Oversupply of nurses forces them to pay to work for free

Nurse Salva (not his real name) is harried and hungry as he inspects a patient’s intravenous line in the surgical ward of a government hospital in Quezon City. It is almost 10 a.m. and doctors are winding up their rounds. He has been up since 4 a.m. but his exacting eight-hour work shift rarely gives him time to get a full meal, so he gets by on cheap hard candies when hunger pangs strike.

“Through tough perseverance, I managed to survive. Going to the bathroom to take a leak was already a luxury at the time,” the 23-year old nurse recalls his experience as a volunteer nurse.

A few kilometers away, nurse Krisma (not her real name) also toiled on the morning shift at another hospital ward. “We were willing victims of hospitals,” the 22-year-old nurse said in a separate interview.

Salva and Krisma graduated from the Institute of Nursing of the Far Eastern University and passed the licensure exams in June 2009. For fear of losing job opportunities, they agreed to be interviewed only if their identities and the hospitals where they served as volunteer nurses would not be revealed.

Ideally, the global standard is to have one nurse for every 8-10 patients, but this is hardly observed in most local hospitals, according to the Philippine Nurses Association (PNA). Private hospitals are averse to publicizing their nurse plantilla positions, said Teresita Barcelo, national president of the PNA.

Meanwhile, public hospitals are limited in their personnel hiring by World War II-era charters, and so despite the significant increase in the number of patients, budgetary constraints limit their wards to only one nurse per 40-50 patients, she said.

To make up for the shortfall, hospitals started accepting new registered nurses as volunteers, but with a twist: aside from providing free labor, the nurses had to pay so-called “training fees.” Salva and Krisma are two such “volunteer nurses” who paid two hospitals 3,000 pesos each in return for a three-month stint tending to patients.

“In the volunteer nurse scheme, hospitals are able to cut costs and at the same time raise revenues through the fees paid by the volunteer nurse or nurse trainees. This practice saves hospitals money because they don’t have to hire regular staff nurses,” Barcelo said.

The scheme has been “rampantly practiced all over the country” for many years now, added Alvin Cloyd Dakis, national president of the Alliance of Young Nurse Leaders and Advocates International (AYNLA).

Citing statistics from the Professional Regulatory Commission, Dakis said the number of unemployed and under-employed registered Filipino nurses is estimated to range from a low of 160,000 to a high of 200,000.

“With hundreds of thousands of unemployed licensed nurses desperate for work, thousands of them went to hospitals to pay for the limited volunteer nurse slots or to train in order to gain bedside clinical experience in exchange for certificates stating that they were nurse volunteers or trainees for a specific period of time,” said Dakis.

A ‘well-known secret’

Unemployed or under-employed nurses shelling out up to 10,000 pesos for a six-month term as volunteer nurses or nurse trainees in both public and private hospitals has long been known in the health industry, but authorities have repeatedly denied the existence of the problem.

Dr. Rustico A. Jimenez, president of the 600-member Private Hospitals Association of the Philippines (PHAP), said his organization has asked volunteer nurses and their supporters to show evidence so they can investigate the issue.

“If we cannot see any written proof such as receipts or contracts, we cannot act accordingly,” Jimenez said. “We want to see contracts that say nurses were made to work in a hospital and yet were even asked to pay instead of the hospitals paying for their services rendered.”

Health Secretary Enrique T. Ona has also encouraged aggrieved nurses to report their complaints against erring hospitals to the Department of Health (DOH) through the agency’s website, even assuring their anonymity. “They can come here. We will not reveal their names and identities. Or they can write to the DOH. They may not put their names,” he said, adding that they have not received any formal complaint yet.

Ona takes action

When the issue was raised in the media last month, Ona issued a memorandum ordering the department’s medical directors and chiefs of hospitals to submit a list of training programs “that are meant to provide students of allied health programs and/or allied health professionals with the required competencies that are integral part of their professional education and/or as part of the hospital staff’s capability-building efforts.”

A copy of Memorandum 2011-0018 issued Jan. 18 and obtained by GMA News Online indicated that Ona ordered “a thorough review” of the training programs, saying “there have been anecdotal evidences that nurses were required to pay for attending training programs in hospitals.”

At a news conference where the issue was raised, Ona asked: “What do they mean by nurses working in hospitals without pay? Who are these hospitals engaged in this practice? I want to know what is the agreement of these volunteer nurses with the hospitals. If these are illegal, there may be particular sanctions.”

But this may be easier said than done. Barcelo of PNA points out: “If you are a young or newly registered nurse, you have a whole life ahead of you. Why will you risk your career to complain about this scheme publicly?”

Barcelo told GMA News Online the problem of ‘nurse-volunteers for a fee’ is a “well-known secret. It is an injustice. It is exploitation.”

Promise of jobs

“In the case of the nurse volunteers who are members of AYNLA, volunteering means paying hospitals exorbitant training fees while providing nursing services without getting paid professional fees and at the same time, working like paid staff nurses,” said Dakis, a former nursing clinical instructor at the Cebu Normal University.

“Volunteer nurses or trainees expect or hope to be given preferential treatment when a rare vacancy in their hospital of affiliation occurs,” said Dakis, who never volunteered himself because he considered it a form of exploitation.

Many newspaper advertisements specify that Filipino nurses who want to work abroad are required to submit certification to prospective employers of having worked continuously as staff nurses for at least two years in a local 250-bed tertiary hospital.

“Nurses have been informed that certifications attesting to their being nurse volunteers or trainees of certain hospitals would be equivalent to work experience and credited as part of the required work experience for overseas employment. Unfortunately, this is not the case for most countries. Only Middle Eastern countries accept this kind of volunteer or trainee certificates,” Dakis said.

Barcelo said that through the current nurse volunteerism-for-a-fee cum training scheme, hospitals can give nurses certification of work hours spent in their health facilities.

“In the past, this certificate was submitted for employment abroad. Unfortunately, foreign employers have come to know of this erroneous practice. Now, they no longer accept certificates of experience through volunteerism,” she said.

“What these foreign employers are looking for is experience of paid work as a regular staff nurse in a tertiary hospital. These foreign hospitals now call on hospitals to check and verify whether nurse applicants are indeed in the payroll as a regular staff nurse,” Barcelo added.

Many nurse ‘trainees’ don’t get training

“Some hospitals changed the name of ‘nurse volunteer’ to ‘nurse trainee’ to justify the training fees collected,” Dakis reveals. “However, specialty training in nursing practice means advance practice which focuses on specialty areas such at peri-operative, dialysis, oncology, and critical care nursing.”

He continues: “Training in a medical surgical ward, for example, which only makes a volunteer nurse or a trainee nurse assume the roles and functions of a basic staff nurse is not specialty training. Why? Because basic training is expected to have been mastered by a student nurse during his 3rd and 4th years in nursing schools.”

In contrast to Salva and Krisma, for instance, fresh graduate Reigner Jireh Antiquera managed to secure a slot in the competitive “critical care nursing course” offered by a specialty hospital in Quezon City. The two-month course costing 6,000 pesos was paid for by his older brother who is working as a nurse overseas,.

Antiquera, who ranked 10th in his 182-member graduating class in a school of nursing in Pasay City, said it was worth his brother’s money and his time. “We had intensive lectures and clinical instructors closely supervised us when we do bedside procedures,” the 21-year-old unemployed nurse said in an interview.

“The critical care nursing course being offered by the hospital is a program intended to prepare nurses to be responsive to the complex needs of the critically ill,” Antiquera said. “The course was not a simple case of attending to the bedside needs of patients.” He added that from the start, it was made clear to the nurses who took the course that they would not be hired after the training.

Barcelo of PNA asserts that her group is not against training in general. “Training in its real meaning is alright. Say, I would like to become a critical-care nurse. If I were a fresh graduate, obviously I am not a specialist. To get to a certain level of being a specialist, I need training,” she said.

“What we are particularly against is this: you are volunteering and this is not structured training. Yet, to volunteer, you have to pay. Here what you have is that the volunteer nurses are not paid, but still asked to pay for ‘training’. This is exploitation,” Barcelo said. “We do not have a specialty training called ward nursing.”

Unfortunately, Barcelo notes, “There is no law that directly allows or prohibits the practice of nurse volunteerism for a fee. But these are registered nurses. They have earned their degrees and licenses. They have had clinical practicum of more than 2000 hours in their four years of studies. I do not see any reason or a need for our nurses to go on volunteerism for a fee which now has evolved into a training program.”

Volunteer nurses pay to be ‘slaves’

Generally, Barcelo said nurses engaged in volunteer work disguised as specialty trainings are simply “doing the tasks of a ward nurse.” The experiences of volunteer nurses interviewed for this story validate this assertion.

Volunteer nurse Salva said he initially applied as a staff nurse at a hospital in Quezon City, but was told there was no vacancy. Instead, officers at the hospital told him they “accept volunteer nurses who are willing to pay 1,000 pesos per month.” From December 2008 to March 2009, Salva functioned like an ordinary staff nurse and was posted in the operating room, surgical ward, obstetric and gynecology ward, and pediatric ward.

Krisma, a volunteer nurse from September to December 2010, recalled: “I thought it was normal practice for a newly registered nurse to undergo the stage of volunteer nurse or nurse trainee, that is why I immediately joined.” She realized belatedly that the so-called “training” was not worth it.

“The masters of the wards are the staff nurses and their slaves are the volunteer nurses,” she recalls. “While the staff nurses lounge at the nurses’ station, the volunteer nurses do all their tasks from the menial to the most complicated. They initially assisted us, but eventually they left us to fend for ourselves. Staff nurses will only go to the bedside of a patient in instances when a cardiac arrest occurs or any similar extreme situations.”

Currently working as a pharmacy assistant, Krisma asks: “Why did we, volunteer nurses, have to pay to do what the paid staff nurse should be doing?”

Like Salva, who is now a part-time nurse specializing in diabetic patients and also a blogger, Krisma and other nurses want the government to investigate and put an end to the practice of “volunteer nurses” that they consider not only abusive but also illegal.

“These so-called volunteer nurses or nurse trainees do not have regular staff nurses with them when they attend to patients. It is not legal because these volunteer nurses are not regular employees of hospitals,” said Barcelo of PNA. “Suppose a volunteer nurse commits an error in the course of carrying out his or her duties attending to a patient, who does the patient run after? The hospital may not be liable because a volunteer nurse is not a regular employee.”

She said patients are at the losing end in this situation. “A volunteer nurse has no accountability. The affected patient cannot do something against the erring hospital because the volunteer nurse is not a regular employee of the said hospital. The patient is helpless in this scenario,” Barcelo said.

Barcelo said volunteer nurses “sign a contract specifically stating there is no employer-employee relationship” between them and the hospital. The contract also states “that it is only purely a ‘training program’ and that they cannot receive benefits and compensation.

“Some quarters tell me, how come these nurses do not complain? I say, who do you go to? To the Labor Department? But these volunteer nurses are not employees. How can the Labor Department come in? They cannot,” she said.

Oversupply of new nurses, undersupply of skilled nurses

To correct this situation, the nurses said the government has to take the lead in hiring more nurses to fill up positions in public hospitals and health facilities. However, one problem is the difficulty in getting accurate statistics.

“I cannot tell you the exact figure of how many nurses we have in the Philippines. Many hospitals do not want to declare their nursing plantilla positions,” said Barcelo.

She said one way of getting the numbers is through the annual Nurses Licensure Examinations (NLE). In the June 2010 NLE, for instance, about 92,000 took the examinations; in the December 2010 NLE, approximately 86,000 sat for them and nearly 30,000 passed, results that were announced Saturday.

“Annually, on the average, about 40 percent of the nursing board-takers pass. So, if you have a total of 178,000 for 2010, 40 percent of that is about 71,200 passers. This will give you an idea of how many registered nurses we have every year,” Barcelo said.

“In the Philippines, what we have is an oversupply of fresh nursing graduates and an undersupply of skilled nurses. Our skilled nurses, such as those with intensive care and critical care trainings, are the favorites of foreign recruiters. Operating room and emergency room nurses are in demand abroad,” she said.

Barcelo said the supply problem started sometime in 2003-2004, when foreign manpower experts projected that the global demand for nurses was estimated to be “about 1 million by 2020.” This triggered a demand for nursing courses, resulting in a huge leap from about 170 nursing schools in 2003 to 472 schools in 2010.

The huge number of enrolees translated to a bigger number of student-nurses seeking affiliation with hospitals, crowding out available slots for training. By July 2008, when the nursing boom started producing graduates, PNA issued a statement saying, “many Filipino nurses are now underemployed and unemployed.”

The statement noted that the licensure exams in 2006 produced 37,030 new nurses while in 2007, another 31,275 nurses joined the labor force. However, the surge coincided with decreased global demand in the US and the UK, two of the major markets for Filipino nurses, which started to prioritize recruitment of their own health workers.

“The domestic market is now oversaturated, with nursing pools in major hospitals as high as 1,500 and with employment waiting times ranging from six to 12 months. Nursing pools refer to those deemed qualified by hospital employers but waiting to be formally employed,” the PNA statement said. “The current nursing employment market is a buyers market that allows current employers to be highly selective and where the quality of a vast number of job seekers is very closely scrutinized.”

Barcelo said the failure of Philippine nursing schools to consider that the demand for nurses would not come from the Philippines alone, coupled with the global economic recession that started in 2007, contributed to the oversupply of nurses. However, other factors also come into play.

“What drives students to take up nursing, hotel and restaurant management courses or becoming a seaman, or even doctors to become nurses is the opportunity to go abroad, specifically the US,” Barcelo said.

“One part of the equation of the desire of nurses to go abroad is recognition. In the Philippines, the contribution of nurses is not expressedly recognized,” Barcelo said. “In a real-life hospital setting, nurses are so powerless. Nurses cannot make decisions.”

She thinks one of the key solutions in combating the oversupply of nurses is to close down nursing schools that are not performing well and allowing the good ones to flourish. “The students who would be left behind are students who really went into nursing because they genuinely like nursing and not just to go abroad.” – YA/HS, GMA News

The author is a journalist and registered nurse who has undergone advanced specialty training in intravenous therapy. –IBARRA C. MATEO