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  • 1. Misamis University Ozamiz City Graduate SchoolIssues 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
  • 2. Issues and Problems in Nursing 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 15years, our health care system is on the verge of an overwhelming nurse shortage andhealth care crisis. In fact, an estimated 50% of nurses will be at retirement age within 15years, and new nurses arent entering the field fast enough to stabilize the imminentmass departure. This and other issues are explored in depth in "Extended Hours Issuesin Nursing: Exploring the Problems, Finding the Solutions," by Circadian, aninternational research and consulting firm. The consequences of this current and future shortage are further reaching thanthe economics of supply and demand. Like 20% of American workers, nurses worklong, 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 08 Jul, 2011. 2005 Jannetti Publications, Inc.COPYRIGHT 2007 Gale GroupREACTION: Although this article discusses the issues of nurses in the UnitedStates of America, the same concerns apply to nurses in the Philippines.There is also a turnover rate of nurses in the Philippines. Nurses usually stayin their hospital jobs for about two to three years, as this is the requiredlength of work experience for nurses to go abroad. There is no actual data inthe Philippines related to occupational injury or illness but a few nurses’ getsinfected 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 itis usually left unreported. Fatigue is pretty common among nurses as theyare usually overworked and the length of shift lasts from eight to more thantwelve hours. With the changing shifts of nurses every few days, theincidence of sleep disorders may be increased since their biological clocksare constantly adopting with the frequent change of shifts and schedules.Despite the increasing number of nurses in the Philippines, staffing is oftenshort leaving nurses to have high fatigue because hospitals often choose toaccept inexperienced “volunteer” nurses than hiring highly qualified nurses. 2|Page
  • 3. Issues and Problems in Nursing Problems With Nursing Informatics Heidi Cardenas Informatics includes machinery. Informatics is the process of advancing in adiscipline with a combination of data, information and knowledge. Nursing informaticsencompasses the devices, machines, resources, and methods of utilizing information,computers, and nursing science in nursing. It is a recognized specialty for registerednurses, but does present challenges that academics and medical practitioners areworking to improve or eliminate.Significance In 2007, the Healthcare Information and Management Systems Society NursingInformatics Awareness Task Force estimated that 50 percent of a nurses time is spenton documentation. Because of explosive strides in information technology and the hugebody of medical knowledge amassed, controlling medical errors and health care costsare paramount in the health care professions, including nursing. According to RNJournal, handwriting on a piece of paper has been largely replaced by reports frommedical devices at the point of care, and nurses have to master electronicdocumentation.Function Nursing documentation is complex and situation-dependent. With differenttechnology and medical charting methods in use, consistent education and training ondocumentation is difficult to achieve, especially electronically.Research Concerns and controversies over privacy issues have challenged the health careindustry regarding electronic medical records. In President Obamas first weeklyaddress in January 2009, the U.S. government plans to "computerize the nations healthrecord 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 tosupport their work in information-intensive environments. The informatics nursespecialist role was first credentialed in 1995 to ensure nurses will be qualified to workwith computerized medical data.Considerations There is no single device that generates a comprehensive patient record, storesit and makes it accessible to care providers in different locations. Bar codes onmedicines, computerized physician order-entry, automated scheduling systems fornurse administrators, nursing student preparation for IT tools and HIPAA concerns arejust a few of the problems in nursing informatics.Potential Mobile devices, communication technologies, efficient applications, andenhanced 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 analmost unobtainable goal with the rapid advances in research, medicine and informationtechnology. One thing is certain---nursing and information technology are integrallyintertwined and will remain so in the future.Problems With Nursing Informatics | eHow.com 3|Page
  • 4. Issues and Problems in NursingREACTION: Nursing Informatics is not very new in the Philippines; however,its implementation is almost limited to lectures in the classroom andused in some large hospitals. In the article Problems with NursingInformatics (from the previous page), the United States of Americahas long implemented Nursing Informatics but they have not yet fullycomputerized their health records and some concerns are arising. Nurses spend a whole lot of time on documentation and it will bevery helpful to fully implement computerization of medical records inthe hospitals in the Philippines. Nurses would save a lot of time indocumentation and accuracy of records will be improved since poorhandwriting issues would be eliminated. On the other hand, it will becostly to train nurses on the use of the program for electronicdocumentation. Nurse informaticists are also scarce in the Philippines. The path for full implementation of electronic documentation andother areas of nursing informatics is still a long and rough road forFilipino nurses in the country. Nurses must learn and practice using thecomputer and its basic functions and programs to hasten the road fornursing informatics in the Philippines. 4|Page
  • 5. Issues and Problems in Nursing 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, COHNABSTRACT Nursing is a hazardous occupation in the United States, but little is known aboutworkplace health and safety issues facing the nursing work force in the Philippines. Inthis article, work-related problems among a sample of nurses in the Philippines aredescribed. Cross-sectional data were collected through a self-administered surveyduring the Philippine Nurses Association 2007 convention. Measures included fourcategories: work-related demographics, occupational injury/illness, reporting behavior,and safety concerns. Approximately 40% of nurses had experienced at least one injuryor illness in the past year, and 80% had experienced back pain. Most who had an injurydid not report it. The top ranking concerns were stress and overwork. Filipino nursesencounter considerable health and safety concerns that are similar to thoseencountered by nurses in other countries. Future research should examine the workorganization factors that contribute to these concerns and strengthen policies topromote health and safety.Applying Research to Practice The significant number of nurses in the Philippines not reporting injuries andillnesses suggests the need for active surveillance tailored to this work force.Surveillance systems that capture health care-specific exposures among nurses areneeded. Also, a national surveillance system that includes mechanisms for bothemployers and workers to report injuries and illnesses should be considered.Occupational health nurses in the Philippines should ensure that nurses understand therelationship between injury and illness and workplace factors by implementingeducational and training strategies focusing on workplace health and safety. Given thehazards, concerns, and working conditions that nurses in the Philippines report,advocacy is needed at the national and organizational levels for the enforcement ofoccupational health and safety policies. Additionally, occupational health nurses canidentify priority areas for research and can partner with researchers to investigate theseissues more thoroughly.DISCUSSIONSOccupational 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 awork-related injury. Moreover, about one third stated that they missed 2 or more days ofwork as a result of these injuries and illnesses. These proportions were similar to thosereported by American nurses participating in the ANA survey (Houle, 2001). Forexample, 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 inboth this sample and the ANA sample, about 30% had a second job, and it is possiblethat some of these injuries occurred when working that second job. However, theseproportions are more than threefold higher than what was reported for a national sampleof the U.S. general working population (11%; Waters, Dick, Davis-Barkley, & Krieg,2007). The analyses suggest that future investigation is warranted and should providecomprehensive 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 dueto injury or illness. These findings are not atypical. For example, roughly one fourth ofU.S. nurses also reported missing 2 or more days for work-related injury or illness 5|Page
  • 6. Issues and Problems in Nursing(Houle, 2001). Potential reasons for these findings include underutilization of workers’compensation, concerns of reprisals or loss of income for taking time off, reportingbiases, and inadequate treatment for injured or sick nurses. Although the hypothesescould not be evaluated, future research should investigate them further. This study found that more than three fourths (78%) of the respondentsexperienced back pain. The estimated prevalence of back pain for U.S. nurses rangesfrom 20% to 52% (Harber et al., 1985; Nelson, 2003; Owen, 1989). The causes of thispain are unclear. It is likely that some of this pain results from nursing work and some ofit 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 saidthey continued to work despite the back pain. Because back pain is an important causeof disability, this acknowledgement of working after an injury suggests that ergonomiccontrol measures (e.g., mechanical patient lifting equipment and training) may improvenurses’ well-being and, potentially, the quality of patient care.Reporting Behavior Although a large proportion of participants indicated a work-related injury, manydid not report their injuries to their employers. Underreporting of work-related injuriesand illnesses has also been noted as a significant problem among nurses in the UnitedStates (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 torespondents feeling that the injury was not significant, but other key reasons were thatnurses were too busy or felt that the injury was just “part of the job.” These reasons areconcerning as they not only contribute to nurses working with injuries, but could alsoresult in an artificially low injury rate. Efforts must be made to encourage nurses toreport their injuries within their schedule to improve nurse outcomes and the accurateassessment of workplace health and safety.Safety Concerns About one third (30%) of Filipino nurses in this study reported that they felt eithersomewhat 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 besafer in the Philippines than in the United States. However, this difference may alsoreflect nurses’ lower expectations for safe working conditions. Currently, in thePhilippines, nurses are not unionized and therefore do not have a formal mechanism toidentify workplace hazards and advocate for improved working conditions.Characterizing Filipino nurses’ impressions and expectations of a safe workenvironment is another possible direction for research. Two occupational hazards reported in this study are worth noting. First, a largemajority (80%) of the respondents used powdered latex gloves. This raises concernsgiven 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 reportedamong nurses in the Philippines, it is recommended that an investigation into thispotential problem be undertaken. Also, health care facilities should consider instituting alatex-free policy. Second, one third of the Filipino nurses in this study reportedexperiencing threats or verbal abuse. Even physical assault was reported by 7% of therespondents. Workplace violence is a serious problem among nurses (Henderson,2003; Kingma, 2001). In the United States, patients and coworkers (including physiciansand other nurses) are the major sources of workplace violence against nurses. Acts ofviolence may be motivated by a sense of entitlement among patients, physicians, andother nurses with more seniority. The researchers did not inquire about the source ofworkplace violence among the respondents, however. It is possible that violenceagainst health care professionals is less a part of patient and coworker behavior in thePhilippines, or that the perpetrator profile is different altogether (e.g., only physicians orpatients’ family members). Given the number of respondents who reported experiencingthreats or verbal abuse, this is certainly worthy of continued investigation. 6|Page
  • 7. Issues and Problems in Nursing To assess whether nurses in the Philippines and nurses in the United States areconcerned about similar health and safety issues, the researchers asked respondents torank 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): acuteand chronic effects of stress and overwork. Previous research has noted that certainwork organization factors contribute to stressful working conditions, which can ultimatelylead 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 wereconducted in Western countries. The researchers hypothesize that similar workorganization factors have comparable effects among Filipino nurses; however, no studyalong these lines has been conducted to the authors’ knowledge. Given that the currentsurvey was modeled after the ANA survey, some items that may have been particularlyimportant in the Philippines were omitted (e.g., loss of electricity or “brain drain” todeveloped countries). It would be important for a future study to provide an open-endedstructure to investigate these potential issues and to assess their relative rankings.IMPLICATIONS FOR PRACTICE This study suggests several ways to improve occupational health and safetyamong Filipino nurses. First, the underreporting of injuries and illnesses found in thisstudy indicates that injury and illness surveillance specifically designed for the nursingwork force in the Philippines could be useful in better identifying problems. ThePhilippine Bureau of Working Conditions collects the Work Accident Injury Report (WHORegional Office for the Western Pacific, 2006). Because this system relies on employersto provide information, underreporting may be a problem. In addition to the incidence ofworkplace injury and illness, a surveillance system that captures health care-specificexposures such as hazardous drugs and bloodborne pathogens would informintervention strategies for improving nurses’ health and well-being. The underreporting of occupational injuries and illnesses found in this study alsohighlights an important role for occupational health nurses: to explore strategies to helpnurses recognize the potential seriousness of work-related injuries and illnesses. Forexample, increased education and training that facilitates nurses’ understanding of theconnection 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 bythe PNA and OHNAP, holding frequent seminars for staff within organizations, andincorporating health and safety content within nursing school curricula. Occupational health nurses must advocate for occupational health and safetypolicies. At the national level, these policies should include formalized regulations withenforcement mechanisms. This way, health care organizations will be responsible andaccountable for maintaining a healthy and safe work environment for their nursingstaffs. Policies that address the prevention of occupational injury and illness can also beadopted within the health care workplace. Occupational health nurses can beparticularly effective at this level by directly monitoring workplace exposures andadvocating 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 partneringwith researchers to explore the issues found with this assessment. Some potentialpriority areas include job stress, the impact of verbal abuse on nurse well-being, andfactors that contribute to back pain. Occupational health nurses are in optimal positionsto identify research needs and facilitate study participation among the nursing workforce they serve.CONCLUSION Studies in the United States and other Western countries suggest that nursesface considerable occupational health and safety risks. Although preliminary, this survey 7|Page
  • 8. Issues and Problems in Nursingsuggests many commonalities in the types of issues reported by nurses attending the2007 PNA annual national convention and nurses elsewhere. Many respondentsreported helpful workplace policies and practices, such as the provision of patient liftingdevices, but about one third of the sample reported poor or no employer informationrelated to nursing occupational hazards. Future research should verify these findingsand assess the potential interventions that may enhance nurses’ health and well-beingand promote quality patient care. Nurses face considerable occupational health and safety risk intheir daily duties. Despite the importance of occupational health andsafety among nurses, it is not given very much attention in thePhilippines. The Philippine Nurses Association must look into this andadvocate ways of promoting health and safety of healthcare providers,the nurses. The study found out that there is underreporting of work-relatedinjuries and illnesses among nurses. A surveillance system must beenforced to collect data regarding this matter. Occupational healthnurses must also explore strategies to help nurses recognize thepotential seriousness of work-related injuries and illnesses. Occupational health nurses must also advocate for betteroccupational health and safety policies. There should be a formalregulations regarding this matter. Other potential work-related injuries and illnesses may includejob stress, verbal abuse, and back pain. This areas must also be lookedinto. 8|Page
  • 9. Issues and Problems in Nursing 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 strategicsolutions in sight, expect a worsening of the health crisis already plaguing our country. Itis not only the nurses the country is losing, our medical doctors are now enrolling innursing schools offering an abbreviated course for doctors to become nurses. Why? There is an acute shortage of nurses in the countries mentioned abovewhich became palpable 3 to 4 years ago. The need will not just be for a year or two butfor at least the next 10 to 15 fifteen years. So it will no longer be the roller coasterdemand for foreign graduate nurses by developed countries which characterized theoutflow 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 whilethe U.K., Ireland, the Netherlands and other European countries would need another50,000 nurses a year. Austria and Norway have also announced their need for foreignnurses 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 thegraying of their population. These factors create increasing pressure on their healthsystems for greater response mechanisms to the health problems of a growingproportion of the elderly. Their youth population no longer take interest in the nursingprofession due to relatively difficult and riskier working conditions such as eveningduties, care of the chronically ill and exposure to HIV/AIDS. Thus, there is a greatdemand for foreign graduate nurses.The Problem The Philippines will never be able to compete with the salary scales of nurses inthese Northern countries. The basic monthly pay there is US$3,000-US$4,000 a monthcompared to the US$150-US$250 that nurses receive in the Philippines. Yes, ourFilipino nurses are globally competitive in professional nursing care and practice but ourFilipino salaries will never be competitive. Filipino doctors are going through a reversalof health human resource development by becoming nurses. Even specialist doctorsare enrolling in nursing schools. The current income of doctors in the Philippines ofUS$300 to US$800 a month is still a pittance compared to the monthly salary of US orEuropean based nurses. Hospitals in the USA even offer additional attractive benefits like residency visastatus for nurses, their spouse and children plus other perks like subsidized housingand 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 tothe U.K. with 5, 383 nurses, Saudi Arabia with 5, 045 and Ireland 1,529. The POEAreported only 304 nurses going to the USA. This is definitely gross underreporting sincethe International Union of Nurses reported that close to 10,000 Filipino nurses weredirectly hired by US based hospitals in 2001 through their nursing job fairs held invarious parts of the Philippines. In 2002, the POEA further reports that a total of 11,911 Filipino nurses left for 33countries. In 2003, POEA initially reported 8,968 nurses leaving. Again withunderreporting 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 ourFilipino nurses. These annual outflow of Filipino nurses for Years 2001-2002 is two to three timesgreater than the annual production of licensed nurses during the same two year period.Since 1999, the Professional Regulation Commission (PRC) through the Board ofNursing gives licenses to only 5, 784 to 8,419 nurses annually. This is despite the 9|Page
  • 10. Issues and Problems in Nursingincrease of nursing schools from 142 to 240 within the last four years. There were only40 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 hasshown signs of deterioration as measured by the proportion of nursing graduates whopass 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 licensureexaminations from 1994-1998 which was 57 percent. Will the Philippine government just tolerate this trend of health human resourceoutflows to other countries? Will we, as Filipinos, just wait, standby and not dosomething about this health threatening situation now? Will the Department of Healthact only when the catastrophe is already beyond resuscitation?Seven Strategic Solutions This national crisis in nursing and medicine is a very complex issue requiringstrategic thinking, multidisciplinary approaches and long-term goals. Since the problemis both global and national in scope, it also requires solutions that are global andnational in nature. A win-win strategic solution between the Philippines and the nursing importingcountries of the North must be the ultimate goal in dealing constructively and resolvingthe crisis in nursing and medical human resources and services. There is no longerroom 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 nationalproblem deserving urgent attention and action.A seven-point policy action agenda is hereby proposed: One. Creation of a National Commission on Health Human ResourcesDevelopment. Initially, through a Presidential Executive Order, and later as a legislativeact, this National Commission will be composed of the leaders from the Executive andLegislative branches of government with participation from the private sector, academeand 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: anintensive review of the past, current and future scenarios of the nursing and medicalhuman resources; completion of a data base of Filipino health human resources;updating of the 25 year National Health Human Resources Policy and DevelopmentPlan (1996-2020) formulated with the guidance of Drs. Fernando Sanchez and DennisBatangan in 1992-95 for the Department of Health; and the development of a unifiedhealth human resource development policy and a national policy research agenda onhealth human resources. Two. Initiation of High-Level Bilateral Negotiations with Northern CountriesImporting Filipino Nurses. Led by a team composed of Secretaries of the Departmentof Foreign Affairs (DFA), Department of Labor and Employment (DOLE), the NationalEconomic Development Authority (NEDA), Commission on Higher Education (CHED),Department of Trade and Industry (DTI) and the Department of Health (DOH), bilateraldiscussions with the United States, United Kingdom, Republic of Ireland, Netherlandsand Saudi Arabia will center on a partnership approach between the Philippines andthese countries. The current approach to the importation of Filipino nurses by these richcountries has been lopsided and advantageous only to such countries while thePhilippines continue to wallow in poverty, underdevelopment and inadequate healthcare. In the negotiations, these rich countries must be made to realize that the agendaand interests of their Departments/Ministries of Health and their Development Agenciescan coincide. Thus for example, USAID, in behalf of the US government and DFID, inbehalf of the United Kingdom, will include in their aid package to the Philippines,financial assistance to continuously train globally competitive nurses, constantlyupgrading nursing education, nursing health services and nurse remuneration andoffering nursing scholarships. Such aid will eventually benefit both countries e.g. the US 10 | P a g e
  • 11. Issues and Problems in Nursingand UK having a regular pool of nurses to serve their needs since many of these nurseswill eventually work there, while the Philippines will be ensured also a regular productionand supply of nurses for its health care system. The Philippine Cabinet Bilateral Negotiation Team must be able to come up withconcrete investment packages for nursing and health human resource development fordiscussions with these countries at the soonest possible time. Three. North-South Hospital to Hospital Partnership Agreements. Whilebilateral country negotiations are on-going and the financial aid packages for nursingdevelopment eventually actualized, Northern country hospital to Philippinehospital/nursing school agreements should proceed with the same vigor and pace. Suchpartnership would focus on the provision of a financial grant given by the Northerncountry hospital for every Filipino nurse that enters its staff. The said financial grant willgo to a Nursing Development Trust Fund of the Philippine hospital/nursing school, to beused to improve nurse salaries, training and nursing practice, upgrade hospital andeducational facilities and nurse scholarships. Current estimated total cost of educatingand producing a nurse that will pass the Philippine nursing licensure examinations arein the range of US$4,000 to US$7,000. Thus for example, the Philippine GeneralHospital (PGH) will enter into a partnership agreement with the Johns HopkinsUniversity Hospital (JHUH) in Maryland, USA. JHUH will donate a negotiated amount tothe 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 singlecentavo in the production, development, education and licensure of Filipino nurses. Atthe very least, they should be able to pay partially if not fully the cost of nursingdevelopment since they are going to benefit from the services of that nurse for at least25 years. Fourth. Institution the National Health Service Act. The Philippines is one ofthe 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 serveanywhere within the country for a number of years equivalent to the number of years ittook them to study their health professions. While in the past there were attempts tohave such a law passed, major objections centered on the individual human rights tomove freely and practice their profession where each individual wants, such as inanother country. However, with the globalization and active trading of health humanresources and the inevitability of the severest brain drain to hit the Philippines, thecountry’s collective interest and collective rights should now prevail. At best, health professionals graduating from state universities, schools andcolleges must be covered by the National Health Service Act. Their educations havebeen heavily subsidized with the taxes paid by the Filipino people. It is but right thatthey 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 fromprivate 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 programscientifically the exit of our health professionals, thus ensuring a steady maintenance ofhealth human resources in all health facilities, whether rural or urban. Fifth. Establish Philippine Nursing Registries. A nursing registry is corporatelyrun human resource development center that provide hospitals, clinics and other healthfacilities with their nursing needs. It has management mechanisms that efficientlylocates and monitors nursing human resource availability. It actively negotiates forbetter remuneration and benefits, better working conditions, keeping always nursingwelfare high in its agenda. Usually private sector led, nursing registries can be createdat the local level covering a specific geographical area. It can start within a localgovernment unit (LGU) service area, either at the city, province or municipality level or a 11 | P a g e
  • 12. Issues and Problems in Nursingdistrict health system (DHS) level, covering a network of public and private healthfacilities in various LGU locations. The registry can also center around a tertiary hospitaland cover its referral units and catchment areas. While nursing registries are functioning well in the United States and Europe, thePhilippines still has to catch-up with this nursing development. The numerous collegesand schools of nursing should complement this service by making sure that their officeof alumni affairs keep a regularly updated directory of all their graduates, keeping tracknot only of where they are but of how they are, in terms of their human welfare andprofessional growth. With the era of advanced computer software systems and globalcommunication technologies, there should be no more excuses for nursing schools toguarantee this. Sixth. Expand Nursing Residency and Nurse Practitioner TrainingPrograms. This strategy was adapted from the Board of Nursing-led policy workshops.Patterned after medical specialist residency training programs, all secondary andtertiary hospitals should start a similar one for nurses. These will also be three yearresidency 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 programscentering on sub-specialty nursing such as cardiac care nursing, neurology care nursing,genetic nurse counselling, chronic care nursing and palliative and hospice care. ABoard of Nursing Specialties, entirely separate from the Board of Nursing of thePhilippine Regulations Commission, should be established to regulate the productionand development of these nursing residency and fellowship training programs. Another nursing development program is the offering of nurse practitionerpostgraduate courses. Nurse practitioners are independent, highly skilled nurses thatwork in solo, group or networks. While the Philippines produces a lot of graduates ofMasters in Nursing which focuses more on nursing management, administration andresearch, it has been lagging behind in developing a nurse practitioner educationprogram. This will give room for clinical skills in the nursing areas of wellness,counselling, public health, community health, complementary and alternative healthcare. The course can be offered by colleges of nursing and can also be regulated by theBoard of Nursing Specialties or another new board as well. Once this course isavailable, the time will come when Filipinos can benefit from direct nursing care fromstandalone nurse clinics, nurse wellness centers and other modalities of nursepractitioners’ facilities. The above-mentioned developments in nursing education will become venues fornurses to comply with the National Health Service Act without neglecting theirprofessional growth. These will also ensure better nurse holding mechanisms tomaintain a steady pool of nurses to stabilize nursing care in our health care deliverysystem. Seventh. Create the Philippine National Council for Nursing Concerns. Thiswill be composed of all the major national organizations involved in nursing. Some ofthese are the Philippine Nurses Association, the Association of Deans of Colleges andSchools of Nursing, the Board of Nursing, the League of Government Nurses, and thePrivate Duty Nurses Association. The possible functions of this national council are: todevelop a 10 year strategic plan for nursing development in the Philippines; to act as anoversight 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 nationalsounding board for all nursing issues and concerns; and to coordinate all efforts in upliftand upgrade the nursing profession. To ensure funds for its initial three years ofoperations, a Presidential Executive Order can be issued to create this National Counciluntil 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 trustfunds of hospitals and nursing schools. The President can also appoint the first ever 12 | P a g e
  • 13. Issues and Problems in NursingUndersecretary of Health for Nursing Concerns, who should be a nurse, to chair thisNational Council. Let us just not hope but act now on these seven strategic solutions. Let us callupon the President, the Cabinet Members, the Senate and Lower House leadership andthe country’s leading personalities in health and nursing for urgent and immediateactions to solve this current and future crisis in nursing and medicine.Give your critical comments by e-mail: 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 Philippinesis undeniable. Highly skilled and experienced nurses go out of thecountry to seek better employment opportunities with a much highercompensation and both monetary and nonmonetary benefits. This leavesthe country with inexperienced novice nurses. The mushrooming of nursing schools throughout the country isalso another factor of the crisis. Many people aspire to be nurses andwith the increased demand for nursing schools, almost every college oruniversity now offers Bachelor of Science in Nursing (BSN) degree.The deterioration of quality of nursing education is very evident in theresults of the Nurse’s Licensure Examination with only 40% passers. The increase in number of nurses is not proportionated with theincrease in jobs, both local and abroad, causing nurses to “volunteer” tohospitals without pay while actually doing the functions of a staffnurse. Nurses are baited to such schemes in the hope of receiving acertificate of employment for two to three years, which can serve astheir ticket for a job abroad. The current decline in the number of enrollment for BSN innursing schools led to colleges of nursing to lessen the number of theirfaculty and some colleges to voluntarily close the program. However,many schools are opening master’s degree in nursing. This prompted theCommission on Higher Education to issue a ban on opening new nursingdegree programs. Both the government and nurses must do their part in helpingsolve the nursing crisis. 13 | P a g e
  • 14. Issues and Problems in Nursing 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, RNIntroduction “One of the unspoken realities of life in organizations is that people suffer” Ethical issues that are challenging for nurses in their everyday practice areperceived as a second order problem in bioethics—one that is important, but notprioritized in mainstream bioethical writing and publication, reflection, dialogue, or mediacoverage. Mitroff calls this an “error of the third kind” or one that occurs when theproblem 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 moralagents given the many difficult ethical challenges they encounter in the healthcaresystem. Indeed, many nurses are frustrated, overwhelmed, fatigued, feel powerless,and have even become physically ill working within non-supportive health careinstitutions; and 25% or more intend to leave their positions. This is a bioethical concernof first order significance with serious policy ramifications for the profession and thebroader public good. What should nurse bioethicists do about these problems? Howshould nurse bioethicists advocate for nurses? The purpose of this paper is to opendialogue and begin to identify strategies for developing wise nurse leaders who canbalance multiple stakeholder interests, establish compassionate organizations, andprioritize and negotiate for the resources and guidance that nurses need to handle theethical challenges in their practice.Reframing the Problem Lennick and Kiel argue, “There are few issues with more significant impact on lifein and out of organizations today than that of moral action”. Ethical problems in nursingpractice are frequent and intense and are generally ubiquitous in all nursing specialties.It is not uncommon to read or hear commentators’ scholarly and anecdotal accountsrelated 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 andhighlight institutional failings, including medical errors and the lack of compassion,caring, and dignity by healthcare providers and the settings in which they practice. Yetthese concerns receive limited attention from the broader bioethics community forreasons that are not always clear. Generally, bioethics provides an “external voice” to those emerging andreemerging 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 inbioethical discourse over the everyday ethical concerns of providing human care innursing practice. These hot button issues clearly demand ethical thought andphilosophical 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 ethicaldiscord in nursing could potentially redefine and elevate the issues for nursingleadership as well as our interdisciplinary colleagues and the broader public good. We 14 | P a g e
  • 15. Issues and Problems in Nursingconcur with Benner who noted that “healthcare professionals must not be left alone tothink 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 toequity in health care access.” Ethical problems within healthcare organizations can be profound and the burdenof patient advocacy has left some nurses questioning the ethical integrity of theorganizations in which they work and to some extent, their own significance and worthwithin the healthcare system. Lack of respect, powerlessness, and limited autonomy arerecurring 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 passivitywith an inability to morally act in the patient’s best interest. Unfortunately, “moralactivism by nurses seems conspicuously absent or at least invisible.” This comes at atime when we face not only unprecedented social, economic, and political challengesnationally and internationally but also when we continue to need healthcare providerswho are “knowledge workers”—those who can readily translate, interpret and problemsolve complex phenomena and have, “the ability to get the right thing done.” Theworkplace is a major part of our lives and organizational toxicity is costly in terms ofloyalty, absenteeism, diminished efficiency, and retention of employees. Too few nursesdoes 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 andpractice under, too few nurses creates the danger of a much more significant loss interms of CARE. One study showed that nurses have limited ethics education, which in turninfluences their ethics confidence and ability to act as moral agents. Almost ¼ (23%) ofnurses reported no ethics training. Is it fair to ask them to be moral agents? Moreimportantly, can they be “good moral agents” and demonstrate moral competencewithout the requisite skills? As moral agents, nurses are often called on to do the goodand right thing even in the face of adversity and to facilitate and promote positiveoutcomes for those in their care or greater community. They are perceived by society aschampions for the sick. But, how will nurses know what to do if they do not know what toquestion? If not nurses, who will advocate for the chronically ill (both young and old), theunder and uninsured, and the most vulnerable with complex health needs? Who willquestion the rightness or wrongness of aggressive care, technological advancements,and determinations of quality of life? Who will address patient concerns related toinformed consent, surrogate decision-making, and the risks and benefits of treatment orresearch? And who will challenge ineffective or inefficient nursing, physician, andadministrative leadership standards and styles that underestimate the significance ofethical problems on patient outcomes and nurse productivity and retention? Thesephilosophical questions are at the core of our deeply held values and beliefs about whowe 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 contendthat we can not only lose our differentiation and unique qualities that facilitate thosebroad ethical goals of humanization, meaning, choice, quality of life, and healing inliving and dying for our patients but we also become vulnerable to the internal andexternal pressures of others who speak on our behalf. How then can we promoteethical, caring, and compassionate organizations and develop organizational leaderswho 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 toadvocate for an ethical work environment that “screens out the toxins most damaging to 15 | P a g e
  • 16. Issues and Problems in Nursingthe human spirit.” If we do not, the ethical issues in nursing practice will remain asecond order problem of first order significance that is an “error of the third kind”.culrich@nursing.upenn.eduPhone: 215-898-0898Fax: 215-573-7496REACTION: Nurses face ethical dilemma in their practice of the profession.Bioethics and the like is becoming a major part of the practice ofnursing in the Philippines. They are faced with a moral dilemma ondifferent issues such as right to die or right to treatment. However,few nurses have actual ethical training. They need more trainingregarding this matter to better enhance their ethics confidence andability to act as a moral agent. In the end as Benner said, “healthcare professionals must not beleft alone to think and decide in isolation about crucial questionsconcerning rights to treatment, rights to die, informed consent, newbiological possibilities in reproduction and fertility, new genetic testingand therapies, cloning of human embryos, and continued threats toequity in health care access.” It is not only the decision of nurses ordoctors but of the entire humanity. 16 | P a g e