Chapter 2

Review of Related Literature

How the Philippines Created a Global Network of Nurses

From Chicago to London, people are bound to find Filipino nurses working

in hospitals across the globe. It comes as no surprise, as The Philippines is the

largest exporter of nurses in the world out of the 2.2 million Overseas Filipino

Workers (OFWs), 25 percent commit their lives to caring for others (Caulin,

2018).

As countries saw a shortage of nurses and the cost-effectiveness of hiring

of Filipinos rather than training their own nurses locally, other countries began

hiring nurses from the Philippines. Saudi Arabia became the leading destination

for Filipino nurses. European countries also tapped Filipino labor for their health

care, with Filipinos working as nurses in Germany, the U.K. and Ireland.

Neighboring countries like Singapore and Japan also began hiring Filipino

nurses. A lot of Filipino families view the nursing profession abroad as the ticket

to better life as seen in more than 500 nursing schools in the Philippines

today. For many Filipinos, being a nurse makes it easy to become a professional

foreign worker there is less competition from the local workforce and other

foreign workers. With American-standard nurse training, English fluency and the

innate nature of Filipinos to care for the elderly and sick family members,

Filipinos fit the bill for nursing (Caulin, 2018)

The Filipino Nurse

In California, 20 percent of all registered nurses are Filipinos. That's one-

fifth of nurses in the entire state. We are a top exporter of nurses, due in part to

the steep wage gap between nurses working in the Philippines and nurses

working abroad, which is clearly stated on the website of the Bureau of Local

Employment under the Department of Labor and Employment (Ichimura, 2018).

In line with the little pay and no benefits, there’s also the burden of unsafe

nurse-patient ratio, 12-hour shifts, mental and physical burnout, unpaid overtime,

bullying by management, and pressure to work overseas, according to St. Luke's

Medical Center Employees Association May 2015 survey (Ichimura, 2018).

Despite and because of all these obstacles faced by Philippine-based

nurses, efforts have been taken to improve their livelihood. In February of this

year, the Makabayan bloc filed House Bill 7196 or “An Act Upgrading the

Minimum Monthly Salary of Nurses to P30,000 and Providing for Benefits for

Nurses.” Following the salary hike of soldiers and police officers, Bayan Muna

Rep. Carlos Zarate hopes that the salary increase of nurses will “help cushion

the impact of the Tax Reform for Acceleration and Inclusion (TRAIN) and the

skyrocketing prices of basic commodities.” While the bill still has a long way to

go, it’s a step to progress (Ichimura, 2018).

Implications for nursing management

The Philippines is the world's largest nurse exporter with nearly 90

percent of Filipino nurses working overseas. The Philippine Overseas

Employment Administration, an agency that monitors deployment of Filipino

workers abroad, reported a high number of professional nurses emigrating from

2004 to 2010. Filipino nurses' decision to migrate relates to a myriad of factors

such as low incomes, lack of benefits, lack of opportunities and professional

growth, high patient-nurse ratios, and poor enforcement of nursing laws. This will

have negative consequences on the ability to provide effective health care

services for this country. The loss of those nurses who have significant amounts

of experience and expertise who can mentor new nurses will impact the

provision of effective patient care by increasing the workloads in the healthcare

facilities leading to a negative impact on the nursing workforce.

The Philippine nursing community has identified that many qualified

nurses leave the country or their current jobs. This adds considerably to the

current nursing shortage and difficulties in managing safe and effective patient

care. The situation is even more significant in rural areas where many nurses

struggle related to appropriate salaries, heavy workloads, lack of opportunities

for professional growth, and a poor work environment. This is further aggravated

by a serious shortage of health care workers, nurses in particular, as many

nurses prefer to work in urban areas where most health care facilities are located

and the pay is considerably competitive. All these could adversely affect work
9

performance, work satisfaction, work commitment, and ultimately increases the

intention to leave their jobs (Labrague et. al, 2019).

Health Care System In The Philippines

For the past 30 years, the Philippines has reformed the health care system in

hope of change for the better where the health service delivery, health regulation

and the health financing is in the center. Those reforms were mainly to address

the poor accessibility, inequality and inefficiency in the healthcare system

(Romualdez et. al, 2011).

According to Pachanee et al. (2019). The World Health Organization( WHO)

refers to the Filipino Health care System as “divided .There is a history of unfair

and unequal access to health services that significantly affects the poor” , where

the government spends a minimal allowance on the program which causes high

out of pocket spending and further broadens the gap among the rich and poor.

The Philippine Health Insurance Corporation (Philhealth) is the administrator

of the National Health Insurance Program (NHIP) in the country. All employees

in the Philippines, including foreigners, are eligible to the PhilHealth. Employers

and employees, as well as local and national government subsidies finance this

insurance system.The employee and employer will equally share the monthly

contribution rate of 2.75 percent (as from January 2018). There are a salary

floor and ceiling of Php10,000 and Php40,000, respectively.(Philhealth , 2014).

PhilHealth, covers 93 percent of the population as of December 2017 with a

support value of 55 percent Out of the 90 million people living in the Philippines,

many do not get access to basic care. The country has a high maternal and

newborn mortality rate, and a high fertility rate. This creates problems for those

who have especially limited access to this basic care or for those living in

generally poor health conditions.There are more than 3,500 public health

facilities were updated across the country. Many Filipinos face diseases such as

Tuberculosis, Dengue, Malaria and HIV/AIDS. These diseases pair with protein-

energy malnutrition and micronutrient deficiencies that are becoming

increasingly common. Filipino families who can afford private health facilities

usually choose these as their primary option. Private facilities provide a better

quality of care than the public facilities that lower income families usually go to.

The public facilities tend to be in rural areas that are more run down. These

facilities have less medical staff and inferior supplies. Only 30 percent of health

professionals employed by the government address the health needs of the

majority. Health care in the Philippines suffers because the remaining 70 percent

of health professionals work in the more expensive privately run

sectors.Although advances have been made to improve health care in the

Philippines, there are still many issues that the country has yet to overcome to

achieve a high quality, cost efficient health care system (Kenworthy, 2017).
12

Nurses of the Philippines

If a qualified nurse working in the Philippines, the phrase ‘overworked and

underpaid’ has probably crossed nurses mind a thousand times. The second

thought that must have crossed their minds will be seeking better job

opportunities abroad (Adrian, 2018).

According to the Philippine Overseas Employment Agency (POEA) almost

19,000 nurses leave the country every year. While this may be seen as a sign of

competitive edge of Filipinos in the global landscape, it is, on the other hand, a

sign that the country isn’t providing enough to these professionals for them to

practice their expertise in the country.Overworked and underpaid is the biggest

challenge that nurses face in our country’s health care set up is the high nurse to

patient ratio, especially in rural and public hospitals. Top this off with an

extremely low salary with minimal benefits that drive qualified candidates away.

This leaves hospitals and nurses currently working in these centers short-

handed, thus creating the chaotic set up for nurses now where it’s common for

them to work longer hours without getting paid extra and take care of more

patients that they could handle. While working an extra 1 to 3 hours in an office

set-up on an extremely busy day can be normal, it’s basically a normal scenario

for nurses every day. On a typical day, they work beyond their working hours

endorsing all their patients to the next shift without getting paid for their one or

two hour overtime service. On some days, nurses have been known to work 16

hours straight due to an unexpected absence of a colleague.

Philippine country is one of the top exporter of nurses, due in part to the

steep wage gap between nurses working in the country and nurses working

abroad, which is clearly stated on the website of the Bureau of Local

Employment under the Department of Labor and Employment. “In the local labor

market, an entry-level registered nurse receives a salary of P8,000 to P13,500

per month. Registered Nurses hired at Hospitals commonly receive an average

salary of P9,757 per month. In the government, the average salary per month is

around P13,500 while in private sector, the rate average is around P10,000 per

month. Overseas, the pay scale is way above local rates with the US market

offering an average salary of $3,800 (P205,412.80) per month, the United

Kingdom with £1,662 (P118,706.69), and Canada with $4,097 (171,530.10) for

entry-level.” It’s the chance at a higher salary and better benefits that has almost

19,000 Filipino nurses leaving per year. In 2017, the Philippine Overseas

Employment Agency (POEA) stated that 92,277 nurses have left the country to

work abroad from 2012 to 2017 (Ichimura, 2018).

In 2016, former President Benigno Aquino III vetoed a proposed bill that

could have potentially raised the monthly minimum wages of nurses from

$153.82 (P 7,844.82) to $480.58 ( P 24,509.58 ). House Bill Nos. 6411 and 2720

titled “An Act Providing for a Comprehensive Nursing Law towards Quality

Health Care System, and Appropriating Funds Therefore” met an untimely end

when Aquino cited “dire financial consequences” as the reason for the veto. In a

statement, he explained that this bill would create a domino effect which not only

affects the salary grades of other health professionals in the public sector but
14

also other government employees in the hospital settings. Since 2010, the

Philippine Nurses’ Association has made efforts to convince Aquino to pass bills

such as these. Aquino was adamant however and pointed out that the existence

of Executive Order No. 201 has already raised the monthly minimum wages of

nurse to $365.24 (P 18,627.24). Furthermore, he added that nurses are provided

different benefits under the Magna Carta of Public Health Workers. Nursing as a

profession in the Philippines demands too much time and energy without being

properly compensated. Nurses have been leaving their hometowns to pursue

greener pastures abroad. The number one reason why they leave is that they

are never given enough. Aquino insists that this concern has already been met

but employers work around this by hiring nurses on contractual basis. Doing so

gives them the leeway to undercut salaries while still maintaining a full-time

workload with extras in overtime. Hospitals also circumvent the law by promising

employment but only after completing a “training or probationary” period that

often lasts between six months to one year. They stipulate that within such time,

nurses would not receive any salary yet; instead nurses are given “cash

allowances” that range from $1.92 - 3.84( P 98 - 200) per day. Aside from the

below minimum wage, Filipino nurses report the staggering amount of work and

the abuse they receive from the people under their care. This is only the tip of

the iceberg when it comes to the daily struggles of a Filipino nurse. It is an age

old problem that continues to plague the upcoming batches. Although there have

been attempts at making them stay, the general consensus would rather find

their future in countries beyond the Philippine Islands (Berlin, 2018).

Salary of nurse

Most of the time, registered nurses (RN) work for hospitals or medical

clinics. They may also work for other organizations, such as outpatient facilities,

rehabilitation centers, or senior centers. Their main job is to promote wellness

and health. To become RNs, they must have an associate degree in nursing

(ADN) or a bachelor’s degree in nursing (BSN) (Payscale,2019).

The average salary for a Nurse is Php 17,437 per month in the

Philippines. Salary estimates are based on 3,265 salaries submitted

anonymously to Indeed by Nurse employees, users, and collected from past and

present job advertisements on Indeed in the past 36 months. The typical tenure

for a Nurse is less than 1 year 9 (Indeed, 2019).

Pay by Experience Level for Registered Nurse (RN)

An entry-level Registered Nurse (RN) with less than 1 year experience

can expect to earn an average total compensation (includes tips, bonus, and

overtime pay) of PHP 125,714 based on 65 salaries. An early career Registered

Nurse (RN) with 1-4 years of experience earns an average total compensation of

PHP 151,058 based on 470 salaries. A mid-career Registered Nurse (RN) with

5-9 years of experience earns an average total compensation of PHP 190,000

based on 190 salaries.

An experienced Registered Nurse (RN) with 10-19 years of experience earns an

average total compensation of PHP 201,850 based on 57 salaries. In their late

career (20 years and higher), employees earn an average total compensation of
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PHP 7,060,000 (Payscale, 2019).

Nursing Hourly Average Wage in Philippines

The average hourly wage (pay per hour) in Philippines for Nursing is 246

PHP. This means that the average person in Philippines earns approximately

246 PHP for every worked hour.The hourly wage is the salary paid in one

working hour. Usually jobs are classified into two categories: salaried jobs and

hourly jobs. Salaried jobs pay a fix amount regardless of the hours worked.

Hourly jobs pay per worked hour. To convert salary into hourly wage the above

formula is used (assuming 5 working days in a week and 8 working hours per

day which is the standard for most jobs). The hourly wage calculation may differ

slightly depending on the worked hours per week and annual vacation

allowance. The figures mentioned above are good approximation and they are

considered to be the standard (Salaryexplorer, 2019).

Possible Factors That Affect Nurses Loyalty In Government Hospitals

Nurses deal with modern day problems that affect their abilities to remain

resilient. Motivation in the workplace is influenced by a set of complex economic,

social and professional factors. According to Dzaher (2017), there are several

reasons why nurses are motivated in their job and continue to stay in it.

Generally, they will be motivated and have job satisfaction if they believe that

they are effective in their jobs and are able to perform well. However, passion for

providing patient care, being able to choose from several specialization, the high

demand for nurses as well as learning opportunities can also motivate one to be

a nurse.
17

Being a nurse in Philippines can open a gateway of opportunities both on

domestic and global front. Once you get an examination clearance and practice

license from the board, you can explore end number of job opportunities in your

choice of specialization. However, the fact remains intact that on a domestic

front, approximately 2, 000,000 registered Filipino nurses are struggling to find

jobs due to the saturating markets in the country ( Inscol.inc, 2018)

According to the study of Yeager and Wisniewski (2017) . Some factors that

influence nurses to begin and remain working in local governmental public health

agencies, such as flexible schedules and employee autonomy, are factors that

governmental public health agencies can design into positions and highlight

when recruiting from health care organizations, private industry, and academia.

Nurses' work environment has been defined by Kirwan et. al (2013) as the

characteristics of the organization that either facilitate or limit the practice of

nursing.

The retention of nursing faculty is a growing concern in the United States

and a major challenge for nursing education administrators. As stated in the

study of Davis (2014) entitled “ Predictors of Nursing Faculty's Job Satisfaction

and Intent to Stay in Academe”, those highly educated, experienced nursing

faculty reported having more intent to stay in academe.

Leaving one’s family in search for a better future and lucrative opportunities

is a difficult decision to make. For foreign educated registered nurses from the

Philippines, this decision is the beginning of a promising life for their families and

their personal and professional growth. Although the journey is different for
18

everyone, in terms of money and effort, most nursing graduates from the

Philippines do their best to achieve the American dream. However, not all

registered nurses from the Philippines achieve the American dream, resulting in

hardship for those individuals who must return to the Philippines and creating a

turnover of registered nurses for their American employers. To reduce the

turnover of Philippine educated nurses thereby maintaining the number of

registered nurses in the United States, employers must implement strategies that

induce theses registered nurses to stay. For these strategies to be effective, they

must be based on an understanding of why registered nurses from the

Philippines stay with their American employers (Reyes, 2015).

According to the study of Heidari et al. (2017) entitled “Nursing staff

retention: Effective factors” the findings shows that 99.16 percent of nurses are

in age range of 21–25 years old and 72.77 percent were female. Being female

has various roles within itself. Supplying mental and emotional needs, the

important social role of women, the effect of job stress on those who have the

responsibility of nurturing children in addition to the maternal role show

significant factors on retention. Demographic characteristics such as age, the

role of work values, personality traits, and type of hospital were crucial in

enhancing the level of intent to stay at work. Distance from home to the hospital

(88.8percent) and access to public transport to hospital (88 percent) are also

affective factors on retention. Many have expressed concern that many new

graduates may actually leave the professional role as a result of negative

working conditions. New graduate nurses were positive about their working
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conditions. Structural and personal factors explained amounts of variance (31

percent– 68 percent) in job satisfaction and turnover intentions. Empowerment

and work engagement were important predictors. Nurse managers can support

new graduate nurses’ professional practice behavior by providing empowering

supportive professional practice environments. It is very important for nurse

managers to recognize personal characteristics to identify and implement

successful strategies for improving the organizational culture and supporting the

nurses’ personal.Successful workplace advocacy requires nurse managers who

understand the importance of these intrinsic factors in the lives of their nursing

staff so that recruiting and retaining a dedicated and qualified nursing workforce

is becoming a common and widely used strategy.