Research Findings

Clocking out: Nurses refusing to work during a pandemic

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September 8, 2022

In the early months of the COVID-19 pandemic, the Philippine government instituted what may be considered one of their most controversial emigration policies. For an indefinite period, state agencies decided to ban Filipino healthcare workers from leaving the country for jobs overseas.

This “deployment ban” was unprecedented, not only in scope but because the Philippines is also the primary source of migrant nurses worldwide. While the state curtailed the departure of 13 health professions, nurses comprised the largest group, with hundreds unable to leave for jobs waiting in the US, UK, Saudi Arabia, and Singapore.

Philippine government officials argued that the ban would redirect human resources toward national health needs. Yet, instead of consolidating the country’s pool of nurse labor, the ban divided nurses into two distinct groups.

The first group complied with the state’s call to service and entered its “urgent hiring scheme,” channeling them into the country’s COVID-19 hospitals.

Meanwhile, the second group chose to either remain at home or obtain non-nursing jobs instead.

This contrast underlines two questions that sociologists of work have long sought to answer: How do professionals choose to commit to their work despite increasing risks? Conversely, how do others decide to forego professional obligations despite external pressures to remain on the job?

Professional values?

We sought to address these questions in a recent study where we spoke to 25 nurses who chose to enter the state’s urgent hiring scheme (“compliant nurses”), and 26 nurses who resisted the state’s deployment ban and refused to serve (“resistant nurses”).

Government leaders and the Filipino public quickly pit these two groups of nurses against each other. Compliant nurses were the “healthcare heroes” who risked their lives to fight the virus. Meanwhile, resistant nurses were selfish opportunists who put their migration interests before their patients.

However, our findings revealed a completely different story.

Contrary to public perceptions, both compliant and resistant nurses expressed high aspirations to leave the Philippines. Even compliant nurses were making active plans to work overseas. Most of the nurses in this group (21 out of 25) opposed the state’s deployment ban, even if it promised to channel more nurses into COVID-19 hospitals.

Rather than selfless professionalism or patriotism, we found that nurses’ willingness to serve in the Philippines’ COVID-19 hospitals hinged on the point at which the deployment ban interrupted their progress towards emigration.

Accumulating skill

Before the pandemic, most foreign employers required migrant nurses to obtain clinical experience in their origin countries. As a result, gaining experience in the home country is often seen as an essential first step toward future emigration.

Yet, for the past two decades, finding a full-time position within Philippine hospitals has been extremely difficult. In the 2000s, private nursing schools created an oversupply of nursing graduates that flooded the domestic labor market.

Making things worse, Philippine health institutions did not offer enough full-time positions for staff nurses, leaving aspiring nurse migrants unable to complete the two years of work experience that most foreign hospitals required.

The pandemic led to a sudden need for nurses in the very same hospitals that used to turn them away. In our study, we found that the desire for local clinical experience determined Filipino nurses’ response to their government’s call to service.

Compliant nurses were unable to obtain hospital jobs and actually had minimal clinical experience. Before the pandemic, many had been working in other industries like education, retail, and hospitality. As such, they saw the pandemic as a chance to resume career plans that had been stalled for many years. This idea of restarting one’s migration trajectory was the defining reason why they chose to enter the country’s COVID-19 hospitals.

In contrast, Resistant nurses already spent considerable time (2 to 7 years) working in clinical settings within the Philippines. Unlike Compliant nurses, they had fulfilled the required period of clinical practice that most foreign employers required. Having completed this requirement, these nurses had clocked out of Philippine healthcare and were determined never to return.

Clocking out of the profession

The decision to clock out was not only justified as having served enough but having endured the poor work conditions of Philippine hospitals for long enough. Many of the resistant nurses had worked as hospital staff for very low wages with no benefits or security.

These results were both sobering and important. While there are many studies on nurse attrition, scholars tend to explain this problem as a giving up of professional identities. This tendency is especially salient in research on nurses, where staff attrition is largely interpreted as the erosion of professional ideals.

It is true that healthcare workers can become disillusioned or burnt out with their profession. However, there is a danger in assuming that those who remain in their jobs still adhere to their professional obligations, even as others have given up. This assumption reinforces a binary view of healthcare workers as either “selfish” or “selfless” with their skills – a narrative that has proven to be unhelpful in trying to stem shortages in human resources for health.

Rather than view the decision to emigrate as merely a giving up of professional values, we frame nurses’ service to local hospitals as only one phase in a broader migration trajectory that requires clinical experience within the Philippines. The notion of “clocking in” and “clocking out” can help describe how aspiring nurse migrants treat such local service as a designated time of work – much like punching a timecard through a Bundy clock.

We found that once Filipino nurses had clocked out of their time spent in Philippine healthcare, they were unlikely to return to jobs where they felt poorly treated and overworked. This case underlines how efforts to maintain human resources for health within source countries cannot be mitigated by simply blocking emigration.

Nurses subjected to poor working conditions within local hospitals will eventually clock out of the system and leave the profession instead.

Read more

Yasmin Y. Ortiga, Michael Joseph Diño, and Romeo Luis Macabasag. “Clocking out: Nurses Refusing to Work in a Time of Pandemic” in Social Science and Medicine 2022.

Image: Asian Development Bank via Flickr (CC BY 2.0)

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