International Council of Nurses Asia Workforce Forum 2003 November 27-28, Record of Meeting. 1. Opening-Introductions (09:00-09:30)

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1 International Council of Nurses Asia Workforce Forum 2003 November 27-28, 2003 Record of Meeting 1. Opening-Introductions (09:00-09:30) Official introduction of co-chairs: Dr Eui-Sook Kim, President KNA Dr Mireille Kingma, ICN-secretary to the SEW Committee The purpose of the forum is to: stimulate thinking, enhance learning and to develop proactive strategies; discuss trends in reward strategies; support international partnerships in the area of socio-economic welfare. Addendum issue - country reports in preparation of future meetings: Six months preparation time will be given for the drafting of country reports. The host associations will write the overview paper and send this paper to each association two weeks prior to the meeting. 2. Nurses wages and their context (10:05-10:50) Discussion of nurses wages was based on the ICN wages questionnaire sent to each association. The floor was opened up for discussion of the questionnaire and to identify similar and opposing trends between the countries. Nurses wages depend on the number of years of education and where nurses are working. The government-owned hospitals provide higher salaries with more benefits in the Philippines and Macau while the opposite is true in the other participating countries. The government-owned hospitals have fixed salary scales, while wages provided by the private hospitals depend on the number of patients and level of income. Priority issues for most of the countries: - decrease in wages for nurses; 1

2 - increase in shortage of nurses as a result of decrease in wages. The countries agreed that there are significant differences in the pay system used by each country. Differences between the systems used in the government-owned hospitals and private hospitals were also noticed. A similar trend in the loss of nurses rights was seen in all the countries. It is therefore important to fight for those acquired nurses rights and to negotiate for the maintenance of their salary scale. 3. Environmental scan (11:00-12:10) The purpose of the discussion of environmental scan was to: - focus on the implications of trends and current or future initiatives affecting nursing in the workplace; - identify major national or regional developments within and around nursing. Environmental issues within nursing: - Early retirement * - Change in role of nurses - Aging - Increase in occupational health hazards - Nursing shortage/immigration of nurses - Increase in young nurses - Decrease in staff levels * - Pay cuts - Increase in category of nurses (entry level difference) - Increase in competency in rural areas - Increase in RN entrepreneurs - Increase in other professions entering nursing - Changing career path - RN reimbursement - Increase in short contracts - Lack of evidence of RN cost/effectiveness * - Increase in credentialing/ certification * - Increase in need for leadership - Increase in knowledge management - Lack of business strategy - Trans-cultural nursing - Increase in community global standards 2

3 Environmental issues outside nursing: - Increase in performance-based pay - Increase in non-rn health care workers - Increase in RN entering other sectors - Shrinking economy * - Decentralisation of services * - Change in finance systems - Change in insurance systems - Increase in need for chronic care - health promotion - Increase in multicultural patients admitted to the hospital - Decrease in budget of department of health - Increase in emerging diseases (SARS) - Elections of nurse candidates to parliament - Difficulty of professional indemnity (access) - Increase in lawsuits (malpractice) - Early discharge of patients - Increase in health worker categories - Increase in threats - Increase in patient demands - alternative medicine - Reform of social security * - High technology - computerisation - Change in values - Change in expectation of nursing law - Hospital business - Tendency to become business-oriented Strategies proposed: - Collection of data on nurses added value* Creating alliances with other groups - Knowledge management Sharing and disseminating information to nurses and to public - Increase of the political power * Through elections, one voice, partnerships, trained spokespersons, networking - Active participation in policy-making programs With increase in public support: NGO's, manpower, professional associations By having RNs in decision-making positions, e.g. Ministry of Health - Creating new nursing service models 3

4 - Valuing the differences in nursing skills - Public relations * - Capacity building of nursing associations - Drafting the policy using appropriate language for the target audience The priority issues identified in the meeting are those in bold print with an asterisk. Several strategies to deal with these priority issues were mentioned and all the countries agreed that the following strategies should be focused on in the coming year: collecting data; increasing the political power; increasing the effectiveness of public relations; drafting policy using appropriate language. The most important strategy was concluded to be the collection of nursing data. A government authority is responsible for collecting the actual data and reporting it. The next step is to access the information, use it appropriately and report it in the ICN questionnaire. Nurses need to have this data at the national level in order to speak in one voice and have political power. It was concluded that since data collection is such an important issue, there is a question as to whether to continue to try to collect the data through the associations or to go through some other means. It was agreed that, whatever strategy is used, there is a need to introduce resources to ensure the members of the association are the first people to receive the data. 4. Nursing Workforce Profile (12:10-12: 30) Good statistical information is needed in order to make sound decisions. In addition, nursing needs to have adequate supply of licensed and trained personnel at all levels of the health care system, in order to support the provision of quality services. A questionnaire was sent to all the member associations so that a more complete picture of the nurse workforce statistics could be seen. However, it was difficult to have an accurate data analysis since only a few countries responded to the survey. Discussion was held regarding the poor response to the survey. The countries stated that the reason for the poor response might have been due to problems with the mailing system or having difficulty with term definitions. 4

5 Other organisations that have been interested in the nursing data: - International Organisation for Migration - UN Commission on Trade and Development - European Union - World Health Organisation All the countries agreed that the data was useful when speaking on behalf of the profession. It is also useful to pinpoint areas where the data was not being collected. Private sector data was reported to be more difficult to collect and verify. It might be necessary to think of other means of collecting the data, other than through the association, which may not have adequate resources for collection or dissemination. 5. Update on projects /priorities identified in 2002 (14:00-15:35) Priority areas of work for activities were identified in the meeting held last year (2002). Each NNA presented their priorities, and stated which strategies had been used and the impact they had had. Country Main priority issue in 2002 Strategies Hong Kong Human resources planning Appointment of new graduates brought about by change in the environment, e.g. SARS. A surplus of nurses has now become a shortage. Japan Human resources hospital - Community health setting Involvement of nurses in successful political actions Development of an alliance of four professional organisations Nurses to join the central system committee deciding professional fees and reimbursements Development of the Visiting Nurse Foundation (JNA business venture) encouraging entrepreneurship Introduction of the risk manager in all hospitals JNA continuing education programmes to prepare nurses Korea Career development Unifying the nursing education system with a 4 year baccalaureate programme Launched the public opinion survey Development of 6 more advanced practice programmes and launch of credentialing centre Macau Career development Participation in health care reform committees Continue nursing education Introducing 4 year college degree Thailand Career development Development of advanced nursing practice (49 5

6 Taiwan Philippines Indonesia Occupational health and safety Lobbying for approval of the Philippine nursing act Improving the nursing curriculum Create critical mass with leaderships skills Establishment of nursing council for self-regulations through issuing of the nurse practice act. Providing input for policy development for all sectors graduates in 2003) Continue to market this position Still working on the proposal to have the APN within the formal nursing service Development of nurse independent practice may be possible through health care reform (now only midwife and medical assistant) Led to proposal: RN passing the 4 month training of primary medical care can conduct physical assessment (outcome research positive) Development of education for technical nurse to become registered nurse. This will help fill vacancies in primary health care units at district level. Introducing re-licensure every 5 years based on continuing education credit units (15) Still working on migration. Very active recruitment from overseas. NNA and Council do not support. Increasing cases of malpractice Trying to improve occupational health and safety, raising awareness of employers re impact of working conditions on quality of care provided Change in environment (SARS) caused NNA and union to work together Development of advanced nursing specialists. This act has already been passed, but no regulation to start it yet. Working to co-host the ICN congress in 2005 Working on introduction of nursing license renewal policy and procedures Lobbying for implementation for increase in salary through Nurses Act, attempt to decrease the migration of nurses. Very concerned about migration of nurses. Already 300 primary level hospitals have closed due to few numbers of nurses. Introduction of 2-year bonding period after graduation. Approval of the code of ethics with expanded scope of practice. Exploring option to improve nursing curriculum A lot of other professions entering the nursing course, therefore need to continue to upgrade the curriculum In terms of creating critical mass: increased number of provincial boards of INNA from 15 to 29, increase from 212 to 336 district board of INNA Introduction of leadership training courses More than 150 nurses graduated with masters in management and leadership in nursing Working closely with the government Some issues such as nurse recruitment, migration, career development and the role of the 6

7 advanced nurse practitioner were seen to have common ground in most of the countries. In addition, the issue of unethical recruitment was also a major concern in most countries. It was therefore concluded that more collaboration is needed between the different countries and that the development of a regional alliance among the nurses associations might help in addressing certain priorities. There was consensus, and the Alliance of Asian Nurses Associations (AANA) was launched at the close of the AWFF meeting. (See item 8 below.) 6. Workload measurement tools in determining staffing levels (16:00-17:00) The workload measurement tools, used in determining staffing levels, were seen to fall into various categories: - dependency based; - activity based; - care plan driven. Discussion was based on the impression of the workload, the evaluation of the past, and what needs to be done in the future. Thailand: A tool is necessary for many reasons. In particular, it provides a way to measure the need of the patients. In addition, the tool is able to provide some evidence for staffing purposes. Thailand usually uses a NHPPD tool (nursing hours). There is a five-category patient classification system. There has been a change in the constitution granting citizens the right to quality health care. Japan: Japan has measurement tools to determine staffing. Although some hospitals have well built-in systems, it is difficult to learn from them. The government has developed a study to identify some scales. Nurses undertake parallel tasks and measurement tools do not often capture the real work being done at any given time. In order for tools to be practical on a daily basis, a pool of nurses is necessary to allow for flexibility in staffing levels. The reimbursement system also has a ratio of 1 RN per 1.5 patients during the day and 1 RN per 10 patients per night shift, which is considered unacceptable. On the evening shift, there is 1 RN per 4 patients. It is estimated that if the ratios were strictly applied, hospitals would have to be closed for lack of staff. Korea: Presently the medical law stipulates 1 RN per 2.5 patients. However, no hospital meets this ratio. Hospitals always wish to decrease the ratio and nurses have no data to fight this trend. KNA is working on developing tools. It is necessary to develop both a micro and macro staffing method to measure and assess the number of nurses per patient. The question was posed as to how many auxiliaries per nurse was recommended. 7

8 Indonesia: Some kind of formula to deal with primary nursing and team nursing is necessary. The formula may depend on hours by category, total working hours, or the shift itself. There is a weekly roster of nursing staff. Philippines: There are not enough beds or health care workers to take care of the increasing number of patients. This problem is seen especially in the hospitals in the rural areas, where there are a limited number of beds in the hospitals. It is not unusual for a rural hospital to have 35 beds, 65 patients and 2 nurses per shift. Hong Kong: The trade union is not satisfied with the manpower indicators used and considers the number of nurses allocated too small. However, nurses have been prepared to accept fewer nurses on the night shift in order to reduce the number of night shifts each nurse is assigned. The trend is to increase the number of nursing auxiliaries and stop training licensed practical nurses. Taiwan: There is a problem in staffing. On the day shift, there is often 1 RN per 2.5 patients in the intensive care units. It was noted that, in most countries in this region, family members provide much of the personal (hygiene) care in hospitals. In certain cases, nurses no longer wish to provide this care. It is clear, however, that lay carers are not included in the workload measurement process. Infection control hazards were highlighted. During the recent SARS epidemic, lay carers were seen to spread the disease within the hospital and to the community because of lack of training. Although there are private companies training these lay carers, they give insufficient information. It was concluded that all the countries use a certain measurement tool to measure the needs of patients, to provide some evidence for staffing purpose and to measure and assess the number of RNs per patient. All agreed that a tool is necessary and that the formula used in one country may not be applicable in other countries, since each country has its own set of unique laws and situations. It was also concluded that trained nurses are needed to make clinical judgments, working toward a more effective clinical outcome. The need to learn the language in order to negotiate effectively was also thought to be necessary by all the associations. It was mentioned that the principles of safe staffing is provided on the American Nurses Association (ANA) website. All of the factors that should be taken into consideration are mentioned here. ICN was congratulated for having developed the monograph on workload measurement, which was found to be a very helpful resource. 8

9 7. Globalisation (09:00-10:35) Last year, it was identified that the region was under the influence of globalisation. The status in each of the countries as well as the signs of globalisation in each of the countries was discussed: Factors facilitating globalisation: - High technology - E-learning * - Transfer of technology/skills - Migration/travelling - Rapid growth of knowledge - Trade agreements/ WTO - Legislation/ policy - Recognition of regulation bodies - Individual eagerness - Networking * - Benchmarking of education systems - National economy - Partnerships-exchanges - Business interests - Successful stories - Contracting student Barriers to globalisation: - High technology - Limited resources -financial - Language * - Cultural difference */ lifestyle - Qualifications/ licensure * - Different systems of education/ development - Increase in epidemics - Protectionism of nationalism - Stigma - Lack of family support - Impact on economy - Religious dogma - National economy 9

10 - Ignorance - Bad experience Impact of globalisation on the region: - The shift to professional development (if temporary migration) - Both Brain drain and Brain gain - No long-term HR plan - Need to work on workforce environment. - Other professionals entering nursing (bridge to other employment opportunities) - Support of Gross National Product (Government support) - Improved national image, national growth - Flexibility of entering into the profession - The need to circulate ideas with other countries - Nurses becoming the pioneers of globalisation - Social status The concept of globalisation has been widely accepted in most countries, with a move towards acceptance of foreign nurses. Many nurses are also sent to foreign countries for more experience in the different fields. Many countries stated that collaboration was important not only to develop and promote nursing education, but also to develop nursing service. In cases of nurse surplus, NNAs have been known to facilitate migration, e.g. Korea. The KNA wishes to improve the protection of the migrating nurse as well as the quality of the Korean nurse in order to take full advantage of migration opportunities. KNA is using the World Trade Organisation debate to push for higher education of nurses in Korea. There is also a large migrant population of nursing students, e.g. Korean and Chinese students studying in the Philippines. In Hong Kong, where migration has decreased dramatically in the last 10 years, there is a growing sense of isolation and a decrease in the exchange of ideas internationally. In Macau, where there is a good standard of living, there is very little migration. Only 6% of the nurses in Macau are from other countries. In Taiwan, the NNA is helping nurses learn English, thus supporting the migration opportunities of their members. The point was made that in many Asian countries, foreigners (including foreign nurses) are not well accepted. This trend is starting to change. It was recognised, however, that a nurse with international expertise is often more highly regarded when s/he returns to her/his native country. 10

11 It was encouraging to see that many of the NNAs are being consulted by their governments with regard to the development of their trade agreements, e.g. GATS Mode 4 (Korea, Japan, Philippines). A number of the NNAs have begun to establish foreign branches in order to better serve their membership, e.g. Philippines, Korea, Hong Kong, Thailand. Some of these foreign branches are fundraising in order to support the training of new nursing students from their native countries. Three options were proposed to deal with the issue of migration. role of the association to protect the nurses; keep nurses well informed; establish reintegration programmes for returnees to encourage migrant nurses to return to their native country. In conclusion, it was clear that migration had both positive and negative aspects. It was also clear that, whether it was in large or small numbers, migration would always occur in the nursing profession. The members of the association therefore play an important role by providing information to nurses who go abroad and by facilitating reintegration of nurses returning to their own countries. 8. Discussion of the creation of a united Asian Association (11:00-11:40) Name of organisation: Alliance of Asian Nurses Association (AANA) Main purpose: to provide networking and sharing ideas or information between countries Membership: start with 12 Asian members List of members in alphabetic order are: China, Hong Kong, Indonesia, Japan, Korea, Macau, Malaysia, Mongolia, Philippines, Singapore, Taiwan, Thailand Major functions: - Network-type administering in a similar way to the ICN workforce forum - To make an agreement about the decisions made (vote has to be 2/3 or unanimous) Organisation: - The Asian Nursing Forum is under the umbrella of AANA - NNAs hosting the next scheduled meeting will act as the Secretariat and be held responsible for all work between meetings Meeting: - The AANA is to meet every year 11

12 - The Asia Nursing Forum (conference) is to be held every other year 9. Disciplinary actions against nurses (11:40-12:30) Malpractice exists in all the countries and should be eliminated from nursing. The nursing associations may be involved in various ways: - creation of a work environment to support good practice; - development of malpractice policy and infrastructure; - participation in the review panel; - representation of members. Several factors need to be considered: - competent authorities; - procedures; - representation; - penalties; - recourse/appeal procedures. At the beginning of the discussion, it was stated that if nursing is to become an autonomous profession, then nurses have to be responsible for their own actions. Each NNA stated that their country has laws addressing this issue. Consumer awareness is rising as well as consumer demands on the profession. There was agreement that aggression against the profession is increasing, as is the number of suits brought against nurses. Similarly the punishments imposed are more serious in length and nature. Most of the countries are similar in that they have some kind of nursing council, which is also a legal council. In certain cases, the NNA representative participates in the council board and decision-making. Most countries have nursing acts and nursing ethics codes. Indonesia is working with the nursing councils, while Hong Kong, Taiwan and Macau do not even have councils. Many of the NNAs provide legal aide to their members, inform lawyers with regard to health issues and support nurses who wish to get a degree in law. Difficulty in getting access to professional liability insurance was also mentioned, e.g. Hong Kong. In the case of Japan, JNA through special cooperation with a company now runs its own internal medical insurance company. In summary, it was concluded that currently there is a growing interest in public rights and consumer oriented services with more discussion on legal issues. The need for more advanced 12

13 practice and the nurse's role as an autonomous profession has made the malpractice law an important issue for nursing. The need to work on improving the environmental situation while at the same time on improving the quality and standard of nurses was also emphasized. Professional accountability and the need to refuse bad orders were highlighted. 10. Workplace violence (14:30-15:00) Violence in general is becoming very common in health care settings, and nurses are seen to be particularly vulnerable. Workplace violence includes not only physical violence, sexual assault and harassment, but verbal abuse as well. This topic was addressed last year by some of the nursing associations who agreed to undertake research to collect baseline data, and to translate the ILO/ICN/WHO/PSI Framework Guidelines. Each country was asked to give a progress report of this work. In Japan, a survey was done in 2001, which showed that: - 30% of the hospitals reported having violence against the hospital staff. - More than 60% of the hospitals reported having inadequate security especially at night. - There were also more thefts within the hospitals rather than violence itself. In Thailand, the questionnaire was sent to 708 managers and nurses, and the results showed that: - All the hospitals had safety precaution procedures during working hours. - The accidents usually happened during working hours, with needlesticks to be the most common type of accidents. - 23% of the violence occurred in the workplace (bullying and thefts). - 2% of the violence was related to verbal abuse % of the violence were related to sexual harassment (verbal). - There was an increase in the number of thefts and violence against nurses commuting to work. - There were very few cases of racial discrimination. In Macau, no research was done in terms of work place violence. However the association believes that nurses face similar situations as those mentioned in other countries. In order to avoid these situations, more support should be received from the government. More studies should also be done to determine the cause of the violence in hospitals. In addition, nursing quality, communication skills, and education standards should continue to be emphasized, in order to reduce misunderstandings between nurses and patients. In Indonesia, a large percentage of the violence is believed to be caused by the patients and 13

14 family members. The local health officers are always involved in this matter. In Hong Kong, the reported number of cases of violence in the workplace was quite low. The type of violence mainly seen was: - verbal abuse; - communication problems between patients and nurses, or relatives and nurses. Physical abuse and thefts are seldom seen. Thefts would usually occur during the night shift, but these were rare. Korea stated that currently the public communication was broadcasting the low level of security in hospitals. There had been a report of how vulnerable hospitals and patients are to danger. Most of the workers on the night shift are women. This has therefore started to become an important issue for the whole society. Three types of interventions based on research done at ICN: - Individual focused interventions (which have been used in the past, where nurses are taught how to better manage the conflict situations). - Need to look at other organisational aspects: staffing levels, having time to explain properly to the patients. - Environmental factors: temperature, level of noise, access to restrooms, and access to phones. In conclusion, workplace violence is increasingly a professional issue as more nurses are reporting violence as a reason for leaving the profession. Two issues should therefore be considered: the issue of prevention and the issue of rehabilitation. Both issues are equally important and should be addressed. Many countries reported similar types of violence such as bullying between nurses as well as sexual harassment and verbal abuse. Sometimes assertive training courses can help nurses deal with certain situations. It was agreed that continuing education was important as well as teaching new students. The nurse's association should take a role in many areas: - lobbying; - support of victims; - rehabilitation; - improving relationships with other professions; - providing good role models. 14

15 11. Planning for the future (15:45-16:25) Major current and future SEW priorities were discussed: Early retirement Nurse cost/ effectiveness Decrease in staffing levels Increase in credentialing/ certification Reform of social security Shrinking economy Decentralisation issues Common issues were identified as future agenda topics: Mutual recognition agreements Networking or partnerships with other organisations, e.g. unions Occupational health and safety Mobilisation of volunteers as a resource for association Welfare of disaster relief nurses Environmental scan Patient safety. The 2004 ICN Asia Workforce Forum will be held in Thailand. The tentative meeting dates of 25 November 2004 for the AANA, and November 2004 for the ICN Asia Workforce Forum were proposed. The President of the Thai NNA will be the secretary of AANA. In 2005, the ICN Congress will be held in Taiwan. There will be no conference, no nursing forum or workforce forum. There will only be a one-day meeting of AANA. Japan volunteered to be the host of the 2005 Workforce Forum, if it was seen to be necessary. The issue of finance was brought up. It was decided that, in the future, every association would be responsible for covering the travel and accommodation costs of their representatives. 12. Evaluation and closing (16:25-16:40) Before the session was brought to a close, the floor was opened up to find out if any of the countries wanted to do any special projects. No new projects were proposed, and all the NNAs 15

16 agreed that they would continue to work on the priorities and topics identified in the meeting and to give an update report next year. The participants agreed that the forum objectives were met and that the forum discussions were very focused. Everyone agreed that it was important to share ideas with one another and to learn from one another. Strong emphasis was also placed on the notion of all the countries joining together to have one voice. In conclusion it was agreed by all the countries that the Forum had met all their expectations and that it had been a useful discussion. The forum was then adjourned, with thanks to the host association and to the members for the kind hospitality and solid support. All were pleased at having been given this opportunity to express their thoughts and to have a frank discussion. Appreciation was also expressed to ICN for facilitating this yearly regional discussion. High expectations and eagerness were expressed with regard to next year s forum to be held in Thailand. 16