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Friday, September 4, 2009

Just By Being There: Nursing Beyond Limits’ In A Time Of Crisis

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(Keynote speech at the Midyear Convention of the Association of Nursing Service Administrators of the Phils., Inc., August 20, 2009, Fiesta Pavilion, Manila Hotel, with the theme “Nursing Administrators: Leading Beyond Limits”)

STANDING here—rather, trying to stand here because I just checked out of The Medical City for a bad back; forgive me if I seem a little intimidated before such a powerhouse group of health-care professionals. I refer to nurses, who are constantly in the front line of health care.

It is with nurses that patients are longest and most directly in contact in the patient’s most vulnerable state: administering drugs, taking blood pressure and temperature, monitoring the progress of our ailment and recovery, paying heed to our discomforts.

In mentioning powerhouse professionals, I refer also to doctors, whom I have observed the nurses sometimes consult.

What is evident is that it is nurses who are constantly observing the effects of the treatments prescribed, I guess to check if they are right, if they are working as expected, if they are too much or too little. And always and ever, attending to the patient’s constant need to feel less discomfort in this part or that, feel less pain. Standing as a constant assurance that whatever the hour someone who knows cares. The best nurses have this ability to make you feel like the only patient on the floor.

So naturally I am thrilled, although barely able to stand before those in whose hands, just a few days ago, I surrendered my fate: my fate as an invalid and my only hope of getting well, along with the doctors of course.

I am sure the doctors in the audience are chuckling and other members of the audience who are not nurses are amused.

Do not be. I am serious, for what I have just related is, if not the only, certainly the most prevalent and direct experience of medicine, medical attention and any other facet of health care that a patient has.

And it is the patient, after all, who stands, or rather lies in hospital gown, at center stage of the universal drama of human ailment and health care. Whenever the curtain rises on this drama, the spotlight is longest on the patient and his nurse.

Always has been, since Florence Nightingale

This was so since Florence Nightingale injected her presence into a man’s world and demanded more humanity from military surgeons on the battlefield, as they decided with cold detachment who was too hurt to go on living and who was worth the trouble of saving.

What of the rejected, and what of those whom the cure was killing more surely than the disease? It was for them that Dame Nightingale created modern health care and entrusted it to women.

From Dame Nightingale to Mother Teresa, the nurse’s code has been the hard and iron duty to be soft with those who are hurting, to be firm with those who are malingering, to watch at every step the progress of an illness or recovery so that nothing but wellness is irreversible; always and ever to care for as long as there was a living spark there. While there is life there is need for care, and if there is no more hope of recovery, there is always the imperative of nurturing every living moment that remains. Because life, however short it is expected to be, however long its suffering must extend, deserves a nurse’s total care. It is the patient, who may often be difficult and sometimes impossible to like because discomfort makes him so, who is the main focus of the nurse’s attention.

When the all-powerful French Cardinal Richelieu, the contrabida in The Three Musketeers movie, went to his dying king, it was not as a doctor to cure him but as a nurse to give him comfort, feeding him, from time to time, a teaspoon of raw egg. So it was not as a doctor that the great cardinal came to the king, to assure him that he would make him well as he had made him great, but as a nurse to comfort the king in his dying.

At this hour, I should be at my radio show, Karambola, laughing at all the problems of bad government. But this is a serious audience of people with serious commitments and concerns. And you are not in a laughing mood.

I don’t blame you.

The richest countries in the world lack nurses but no effort is made by them to make it easier to recruit our nurses, who are, far and away, the best. Instead, many nurses have to depend on unscrupulous recruiters here and worse employers abroad. The attitude abroad seems to be, let the nurses go through the eye of a needle and a gauntlet of overwork and underpay and other discriminatory practices, and then maybe, just maybe, let them stay on as second-class citizens.

Meanwhile, Philippine recruiters squeeze the nurses for more than they can afford before they leave, sometimes for nonexistent jobs abroad. Then they tie them down to financial servitude for the duration of their exile. Meanwhile the country’s foreign-exchange reserves grow from nurses’ remittances so politicians can change their ill-gotten gains to dollars for their junkets abroad.

Our country sorely needs more nurses; but going by the law of supply and demand and considering how poorly nurses are paid, you would think we had more than we know what to do with. I will let the private hospitals explain for themselves why this is so. But, coming from government, I can tell you the government has no excuse not to pay nurses more. The government is swimming in money. Look at the expected revenues, and look at the budget. There wouldn’t be a budget deficit if government were smart enough to spend more money on nurses than it throws away on bad projects for the kickbacks.

And, let me tell you, coming as I do from government, that the private sector could pay nurses much more if only the government stopped squeezing the private health sector for more and more taxes, and gave the sector as many tax exemptions, tax holidays and outright financial grants and easy credit as government does to so-called foreign and local pioneering enterprises. What is so pioneering about selling gasoline and yet government allowed Shell and Petron to escape taxes through a tax-credit scam that the government is too slow to prosecute up to now.

Poor national health care and the plight and proper place of the nursing profession in health-care reform, all these are problems to which the fastest and best solution is to throw money at them. Insufficient training of nurses after graduation? Subsidize their training with cash grants to the nurses and tax holidays to the training hospitals.

Ineffective nursing education? Throw more tax holidays and financial assistance at nursing schools; devote more funds to the stricter monitoring and regulation of teaching practices and educational standards in the nursing schools.

Is it wise to throw money at problems? Of course it is, as the most serious economists today recommend in the global crisis.

But if we do not have all that much money to throw around, we surely have more than enough to “devote to”—that is the proper phrase, “devote to” and not throw around—one of the highest priorities of government: the national health.

‘Beyond limits’

The theme of your convention—“Nursing Administrators: Leading Beyond Limits”—imposes on yourselves a part of the formidable challenge of national health care.

There’s no glossing over, no understating, the problems that our health care sector faces; much less the very real limits that tie the hands of those seeking to solve them. But since you have so bravely undertaken to go beyond those limits, I will try to walk with you down a road that’s hardly taken.

First of all, let me congratulate those of you who have opted to stay behind in this country, when we all know that the overwhelming majority of people studying to be nurses do so in hopes of landing better-paying jobs abroad.

I do not begrudge them for seeking not just greener pastures but pasturage of any description.

Nor do I conclude that those who chose to stay do not need the better pay that nurses get in First World countries.

Those who stay, attend to the sick over here. But they suffer the frustration of not being able to do as much as their training would allow them. Too few people can afford the quality health care that our nurses are equipped to give. And government isn’t spending enough to bridge the gap between increasing health care needs and the diminishing capacity to meet them—on the part of the Philippine health care systems, doctors, nurses, hospitals, clinics and on the part of patients.

Universal health care would create a whole new universe of nursing opportunities right here in our country—and government can afford it, if it only stops stealing.

Those who chose to leave, on the other hand, trade off family for better opportunity—many times so as to help family back home. What they get instead is years of loneliness and hardship, as they struggle to cope with a higher standard of living with what remains of their pay after the recruiters get their share.

These are tough choices.

Consider: a nursing graduate who lands a job in a small private hospital would be “lucky” to get a salary of P10,000 a month. The usual entry level is P8,000. Recently, as a result of the enactment of the amended salary standardization law, nurses in government hospitals are now entitled to a salary range of between P14,000 and P18,000; better but far below starting rates for Filipino nurses who make it to the US, the UK, Canada or, heaven forbid, the Middle East.

Little wonder that most nursing administrators are reeling from the fast turnover of newly trained nurses; no sooner have nursing administrators finished training one batch than another foreign-based recruiter poaches them.

Ironically, even as more and more nurses are being graduated, trained, and then recruited abroad, most hospitals—private and public—have the same complaint about not having enough qualified nurses. In short, we seem to have an oversupply of under-trained nurses. So we have too many “nurses” in quotes and too few nurses without quotes to go around. Many of the good ones are poached by foreigners.

Frustrating paradox

This paradox arises from a frustrating situation: the nursing employment “boom” in other countries fueled the rise of so many nursing schools in this country, including not a few diploma mills. This June, 32,000 aspiring nurses passed the board exams. Where will these go, when there aren’t enough hospitals that can give them adequate training?

Ideally, you shouldn’t shortcut the training of a nurse, and a young nursing graduate is expected to post many months and hundreds of man-hours in the wards, the emergency and trauma rooms, in ICU and surgery. But comparatively too few get the chance.

In hospitals where such training is taken seriously, there are even more frustrating trends. As soon as a nurse finishes the ideal period for training, the headhunters descend on the hospital to harvest them.

We see here a net resource transfer from poorer to richer countries. Long before nurses can be deployed abroad to earn enough to repay recruiters and remit their better wages to families back home, and thus make the brain drain worthwhile in other respects—long before that can happen, they are poached by foreign countries that did not spend a cent on their education and training.

I can commiserate with the exasperation of nursing service administrators who have struggled mightily, these past several years, to keep the critical balance of human resources in our health care sector, the relentless foreign poaching notwithstanding.

From this background, then, arise the most serious challenges facing the nursing service administration in the country:

First, the challenge of maintaining, always, a high quality of health care despite limitations in terms of physical facilities, financial resources, and the lack of adequately trained nursing staff given the quick turnover.

Second, the economic crisis that has made things worse for everyone all around; forcing budget cuts in state hospitals and cost cutting in private ones, and setting further back hopes of salary upgrades for nurses. Worse, costly and too strict medical insurance forces most people with serious ailments to forego treatment, thus adding to the difficulty of caring for them when they are too far gone.

Third, the mismatch between supply and demand, not just in the number of nurses, but also in the kind of job and career opportunities that are opening up to our nursing graduates. Even as thousands of them are needed in the lesser cities outside the great metropolitan centers and worse yet in far flung areas that have never been reached by any decent health care program, there aren’t enough nurses to go around.

I am not suggesting that nurses should sacrifice personal income for outreach services. I am saying that the national government, which throws tens of billions at sure-to-fail, never-intended-to-succeed projects, just for the commissions, could throw more money at making health care reach more people, even to the farthest corners of our country.

On the third challenge, most of you are aware of how medical tourism, which the government is understandably encouraging, has drawn away many of our best nurses from serious health care to spa services pretending to offer real medical solutions to insoluble old age and wear-and-tear problems like cellulite, wrinkles and osteoporosis.

Don’t get me wrong, but it seems to me we can’t tolerate for long a situation where thousands of our nursing graduates are doing work as call-center agents or spa attendants or running small businesses because there aren’t enough good hospitals paying decent wages.

You should know that no country in the world could support a well-functioning public or private hospital system—or both—without universal health care coverage. In short, without government paying for most health-care services.

Pardon me if I seem to be in a griping mood. There just seems to be little in the local health-care sector we can see as a bright spot.

Some reforms

To be sure, we have seen the start of the implementation of a landmark law, The Cheaper Medicine Act. That reform didn’t come easy. The foreign drug firms were all over Congress. I objected to their presence. They said they had the right to be there because the offices of European and American drug companies are in Makati. They tried to “influence” me in quotes. I said I did not remember giving them the right and threw them out of Congress. It took all of 10 years to get the law passed and then another year to get it implemented.

Reforms in health care come hard but not, I dare say, slowly. Not if you have the political will and the sincere desire to help.

It didn’t really take 10 years to pass The Cheaper Medicine Act. There were many attempts over 10 years but only one night of fighting to get it passed. It didn’t take almost a year to get it implemented but just one morning of threatening the Department of Health to act.

So don’t believe anyone who tells you it takes time to make reforms. It takes one day, one will, hell, one person even—to lead the pack and win the day.

You want pay commensurate with service? Then join those of us who are telling government to stop spending on itself and start spending on the people—especially on people who make a difference such as health-care providers like nurses.

And doctors, of course; we can see how useful they are to nurses, such as in instructing them on what medication to give and in what dosages, as nurses go about the time-consuming, all absorbing task of direct, unceasing, person-to-person health care.

But even as you continue to push the envelope on upgrading nursing performance through rigorous and focused strictly health care training, I trust you’ll always remember that besides those skills, our people look to the nurse as the one special person who fills in all the gaps of a health-care system—whether it’s for a doctor who’s too busy to check on the patient as often as needed; a malfunctioning equipment for which they must improvise; or an ill-tempered billing clerk; or dirty facilities and dirty linen or lack of clean water in the hospital.

It is effective nursing administration that ensures a steady supply of the kind of nurse who, although really powerless to do everything the patient wants or needs, seems to make it all better just by being there.

And that, I think, is the core meaning of “leading beyond limits.” For beyond the limitations imposed by limited resources, limited manpower, limited this and limited that, is someone who fills the empty places by something intangible but evidently there: a constant caring for the patient who is, in every room if she can afford it, or in every space in a ward if he cannot, always at center stage in the unceasing drama of health care.

I return to where I started…to the nurse as she or he should be: competent, for sure, and always caring; gentle yet firm; seeing her profession as a vocation and not just a job. That is why a Filipino nurse or, for that matter, a Filipino doctor, working abroad are still a nurse and a doctor and not economic refugees.

It is the highest vocation of all, the equal of priest or religious, though I am told nursing is much more fun: the cure of bodies to the cure of souls.


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