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Pacific Northwest Magazine By Paula Bock
Taking CareAs the need for nurses swells, the foreign-born step up
OF ALL THE differences between hospital life in her native Philippines and here, in Washington state, one in particular has stuck with Maricris Espino, RN. It's not so much the salary (though she earns in two days the equivalent of a month's wages in her home country), or the technology (i.v. pumps, fancy electric beds), or the hospital hierarchy in which nurses examine patients and make suggestions to doctors. What so often strikes Espino when she walks into a patient's room is that they're alone. In the Philippines, patients are almost never alone. Their bedsides are cluttered with relatives to help with baths, meals, brushing teeth. The hospital wards are filled with the aroma of chicken adobo and pork asado brought in from home or a favorite hawker's cart rather than carefully calculated portions of antiseptic hospital food. "In the Philippines," Espino recalls, "you don't have someone coming up to the nurses' station to say, 'My mom has to go to the bathroom.' Here, the concept is different. Even if the family is in the room, they won't touch their parents. They're not going to clean up the father or mother. Maybe they're afraid they're going to drop the patient. Or partly it's culture. In the Philippines, (patients) would prefer their daughter is going to see them naked rather than other people. Here, they'd prefer a nurse. The critical problem No. of RNs: 71,755 Shortage now: 5,160 Shortage by 2020: 30,000 In the nation No. of RNs: 2.9 million No. of new RNs needed by 2020: 800,000 No. of foreign-educated RNs: 100,791 Percentage of foreign-educated RNs: 3.5 Percentage from the Philippines: 50.2 Sources: Washington State Nurses Assn.; U.S. Dept of Health and Human Services, 2004 survey; Bureau of Labor Statistics (2004 data), American Nurses Assn. "Here, I do everything. Give them medication. Take them to the bathroom. Give them a bath. I don't mind, but y'know, I feel sorry for the patients who have nobody. . . . When my mom was sick, we did everything." Three years ago, Espino left her homeland and her dying diabetic mother to start a new job and a new life as a nurse at Allenmore Hospital in Tacoma. She was 31, a wife, a mother of two, the only sibling with the earning potential to pay her mom's medical bills. "My presence there would have filled up her loneliness," Espino says, "but I could see I have my family to take care of. And I knew she was going to get even sicker eventually and I would have to pay for it." Espino was one of 47 nurses recruited from the Philippines to relieve staffing shortages at two of MultiCare Health System's hospitals in Tacoma. "We had a significant nursing vacancy and we were planning for our future as well," says Rita Wilson, who then led MultiCare's nurse-recruiting program. "Our nursing population is getting older. We had to do something so we'd have a steady stream coming in." NURSING SHORTAGES are nothing new. Since World War II, the United States has experienced a nursing shortage every 10 years or so. But this one is different. It's expected to cut deeper and last longer because it's caused primarily by demographics rather than economics, says Linda Tieman, executive director of the Washington Center for Nursing, a private nonprofit focused on making sure this state has enough nurses. Washington has 71,755 registered nurses — 5,160 short of what's needed. Looking ahead is even more alarming. If nothing is done, the state will be down 30,000 nurses by 2020, according to the Washington State Nurses Association. Nationally, if trends continue, the country will be short 275,000 nurses by 2010. Federal estimates project the nation will need to train or recruit at least 800,000 nurses by 2020 to keep up with nurse retirements and a growing need as baby boomers age and require more medical care. "The reality is that we aren't going to be able to do that," says Cheryl Peterson, senior policy analyst for the American Nurses Association. "What about funding for nursing education? Better working conditions?" she asks. How does the health-care system need to be reformed to make better use of staff it already has? During an era of restructuring in the mid-1990s, Peterson says, staffing cuts and belt-tightening in the American heath-care industry drove away nurses who felt overworked and were worried about patient safety as well as their own. By 2005, about half a million registered nurses left the profession. Consider: The average age of nurses in Washington state is 45. So the bulk of the state's nurses are in their 50s and likely to soon retire. They are the tail generation of American women for whom job options were severely limited. "Nurses, teachers, secretaries. Those were the career options," recalls 59-year-old Tieman. "Women have unlimited choices now." No surprise that there was a dip in nurse demographics as post-boomer women chose to become doctors or go into law, business, computers, marine science. Yet plenty of Americans want to be nurses now, especially given improving salaries. (At Allenmore, for example, base salaries for registered nurses start at $42,000 a year, rising to $83,000 with 28 years' experience. The state average RN salary is $60,000. Nationally, agency and traveling nurses who work as "temps" can earn more than $110,000 annually, without benefits.) These days, lack of interest isn't what's restricting the flow of nurse grads. The problem is that nursing schools don't have enough teachers. Last year, the state's 40 nursing programs turned away 45 percent of qualified applicants. Again, witness the baby-boom effect. The average age among the nursing faculty in Washington is 54. And given relatively low academic salaries, schools find it hard to compete for experienced nurses who want to retire or work in more lucrative industry jobs. This year, the Center for Nursing raised about half a million dollars to expand the capacity of nursing schools and support training for nurses who want to become nursing educators. Tieman says health-care facilities and nursing schools are starting to talk about how to reform the system so more nurses can be trained. But it's too early to say how many more or how fast. Meanwhile, across the country, as older nurses age out and burn out and students can't squeeze through the school bottleneck fast enough to replace them, foreign-educated nurses are increasingly filling the gap. AT 7:40 A.M. on Floor 2 West in Allenmore Hospital's Progressive Care Unit, Maricris Espino taps on the door of Richard Bergren, a 64-year-old Atlas foundry foreman with a mop of white hair who manages to grin and wink despite the stroke he suffered four days before. He's alone except for the television. With her smile and cheerful flowered scrubs, Espino is a welcome diversion. "Tell me your name," she touches his arm gently while double-checking his wristband. She'll feed him breakfast — that's the prize — but first a tray of about a dozen medications, each pill accounted for with her login and password in a high-tech medicine-supply closet, the insulin dose witnessed and initialed by a second nurse, per hospital protocol. In the Philippines, Espino recalls, each patient's meds were just stashed in a bucket. Bergren is asthmatic, diabetic, a heavy smoker with high cholesterol. "That's what you get when you don't go to a doctor!" he laughs. He hasn't had a checkup in 20 years because he's afraid of doctors. Yet he doesn't flinch while Espino injects blood-thinner heparin into his belly and insulin into his arm, changes a nicotine patch and has him suck on two inhalers, handing him a Styrofoam cup to rinse between each. Like a mother with an infant, she feeds him custard, each spoonful containing a pill: aspirin, multivitamin, metformin to control his blood sugar, something for cholesterol, a blue tablet to coat his stomach, a red capsule to soften his stool. "Grip my finger," she tells him. His left arm and leg are numb. His grown children live in Nevada and Oregon. His wife will come by later. Espino lifts the stainless steel cover on his breakfast plate. Scrambled eggs. White toast. A tiny tub of grape jelly. "Jelly!" He's ecstatic. When you're in the hospital, little things mean so much. As Espino butters his toast, he winks. NURSE RECRUITER Rita Wilson always dreamed of being a doctor. But her mother didn't believe in college for girls. It was the late 1960s. "She felt that was a waste of money," Wilson says. "Boys you could educate. Girls just married and had babies. My brothers went to college. I didn't." Instead, Wilson attended Bates Technical College in Tacoma for free, training as a licensed practical nurse. After a decade on the job, she took care of a patient who happened to be the vice president of development for Pacific Lutheran University. He was so impressed with her care and commitment, he offered her a scholarship and became her mentor. She earned a baccalaureate degree in nursing at PLU, and later went back to school for her master's. Now 55, Wilson is Espino's nursing supervisor on 2 West. Several years ago, during a stint in human resources, she led MultiCare's trip to the Philippines. "We didn't want to go to a country also struggling with a nursing shortage and raid their nurses," she says. "In the Philippines, there was an abundance. They overtrained purposefully to improve the economy. Nurses would work abroad and send money back." No one tracks how many foreign-educated nurses work in Washington. Nationally, about 100,000, or 3.5 percent of registered nurses are foreign-educated, according to a 2004 survey by the Department of Health and Human Services. Of those, 50 percent are from the Philippines, which provides an estimated 5,000 to 6,000 nurses to the U.S. every year. World health officials have long accused developed countries of creating a "brain drain" by luring health-care workers away from impoverished nations that have low wages, unsafe working conditions — and great need. The U.S. has 825 nurses per 100,000 people; parts of sub-Saharan Africa have fewer than 10. During the past decade, the Philippines exported close to 90,000 nurses, including 4,000 doctors who retrained as nurses so they could find work abroad. About 10 percent of the island's 2,500 hospitals have closed, mostly for lack of doctors and nurses, according to Dr. Jaime Galvez Tan, a former secretary of health for the Philippine government and vice chancellor at the University of Philippines, Manila. Though they support the right of individual nurses to immigrate, the American Nurses Association and the Washington State Nurses Association both strongly oppose the recruitment of foreign-educated nurses as a solution to the nursing shortage. "It doesn't fix the real problem," says Judy Huntington, WSNA executive director. "It's shortsighted." But hospitals and care-homes here say they can't wait for a long-term fix. They need nurses now. This past May, a provision in the U.S. Senate immigration bill to lift the cap on nurse immigration sparked outrage in the developing world, especially the Philippines, where a headline read: "It's Not Brain Drain, It's Hemorrhage; The Shortage of Nurses in the U.S. and the U.K. has Triggered an Exodus. Now the Philippines' Health Care System is on the Verge of Collapse." In the Philippines, the lure of lucrative nursing jobs abroad spawned the creation of dozens of fly-by-night nursing schools as well as a testing scandal in June, when questions on the 2006 Nursing Licensure Examination were leaked. The matter went all the way up to Philippine President Gloria Arroyo, who recently ordered retesting to protect the nation's reputation for highly-skilled, well-educated nurses. Historians trace today's migration of Filipino nurses to U.S. colonialism in the early 1900s, when American health-care workers trying to fight cholera set up an Americanized hospital training system and, in 1907, the first nursing school, writes Catherine Ceniza Choy in "Empire of Care: Nursing and Migration in Filipino American History." Though Filipino culture viewed nursing work as "menial and wholly beneath a person of any family or birth," American public-health workers encouraged Filipino women to enroll. Previously, under Spanish occupation, few girls were educated, and even then, only in primary school. To deal with labor shortages after World War II, the U.S. created the Exchange Visitor Program, opening the door to Filipino nurses. Then came the Immigration Act of 1965. Between 1956 and 1969, more than 11,000 Filipino nurses came to the U.S. — including hundreds to the Seattle area. "They're still coming over, and they'll continue as long as economic conditions in the Philippines remain bad or get worse," says Esther Simpson, a longtime president of Seattle's Filipino Nurses Association who emigrated here in the 1970s. "Historically, because of our colonization, we tend to look up to the U.S. We were speaking English, studying your books, singing about snow and apples, which are not readily available in the Philippines. We had U.S. military aid . . . American companies that took over . . . the Dole plantation, Phillips Radio, Colgate. We knew America in our hearts and minds, so that's what we preferred. It's like your life as a nurse is not complete unless you go to America." Come time for Rita Wilson to recruit nurses from the Philippines, there were hundreds of applicants. The recruiting team narrowed the resumes to 75 and flew to Manila to interview candidates. AS A GIRL, Espino never thought of going to America, but she always wanted to be a nurse. In the Philippines, nurses wear smartly pressed white uniforms with little caps and "look fabulous," Espino recalls. She liked the uniform and admired older cousins and uncles who went to nursing, medical and dental school. "When you're little," Espino says, "you have good intentions. I always said, 'When I grow up and my mom and dad get sick, I'll take care of them.' " Espino grew up in Davao, a mid-sized city of beautiful beaches and coconut palms in southeastern Mindanao. She was the youngest of three children in a family starting to crumble. Her late grandfather, Paciano Bangoy, had been governor; Davao International Airport was once named after him. The extended family clan lived in a compound with thick stone walls and flowering trees. "My mom grew up with all the things she wanted in life," Espino says. "She went to boarding school and culinary school, and when she got married became a housewife. During her leisure time, she played mah jong with friends. She didn't know how to work. She didn't really prepare for the future because she grew up spoon-fed. I don't blame them because back then life was simple, and you didn't have a clue life would be complicated and things would change." Who can disentangle one family's troubles from a country's turmoil? While the Philippines whirled through political upheaval, economic instability and regime changes, Espino's family lost its fortune. Her father inherited the family business but wasn't much of a businessman. Espino's mother survived by selling off the land her family had left her. "When my mom had nothing left," Espino recalls, "she asked my cousins, the nurses in the States, if they could give us some help." The cousins sponsored Espino through nursing school. Espino graduated, married, had two children and worked both in a private practice and in a hospital. After several years, she realized her husband's salary wasn't enough for the family to get by, and her mother was getting sicker, letting her diabetes rage out of control. Carbs, ice cream, non-diet Coke at every meal — despite her daughter's warnings. "I've got nobody to depend on," and a family to support, Espino said. She became determined to work abroad. With her husband's support, she quit her job, went to review school, studied for the foreign nursing exams. A nurse cousin in New Jersey paid the sizable exam fee. Espino flunked. Another nurse cousin in Australia paid for the second test. Espino passed. She heard from other nurses at her hospital that "a really good hospital" in Washington was recruiting. She applied, only later discovering the difference between Washington state and the nation's capital. In the Manila Shangri-La's hotel conference room, Rita Wilson recalls thinking the applicants were all so eager and brave about leaving their homeland. She laughed when one nurse said he'd already fallen in love with Tacoma after watching the Chamber of Commerce video. Espino was also savvy and smart. Come time for the key interview question: What would you do if you got an order from a physician you didn't agree with? Espino had exactly the right answer. "I'd approach it in a diplomatic way and ask the doctor to reclarify the order. If he still thinks he's right, I'd go talk to my supervisor." She was hired on the spot. LEAVING WASN'T easy. Her mother's eyes were damaged by retinopathy, and an abscess on her big toe took ages to heal. Every day for five months, Espino drove an hour to do the dressing change. To her relief, the wound closed just before her departure date. Espino hired a nanny to care for her mother, and when she settled in at Allenmore, worked double shifts to pay her mother's medical bills. At first, on the wards, there was resentment, Espino recalls, especially from the lower ranks. How could the new Filipino nurses possibly be medically competent if they didn't even know which buttons adjusted the beds? And sometimes it was hard to understand the new nurses' accented English, especially on the phone. The challenges of settling in overshadowed the initial excitement about new life in a new land. "The realization you were really leaving your native soil was not until the moment the wheels of the plane lifted off the ground," says 42-year-old Eric Umandap, another Filipino nurse recruit who works at Allenmore. "I knew I wouldn't see my family for a year or so. I didn't know what the weather would be, the food, the people. All I knew was I have myself and my knowledge." The new nurses went through a year of special training on the new technology as well as review of all organ systems. They took tests, enrolled their kids in school, figured out Halloween wasn't a hostage situation, learned to leave shopping carts at the grocery store instead of wheeling them home. Espino and her husband sent money to her mother and two siblings, paid nursing-school tuition for two nieces, recently bought a house. Meanwhile, Espino knew her mother was getting sicker. In spring 2005, she took her husband and two children back to the Philippines to visit. They celebrated the homecoming at a beach restaurant, eating favorite foods. That night, mother and daughter shared a room. "I woke up in the middle of the night," Espino recalls. "She was standing beside me, gasping for breath. Her plan was to die beside me, but I called a cab to take her to the hospital. Good thing." After that visit, Espino returned to Tacoma. When her mother suffered another toxic attack in July, she flew back to the Philippines. In the hospital, Espino stayed by her mother's bedside. Took her to the bathroom. Gave her a shower, washing every part of her body with soap. In the last days, Espino's mother told her daughter she wanted to stay together, to go with her back to the U.S. They both knew her mother probably wouldn't leave the hospital, but Espino, being a realist, couldn't just nod, instead talking about the difficulties of that plan, the visa, the uninsured medical costs and how there'd be nobody to take care of mom when she was at work. Her mother passed peacefully, at noon, with her daughter right beside her. "I was with her," Espino says, "at her final moment." IN THE END, it is nurses who will be there for us. A month after returning from her mother's funeral, Espino cared for another family's matriarch. They wanted their mother to be comfortable. Espino made sure the morphine drip erased all pain. But the woman lingered, her breath labored. The family grew anxious. Why was she still here? "I just told them maybe it's not time yet," Espino said. "But it will come. It will eventually come." Paula Bock is a Pacific Northwest magazine staff writer. Email: pbock@seattletimes.com. Erika Schultz is a Seattle Times staff photographer.
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