Issues and problems in nursing

Misamis University
Ozamiz City

Graduate School

Issues and Problems in Nursing

In partial fulfillment of the requirements in ADM 214

Submitted to:

MS. LORELEI D. PROCIANOS, RN, MAN

Faculty, Graduate School

Submitted by:

REYNEL DAN L. GALICINAO, RN

Student, Master in Nursing
Major in Nursing Educational Administration

July 9, 2011


Extended Hours Issues in Nursing:
Exploring the Problems, Finding the Solutions
Despite projections that nursing is one of the top ten growth jobs for the next 15
years, our health care system is on the verge of an overwhelming nurse shortage and
health care crisis. In fact, an estimated 50% of nurses will be at retirement age within 15
years, and new nurses aren't entering the field fast enough to stabilize the imminent
mass departure. This and other issues are explored in depth in "Extended Hours Issues
in Nursing: Exploring the Problems, Finding the Solutions," by Circadian, an
international research and consulting firm.
The consequences of this current and future shortage are further reaching than
the economics of supply and demand. Like 20% of American workers, nurses work
long, irregular shifts. For nurses, employers, and patients, this means a host of hazards,
including the following:
 Health care shows the second-highest turnover rate of all "extended hours"
industries.
 Nursing is one of the ten industries with the highest levels of occupational injury
or illness requiring days away from work.
 The most prevalent injuries in nursing are musculoskeletal disorders and
needlestick injuries. In 89% of needlesticks, the needle was contaminated.
 Work-related fatigue prompted nearly 20% of nurses to cite "having an accident
while commuting back home" as one of the top three job-related health and
safety risks.
 Nurses show high instances of sleep disorders, severely affecting productivity.
 High fatigue and short staffing severely affect quality of patient care.

"Extended hours issues in nursing: exploring the problems, finding the solutions". MedSurg Nursing.
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COPYRIGHT 2005 Jannetti Publications, Inc.
COPYRIGHT 2007 Gale Group

REACTION:
Although this article discusses the issues of nurses in the United
States of America, the same concerns apply to nurses in the Philippines.
There is also a turnover rate of nurses in the Philippines. Nurses usually stay
in their hospital jobs for about two to three years, as this is the required
length of work experience for nurses to go abroad. There is no actual data in
the Philippines related to occupational injury or illness but a few nurses’ gets
infected with tuberculosis from exposure to TB patients.

There is also no available data regarding injuries among nurses.
Needlestick injuries however is not uncommon in the hospital setting and it
is usually left unreported. Fatigue is pretty common among nurses as they
are usually overworked and the length of shift lasts from eight to more than
twelve hours. With the changing shifts of nurses every few days, the
incidence of sleep disorders may be increased since their biological clocks
are constantly adopting with the frequent change of shifts and schedules.
Despite the increasing number of nurses in the Philippines, staffing is often
short leaving nurses to have high fatigue because hospitals often choose to
accept inexperienced “volunteer” nurses than hiring highly qualified nurses.

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Problems With Nursing Informatics
Heidi Cardenas

Informatics includes machinery. Informatics is the process of advancing in a
discipline with a combination of data, information and knowledge. Nursing informatics
encompasses the devices, machines, resources, and methods of utilizing information,
computers, and nursing science in nursing. It is a recognized specialty for registered
nurses, but does present challenges that academics and medical practitioners are
working to improve or eliminate.

Significance
In 2007, the Healthcare Information and Management Systems Society Nursing
Informatics Awareness Task Force estimated that 50 percent of a nurse's time is spent
on documentation. Because of explosive strides in information technology and the huge
body of medical knowledge amassed, controlling medical errors and health care costs
are paramount in the health care professions, including nursing. According to RN
Journal, handwriting on a piece of paper has been largely replaced by reports from
medical devices at the point of care, and nurses have to master electronic
documentation.

Function
Nursing documentation is complex and situation-dependent. With different
technology and medical charting methods in use, consistent education and training on
documentation is difficult to achieve, especially electronically.

Research
Concerns and controversies over privacy issues have challenged the health care
industry regarding electronic medical records. In President Obama's first weekly
address in January 2009, the U.S. government plans to "computerize the nation's health
record in five years, saving billions of dollars in health care costs and countless lives,"
but the National League for Nurses found in 2008 that new nurses need programs to
support their work in information-intensive environments. The informatics nurse
specialist role was first credentialed in 1995 to ensure nurses will be qualified to work
with computerized medical data.

Considerations
There is no single device that generates a comprehensive patient record, stores
it and makes it accessible to care providers in different locations. Bar codes on
medicines, computerized physician order-entry, automated scheduling systems for
nurse administrators, nursing student preparation for IT tools and HIPAA concerns are
just a few of the problems in nursing informatics.

Potential
Mobile devices, communication technologies, efficient applications, and
enhanced workflow and documentation will be the norm going forward and in the future.
Ideally, every nurse would learn a universal IT platform for all patient care, but that is an
almost unobtainable goal with the rapid advances in research, medicine and information
technology. One thing is certain---nursing and information technology are integrally
intertwined and will remain so in the future.

Problems With Nursing Informatics | eHow.com
http://www.ehow.com/about_5657356_problems-nursing-informatics.html#ixzz1RZHDA8R9

3|Page


REACTION:

Nursing Informatics is not very new in the Philippines; however,
its implementation is almost limited to lectures in the classroom and
used in some large hospitals. In the article Problems with Nursing
Informatics (from the previous page), the United States of America
has long implemented Nursing Informatics but they have not yet fully
computerized their health records and some concerns are arising.

Nurses spend a whole lot of time on documentation and it will be
very helpful to fully implement computerization of medical records in
the hospitals in the Philippines. Nurses would save a lot of time in
documentation and accuracy of records will be improved since poor
handwriting issues would be eliminated. On the other hand, it will be
costly to train nurses on the use of the program for electronic
documentation. Nurse informaticists are also scarce in the Philippines.

The path for full implementation of electronic documentation and
other areas of nursing informatics is still a long and rough road for
Filipino nurses in the country. Nurses must learn and practice using the
computer and its basic functions and programs to hasten the road for
nursing informatics in the Philippines.

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Occupational Health and Safety Issues
Among Nurses in the Philippines
A. B. de Castro, PhD, MSN/MPH, RN, Suzanne L. Cabrera, MN, RN,
Gilbert C. Gee, PhD, Kaori Fujishiro, PhD, and Eularito A. Tagalog, RN, COHN

ABSTRACT

Nursing is a hazardous occupation in the United States, but little is known about
workplace health and safety issues facing the nursing work force in the Philippines. In
this article, work-related problems among a sample of nurses in the Philippines are
described. Cross-sectional data were collected through a self-administered survey
during the Philippine Nurses Association 2007 convention. Measures included four
categories: work-related demographics, occupational injury/illness, reporting behavior,
and safety concerns. Approximately 40% of nurses had experienced at least one injury
or illness in the past year, and 80% had experienced back pain. Most who had an injury
did not report it. The top ranking concerns were stress and overwork. Filipino nurses
encounter considerable health and safety concerns that are similar to those
encountered by nurses in other countries. Future research should examine the work
organization factors that contribute to these concerns and strengthen policies to
promote health and safety.

Applying Research to Practice
The significant number of nurses in the Philippines not reporting injuries and
illnesses suggests the need for active surveillance tailored to this work force.
Surveillance systems that capture health care-specific exposures among nurses are
needed. Also, a national surveillance system that includes mechanisms for both
employers and workers to report injuries and illnesses should be considered.
Occupational health nurses in the Philippines should ensure that nurses understand the
relationship between injury and illness and workplace factors by implementing
educational and training strategies focusing on workplace health and safety. Given the
hazards, concerns, and working conditions that nurses in the Philippines report,
advocacy is needed at the national and organizational levels for the enforcement of
occupational health and safety policies. Additionally, occupational health nurses can
identify priority areas for research and can partner with researchers to investigate these
issues more thoroughly.

DISCUSSIONS

Occupational Injury and Illness
A considerable portion of the respondents reported they had experienced work-
related health problems during the past 12 months. Roughly one third mentioned a
work-related injury. Moreover, about one third stated that they missed 2 or more days of
work as a result of these injuries and illnesses. These proportions were similar to those
reported by American nurses participating in the ANA survey (Houle, 2001). For
example, 37% of this sample and 40% of the ANA survey respondents indicated a past-
year work injury. These proportions should be interpreted with some caution because in
both this sample and the ANA sample, about 30% had a second job, and it is possible
that some of these injuries occurred when working that second job. However, these
proportions are more than threefold higher than what was reported for a national sample
of the U.S. general working population (11%; Waters, Dick, Davis-Barkley, & Krieg,
2007). The analyses suggest that future investigation is warranted and should provide
comprehensive information on the type of injury, the severity, and the potential causes.
Nearly one third of Filipino nurses reported missing two or more days of work due
to injury or illness. These findings are not atypical. For example, roughly one fourth of
U.S. nurses also reported missing 2 or more days for work-related injury or illness

5|Page


(Houle, 2001). Potential reasons for these findings include underutilization of workers’
compensation, concerns of reprisals or loss of income for taking time off, reporting
biases, and inadequate treatment for injured or sick nurses. Although the hypotheses
could not be evaluated, future research should investigate them further.
This study found that more than three fourths (78%) of the respondents
experienced back pain. The estimated prevalence of back pain for U.S. nurses ranges
from 20% to 52% (Harber et al., 1985; Nelson, 2003; Owen, 1989). The causes of this
pain are unclear. It is likely that some of this pain results from nursing work and some of
it arises from other causes, such as a preexisting injury or work at a secondary job.
Regardless of the cause, however, 81% of the respondents experiencing back pain said
they continued to work despite the back pain. Because back pain is an important cause
of disability, this acknowledgement of working after an injury suggests that ergonomic
control measures (e.g., mechanical patient lifting equipment and training) may improve
nurses’ well-being and, potentially, the quality of patient care.

Reporting Behavior
Although a large proportion of participants indicated a work-related injury, many
did not report their injuries to their employers. Underreporting of work-related injuries
and illnesses has also been noted as a significant problem among nurses in the United
States (Brown et al., 2005; de Castro, 2003; Haiduven, Simpkins, Phillips, & Stevens,
1999; Siddharthan, Hodgson, Rosenberg, Haiduven, & Nelson, 2006; Tabak,
Shiaabana, & Shasha, 2006). In part, low incident reporting in this sample was due to
respondents feeling that the injury was not significant, but other key reasons were that
nurses were too busy or felt that the injury was just “part of the job.” These reasons are
concerning as they not only contribute to nurses working with injuries, but could also
result in an artificially low injury rate. Efforts must be made to encourage nurses to
report their injuries within their schedule to improve nurse outcomes and the accurate
assessment of workplace health and safety.

Safety Concerns
About one third (30%) of Filipino nurses in this study reported that they felt either
somewhat safe or not safe at all where they work as a nurse, compared to 44% of U.S.
nurses (Houle, 2001). On the surface, this suggests that working conditions may be
safer in the Philippines than in the United States. However, this difference may also
reflect nurses’ lower expectations for safe working conditions. Currently, in the
Philippines, nurses are not unionized and therefore do not have a formal mechanism to
identify workplace hazards and advocate for improved working conditions.
Characterizing Filipino nurses’ impressions and expectations of a safe work
environment is another possible direction for research.
Two occupational hazards reported in this study are worth noting. First, a large
majority (80%) of the respondents used powdered latex gloves. This raises concerns
given the adverse effects of latex glove use (i.e., latex allergy and contact dermatitis).
Because the prevalence of latex allergy and contact dermatitis has not been reported
among nurses in the Philippines, it is recommended that an investigation into this
potential problem be undertaken. Also, health care facilities should consider instituting a
latex-free policy. Second, one third of the Filipino nurses in this study reported
experiencing threats or verbal abuse. Even physical assault was reported by 7% of the
respondents. Workplace violence is a serious problem among nurses (Henderson,
2003; Kingma, 2001). In the United States, patients and coworkers (including physicians
and other nurses) are the major sources of workplace violence against nurses. Acts of
violence may be motivated by a sense of entitlement among patients, physicians, and
other nurses with more seniority. The researchers did not inquire about the source of
workplace violence among the respondents, however. It is possible that violence
against health care professionals is less a part of patient and coworker behavior in the
Philippines, or that the perpetrator profile is different altogether (e.g., only physicians or
patients’ family members). Given the number of respondents who reported experiencing
threats or verbal abuse, this is certainly worthy of continued investigation.

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To assess whether nurses in the Philippines and nurses in the United States are
concerned about similar health and safety issues, the researchers asked respondents to
rank order the concerns reported by the ANA survey respondents. In the current study,
the highest ranked concern was the same as for the ANA survey (Houle, 2001): acute
and chronic effects of stress and overwork. Previous research has noted that certain
work organization factors contribute to stressful working conditions, which can ultimately
lead to staff turnover or nurses leaving the profession entirely (Erenstein & McCaffrey,
2007; Escriba-Aguir, Martin-Baena, & Perez-Hoyos, 2006; Estryn-Behar et al.,
2007; Hochwalder, 2007). However, as mentioned, most of these studies were
conducted in Western countries. The researchers hypothesize that similar work
organization factors have comparable effects among Filipino nurses; however, no study
along these lines has been conducted to the authors’ knowledge. Given that the current
survey was modeled after the ANA survey, some items that may have been particularly
important in the Philippines were omitted (e.g., loss of electricity or “brain drain” to
developed countries). It would be important for a future study to provide an open-ended
structure to investigate these potential issues and to assess their relative rankings.

IMPLICATIONS FOR PRACTICE

This study suggests several ways to improve occupational health and safety
among Filipino nurses. First, the underreporting of injuries and illnesses found in this
study indicates that injury and illness surveillance specifically designed for the nursing
work force in the Philippines could be useful in better identifying problems. The
Philippine Bureau of Working Conditions collects the Work Accident Injury Report (WHO
Regional Office for the Western Pacific, 2006). Because this system relies on employers
to provide information, underreporting may be a problem. In addition to the incidence of
workplace injury and illness, a surveillance system that captures health care-specific
exposures such as hazardous drugs and bloodborne pathogens would inform
intervention strategies for improving nurses’ health and well-being.
The underreporting of occupational injuries and illnesses found in this study also
highlights an important role for occupational health nurses: to explore strategies to help
nurses recognize the potential seriousness of work-related injuries and illnesses. For
example, increased education and training that facilitates nurses’ understanding of the
connection between workplace factors and their injuries and illnesses may be in order.
This could occur at various levels, such as launching a national campaign organized by
the PNA and OHNAP, holding frequent seminars for staff within organizations, and
incorporating health and safety content within nursing school curricula.
Occupational health nurses must advocate for occupational health and safety
policies. At the national level, these policies should include formalized regulations with
enforcement mechanisms. This way, health care organizations will be responsible and
accountable for maintaining a healthy and safe work environment for their nursing
staffs. Policies that address the prevention of occupational injury and illness can also be
adopted within the health care workplace. Occupational health nurses can be
particularly effective at this level by directly monitoring workplace exposures and
advocating to management for actions that protect workers.
Finally, future research is recommended with this worker population.
Occupational health nurses in health care settings can play a vital role by partnering
with researchers to explore the issues found with this assessment. Some potential
priority areas include job stress, the impact of verbal abuse on nurse well-being, and
factors that contribute to back pain. Occupational health nurses are in optimal positions
to identify research needs and facilitate study participation among the nursing work
force they serve.

CONCLUSION

Studies in the United States and other Western countries suggest that nurses
face considerable occupational health and safety risks. Although preliminary, this survey

7|Page


suggests many commonalities in the types of issues reported by nurses attending the
2007 PNA annual national convention and nurses elsewhere. Many respondents
reported helpful workplace policies and practices, such as the provision of patient lifting
devices, but about one third of the sample reported poor or no employer information
related to nursing occupational hazards. Future research should verify these findings
and assess the potential interventions that may enhance nurses’ health and well-being
and promote quality patient care.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797477/

REACTION:

Nurses face considerable occupational health and safety risk in
their daily duties. Despite the importance of occupational health and
safety among nurses, it is not given very much attention in the
Philippines. The Philippine Nurses Association must look into this and
advocate ways of promoting health and safety of healthcare providers,
the nurses.

The study found out that there is underreporting of work-related
injuries and illnesses among nurses. A surveillance system must be
enforced to collect data regarding this matter. Occupational health
nurses must also explore strategies to help nurses recognize the
potential seriousness of work-related injuries and illnesses.

Occupational health nurses must also advocate for better
occupational health and safety policies. There should be a formal
regulations regarding this matter.

Other potential work-related injuries and illnesses may include
job stress, verbal abuse, and back pain. This areas must also be looked
into.

8|Page


The National Nursing Crisis: 7 Strategic Solutions
Jaime Z. Galvez Tan M.D., M.P.H.

Introduction
At the rate we are losing monthly our highly skilled nurses to the United States,
the United Kingdom, Ireland and the Netherlands, and with the Philippine government,
via the Department of Health raising its hands in helplessness, offering no strategic
solutions in sight, expect a worsening of the health crisis already plaguing our country. It
is not only the nurses the country is losing, our medical doctors are now enrolling in
nursing schools offering an abbreviated course for doctors to become nurses.
Why? There is an acute shortage of nurses in the countries mentioned above
which became palpable 3 to 4 years ago. The need will not just be for a year or two but
for at least the next 10 to 15 fifteen years. So it will no longer be the roller coaster
demand for foreign graduate nurses by developed countries which characterized the
outflow of nurses from developing countries during the last 35 years but a persistent,
chronic need is transpiring. The USA would need around 110,000 nurses a year while
the U.K., Ireland, the Netherlands and other European countries would need another
50,000 nurses a year. Austria and Norway have also announced their need for foreign
nurses this year. Japan is expected to open its doors to foreign nurses by 2005.
The Northern countries of the world are experiencing longer lifespan and the
graying of their population. These factors create increasing pressure on their health
systems for greater response mechanisms to the health problems of a growing
proportion of the elderly. Their youth population no longer take interest in the nursing
profession due to relatively difficult and riskier working conditions such as evening
duties, care of the chronically ill and exposure to HIV/AIDS. Thus, there is a great
demand for foreign graduate nurses.

The Problem
The Philippines will never be able to compete with the salary scales of nurses in
these Northern countries. The basic monthly pay there is US$3,000-US$4,000 a month
compared to the US$150-US$250 that nurses receive in the Philippines. Yes, our
Filipino nurses are globally competitive in professional nursing care and practice but our
Filipino salaries will never be competitive. Filipino doctors are going through a reversal
of health human resource development by becoming nurses. Even specialist doctors
are enrolling in nursing schools. The current income of doctors in the Philippines of
US$300 to US$800 a month is still a pittance compared to the monthly salary of US or
European based nurses.
Hospitals in the USA even offer additional attractive benefits like residency visa
status for nurses, their spouse and children plus other perks like subsidized housing
and transportation.
In the year 2001, the Philippine Overseas Employment Administration (POEA),
reported the departure of 13, 536 Filipino nurses to 31 countries. The majority went to
the U.K. with 5, 383 nurses, Saudi Arabia with 5, 045 and Ireland 1,529. The POEA
reported only 304 nurses going to the USA. This is definitely gross underreporting since
the International Union of Nurses reported that close to 10,000 Filipino nurses were
directly hired by US based hospitals in 2001 through their nursing job fairs held in
various parts of the Philippines.
In 2002, the POEA further reports that a total of 11,911 Filipino nurses left for 33
countries. In 2003, POEA initially reported 8,968 nurses leaving. Again with
underreporting of those who left for the USA. Clearly, the trend is here to stay. Sadly,
this is no longer “brain drain” but more appropriately “brain hemorrhage” already of our
Filipino nurses.
These annual outflow of Filipino nurses for Years 2001-2002 is two to three times
greater than the annual production of licensed nurses during the same two year period.
Since 1999, the Professional Regulation Commission (PRC) through the Board of
Nursing gives licenses to only 5, 784 to 8,419 nurses annually. This is despite the
9|Page


increase of nursing schools from 142 to 240 within the last four years. There were only
40 nursing schools in the 1980s. So very soon, the Philippines will be bled dry of nurses.
With the proliferation of nursing schools, the quality of nursing education has
shown signs of deterioration as measured by the proportion of nursing graduates who
pass the Board of Nursing licensure examinations. In 2001, 54 percent (4,430 nurses)
passed the nurse licensure examinations. In 2003, only 45 percent (4, 227 nurses)
passed. Compare this with the average proportion who passed the nurse licensure
examinations from 1994-1998 which was 57 percent.
Will the Philippine government just tolerate this trend of health human resource
outflows to other countries? Will we, as Filipinos, just wait, standby and not do
something about this health threatening situation now? Will the Department of Health
act only when the catastrophe is already beyond resuscitation?

Seven Strategic Solutions
This national crisis in nursing and medicine is a very complex issue requiring
strategic thinking, multidisciplinary approaches and long-term goals. Since the problem
is both global and national in scope, it also requires solutions that are global and
national in nature.
A win-win strategic solution between the Philippines and the nursing importing
countries of the North must be the ultimate goal in dealing constructively and resolving
the crisis in nursing and medical human resources and services. There is no longer
room for piece-meal approaches to this issue. But first, President Macapagal-Arroyo,
the Cabinet and Congress leaders must accept that this is indeed a serious national
problem deserving urgent attention and action.

A seven-point policy action agenda is hereby proposed:
One. Creation of a National Commission on Health Human Resources
Development. Initially, through a Presidential Executive Order, and later as a legislative
act, this National Commission will be composed of the leaders from the Executive and
Legislative branches of government with participation from the private sector, academe
and civil society groups involved in nursing and medical human resources development.
With budgetary support and a lifespan of 3 to 5 years, its major tasks include: an
intensive review of the past, current and future scenarios of the nursing and medical
human resources; completion of a data base of Filipino health human resources;
updating of the 25 year National Health Human Resources Policy and Development
Plan (1996-2020) formulated with the guidance of Drs. Fernando Sanchez and Dennis
Batangan in 1992-95 for the Department of Health; and the development of a unified
health human resource development policy and a national policy research agenda on
health human resources.

Two. Initiation of High-Level Bilateral Negotiations with Northern Countries
Importing Filipino Nurses. Led by a team composed of Secretaries of the Department
of Foreign Affairs (DFA), Department of Labor and Employment (DOLE), the National
Economic Development Authority (NEDA), Commission on Higher Education (CHED),
Department of Trade and Industry (DTI) and the Department of Health (DOH), bilateral
discussions with the United States, United Kingdom, Republic of Ireland, Netherlands
and Saudi Arabia will center on a partnership approach between the Philippines and
these countries. The current approach to the importation of Filipino nurses by these rich
countries has been lopsided and advantageous only to such countries while the
Philippines continue to wallow in poverty, underdevelopment and inadequate health
care. In the negotiations, these rich countries must be made to realize that the agenda
and interests of their Departments/Ministries of Health and their Development Agencies
can coincide. Thus for example, USAID, in behalf of the US government and DFID, in
behalf of the United Kingdom, will include in their aid package to the Philippines,
financial assistance to continuously train globally competitive nurses, constantly
upgrading nursing education, nursing health services and nurse remuneration and
offering nursing scholarships. Such aid will eventually benefit both countries e.g. the US

10 | P a g e


and UK having a regular pool of nurses to serve their needs since many of these nurses
will eventually work there, while the Philippines will be ensured also a regular production
and supply of nurses for its health care system.
The Philippine Cabinet Bilateral Negotiation Team must be able to come up with
concrete investment packages for nursing and health human resource development for
discussions with these countries at the soonest possible time.

Three. North-South Hospital to Hospital Partnership Agreements. While
bilateral country negotiations are on-going and the financial aid packages for nursing
development eventually actualized, Northern country hospital to Philippine
hospital/nursing school agreements should proceed with the same vigor and pace. Such
partnership would focus on the provision of a financial grant given by the Northern
country hospital for every Filipino nurse that enters its staff. The said financial grant will
go to a Nursing Development Trust Fund of the Philippine hospital/nursing school, to be
used to improve nurse salaries, training and nursing practice, upgrade hospital and
educational facilities and nurse scholarships. Current estimated total cost of educating
and producing a nurse that will pass the Philippine nursing licensure examinations are
in the range of US$4,000 to US$7,000. Thus for example, the Philippine General
Hospital (PGH) will enter into a partnership agreement with the Johns Hopkins
University Hospital (JHUH) in Maryland, USA. JHUH will donate a negotiated amount to
the PGH Nursing Development Trust Fund, for every nurse that it recruits from the PGH.
This is but just since hospitals from countries of the North do not spend a single
centavo in the production, development, education and licensure of Filipino nurses. At
the very least, they should be able to pay partially if not fully the cost of nursing
development since they are going to benefit from the services of that nurse for at least
25 years.

Fourth. Institution the National Health Service Act. The Philippines is one of
the few countries in Southeast Asia that does not have a National Health Service Act.
This is a compulsory requirement for all licensed health professionals to serve
anywhere within the country for a number of years equivalent to the number of years it
took them to study their health professions. While in the past there were attempts to
have such a law passed, major objections centered on the individual human rights to
move freely and practice their profession where each individual wants, such as in
another country. However, with the globalization and active trading of health human
resources and the inevitability of the severest brain drain to hit the Philippines, the
country’s collective interest and collective rights should now prevail.
At best, health professionals graduating from state universities, schools and
colleges must be covered by the National Health Service Act. Their educations have
been heavily subsidized with the taxes paid by the Filipino people. It is but right that
they repay the country with their services equivalent to the number of years of subsidy.
If the Philippine Military Academy (PMA) has been doing this since its foundation,
government health sciences schools should no longer be exempted. Graduates from
private health sciences schools can have a modified scheme in complying with the Act,
but nevertheless should be covered as well.
With the National Health Service Act, the country will be able to program
scientifically the exit of our health professionals, thus ensuring a steady maintenance of
health human resources in all health facilities, whether rural or urban.

Fifth. Establish Philippine Nursing Registries. A nursing registry is corporately
run human resource development center that provide hospitals, clinics and other health
facilities with their nursing needs. It has management mechanisms that efficiently
locates and monitors nursing human resource availability. It actively negotiates for
better remuneration and benefits, better working conditions, keeping always nursing
welfare high in its agenda. Usually private sector led, nursing registries can be created
at the local level covering a specific geographical area. It can start within a local
government unit (LGU) service area, either at the city, province or municipality level or a

11 | P a g e


district health system (DHS) level, covering a network of public and private health
facilities in various LGU locations. The registry can also center around a tertiary hospital
and cover its referral units and catchment areas.
While nursing registries are functioning well in the United States and Europe, the
Philippines still has to catch-up with this nursing development. The numerous colleges
and schools of nursing should complement this service by making sure that their office
of alumni affairs keep a regularly updated directory of all their graduates, keeping track
not only of where they are but of how they are, in terms of their human welfare and
professional growth. With the era of advanced computer software systems and global
communication technologies, there should be no more excuses for nursing schools to
guarantee this.

Sixth. Expand Nursing Residency and Nurse Practitioner Training
Programs. This strategy was adapted from the Board of Nursing-led policy workshops.
Patterned after medical specialist residency training programs, all secondary and
tertiary hospitals should start a similar one for nurses. These will also be three year
residency training focusing on nursing specialties such as intensive care nursing,
operating room nursing, emergency nursing, psychiatric nursing, neonatal care nursing,
geriatric nursing and nurse counselling. There can also be fellowship programs
centering on sub-specialty nursing such as cardiac care nursing, neurology care nursing,
genetic nurse counselling, chronic care nursing and palliative and hospice care. A
Board of Nursing Specialties, entirely separate from the Board of Nursing of the
Philippine Regulations Commission, should be established to regulate the production
and development of these nursing residency and fellowship training programs.
Another nursing development program is the offering of nurse practitioner
postgraduate courses. Nurse practitioners are independent, highly skilled nurses that
work in solo, group or networks. While the Philippines produces a lot of graduates of
Masters in Nursing which focuses more on nursing management, administration and
research, it has been lagging behind in developing a nurse practitioner education
program. This will give room for clinical skills in the nursing areas of wellness,
counselling, public health, community health, complementary and alternative health
care. The course can be offered by colleges of nursing and can also be regulated by the
Board of Nursing Specialties or another new board as well. Once this course is
available, the time will come when Filipinos can benefit from direct nursing care from
standalone nurse clinics, nurse wellness centers and other modalities of nurse
practitioners’ facilities.
The above-mentioned developments in nursing education will become venues for
nurses to comply with the National Health Service Act without neglecting their
professional growth. These will also ensure better nurse holding mechanisms to
maintain a steady pool of nurses to stabilize nursing care in our health care delivery
system.

Seventh. Create the Philippine National Council for Nursing Concerns. This
will be composed of all the major national organizations involved in nursing. Some of
these are the Philippine Nurses Association, the Association of Deans of Colleges and
Schools of Nursing, the Board of Nursing, the League of Government Nurses, and the
Private Duty Nurses Association. The possible functions of this national council are: to
develop a 10 year strategic plan for nursing development in the Philippines; to act as an
oversight body for the implementation of all nursing policies, legislations and regulations;
to be the locus for the national data bank on nurses and nursing; to be the national
sounding board for all nursing issues and concerns; and to coordinate all efforts in uplift
and upgrade the nursing profession. To ensure funds for its initial three years of
operations, a Presidential Executive Order can be issued to create this National Council
until it is able to source out its own financing like as was mentioned in strategic solutions
#2 and #3, that is, bilateral aid funding or a percentage of the nursing development trust
funds of hospitals and nursing schools. The President can also appoint the first ever

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Undersecretary of Health for Nursing Concerns, who should be a nurse, to chair this
National Council.

Let us just not hope but act now on these seven strategic solutions. Let us call
upon the President, the Cabinet Members, the Senate and Lower House leadership and
the country’s leading personalities in health and nursing for urgent and immediate
actions to solve this current and future crisis in nursing and medicine.

Give your critical comments by e-mail: jzgalveztan@hotmail.com or write a letter to Health Futures, P.O.
Box 13 U.P. Diliman, Quezon City.

REACTION:

The existence of crisis in the nursing profession in the Philippines
is undeniable. Highly skilled and experienced nurses go out of the
country to seek better employment opportunities with a much higher
compensation and both monetary and nonmonetary benefits. This leaves
the country with inexperienced novice nurses.

The mushrooming of nursing schools throughout the country is
also another factor of the crisis. Many people aspire to be nurses and
with the increased demand for nursing schools, almost every college or
university now offers Bachelor of Science in Nursing (BSN) degree.
The deterioration of quality of nursing education is very evident in the
results of the Nurse’s Licensure Examination with only 40% passers.

The increase in number of nurses is not proportionated with the
increase in jobs, both local and abroad, causing nurses to “volunteer” to
hospitals without pay while actually doing the functions of a staff
nurse. Nurses are baited to such schemes in the hope of receiving a
certificate of employment for two to three years, which can serve as
their ticket for a job abroad.

The current decline in the number of enrollment for BSN in
nursing schools led to colleges of nursing to lessen the number of their
faculty and some colleges to voluntarily close the program. However,
many schools are opening master’s degree in nursing. This prompted the
Commission on Higher Education to issue a ban on opening new nursing
degree programs.

Both the government and nurses must do their part in helping
solve the nursing crisis.

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Ethical Issues in Nursing Practice: A Second Order Problem of
First Order Significance
That Is an “Error of the Third Kind”

Connie M. Ulrich, PhD, RN and Christine Grady, PhD, RN

Introduction

“One of the unspoken realities of life in organizations is that people suffer”

Ethical issues that are challenging for nurses in their everyday practice are
perceived as a second order problem in bioethics—one that is important, but not
prioritized in mainstream bioethical writing and publication, reflection, dialogue, or media
coverage. Mitroff calls this an “error of the third kind” or one that occurs when the
problem is not taken seriously enough, is phrased incorrectly, defined too narrowly,
addressed to the wrong stakeholders, or not discussed from a systems perspective.
However, nurses continue to find it difficult to practice with moral integrity and as moral
agents given the many difficult ethical challenges they encounter in the healthcare
system. Indeed, many nurses are frustrated, overwhelmed, fatigued, feel powerless,
and have even become physically ill working within non-supportive health care
institutions; and 25% or more intend to leave their positions. This is a bioethical concern
of first order significance with serious policy ramifications for the profession and the
broader public good. What should nurse bioethicists do about these problems? How
should nurse bioethicists advocate for nurses? The purpose of this paper is to open
dialogue and begin to identify strategies for developing wise nurse leaders who can
balance multiple stakeholder interests, establish compassionate organizations, and
prioritize and negotiate for the resources and guidance that nurses need to handle the
ethical challenges in their practice.

Reframing the Problem

Lennick and Kiel argue, “There are few issues with more significant impact on life
in and out of organizations today than that of moral action”. Ethical problems in nursing
practice are frequent and intense and are generally ubiquitous in all nursing specialties.
It is not uncommon to read or hear commentators’ scholarly and anecdotal accounts
related to patient safety, staffing inadequacies, treatment disparities, unjust outcomes,
dissatisfaction, nurse distress, and nurses planning to leave their positions. Indeed,
personal healthcare experiences are often displayed in major newspaper outlets and
highlight institutional failings, including medical errors and the lack of compassion,
caring, and dignity by healthcare providers and the settings in which they practice. Yet
these concerns receive limited attention from the broader bioethics community for
reasons that are not always clear.

Generally, bioethics provides an “external voice” to those emerging and
reemerging professional and public health issues that test our moral obligations,
responsibilities, and sensibilities. “Hot button” issues related to nanotechnology,
neuroethics, regenerative medicine, genetics, and other areas tend to take priority in
bioethical discourse over the everyday ethical concerns of providing human care in
nursing practice. These hot button issues clearly demand ethical thought and
philosophical reflection and it is not our intent to suggest otherwise. At the same time,
garnering interest, engagement and priority for the practical problems that create ethical
discord in nursing could potentially redefine and elevate the issues for nursing
leadership as well as our interdisciplinary colleagues and the broader public good. We
14 | P a g e


concur with Benner who noted that “healthcare professionals must not be left alone to
think and decide in isolation about crucial questions concerning rights to treatment,
rights to die, informed consent, new biological possibilities in reproduction and fertility,
new genetic testing and therapies, cloning of human embryos, and continued threats to
equity in health care access.”

Ethical problems within healthcare organizations can be profound and the burden
of patient advocacy has left some nurses questioning the ethical integrity of the
organizations in which they work and to some extent, their own significance and worth
within the healthcare system. Lack of respect, powerlessness, and limited autonomy are
recurring historical and contemporaneous themes for nurses. Frost calls this type of
“confidence-sapping, esteem-draining pain, organizational toxicity”. It represents a by-
product of organizational life that potentially leads to ambivalence and moral passivity
with an inability to morally act in the patient’s best interest. Unfortunately, “moral
activism by nurses seems conspicuously absent or at least invisible.” This comes at a
time when we face not only unprecedented social, economic, and political challenges
nationally and internationally but also when we continue to need healthcare providers
who are “knowledge workers”—those who can readily translate, interpret and problem
solve complex phenomena and have, “the ability to get the right thing done.” The
workplace is a major part of our lives and organizational toxicity is costly in terms of
loyalty, absenteeism, diminished efficiency, and retention of employees. Too few nurses
does not just mean that there are not enough bodies or limited access to technical skills.
Because of the rich mix of skills, assumptions, and philosophy that nurses learn and
practice under, too few nurses creates the danger of a much more significant loss in
terms of CARE.

One study showed that nurses have limited ethics education, which in turn
influences their ethics confidence and ability to act as moral agents. Almost ¼ (23%) of
nurses reported no ethics training. Is it fair to ask them to be moral agents? More
importantly, can they be “good moral agents” and demonstrate moral competence
without the requisite skills? As moral agents, nurses are often called on to do the good
and right thing even in the face of adversity and to facilitate and promote positive
outcomes for those in their care or greater community. They are perceived by society as
champions for the sick. But, how will nurses know what to do if they do not know what to
question?

If not nurses, who will advocate for the chronically ill (both young and old), the
under and uninsured, and the most vulnerable with complex health needs? Who will
question the rightness or wrongness of aggressive care, technological advancements,
and determinations of quality of life? Who will address patient concerns related to
informed consent, surrogate decision-making, and the risks and benefits of treatment or
research? And who will challenge ineffective or inefficient nursing, physician, and
administrative leadership standards and styles that underestimate the significance of
ethical problems on patient outcomes and nurse productivity and retention? These
philosophical questions are at the core of our deeply held values and beliefs about who
we are as a discipline. Without adequate ethical knowledge and competence; however,
it is difficult to unify nursing on central ethical concepts in the provision of nursing care.
If we are not unified and speaking the same language, Willis, Grace and Roy contend
that we can not only lose our differentiation and unique qualities that facilitate those
broad ethical goals of humanization, meaning, choice, quality of life, and healing in
living and dying for our patients but we also become vulnerable to the internal and
external pressures of others who speak on our behalf. How then can we promote
ethical, caring, and compassionate organizations and develop organizational leaders
who will provide the necessary support and guidance to achieve good outcomes for all.
Nurse bioethicists must begin a dialogue with their colleagues and unify their voices to
advocate for an ethical work environment that “screens out the toxins most damaging to

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the human spirit.” If we do not, the ethical issues in nursing practice will remain a
second order problem of first order significance that is an “error of the third kind”.

culrich@nursing.upenn.edu
Phone: 215-898-0898
Fax: 215-573-7496

REACTION:

Nurses face ethical dilemma in their practice of the profession.
Bioethics and the like is becoming a major part of the practice of
nursing in the Philippines. They are faced with a moral dilemma on
different issues such as right to die or right to treatment. However,
few nurses have actual ethical training. They need more training
regarding this matter to better enhance their ethics confidence and
ability to act as a moral agent.

In the end as Benner said, “healthcare professionals must not be
left alone to think and decide in isolation about crucial questions
concerning rights to treatment, rights to die, informed consent, new
biological possibilities in reproduction and fertility, new genetic testing
and therapies, cloning of human embryos, and continued threats to
equity in health care access.” It is not only the decision of nurses or
doctors but of the entire humanity.

16 | P a g e

Issues and problems in nursing

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