The last couple weeks I observed in the general unit which caters to a wide variety of patients including: pediatrics, medical-surgical, chronic diseases, and mother-baby. This unit is more exclusive to people who can afford treatment, has connections to the hospital, and/or has insurance coverage. The rooms have single beds with an additional bed for family members. Visiting hours don't really exist as family members are able to stay with the patient at all times. Family members are closely involved in assisting the nurses care for the patient which is a big difference from the US. In the Philippines, family is much more hands-on and it is rare for a patient to ever be alone. Family also plays a big role in consenting for procedures. If it is deemed that the patient cannot make a decision regarding his/her care on his/her own, then it is up to the family to decide. Even if the patient is fully capable of making a decision, the family is always consulted. The nurses decide if the patient is able to give consent. Level of consciousness and emotional state are both considered when determining if the patient can provide consent. Sometimes it can take awhile for consent to be obtained as the patient consults even extended family members.
Due to wide range of patient encountered, nurses have to be skilled in a lot of different areas. The nurse:patient ratio is about 1:8 so the nurses are pretty busy for the entire shift. Nothing can be done to lower the nurse:patient ratio as the nursing shortage is increasing in the Philippines. As I talked about before, it's a vicious cycle of under-compensation, burnout, and nurses moving abroad that perpetuates the problem. It doesn't seem like anything is being done about it either. I found out that even nursing assistants abroad get paid more than the nurses in the Philippines. With that being said, the nurses really have to be flexible with the resources that they have. For example, clustering care and multitasking is very important. The nurses are excellent at determining the patient's priority problem and executing the doctor's order in a timely manner.
In the hospitals I've experienced in the US, medications are dispensed using an automated machine. It's fast, user friendly, and decreases the rate of medication errors through certain verification processes. Cabrini does not have that luxury. Instead, medications are dispensed and sorted manually. Each patient has a designated bin where the pharmacist fills with 24-hours worth of ordered medication. The nurses then have their own specific containers for each patient that they use to deliver medications to the bedside. The nurses verify that they have prepared the correct medication/dosage by checking the chart, medication cards, and then by another nurse. It's also important to note that most medications are given at a scheduled time. Unlike in the US where medications can be scattered at random times, at Cabrini medications are given at specific time intervals to avoid disturbing the patient and to cluster care more efficiently. For medication administration, I have been taught the 6 rights of safe medication administration. In the Philippines, the nurses are taught 12 rights (right patient, right drug, right dose, right route, right time, right assessment, right reason, right documentation, right evaluation, right drug preparation, right for patient to refuse, and right of the client to know the reason of the drug) of medication administration which further safeguards the patient from medication error, especially since everything is done manually. I must say that even without the use of an electronic medical record, the nurses deliver medications in a very effective and quick manor. Medication errors do happen, but the nurses are very safe when delivering their medications. I'm glad that I learned another way of medication preparation as it has broadened my knowledge of nursing care without the help of electronics.
As I mentioned before, the patient's family is always at the bedside. This is beneficial since it lessens the nurses' load. The family can assist the patient without having to disturb the nurse. The nurse does have to see the patient every 2 hours, but doesn't see the patient much in-between that time because of the family members continued presence. The family members are even responsible for documentation patient status such as intake and output and basic vital signs. Without a doubt, the Philippines makes family-centered care a priority... which is an aspect that sometimes the US lacks in. If the patient is stable, the nurse usually doesn't bother the patient. It lessens the nurse-patient interaction, but allows the patient to rest more. It can be risky especially if the patient's status changes, but the family is present to monitor for that.
Unfortunately, Cabrini isn't as concerned about infection control as the hospitals in the US are. I also observed this in Barcelona, Spain where many nurses don't wear gloves or PPEs when doing procedures or handling an infectious patient. At Cabrini, I witnessed a nurse handle the blood of a patient with a possible HIV infection without gloves. Blood did get on her hands and she didn't wash her hands for several minutes after... all while touching the cabinets and counters in the nurses' station. Also, tuberculosis (TB) is prevalent in the Philippines where there is inadequate treatment. I witnessed several patient's with TB be put in a standard room without any isolation precautions. The nurses would go in and out of the room without an N95 mask and would instead double up on the standard mask. Thankfully, the nurses would inform me of a patient with TB and provide an N95 mask for me. There was no signage placed on the doors for infectious patients so it was unknown if you were walking into a contagious patient. For my own safety, I came accustomed to wearing a mask whenever I left the nurses' station. Another reason nurses chose not to where PPE is simply the cost. Hospitals simply cannot afford for nurses to use PPEs at every instance of patient contact. Hepatitis B is also very common in the Philippines and mostly transmitted sexually. The nurse described the reason behind this as the lack of sexual education taught in schools. Since the Philippines is a religious and conservative country, children are taught to avoid sex until marriage. The nurse described this philosophy as ironic since many people, especially the younger generation, aren't celibate until marriage. Without the knowledge of safe sex practices, it perpetuates the rate of sexually transmitted diseases.
Cabrini is a for-profit hospital and nurses often get frustrated because care is prioritized to patients who have more money and/or have connections with the hospital. Similar to a hotel, patients can even reserve rooms in advance. For example, 10 patients could be discharged in a day, but 10 other patients could already be coming in because they have already reserved the room. I found this interesting as I have not observed this practice in the US. As I have stated before, receiving payment from the patient is very important. Every single procedure and resource used is documented in the patient chart so that the hospital can receive compensation. There was one instance where a patient was unable to pay her bill and so she was basically held hostage in her room until she paid. She was perfectly fine to be discharged, but was forced to stay because of her unpaid bill. Ironically, she was still charged for the days she was forced to stay in her room. If she were to leave without paying her bill then the cost would come out of the nurse's salary for not watching her properly.
Lastly, there's a culture of the nurse's never questioning the doctor's orders. The doctor is seen as almighty and it would be very detrimental if a nurse were to question him/her. For example, a patient required furosemide because of a pleural effusion, but it wasn't ordered. The nurses didn't think to question it because the doctor hadn't ordered it which delayed care for that patient. Even though the healthcare culture is focused on a doctor's superiority, nurses and doctors share a sense of camaraderie. They realize that the Philippines lack resources and sometimes have to provide care in a unique and unconventional way. They do their best with what they have and minimize the cost to the patient as much as possible.
Overall, my time at station 3 was a learning experience. I learned and observed how to prepare medications without an electronic medical record, give blood products, perform tracheostomy and wound care, suction, administer chemotherapy, remove IVs, and perform assessments. My next stop is the ICU!
Very thorough description of the Health care culture. Consider editing your comments regarding medical errors.