says she witnessed how the nursing student population ballooned from “a handful” when she started teaching, to the high numbers today.

Ticket out of poverty

Mrs. Alvaran is but one of the thousands of Filipinos who have found—or are hoping, anyway—that nursing is their way out of poverty, their sure ticket to better-paying jobs abroad, and—who knows?—the shortest route to getting that coveted green card in the US.

But is it, really?

Some 20,000 nursing students graduated from 350 schools throughout the country in 2005. As more and more developed countries open their doors to migrant health workers, most of the new graduates made a beeline for jobs overseas. That’s the upside.

A good number failed to pass the qualifying exams for nurses. (In the past few years, less than half of those taking the nursing board exams passed.) Or, given the recent scandal involving leakage in the questions for the board examination for nurses, some countries are beginning to entertain second thoughts about getting nurses from these shores.

Former Health Secretary Dr. Jaime Galvez-Tan, now a professor at the University of the Philippines College of Medicine, says the Philippines leads other nations in the export of nurses. Some 164,000 nurses—85 percent of the country’s total—are working outside the Philippines in 46 countries. Out of this total number, about 100,000 have left in the past 10 years, lured by better pay abroad.

Nurses in Philippine hospitals—public and private—are paid between P3,000 and P6,000 monthly. In countries like Japan, the US and the United Kingdom, they could earn between $3,000 and $5,000 a month.

Boom in schools

The high demand for nurses triggered a boom in nursing schools, which sprouted to accommodate the inordinately high enrollment. This in turn led to a decline in the quality of nursing education.

The graduates fortunate enough to make the cut lost no time in applying for jobs abroad, most of them skipping the minimum one-year experience required by hospitals abroad.

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.

No one disagrees that the quality of nursing in the country has deteriorated over the years. While the number of graduates may have increased, the quality has decreased considerably.

Who is to blame for the deterioration?

Data from the National Institute of Health show that migrant health workers (nurses, physical and occupational therapists and midwives) are generally young, aged 20 to 30. 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 who are now taking up nursing. Age is not a hindrance to working abroad, specially in the United States, where one can work for as long as one is able to.

Although the number of male nurses is 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 institute’s study also warns that because the nurses who emigrate 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 postsurgery effects, accidents, injuries and even increased violence from the hands of unskilled, unprofessional nurses.

Cross-stitch matrix

It won’t be a rare day when a patient under an unskilled nurse preparing him for dextrose would find the back of his hand with puncture marks similar to a cross-stitch matrix because she found the vein only after several unsuccessful jabs.

Often going abroad almost as soon as they graduate, the best among new nurses leave a void that 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 they’re outtathere. It is, say many health professionals, a cycle that leaves local hospitals in a state of perpetual displacement—and Filipino patients in constant danger.

Next to India, the Philippines is 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 owing to 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 further deteriorate. To Rita Tamse, deputy director for nursing of the Philippine General Hospital, “That worst is happening right now.”

Julito Vitriolo, executive director of the Commission on Higher Education (CHED), agrees. He even traces the roots of the problem further back: The quality of teaching.

“The teachers lack experience,” he told The Manila Times. He says some of these professors in nursing courses were “forced” to mature as teachers owing to the scarcity of medical instructors.

“Because of the worldwide demand [for health workers] the brightest in the faculty, and even medical instructors in the hospitals elect to go abroad. Naturally, the neophytes are the ones left behind. Because of the worldwide demand we run out of experts to impart knowledge,” he said.

Vitriolo lamented the government’s lack of a clear program on how to stop the deterioration in the quality of our medical experts.

Graying population

He explains: People in developed countries have a longer life expectancy, the so-called graying of the population. But their younger people are not interested in the nursing profession, because of the difficult and risky work conditions: night duty, taking care of the sick and possible exposure to HIV/AIDS. They also have more options for other professions that offer better pay and working conditions.

The solution for these countries: hire foreign nurses to do the job. The US would need around 10,000 nurses a year; the UK, Ireland, the Netherlands and other European countries would need another 10,000 nurses a year.

Austria and Norway also announced their need for foreign nurses this year, and Japan, a new market, is expected to open its doors to foreign nurses this year.

But are our nurses prepared to do the job?

Ray A. Gapuz, founder and professor of the R.A. Gapuz Review Center, has some doubts. He recounts a session when a student asked him what the difference was between two basic medical terms.

“It’s disappointing to have a student who does not know the difference. And this was a student about to take the board exams,” Gapuz told The Manila Times.

Board exams leakage

The R.A. Gapuz Review Center figured in the news recently when the Professional Regulatory Commission traced the leak in the latest nurses examinations to the institution. Dr. Gapuz would explain later that it was an honest mistake. The questions were faxed to the school by a source, he said, and the school passed them on to its students, thinking they were review materials. Gapuz said it was the school’s policy to exchange review materials with its contacts.

Vitriolo and Gapuz suggest going back to basics. The nursing curriculum, they say, must be adapted to the course and attuned to the times.

“What we need is to review the nursing program of the Philippines and make it more global and attuned sa ginagawa sa international centers and market,” says Vitriolo.

He added that if there is a deterioration in the quality of nurses today the old schools and not the new ones should bear the blame, since the new schools have yet to graduate nursing students.

Some 100 new nursing schools have been established since 2004.

Vitriolo and Gapuz also agreed that the deterioration in the quality of nursing education in the country is a cause for alarm.

The Technical Committee on Nursing Education blamed this predicament on the substandard programs offered by many nursing schools as well as the lack of basic facilities and the large number of enrollees.

Among the issues CHED failed to address, the committee said, were the commission’s insistence on using secondary hospitals as base hospitals; the problem in the selection process for members of the technical committee; the lack of support and trust for the committee’s assessment of nursing programs; and the inconsistent interpretation and implementation of policies and standards by the CHED central office and the regional offices.


The inconsistent interpretation, the committee said, has created confusion among nursing deans, students, the Department of Health and the Professional Regulatory Commission.

The committee said CHED lacked the political will to close down schools that fall in the “very poor” category or those that have failed to meet the minimum 5 percent passing rate requirement.

Last year CHED announced it would crack down on nursing schools that failed to meet the standards as it raised the passing rate requirement to 8 percent. It said it would also refuse permits to applicants that lack basic facilities such as base hospital; a one-to-eight faculty-student ratio; affiliation with an active hospital; and a qualified dean and faculty.

CHED Resolution 475 also set the guidelines for the phase-out of nursing schools that have performed poorly in the licensure examinations.

The new measure having been taken, 23 nursing schools failed to meet the requirement and are facing the possibility of being shut down.

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 had 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 scored zero. 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’s plans might seem draconian. 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.

CHED and the Technical Committee on Nursing Education have identified the areas where most nursing schools failed to make the grade: the faculty-student ratio, hospital affiliation and a qualified dean and faculty.

Authorities complain, however, that too many schools have sprouted too soon, as more and more Filipinos want to become nurses so they can leave the country and work abroad.

Tomorrow: Stanching the hemorrhage


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