Evaluation of a Government Deployment Project for Unemployed Nurses as Input to Policy and Programmatic Directions

Purpose: At the peak of nurse unemployment in 2011 with the US and global financial crisis, the Philippine Department of Health organized a training-cum-deployment project for nurses to be fielded in underserved government hospitals and rural health centers called Project RNHEALS.  The Project aimed to enhance competencies of nurses in clinical and public health nursing and augment access to health care in underserved communities.  This study is a program evaluation focusing on assessing implementation and outcomes of the Project as input to policy and programmatic directions. Specifically, it (1) assessed recruitment, selection, deployment process and incentives within the context of the project objectives and guidelines and (2) determine whether the training program enhanced competencies of participating nurses.

Methods: This study used a mixed-method design. Records review, key informant interviews, focus group discussion, a self-administered questionnaire, and an online competency assessment called Nurse MetriX were the main methods of data collection measured at the beginning of the deployment and at 10 months. Competencies of RNH nurses were measured at 3 points: prior to deployment and at 3 and 10 months of deployment.  Through a multi-stage stratified random sampling with probability of selection proportional to size sampling technique, 7 provinces including NCR in 4 regions of the country were covered with a total of 729 RNHEALS nurses from both hospital and rural health units.  A total of 172 implementers of the project were also included as key informants. These included chief nurses, assistant chief nurses, training coordinators, senior hospital staff nurses, city/municipal health officers, senior public health nurses, DOH representatives, as well as DOH-HRDU personnel.

Results: This report will focus on results of process evaluation and RNH nurse competencies at 3-months of deployment.  72% of the RNH nurses had prior nursing experience with 52% as volunteers in hospitals and only 6% in community centers called RHUs.

Generally, the process of recruitment, selection and deployment varied according to region, province, and institution, with biggest variability in the hospitals. DOH gave an option to hospitals to include institutions' standards and criteria like interviews, competency examinations, hospital experiences, trainings, and medical examination for screening RNheals candidates. There was a common perception that final selection was not based on objective criteria.

In terms of the guidelines re the Training Program, there was varying compliance with greatest variability in hospitals.  Almost all hospital-assigned RNheals nurses were rotated in general wards. Only a few rotated in the OPD as well as other special areas. Most RHU-assigned nurses were assigned to Barangay Health Stations, supervised by Public Health Midwives.  This gave rise to some problems related to supervision, not being allowed to give injections and immunizations, and some interpersonal difficulties for the RNH nurses. A few had opportunity to be assigned in birthing clinics depending on the availability of the facility.

In reviewing changes in the DOH guidelines from batch I to IV, there were major changes that led to some confusion in the implementation of the Project, as well as expectations of the RNH nurses and the implementers.

Problems identified included delay in release of their monthly allowance, confusion re PhilHealth insurance registration causing delay, lack of supervision in the hospitals, supervision by the Midwife in the RHUs limiting their achievement of competencies, clamor for a certificate of employment to increase their employability, difficulty of local government units to provide the additional monetary incentive given their resources and the number of RNH nurses. There was a strong sentiment that the number and distribution of RNH nurses deployed should be reviewed and be based on actual need, and to solicit the inputs more of the LGUs and the DOH Representatives who know their community better.  The RNH nurses also resented to some extent being referred to as RNHEALS nurses and trainees as this undermined them and tended to be treated as students rather than RNs.

Despite these concerns, assessment of competencies based on self-report showed significant increase by 3-months into the program.  For hospital nurses, there was significant improvement in all 11 domains (p <0.05, paired samples t-test) except in two items related to preparing patients for procedures and endorsing patients.  For RHU nurses, competencies were based on involvement in public health programs.  As such, although there was reported improvement on most competencies, several or most items related to “care during childbirth”, “postnatal care”, and “essential newborn care” did not.  On “emergency services”, there was no improvement in terms of the item of “providing basic life support and first aid.”  This was consistent with reports that the nurses had limited opportunities in these areas, and depended greatly on availability of the facility and services. The domains related to childbirth and newborn care were also mainly performed by midwives at the health centers or community.

Reports from other sources such as their supervising nurses were consistent with this self-report.  RNH nurses also reported satisfaction with the project and would apply again given the chance.  For the RNH nurses deployed in community centers, there was the added benefit of the nurses viewing public health nursing more positively, and during the FGDs, indicated that some were interested to apply to such positions in the future.

Conclusion: At 3 months, clinical and public health competencies of RNH nurses improved. In general, RNH nurses were satisfied with the Project, particularly in providing them nursing work experience with allowance.  In terms of program implementation, although there was some variability, in general the Project was implemented according to the set guideline. There were problems related to delayed allowance and other incentives, selection and supervision particularly at RHUs where there is only one Public Health Nurse so most of the supervision was by Midwives. Deployment in both hospitals and RHUs even by 3 months showed significant improvement and enhanced employability. Preliminary recommendations for the improvement of the project include transforming the Project from a training program into regular employment even with a decrease in number who can be employed.  This will address issues of employability, certificates and compensation. On the service side, it will provide continuity and better services with improved competency of the nurses.  The number and distribution of RNHEALS nurses or additional positions for nurses in the RHUs should be improved and be based on need of the community/hospital or LGU as well as resources.  Deployment in the RHUs also increased positive interest in public health nursing.