The number of nursing schools in the Philippines has increased recently because of emerging demands from several countries for international nurses. Whereas in the past the need for Filipino nurses came mostly from the Middle East and the United States, employers from other countries are now actively engaged in the recruitment of Filipino nurses. The countries with emerging needs for nurses are in Europe, the Caribbean, and now Asia. This phenomenon is driven by the disparity in the supply and demand of nurses in these countries.
In the United States, the shortage of nurses is driven by several factors. For one, there is a decline in the enrollment of students in nursing while the active pool of nurses are aging and retiring from the workforce. Another factor is the graying of Americans. As baby boomers begin to reach gerontological age, their health needs increase. This drives the need for more health care services. The disproportion between demand for health care and nursing services and the supply of nurses has driven health care facilities to recruit their pool of nurses from countries that parallel the education of nurses in the United States.
The Philippines has been in the past a good source of nurses for the United Statesbecause Filipino nurses are able to communicate with ease in English. In addition, the training and education of nurses from the Philippines closely resembled the education of nurses in the United States. Unfortunately, this advantage has now been diluted because of the emergence of disturbing changes in the education, training, and experience of nurses from the Philippines. These factors are what this article wishes to explore.
Requirements for US Licensure
For nurses educated outside of theUnited States there are several licensure and immigration requirements to meet before they can work in the USA as registered nurses. Before a nurse can qualify as a beneficiary of a US employer, the nurse must meet either the CGFNS certificate requirement or have an active license issued by one of the State Boards of Nursing which includes the 50 United States, the District of Columbia and US territories (Guam, Northern Mariana Islands Commonwealth, the Commonwealth of Puerto Rico, American Samoa and the Virgin Islands). Licensure from one of these states is acquired by meeting the State’s Board of Nursing requirements which includes, among others, success in the National Council of State Boards of Nursing examination for RNs (NCLEX-RN). This examination is given in all states of theUSAand in other international testing centers. Ironically, despite having the most international nurses testing for the NCLEX, it was only recently that the NCSBN approved the Philippines to be a testing site.
One option in meeting visa requirements for USA immigration of Filipino nurses is success in the CGFNS examination. The Commission on Graduates of Foreign Nursing Schools (CGFNS) conducts its qualifying examination in several testing centers around the world three times a year. The Philippines has two sites where the CGFNS qualifying examination is administered. For 2006, there were 9,473 first time test takers with an average pass rate of 73.3%. In 2005, there were 13,959 examinees who sat for the exam with a 70.5% pass rate for first time international nurse graduates. Data as to the pass rate of Philippine educated nurses is not published by CGFNS. However, in my experience, Filipino nurses do not fare well in this examination. Most recently, Filipino nurses opt out of the CGFNS certification and instead take the NCLEX directly.
The other option in fulfilling the requirement for visa issuance (other than the CGFNS) is success in the NCLEX-RN examination. The statistics provided by the National Council of State Boards of Nursing (NCSBN), the organization responsible for the development of NCLEX, shows that in 2004 there were 9384 Filipino nurses who took the NCLEX-RN. Of this group, there was a pass rate of 54.5%. In contrast, the performance of nurses from other countries is better, like India with a pass rate of 72.6%. To further point out the poor performance by Philippine-educated nurses, the pass rate of nurses from other countries whose medium of instruction was other than English were even better than those from the Philippines (South Korea69% and China66.4%). Overall, the pass rate of international nurses that year was 58.2%, with Filipino nurses faring 3.7% below the international pass rate.
In 2005, the NCLEX pass rate for first time internationally educated nurses was 58.1%. Nurses from the Philippines who took the NCLEX that year had a pass rate of 55.4 %, in contrast to India with 72.1% passing, South Korea with 71.6%, and China with a 64.6% pass rate. The mean pass rate of all international nurses taking the NCLEX in 2005 was 2.7% higher than the mean average of Philippine examinees, a decline from 2004. It is clear that Filipino nurses lag in NCLEX-RN success compared to their counterparts educated in other countries. Interestingly nurses from several other countries and educated in non-English instructional medium fared much better.
In addition to the CGFNS or the NCLEX requirement, a nurse must also pass an English language proficiency examination to be issued a visa for US immigration. The most common avenue in fulfilling this requirement is either through the TOEFEL and TSE examinations, IELTS, or several others. The International English Language Testing Service (IELTS) is now the preferred route for Filipino nurses because they only have to apply to one test provider to satisfy both the written and spoken requirements. Another reason is because the test is conducted in several locations in the Philippines and given more frequently compared to the other options. Unfortunately, Filipino nurses have difficulty in passing the English examination, mainly because they fail the speaking section. A band score of 7 (out of 9) is a requirement for visa issuance for the spoken section. Additionally, the total band score which is the average in all sections (speaking, reading, writing, and listening) must total 6.5 out of 9.
The English capability which once upon a long time gave an edge to Filipino nurses in the international market has slowly changed to a handicap. Several reasons could be postulated about this sorry state. However, one has to put the major blame in the educational system in this country. The Philippines has ambivalence in making English as the medium of instruction in schools as evidenced by its ever changing policy as to what medium of instruction is to be used in schools. College graduates can hardly speak English well, and worse, they have difficulty in writing sane and congruent sentences. Unless we make revisions to our English curriculum, unfortunately and tragically, this trend will continue. The Philippines will lose one of its assets, i.e. proficiency in English, if measures are not taken by our educators to reverse this disturbing trend. And in the case of nurses, US hospitals will look elsewhere to other English-speaking countries for recruitment.
Reasons US Nurse-Recruiters Look Elsewhere
The statistics mentioned previously plus the deteriorating quality of nurse graduates from the Philippines has nurse recruiters from the USA shift their search efforts to other countries especiallyIndia. The Indian nurses are favored at this time because of their success rate in the NCLEX and also because their nursing experience are far more superior to those coming from thePhilippines. It is a fact that the health care in India is far more advanced than that of the Philippines. Furthermore, in India there are adequate clinical facilities and patients with whom the student nurses and graduate nurses can gain experience. There is not a glut for students to enter into nursing and there is a very good ratio of hospital beds to nursing students. Furthermore, the medical technology in India closely parallel those found in the USA. In fact, some US medical insurance companies have several approved medical facilities in India where patients can go for discounted surgeries and procedures in what is known as approved medical tourist venues.
Nurse Training in the Philippines
In the Philippines, students do not get adequate training and exposure because the ratio of hospital beds to nursing students is disparate. There are more students than there are patients. Nursing students in the Philippines have become even more less-experienced in the direct care of patients. Unlike in theUnited States where schools of nursing have mandated caps in enrollment, most schools of nursing in the Philippines do not. In the US, the Board of Nursing must approve operation of nursing schools to ensure, among other things, that the number of students do not exceed the learning experience ratio. There must be an adequate number of hospital beds (with patients) that the student can have direct experience in.
In some visits to hospitals in the Philippines, I noticed that in the majority of cases, students exceed the number of patients in a given patient care unit. There might be 5 students for one patient. This is not acceptable not only in the part of the patient being subjected to invasions of different students and personnel but also to the students who will not have the adequate experience of providing the total care of the patient. This results in fragmentation of care and thus dilutes the direct experience of the student in the actual practice of nursing.
In one visit to a hospital, I observed student nurses making cotton balls and folding linens because they did not have enough patients to take care of. These are not nursing functions, yet for lack of any activity, students are relegated tasks that are not within the defined functions of nurses. Students should be assigned to hospitals that offer general services so that there is adequate exposure in the practice of nursing. Nursing schools now affiliate with secondary and primary hospitals. Gone were the days when nursing students affiliated mainly in tertiary hospitals which offered more depth and breadth of nursing experience.
One can presuppose that there must be a compensatory “theoretical expertise” that the student obtains while in school because nursing students in the Philippines cannot get adequate experience in the clinical setting. One has to infer that what they lack in clinical practice must be compensated by theoretical learning. However, this is beyond the reality as manifested in the local nursing board results year after year. Disappointingly, the performance of Filipino nursing graduates in international examinations such as the CGFNS and the NCLEX is even far more dismal.
The deterioration in the quality of nurse graduates from the Philippines may also be influenced by lack of qualified educators in nursing. In the USA it is a requirement that nurses who teach in upper division nursing courses must have a degree in nursing higher than the level of the student. A master’s degree in nursing is a requisite to teach in the baccalaureate level, doctorate- prepared faculty teach in the master’s level and so forth. In thePhilippines, my observation is that new graduates, lacking the experience of bedside nursing and teaching, become clinical instructors soon after graduating. This is a case where the novice guides the novice. There is not an expert teacher leading the budding nurse. It is my understanding that CHED requires that nursing faculty must have a master’s degree in nursing or at least is in the process of obtaining a master’s degree. However, I can personally name many clinical instructors that I know who have neither the graduate degree nor the on-going education as required. Why is this rule not enforced? Who monitors it?
Comparison of US and Philippine Nursing Education
In theUnited States, nursing programs have to be accredited by specific and independent accreditation bodies in addition to and separate from the State Board’s accreditation in which the school is located. For example, a graduate of a nursing program accredited by the National League for Nursing is qualified to take the NCLEX. Graduates of non-accredited schools are not eligible to sit for the NCLEX. In thePhilippines, outside of CHED, there is not an independent organization that commonly accredits nursing programs. Nor is it required for nurse graduates to graduate from an accredited school (outside of CHED’s accreditation as previously described) to sit for the local board examination. If the Philippines were to follow the US model, it would lead to closures of nursing schools who do not meet the rigors required for a legitimate nursing program. However, as a benefit, it would lead to nursing schools with sound programs.
The lack of Best-Practice Emulation of Top Performing Schools
The performance of schools in the board examinations should be made public so that students become cognizant of the ranking of the schools they contemplate to enter in. The best performing schools like UP, UST, Saint LouisUniversityand others for example should be emulated and their models of success should be studied by those schools that rank low.
In a speech of the Indian president, Dr. A.P.J. Abdul Kalam to the nurses attending the 7th Asian Cardiac Conference held in New Delhi on February 20, 2007, and in which I was a symposium speaker, the President related an experience he had at the University of the Philippines in 2006. Apparently, he “interacted with the students and faculty members of the College of Nursing” and was quite impressed with the PhD program there. Beyond the emulation of UP’s nursing program, he urged for Indian nurses to develop similar nursing programs in India. Shouldn’t schools in thePhilippines emulate the success of UP and other top-performing schools as well?
Outdated Nursing Curriculum
The role of the nurse in the international arena has expanded yet the nursing curriculum in thePhilippineshas not kept pace. The curricular design of nursing education in the Philippines ought to be urgently reexamined. One example is in the area of critical thinking. It is argued that nurses are prepared to critically think yet I see more and more nurses who lack that skill. The nurse in the Philippines is still very dependent on physicians for decision-making. That is because in the Philippines, there is always a physician available in the hospital to manage patient problems as they arise. Contrast that in the USA where a physician is not within the hospital setting 24/7 or as patient conditions change. Thus it is imperative for the nurse to be able to make independent actions and to know when it is appropriate to consult a physician.
Unfortunately, the lecture format does not stimulate critical thinking, yet it remains the basic strategy of teaching in Philippine nursing schools. This does not lend credence to the talent of the student in having or developing independent thinking, nor does it engender that way of solving clinical problems and analyzing patient care situations. Other areas that Filipino nurses lag is in the medical sciences. The nursing curriculum should include an emphasis on pathophysiology, pharmacology, and health assessment. Inclusion of these subject areas articulates to the emerging trends in nursing practice internationally.
Books utilized in Philippine nursing schools should be re-examined. I hear Filipino nursing students who claim their teachers ask them to purchase summary books like “Nursing Made Easy” as their primary reference texts. Or worse yet, they are mandated to buy teacher-made notes that are neither original nor substantive These books and “handouts” do not have the depth necessary to lay the foundation of the practice and knowledge in the discipline. They have a purpose as a supplement to the required reading but they should not supplant the books that do provide the necessary body of foundational knowledge.
What nursing schools need are strong, academically prepared nursing scholars to lead the nursing education program. This rests on Deans that have credibility by demonstrating evidence of a solid foundation in scholarship in the nursing profession. Sometime this year, I curiously perused the want ads of a local newspaper and one ad in particular caught my attention. It was an advertisement seeking for a dean for a school of nursing. To my surprise, there was an age limitation included; “No more than 38 years old” as if that was the marker of the setting of cognitive decline. There was not a mention of a requirement of scholarly work and leadership in the profession beyond the earning of a master’s degree. Is this what we ought to value in leaders of nursing education? Should one wonder then why the quality of nurse graduates have deteriorated if we do not value the essentials of scholarship and leadership in choosing deans of nursing programs?
Deficient Clinical Experience of Philippine-Educated RNs
A requirement for the nursing board examination in the Philippines is certification that a candidate has a specific minimum number of cases acting as a scrub nurse, circulating nurse, performing in an actual delivery, or assisted in deliveries or childbirth. Ironically, nursing students often have to extend their academic residences in order to complete this requirement. Worse, they buy certification of case-completion from scrupulous hospital or school personnel. I argue that this requirement has passed its relevance in today’s practice of nursing. Operating Room and Delivery Room Nursing are nursing specialties and thus post-graduate training is the appropriate avenue to train in these specialties.
I would be more interested to have evidence that a nurse graduate has had adequate experiences in injections, IV therapy, physical assessment, medication administration and others than having evidence of exposure to two specific specialty areas. Nursing students in the USA rotate to these specialties but they are not required to scrub, circulate or perform actual deliveries. Only midwives or physicians do the latter. So, if an RN in the Philippines is not licensed as a midwife, why then require them this experience of actual and assisted deliveries? If we remove some of the irrelevant requirements and focus on more updated and appropriate requirements, then perhaps we can improve the preparation of nurses in the actual arena or real-world of nursing practice.
Once a nurse graduates in the Philippines, there is a challenge to find employment and thus clinical experience appropriate for the international market. Because nursing students graduate without adequate contact with patients and thus deficient in experience of the actual practice of nursing, nurse graduates often find it hard to gain employment in a hospital setting. For those who do not wish to be committed to work for 3 years (often the minimum required by Philippine hospitals), they register with hospitals as nurse-volunteers. The concept of volunteer nursing is questionable. It is a facade of “free labor”. Nurse volunteers work like (paid) staff nurses except that they are not remunerated.
Whereas serving as a nurse-volunteer may be a good alternative in obtaining experience in the clinical setting post graduation, there are shortcomings in this program. The learning experience of the nurse graduate is not adequately supervised. Most hospitals who accept nurse-volunteers do not offer a formalized learning program for the nurse to acquire the necessary skills and knowledge in the practice of nursing. A better option is to have hospitals develop a formalized program of learning so that the time spent by volunteers in the clinical area becomes meaningful. Medical graduates have utilized this sort of training in a program called internship. Nurse internships will be better if they are well-planned and structured so that experiential learning is maximized. It is well-known that some volunteer-nurses merely “observe”. Observation is good but it does not provide the hands-on experience that a nurse must have to move from a novice to an expert. Nurse interns should work under the supervision of more experienced preceptor nurses so that they can be guided to practice the science and art of nursing.
There is widespread agreement among USA hospital recruiters to favor Filipino nurses who have worked overseas in particular in the Middle East because this exposure expands the nursing experience of the nurse beyond the Philippine setting. It is noted that nurses who have this experience adjust better to the technology as well as to the modern art of nursing in the west. It would benefit nurses who graduate from Philippine nursing schools to gain this experience so that they can improve their chances of being hired by US hospitals.
The Controversy of the July 2006 Nursing Board Examination Spreads
In a conference of the NCSBN in Philadelphia on Sept. 11, 2006 in which I attended, a question from a participant addressed to the panel was: “What security measures are there to safeguard the integrity of the NCLEX test questions? Is it true that there was a case of cheating in one of the international testing sites?” to which the moderator answered: “I suspect you are referring to the alleged cheating in the national nursing board examination in thePhilippines. This has nothing to do with the NCLEX because we have safeguards to prevent cheating”. The mention of the anomalous nursing board examination in March of 2006 in the Philippines board examination for nurses has casted doubt on the validity of the licenses of these nurses. The minutes of the South Dakota Board of Nursing held on September 12-13, 2006 indicated that a handout of an article “Nursing Board Examiners say cheaters pose a danger to the profession” (referring to thePhilippines) was distributed to its members.
I believe that a better option to have resolved the controversial board examination result was to have all the examinees retake the examination to remove the cloud of doubt that those who passed the said examination were deserving of the license. The purpose of the licensing examination should be borne to light, i.e. the purpose of the board examination is to ensure that those licensed to practice nursing have the education and knowledge to safeguard the clinical safety of the general public. Will the general public have faith and confidence that those who passed the said examination are really safe practitioners of nursing?
The decision by the CGFNS to require those candidates in this group to retake specific sections of the examination to qualify for the Visa Screen Certificate (a requirement for US immigration) reflects the consensus that an examination marred by cheating should be considered null and invalid. Despite the claims of certain Filipino politicians in their efforts to pressure the CGFNS to reverse its decision because of its purported lack of congruency with its governmental judgment, it is a coherent solution to ensuring that those licensed in that examination possess the minimal knowledge in the nursing profession.
Nursing Review Centers
Review centers in the Philippines have proliferated along with the opening of more schools of nursing. These review centers have become “cure-alls” for the deficiencies of students while they were in school. However, I see a great value of these review centers. I am convinced that more learning occurs in review centers than they do in most second-rate and mediocre schools. At least the reviewers in most review centers impart knowledge that is meaningful to the students and the faculty is charged with enthusiasm, qualifications, and passion in their teaching. I argue that most who teach in review centers are more systematic in their approach to teaching than most faculties of nursing schools. And students are more motivated to attend the reviews because they claim that they really learn the “meat” of nursing.
It should be noted that I am not associated with any review center but I am quite cognizant of them because I usually am invited as a (non-paid) guest speaker whenever given the opportunity and time. However, it amazes me to find out that students lack some of the elementary concepts in nursing when they attend sessions in review centers. I often wonder what has been taught them while they were in school paying exorbitant fees.
Interestingly, there is a move to eliminate review centers as independent entities. It is now required that they be affiliated with a school of nursing. I think that this governmental mandate is a dog barking at the wrong tree. What CHED needs to do is not to eliminate these centers but rather to close nursing schools that consistently have poor performances in the Board examination. It should also focus on the controversial practices of nursing schools who endorse review centers for monetary gain, either for the personal benefit of the dean or the school’s administration.
Review centers serve a very important purpose in that it fills in the void made by a faulty nursing curriculum, an abysmal school administration and unprepared faculty. CHED apparently wants review centers to be associated with schools. If they do, then they will be subjected again to the same faulty environment of nursing schools to the detriment of students. What should be mandated is a freeze on new schools of nursing not a forced marriage between schools and review centers.
Proliferation of Mediocre Schools
New schools that sprout have contributed to the deteriorating quality of graduates because they have patterned their education to the diploma and factory model. In the past, nurses were educated either in the diploma program or the baccalaureate. The diploma program has since been eliminated. Now there are entities proposing the associate degree as well as the Licensed Practical Nurse (LPN) training in the Philippines. This is a reversal in the move towards the professionalization of nursing as a discipline by moving away from the baccalaureate as the basic preparation in nursing. Moreover, it should be noted that Licensed Practical Nurses (LPNs) are not in the list of approved professions qualifying for a working or immigrant visa in the United States. The government should not commit another error in judgment by approving this program as it did in allowing so many caregiver schools to open up despite the disproportionate demand for them in the international job market.
Pre-screening nursing students
There should be stricter admission guidelines for entering nursing students. Acumen for the sciences should be evident if a student elects to enter into a nursing program. If this can be identified in the beginning, then there will be lesser opportunities for those who are not cut for the profession from entering. In the US there is a screening examination called the Pre-Nursing qualifying examination for admission into nursing school. In the Philippines, most schools have a free admission policy; whoever has the ability to pay may enroll. This should not be the case in as much as it is doubtful that the interest in nursing can be acquired through 4 years of college work.
Most nursing schools in the USA base their acceptance of students into the nursing program from the student’s performance in required science courses such as microbiology, chemistry, anatomy and physiology. If a student fails or repeats these courses, then they are not deemed acceptable into the nursing program. It is interesting to note that so many young students aim to go to nursing school nowadays. Their motivation may be a genuine interest in the profession or may be driven by other self-serving agendas such as a “passport” to a visa. The evidence to this is the dawning of college graduates in other disciplines taking on second degrees as nurses.
MD to RN Programs
Physicians becoming nurses in the Philippines have become suspect as well. Florida International University in Miami,Florida became the first nursing school in the USA to offer a bridge program for foreign educated physicians wishing to pursue nursing as a second career. The course is 4 semesters in length (1 ½ years) and the students actually complete all the upper division nursing courses.
Contrast that to those who do the same in the Philippines. Physicians are either “exempted” from the nursing clinical requirement or in most instances buy their diplomas to become BSN graduates. This practice is dangerous because the practice of nursing is different from that of medicine. The lay public needs to be aware that medical training is different from that of nursing. When these physicians practice nursing in the USA, they are often confused as to their roles because they never had the opportunity to practice nursing while in the Philippines. Physician-nurses often intervene with medications without having to implement nursing interventions first. The feedback of hospital recruiters in the USA is that they avoid hiring MD-RNs from thePhilippinesbecause of this very reason.
The Malaise of Students
Another factor in the deterioration of nurse graduates is their lay-back attitude or lack of good study habits while in school. I made a presentation in one nursing school as a guest lecturer to about 400 graduating students and was amazed at how many were paying more attention to their cell phones than the presentation. In one nursing review I was conducting as a guest lecturer in the Philippines, I was disgusted at how many competed for the last row of seats. And I am not a boring speaker either, having been awarded consistently best faculty in US universities where I taught. Where has the attentive student and acceptable classroom behaviors gone? Is it because perhaps educators behave the same way?
I have been in similar guest lecturer situations where the faculty made more disruptions than the students. When I make presentations in India as a guest faculty, the students are engaged. They look at me intently and demonstrate attentive behaviors. Indian students have more dedication in learning and they show their motivations to learn. They are engaged in the classroom in contrast to the malaise of their Philippine counterparts. Filipino educators need to engender a climate stimulating to students and inculcate acceptable classroom behaviors. Students need to be cognizant that there is much value in the classroom experience and to realize the importance of faculty-student dialogue.
The factors contributing to the unfavorable reputation of Filipino nurses has been outlined in this article. It is my hope that nurse educators and government officials involved in curricular mandates examine these issues and push for change. An appropriate start is to accept that we have a deterioration of our nursing education in the Philippines. However, the fate of Filipino nurses is far from hopeless. There is time for resuscitating the decline of nursing education in the Philippines and in articulating their training with international standards. There is much to do to regain our dominance as a good source of professional nurses and to once again be the favored source of recruiters not only from the United States but throughout the world.
By: Dr. Tomas Madayag