Overseas nurses are beginning to wonder if they have a future in Ireland, reports Eithne Donnellan, Health Correspondent
Daryl Kho is a Filipino nurse who came to work in Ireland two years ago last May. When her contract expired six weeks ago she was told by the Northern Area Health Board (NAHB) that the most it could now offer her was a further three months' work.
"It was really stressful that time when I heard my contract would not be renewed for a longer period," she recalls.
She sat down to consider her options with her husband, Jerry, who had arrived from the Philippines to be in Ireland with her. They decided they could not plan their lives on a three-monthly basis, particularly as Jerry is not allowed to work here and they were depending on her salary to eke out a living in Dublin.
"We've decided to go to Australia. We leave in August when my contract expires," she explains. "My husband can also work there, so that is a big advantage."
Kho says, however, that she would definitely stay in Ireland if her husband were allowed to work. He was employed in sales in the Philippines but this is a category of worker that the Department of Enterprise, Trade and Employment considers ineligible for a work permit.
There are many others like the Kho family. The Irish healthcare system is propped up by almost 5,000 Filipino nurses at present, but given the shortage of skilled nurses in several countries which are offering more attractive contracts, the danger that many of these Filipino nurses will leave in coming years looms large.
Junylen Utlang, who, like Kho, has worked at St Mary's Hospital in Dublin's Phoenix Park for more than a year, can't understand why the NAHB isn't offering colleagues longer contracts and the stability they need to plan their lives.
"I believe we are still needed in St Mary's," she says. This is definitely an understatement, given that more than 70 per cent of the hospital's nursing staff are from the Philippines.
Utlang's husband and three children arrived from the Philippines last Sunday. They are staying with her and a friend in a two-bedroom apartment in Chapelizod, which sets them back €1,500 a month.
"We just really have to budget our money. My husband works in construction, but he can't get a work permit for here," she says. "If we could both work we would stay here."
This issue of work permits for the nurses' partners, and the uncertainty over contracts in recent months because of pressure on health board budgets, are the biggest factors that will influence whether most of the Filipino nurses on whom we depend stay or go.
The NAHB says it is not in a position to commit itself to contracts longer than six months.
"Our ability to extend contracts will be commensurate with our ability to operate within our budget and employment ceiling numbers," it says. But it acknowledges that six-month contracts are "not ideal".
Anne Carrigy, director of nursing at the Mater Hospital, Dublin says the issue of allowing nurses' partners an automatic entitlement to work here, regardless of their skills, needs to be looked at. "I would like if we could look at facilitating them in some way because if we did not have the overseas nurses we would have a very difficult time providing services for our patients," she says.
There are more than 350 overseas nurses, mainly from the Philippines, in the Mater, where, despite more than 100 bed closures so far this year, their two-year contracts are continuing to be renewed. However, Carrigy says, a factor in whether or not they stay is the more attractive packages now being offered to them in other countries.
"We are unfortunate that we are going to be competing in particular with the UK and Australia for these nurses now, and the conditions of their visas are very attractive to the overseas nurses because they are giving their partners a work permit as well. And I understand that, in Australia, they provide guaranteed free education for their children. Obviously it's very difficult for us to compete with countries where their partners get work permits," she says. "I'm aware of one of my nurses leaving because her husband could not get work here, but I'm not aware of them leaving in large numbers."
The Irish Nurses Organisation (INO) has predicted that some 500 Filipino nurses will leave over each of the next three years unless they are offered some stability in their contracts. If they leave, industrial relations officer Mary Fogarty says the effect on patients will be "devastating" and hospitals will have no option but to close beds.
Furthermore, she says, despite the number of vacancies in the Irish healthcare system - a Health Service Employers Agency study put it at 946 at the end of March, down from 1,315 in early 2001 - few hospitals have guaranteed all their Irish student nurses contracts on qualifying this year.
"It's absolutely crazy," Fogarty says.
In addition, due to a change in nurse education from a three-year diploma to a four-year degree programme last autumn, there will be no Irish nurses qualifying in 2005. At present, there are more than 1,600 in training each year, and how that gap will be filled in two years' time is anybody's guess.
"Unless they plan now and invest with vision and foresight and hold on to the nurses we have it will be a disaster," Fogarty warns.
Carrigy says directors of nursing are already planning for 2005. They hope to meet the shortfall by having the assistance of student nurses on work placement, extending nurses' contracts and through further overseas recruitment campaigns. But she doesn't suggest it will be easy. Even now, one of the greatest challenges for people in her position on a daily basis is to ensure they have enough skilled nurses to provide the services required and at the same time live within their budget.
One of the areas where it has been proving impossible to get enough nurses is in intensive care specialisation. This issue, highlighted in an Intensive Care Society of Ireland report in January 2001, continues to worsen. The 2001 report drew attention to the pressure on intensive care beds but said it was "compounded by the difficulty in retaining critical care-trained nursing staff". The impact, it said, was that critically ill patients "may not receive appropriate care".
When it looked at paediatric hospitals, it found that in 74 per cent of cases where a child was refused access to intensive care it was due to a shortage of appropriate nursing staff.
It was this shortage of intensive care nursing staff which was blamed by Our Lady's Hospital for Sick Children in Crumlin, Dublin, for its decision almost two weeks ago to postpone heart surgery on two-year-old Limerick girl Róisín Ruddle. The child was sent home to await a new appointment and within hours she was dead. A report ordered by the Minister for Health, Micheál Martin, into the circumstances surrounding the cancellation of her surgery is due to be completed by the Eastern Regional Health Authority on Monday.
Carrigy says intensive care nurses are in short supply globally and occasionally beds also have to close in the intensive care ward at the Mater because no intensive care nurses are available to man them. So the problem is not unique to Crumlin.
Prof Linda Shields, of the Department of Nursing and Midwifery at the University of Limerick, says there is a shortage of all nurses internationally.
"Even wealthy countries like Sweden, whose health system is optimally resourced, cannot recruit enough nurses to fill vacancies," she wrote in a letter to The Irish Times on Thursday.
Why? Is it that not enough nurses are being trained? Micheál Martin points out that the numbers in training have increased by more than 70 per cent since 1998. In that year, 968 nurses were in training, compared to 1,640 in 2002. So too have the numbers of nurses in the system - there were more than 33,000 last year, compared to just over 26,000 in 1998.
Furthermore, he says, the average salary increases for nurses since 1997 have been between 30 and 50 per cent. And he stresses that interest in the career among CAO applicants is very high, with some 7,200 applicants putting it down as their first choice of career this year, evidence, he suggests, of the fact that school-leavers and mature students see it as an attractive and worthwhile career choice.
But if that is so, why are we lurching from one crisis to another in terms of nurse staffing numbers? Shields says it's because of the high dropout rate from the nursing profession. She points to nursing as a difficult job. Nurses have to do night work and deal with an increasingly litigious society.
"If a student graduates and becomes a registered nurse, hierarchical power structures mean little autonomous practice," she says. "There are increasingly litigious societal expectations, and pay-scales may not adequately reflect the years of education and level of responsibility.
"Often nurses find other professions with better recognition and fewer problems. Bringing nurses from developing countries is not the answer. In fact, the International Council of Nurses advised strongly against this, as it is unethical to deprive poorer countries of their ever-decreasing nursing workforce."
There is no easy solution, she adds, but suggests nursing organisations and health departments around the world need to meet and come up with strategies to ensure that nurses are valued and retained in their workforces.
The INO has for some time been seeking enhanced pay and conditions to attract and retain Irish qualified nurses. In its last pre-budget submission it called for immediate recruitment and retention measures to address continuing staff shortages. It wants a standard 35-hour working week for nurses, the starting salary of newly qualified nurses to be increased to €25,997 by abolishing the first two points on the existing pay-scale, and the immediate introduction of a Dublin living allowance worth at least €4,000 for all nurses working in the greater Dublin area, where the majority of nursing vacancies are.
The Labour Court recently rejected the INO's claims in relation to a Dublin living allowance, a 35-hour week (currently nurses work 39 hours, but say most paramedics work 35 hours) and extra payments for night duty and weekend work. However, that decision is not binding and INO executives will be meeting in September to decide their next step.
Meanwhile the issue of allowing the spouses of Filipino nurses an automatic entitlement to work hasn't even been looked at. The matter was brought to the attention of the Government by the Philippine ambassador to London and, while the Government told him it would consider applications from the partners of Filipino nurses for work visas favourably, a Department of Enterprise, Trade and Employment spokeswoman said yesterday that the current system of allocating them visas was not under review. She stressed that while partners of Filipino nurses do not have an automatic entitlement to work, there is no blanket ban on them getting working visas either.