Substandard nursing schools sell dreams of a life abroad

The second part of the series looks at how the nursing export boom has also resulted in a boom in nursing education. Many substandard schools have been set up, and many of these play on the dreams of those who aspire for a job abroad. Nursing education in fact has been retrofitted to meet the demands of the global market. Courses like transcultural studies being included in the curriculum and new, shortened designer courses are being offered for doctors and other professionals who want to take up nursing. In these new curricula, the compassionate and caregiving values that are supposed to be inculcated among healthcare professionals are being overlooked; instead nursing is treated as primarily a passport to the good life.

SMACK IN the heart of downtown Manila and around the Professional Regulation Commission can be found the country’s export processing zone for nurses. There, a dozen or so nursing schools and training centers have somehow converged and are thriving, mining the dreams of those aspiring to work overseas.

In one of these schools, students called upon to recite are admonished by the teacher to speak in English. “How can you work abroad if you can’t even answer in English?” the teacher tells them.

Soon, the same school will also introduce a new subject: Transcultural Nursing, which will teach students how to practice their profession in countries whose culture and environment differ vastly from the one they had always known.

Throughout the country, nursing education is being retrofitted to meet the demands of the global market. A surge in demand for nurses among health institutions overseas—particularly in the United States and the United Kingdom—is fueling a boom in nursing schools. But as in any other boom, quality has suffered as the numbers increase, in large part because of skewed priorities.

In the 1970s, there were 40 nursing schools in the country. Today there are about 350, including many that are focusing more on reaping profits from people dreaming of high-earning jobs overseas rather than preparing students for an exacting profession that provides care for ailing patients and technical support for doctors.

Many of these schools lack up-to-date facilities, qualified faculty or affiliation with a hospital, all of which are supposed to be in place before these institutions are allowed to operate.

Yet instead of attending to such problems, many nursing schools have busied themselves adjusting their requirements to fit the needs of a new type of students: middle-age professionals seeking a new career. Called “second-coursers,” they include doctors as well as accountants, clerks, teachers, journalists, government employees and secretaries. All of them hope to become nurses, preferably in a foreign land. More often than not, such students enjoy a shorter term since their basic science subjects in their first course are credited.

But Rita Tamse of the Technical Committee on Nursing Education of the Commission on Higher Education (CHED) urges students to first scrutinize a school’s credentials and past performance before parting with the often-hefty tuition money. She notes, for instance, that 23 of the current number of nursing schools have failed to meet the requirements set by the government for them to operate. These schools are supposed to have until this month to stop operating and start transferring their students but they have appealed to CHED to let them continue for one more year. They have also sought the help of congressmen to avoid closure.

To help students in avoiding the duds among the schools, CHED has issued a list showing the performance of various schools in the Nursing Board Exam. CHED classified the schools in five categories, with those that have 90 percent or more of their examinees passing the Board in the last five years classifying as institutions that had “outstanding performance.” The bottom category is for “very low performing” schools, or those with 29 percent or below of their students passing the exams. (Check out for the list of schools.)

Very low performers made up 21 percent of the total schools listed by CHED. The bulk, or 36 percent of the total, meanwhile belong to the “low-performing” category, or schools that saw 30 to 49 percent of its students passing the Board.

Only 12 nursing schools—a mere six percent of the total—made it to the outstanding category: University of the Philippines-Manila, St. Paul College (Iloilo), Silliman University, St. Louis University, Mindanao State University-Marawi City, St. Paul College (Dumaguete), Pamantasan ng Lungsod ng Maynila, St. Mary’s University (Bayombong), St. Paul College (Manila), and University of the East Ramon Magsaysay Memorial Medical Center.

Of the 94 schools that had less than five years of Board performance, 42 had zero passing rates, meaning none of their graduates passed the national exam.

Under the law, a nursing school must have a passing rate of five percent to be able to continue operating. CHED wants to push the rate up to 30 percent, a level that could close down many of the nursing schools.

To certain schools, CHED might appear to be a villain. But the government and even recruiters know that in the end, having high-quality graduates is the best way the country could stay in the business of exporting nurses.

For almost a year, CHED’s technical committee monitored nursing schools for their compliance with five requirements: adherence to the nursing curriculum, availability of facilities, ratio of faculty to students, affiliation with or existence of an active tertiary hospital to serve as base for students, and a qualified faculty.

Tamse notes that many schools “are really having trouble with the last three requirements.” Depending on the year level of the students, a school is supposed to observe a teacher-student ratio. In the subject on Related Learning Experience, for example, there should be one teacher for just eight students.

A school must also have a dean—a requirement that seems reasonable enough but which nursing schools find hard to meet. “It’s very easy for them to have facilities because they have lots of money,” says Tamse. “They can construct a school, put up air-conditioned classrooms, a nursing laboratory and all that.” But one apparently cannot buy something that’s simply not available, such as qualified teachers and a dean.

Base hospitals are also a problem. “We have too many nursing schools for the number of qualified training hospitals available all over the country,” says Tamse. Not just any hospital can qualify as a base. It has to have the major departments—surgical, ob-gyn and pediatric wards. It should be a tertiary hospital accredited by the Department of Health. And it must have an occupancy rate of 80 percent, which means it is an active hospital where students can be exposed and properly trained.

In addition, some schools want to offer classes in trimesters or quartermasters, a suggestion that would fast track the course but inevitably lead to half-baked students. “In many health sciences, exposure is important because that is where skills are honed,” says the CHED consultant. “If you shorten that, you come up with graduates who are half-baked. And when they get to the hospitals to work, they’re dangerous. Talagang makakapatay (They can really kill people).”

The overwhelming number of students wanting to become nurses obviously contributes to the desire of many schools to have as many graduates as they can. According to CHED, nursing schools had a total of 80,000 enrollees last year, among them “second coursers.” The steep cost of the course apparently did not faze them, perhaps because they expect a quick return in their investment once they land a job overseas.

“Nursing is not a poor man’s course,” admits a social science major who has decided to change professional gears. He ticks off his expenses: tuition per semester is P40,000. Other costs include reading materials, about P5,000 (for books, both bought and photocopied); stethoscope, P850; white shoes, P1,500; white shoe polish, P500; food and lodging, P25,000.

For students who could not afford the full semestral payment, an installment plan is available. A down payment of P10,000 is required, with the balance paid in three “gives,” each to be given before the three major tests: prelims, midterm and finals. Inability to pay at any point would mean dropping out from class, repeating the semester and paying up once more. In the end, the poorer the student, the higher the costs incurred.

There are already schools that turn down enrollees for sheer inability to accommodate them. Far Eastern University, for example, reportedly rejected 5,000 applicants last year. In the same period, the UP College of Nursing admitted only 70 students out of 11,000 who applied. That number for admission will not increase even as 14,000 applicants have already asked to be taken in for the coming school year.

At the same time, there are also nursing schools that do not admit second-coursers, including doctors, in their classes. The demand from regular students appears to be enough to make up for any financial gain that is given up.

Dr. Rusty Francisco, a nurse with a doctorate in nursing education and an owner of a training center for nurses bound for abroad, says many students are deluded into thinking that enrollment in a nursing school is a guaranteed passport to a job abroad.

“Passing all examinations does not make them competitive,” he says. Not many Filipino nurses are familiar with the medical equipment being used in U.S. hospitals, he points out. Neither do they know how to operate in an environment where patients are more assertive and aware of their rights. That is why in his training center, Francisco emphasizes what Filipino nurses should expect when they are in the United States.

He adds that while Filipinos are still the preferred health workers, they may soon be facing stiff competition from the Chinese and the Indians who have come to realize the financial windfall from the export of nurses to developed countries.

Although Filipino nurses are known for being compassionate and caring, these qualities appear to be disappearing because the goals for taking up nursing have changed. From desiring to be of service to another human being, nursing students are now primarily motivated by the need to make money.

Francisco argues that even a high-standard school may not be able to change the mindset of those already determined to earn dollars above anything else. “A school curriculum,” he says, “does not automatically turn a person into a caring, compassionate nurse with the ability to be assertive and articulate.”

Tamse agrees with the observation. “Some of them don’t even have the heart for it,” she says. “They’re just there because they know it’s a good passport for going abroad…Nursing is about caring and being compassionate. It’s difficult to be compassionate if your only purpose is to earn.”

But it is also difficult to deny the validity of the economic reason behind the decisions of many who leave. At the Philippine General Hospital, says Tamse, “99 percent left because they have to finance the schooling of their brothers and sisters, the husband is unemployed or underemployed, the children need to be given quality education and so on.”

She says many of the nurses cry and tell her, “I don’t want to leave naman ma’am, eh. It’s just that I have to do it.” In one exit interview, a nurse underscored the words, “Pera lang po (It’s only the money).”

But the likes of Tan are unwilling to take all these sitting down. In a rather controversial scheme, Tan suggests the enactment of a National Health Service Act that would require health sciences education graduates of state colleges and universities to serve the equivalent number of years of study in the country. Since the state has subsidized the education of these health science graduates, he reasons, they should pay back the favor by serving in the country for a few years.

Several bills have been filed in Congress imposing mandatory service for nurses. Predictably, these have been opposed by nurses’ organizations that say the practice is discriminatory and oppressive.

Tan believes otherwise. He points out that the current health crisis warrants compulsory service by health workers for a specified period. He also notes that countries like Indonesia and Malaysia require their medical and health science graduates to work in the country before going abroad. In fact, Tan says, the Philippines is the only country in Southeast Asia that does not have a National Health Service Act.

Dr. Irineo Bernardo of the Philippine Hospital Association, for his part, says, “We need to look at a problem from many angles.” Instead of dreading the loss of more nurses, doctors and other health workers, he suggests working harder to improve the health condition of Filipinos.

“The government keeps talking about having a strong republic,” he says. “Why not have healthy Filipinos so we can really have a strong country?”

Up to now, Bernardo says, the government has not established the health status of the country. “How healthy or how sick are we?” he asks, adding, “If the number of health providers go down, will that make more people sick? No!”

But if the government fails to look after the health of its people—such as by making it easy for cigarette companies to sell their products—then Filipinos will get sick, he says. Educating the population on how to take care of themselves could do more to improve public health rather than having a big number of health providers, he says. Points out Bernardo: “Sickness comes from our lifestyle, from what we take in. We need food, not medicine.”

While the disappearance of doctors and nurses is indeed a problem, Bernardo suggests taking good care of those who stay behind. “Recognize the competence of nurse anesthetists, for example, and pay them as well as a doctor,” he says. After all, surgery would be impossible if no anesthesia is administered.

There is, in fact, a boon for those who will remain in the country: they would now have a bigger market for themselves, since they will have fewer rivals. “There will be a time when things will not be good,” concedes Bernardo. “But they will become better. Many hospitals will close down but they will be replaced by new players. We will change.”