Clocking out: Nurses refusing to work in a time of pandemic.

Social science research has long critiqued how professional ideals of public service can ignore chronic problems within the healthcare industry, placing unfair burden on the "heroism" of individual workers. Yet, fewer studies investigate how healthcare professionals actively negotiate such demands for service, amidst increasing workplace pressures and risks. This paper studies Filipino nurses' response to a government policy that banned them from working overseas in order to channel their labor to local hospitals during the COVID-19 pandemic. Based on 51 in-depth interviews, we argue that nurses' willingness to serve in the Philippines' COVID-19 hospitals hinged on the point at which the deployment ban interrupted their emigration trajectories. Specifically, nurses' decision to heed their government's call to service depended on whether they saw local hospital experience as valuable for their plans of working abroad. We introduce the concept of "clocking out" to describe how aspiring nurse migrants set limits to the time they devote to local service, as they pursue a career pathway beyond national borders. We discuss how this concept can inform scholarship on nurse retention and professional values, especially for developing nations in times of crisis.

In the early months of the COVID-19 pandemic, the Philippine government instituted a policy preventing Filipino healthcare workers from leaving the country for jobs overseas (Jaymalin, 2020). This “deployment ban” was unprecedented, not only in terms of its scope, but because the Philippines is also the primary source of migrant nurses in the world. 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 UK, Saudi Arabia, and Singapore (Depasupil, 2020).

Philippine state officials justified the ban as a means of redirecting human resources toward national health needs (POEA, 2020). The Philippine Department of Health (DOH) also launched an “urgent hiring scheme” to channel Filipino nurses to public hospitals overwhelmed with COVID-19 patients (Pierson and Santos, 2020). 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 designated COVID-19 hospitals. The second group chose to either remain at home or obtain non-nursing jobs instead.

The emergence of these two groups raises questions that underlie a broader problem of declining human resources for health. First, the pandemic's massive toll on health institutions worsened labor shortages worldwide, emphasizing the need to examine how health workers choose to commit to their work despite increasing risks. Second, the Philippines' deployment ban heightened expectations that health professionals go above and beyond their call of duty. How do some health workers decide to forego professional obligations despite external pressures to remain on the job?

Even before the pandemic, the marketization of healthcare systems had eroded nurses' status and autonomy while increasing work pressures within the hospital. Yet, nurses continued to prioritize patients’ welfare over their own, despite the lack of structural support (McIntosh et al., 2015; Rankin and , 2006). Moreover, the valorous image of nurses as “healthcare heroes” in the battle against COVID-19 reinforced such high expectations while labeling those who stopped working as reneging on their professional oath (Mohammed et al., 2021). However, often missing is the question of how health workers weigh dedication to their work in the context of a professional career pathway geared towards working overseas.

This paper uses the case of the Philippines' nurse deployment ban to analyze how health workers' emigration trajectories impact their commitment to working for health institutions within their home countries. The following section provides an overview of the literature on professionalism and health worker migration. We then outline our methods, focusing on a sample of 51 in-depth interviews with Filipino nurses who either volunteered to work in COVID-19 hospitals or refused to work in any hospital setting at all. Next, we present our results. Beyond the mere adherence to professional values, we argue 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. Given that most foreign employers required migrant nurses to obtain local clinical experience, our interviewees regarded time spent within the Philippine healthcare system as a necessary but difficult phase in their efforts to leave the country. We argue that nurses' response to the government's call to service can be seen as the clocking into (or out of) a period of work within a broader career pathway that spans national borders. We end the paper by discussing how contextualizing health workers' career development in broader migration trajectories contributes to current scholarship on healthcare professions.

Professionalism and work commitment

Social scientists have generally framed the work of health professions as rooted in a “normative value system” (Evetts, 2003: 5), which upholds qualities such as civic engagement and an orientation to service (Parsons, 1939; Tawney, 1921). With the autonomy to provide specialized services to a broader community, an ideal profession supposedly requires its members to work towards a common good. As such, studies on the attrition of healthcare workers have centered on the social structures that undermine professional autonomy and values. Some scholars document workers' disillusionment with the commercialization of health services, while others discuss how state bureaucracies incentivize administrative efficiency, devaluing healthcare workers' independence and creativity (Freidson, 2001; Hafferty and Light, 1995; Racko, 2017; Timmermans and Berg, 2003). Underlying these studies is the warning that as institutions undermine healthcare workers’ ability to practice their professional values, there is a risk of alienating them from their own work.

Scholars have also raised concerns on how employers exploit notions of professionalism to justify poor work conditions. Such is the case for feminized occupations like nursing, where professional values promote the model nurse as naturally selfless and caring (Guevarra, 2010; McIntosh et al., 2015). Researchers have studied how hospital administrators expect nurses to devote themselves to their patients despite the high workload, poor compensation, and low status within the hospital (Kupcewicz, 2022; Rankin and Campbell, 2006). In justifying these work policies, hospital administrators have promoted the image of nursing as a vocational calling – recognized through public adulation rather than proper incentives and benefits (Mohammed et al., 2021). This overemphasis on personal altruism has been blamed for high turnover among nursing staff, particularly in developing nations where health systems are poorly equipped and undermanned (Thompson and Walton-Roberts, 2019).

Yet, in focusing on how professionalism is challenged or exploited at work, there is a tendency to explain the departure of healthcare workers as a giving up of professional identities. Traynor and Buus (2016) argue that this tendency is salient in research on nurses, where staff attrition is largely interpreted as the erosion of professional ideals. Multiple studies show how new nurses are disenchanted when encounters at work contradict the professional values they learn in school (Bochotay, 2018; Hashish, 2017; McNeese-Smith and Crook, 2003). Meanwhile, more recent studies provide sobering evidence linking nurses’ resignation to stress and burnout – problems made worse by the ongoing pandemic (see Lyu et al., 2020).

While these studies reveal essential truths about healthcare professionals' challenges, they center on what causes healthcare workers to drop out of the workplace. Implicitly, there is an assumption that those who remain in their jobs still adhere to their professional obligations, even as others have given up. While partly true, 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. Researchers have countered such perspectives by examining how nurses often protect their professional values through acts of resistance and collective action. These studies have shown how nurses seek institutions where their “voices” are heard and where leaders recognize their professional values (Traynor and Buus, 2016; Krachler et al., 2021). While these studies subvert the stereotype of nurses as self-sacrificing professionals, they do not entirely explain why some choose to enter institutions already notorious for treating nurses so poorly.

Most research on health professions is also situated within developed nations – a serious limitation given that an increasing number of nurses within these countries originate from large migrant-sending nations in the Global South (Timmons et al., 2016). In places like the Philippines and India, the nursing profession is strongly associated with global labor markets and emigration opportunities (Thompson and Walton-Roberts, 2019). Yet, we know little about how healthcare workers make sense of their work commitments within contexts where their profession is also seen as a steppingstone to emigration. In the case of Filipino nurses, we argue that the decision to serve in the Philippines’ COVID-19 hospitals depended not only on their professional values but how they interpreted the significance of such work in the context of their broader migration trajectories.

The migration trajectories of professional nurses

Despite a vast literature on migrant nurses, current studies have focused mainly on two parts of their migration journeys: the physical act of leaving their countries of origin and their integration as immigrants within their new homes abroad (Amrith, 2017; Guevarra, 2010; Showers, 2015). Migration scholars have criticized this overemphasis on cross-border movement as providing only a limited view of people's migration trajectories. Rather than a single voyage between origin and destination, they call for a more in-depth study of how migration journeys comprise multiple movements to various places across long periods. (Schapendonk et al., 2020;2021). Their belief is that in doing so, scholars can better recognize how changing plans, unexpected events, and phases of immobility also characterize migrants' journeys as a whole (Schwarz, 2020).

This emphasis on migration trajectories aligns with recent research on how aspiring migrant nurses navigate different barriers in moving towards their desired destinations. Much of this work involves fulfilling the requirements of an international skills regime that assesses migrant nurses’ capacity to practice their profession abroad (Collins, 2021; Walton-Roberts, 2020). In large source countries like the Philippines, scholars have noted the sharp rise in demand for nursing degrees in response to aggressive recruitment efforts within popular destination countries like the US (Cabanda, 2017; Ortiga, 2018a). Meanwhile, other studies have traced how migrant nurses move from one nation to another in accumulating the hospital experience and certification needed for countries where they would eventually wish to settle (Amrith, 2021; Collins, 2021).

However, few studies have sought to determine how embarking on such migration trajectories impacts nurses' work commitment and professional identities at “home.” There is a general assumption among migration scholars that individuals who have high migration aspirations would also be less motivated to invest in careers within their home countries (see Song, 2015). Nurses’ decision to emigrate is often framed as an escape from poor work conditions and low wages within the Philippines (Amrith, 2017; Guevarra, 2010). Yet, this perspective provides an incomplete interpretation of how Filipino nurses weigh their commitment to the Philippine healthcare system.

As we had argued in our own research, aspiring migrants in the Philippines generally choose to pursue the nursing profession as a steppingstone to emigration. Most Filipino nursing graduates are aware of the poor treatment of nurses within the Philippine healthcare system and have no intention of pursuing their careers within the country (Ortiga and Macabasag, 2021). 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. In this paper, we use the terms “clocking in” and “clocking out” to describe how aspiring nurse migrants treat such local service as a designated time of work – much like punching a timecard through a Bundy clock. The actual time spent working within local hospitals tends to vary widely among aspiring migrants, given that destination countries have different requirements for foreign nurses (Walton-Roberts, 2020; Gillin and Smith, 2020). Yet, aspiring nurse migrants still consider early clinical exposure essential to building their confidence and security as professional nurses (Ortiga and Macabasag, 2021). In the Philippine case, researchers find that nursing graduates tend to perceive workplace practices within the Philippines as similar to other countries (Daniel et al., 2001). As such, gaining experience in the home country is often seen as an important first step toward future emigration. Once completed, they leave the system and devote their energies to the next phase of their emigration trajectories.

In this paper, we argue that this task of accumulating clinical experience determined Filipino nurses' response to their government's call to service.

The case of the Philippines

The Philippines is widely known for its state-led system of labor export, where government agencies deliberately deploy Filipino workers to employers overseas to maximize the remittances they eventually send back home (Acacio, 2008). Among the many Filipino professionals who leave the country each year, nurses have mainly been celebrated as ideal migrant workers, given their success in health systems worldwide (Guevarra, 2010). However, years before the COVID-19 pandemic, the Philippines had been struggling with an unlikely problem: an oversupply of nursing graduates.

In the early 2000s, the country saw the proliferation of private nursing schools, as state officials encouraged the “production” of more nurses to address existing labor needs abroad. School owners expanded nursing programs to maximize profits from student tuition, producing a massive number of nursing graduates every year (Ortiga, 2014). Yet, in the mid-2000s, nursing jobs in popular destination countries began a steady decline. In 2004, the UK stopped the active recruitment of non-European nurses, leading to a drastic drop in the number of nurses from beyond the EU (Gillin and Smith, 2020; Marangozov et al., 2016). By 2008, retrogression at the US embassy limited the visas available for Filipino nurse applicants to the United States (Acacio, 2011). Later that year, the global financial crisis slowed foreign nurse recruitment in the rest of North America and Europe (Buchan et al., 2013).

Making things worse, Philippine health institutions did not offer enough full-time positions for the large number of nurses entering the domestic labor market, leaving aspiring nurse migrants unable to complete the two years of work experience that most foreign hospitals required. Public hospitals claimed to lack the government funding to hire staff nurses and resorted to offering contractual positions for “volunteer nurses” instead. Meanwhile, many private hospitals chose to capitalize on the oversupply of nursing graduates by depressing wages and bringing in nurses through “training programs” that required applicants to pay a fee. These positions demanded the same amount of work but with little to no compensation for their labor (Ortiga and Macabasag, 2021). All these factors created a “migration trap,” where aspiring nurse migrants invested in obtaining credentials for international work yet graduated at a time when those jobs were no longer available (Ortiga, 2018b).

At the onset of the COVID-19 pandemic in 2020, nursing groups stated that there were more than 500,000 registered nurses in the Philippines, most of whom were not working in clinical settings (Depasupil, 2020). As such, the Philippine state's decision to declare the deployment ban caught aspiring nurse migrants by surprise. The state offered a 3-month renewable contract and a competitive salary, hazard pay, and benefits to entice more nurses to enter public hospitals. Government officials also stressed that the ban was “temporary,” assuring nurses that they would eventually be allowed to leave the country (Macaraeg, 2020). However, when it was announced, the state gave no definite date for the lifting of the ban. As such, nursing groups immediately condemned this policy for depriving aspiring migrant nurses of better opportunities abroad. Yet, social media sentiment among Filipinos indicated general support for the ban. Online pundits castigated nurses who refused to work as selfish, unprofessional, and unpatriotic.

Method

This paper draws from in-depth interviews with 51 Filipino nurses who were based in the Philippines at the time of our study. Participants' ages ranged from 26 to 40 years. All had obtained a 4-year degree in Nursing from the Philippines. Our study focuses on the period after the emergence of the Philippines' first COVID-19 cases (February 2020) and the subsequent state deployment ban. We conducted these interviews from April to June 2020, using a mix of Tagalog and English. Each interview was roughly 1–2 h. We obtained ethics approval from the first author's Institutional Review Board.

We distributed a call for interviewees through different Facebook groups for Filipino nurses to recruit participants. We also asked interviewees to share our poster with private chat groups and other friends in their network who were willing to be interviewed. Initially, we only sought out Filipino nurses who had been affected by the state's deployment ban. We realized that while some nurses chose to remain at home, others had heeded the state's call to work in COVID-19 hospitals. We then expanded our recruitment efforts to include Filipino nurses who chose to enter the government's urgent hiring scheme. We concluded our data-gathering after reaching a saturation point in our participants' interview narratives.

As is the case for all qualitative studies, we cannot claim that our findings are generalizable to all Filipino nurses in the Philippines. Our sample is limited in that we were unable to speak to older nurses (above 40 years old) who may have a different perspective of their career trajectories. This limitation could be because we mainly recruited participants through social media. However, it is important to note that during the pandemic, researchers reported that 65% of the Philippines' human resources for health were under the age of 35 years old. While there were no specific demographics reported for nurses, roughly 60% of the study's sample were nurses. These statistics indicate that nurses in the Philippines are relatively young, perhaps because nurses are likely to either emigrate or retire from the profession as they get older (UPPI, 2020). Our sample also comprises individuals who had obtained their degrees at the height of the nursing boom in the 2010s and became registered nurses just as overseas opportunities declined. As we argue in our findings, this period had a substantial impact on how individual nurses planned their future careers. Having a sample of nurses who are within the same age range also allowed us to focus on how their migration trajectories affected their response to the government's call to service.

We divided our sample into two distinct groups of nurses. We refer to the first group (25 nurses) as the Compliant nurses or those who responded to the state's call for health workers to fill staffing needs in designated public hospitals that received COVID-19 patients. Meanwhile, we refer to the second group (26 nurses) as Resistant nurses or nurses who refused to enter any state-led hiring scheme for local hospitals and openly opposed the deployment ban. All the nurses in this group were in the final steps of emigrating to jobs overseas when the pandemic shut international borders. They had resigned from their hospital jobs to prepare for emigration but declined to return to work after the deployment ban deferred their departures.

While divided in their response to the state deployment ban, Compliant and Resistant nurses were similar in many ways. Both groups had comparable profiles in terms of gender, their migration aspirations, and the year they obtained their professional licenses (see Table 1 ). We did not see any discernible pattern regarding family support for (or opposition to) the decision to work in COVID-19 hospitals. Each group also had an even mix of nurses who cared for their elderly parents or had their own children.

Table 1

Descriptive data of Interview Participants (N = 51).

	Resistant Nurses (n = 26)	Compliant Nurses (n = 25)
Gender
Female	17	19
Male	9	6
Year of nursing licensure examination
2019	–	2
2018	–	1
2017	–	–
2016	–	1
2015	3	1
2014	1	–
2013	3	3
2012	5	2
2011	4	4
2010	7	–
2009	3	3
2008	1	3
2007	–	4
2006	1	–
2005	–	–
2004	–	1
2003	1	–
Maintains aspirations to work overseas?
Yes	26	22
No	–	3
Response to deployment ban
Agree	–	4
Disagree	26	21

We developed interview questions based on studies of aspiring nurse migrants and their experiences working towards emigration. As such, we mainly asked interviewees about their motivations for pursuing nursing as a career, their job search experiences after graduation, whether they aspired to work overseas and how they intended to do so. For those with intentions to emigrate, we asked how the pandemic impacted their plans and how they are coping with their current inability to leave the country.

Given that these interviews occurred during the Philippines’ lockdown period, all interviews were conducted over the phone or online. This medium made it sometimes difficult to build rapport with our participants. However, they also enriched our findings in ways that in-person interviews would have not. With online interviews, we could reach nurses from provinces far from the urban centers like Metro Manila. Phone interviews also allowed us to interview nurses who were currently working in Covid-19 wards. These nurses spent their days off in isolation facilities near their hospitals. It would have been impossible to interview these nurses in person during that period.

Except for 11 interviewees who declined to be recorded, all our conversations were audio-recorded, transcribed, and analyzed with Nvivo, a software for qualitative data analysis. We followed the “responsive interviewing” approach (Rubin and Rubin, 2005) by first coding our data in line with themes found in previous studies on nurse migration. We focused specifically on the factors that either compelled them to seek overseas opportunities or convinced them to continue working within Philippine hospitals. Yet, we found that while most of our interviewees expressed high aspirations to leave the country, these desires alone were not the main reason why they complied or resisted government calls for their service. Instead, interviewees rationalized their decision to serve (or not) based on whether they had accumulated enough local hospital experience in their progress towards finding jobs overseas. We added this emerging theme to our analysis and coded our interviews according to nurses’ broader views of their migration trajectories.

Responsive interviewing follows a more interpretative constructionist approach. As such, we were conscious of how our own perspectives as interviewers shaped our analysis. The first author, a sociologist, had been documenting the struggles of aspiring nurse migrants who graduated after opportunities for foreign nurses had declined. Meanwhile, the second and third authors are both registered nurses with very different experiences during the pandemic. The second author was applying for a student visa to the US when the pandemic upended his plans. He could relate to the uncertainty that the Resistant nurses felt. Meanwhile, the third author was called for clinical duty at a university hospital, also receiving COVID-19 patients. While not assigned to bedside care, he understood the heightened risk that Compliant nurses had taken on and their vital role in keeping the healthcare system afloat. All these perspectives shaped our approach to making sense of our data. In the following sections, we outline the main themes that emerged from our findings.

Compliant nurses: clocking in to restart migration plans

As Philippine media reported rising COVID-19 infections in the country, government officials celebrated Compliant nurses as local heroes, heralding their dedication to serving Filipino patients. Yet, in our interviews, Compliant nurses disagreed with the notion that they were more professional or more patriotic than those who refused to work. While they took pride in contributing to the Philippines' COVID-19 response, they were also sympathetic to those who did not feel the same. In fact, most Compliant nurses (21 out of 25) disagreed with the state's deployment ban on health workers. As Cherry, a registered nurse since 2018, explained,

I don't blame them. Knowing the system, being in the system, it is so discouraging to work as a nurse here … Before people start getting mad at those nurses, they should first meet their demands like better compensation and better work conditions.

Cherry's statement shifted the focus from nurses' professionalism to the private hospital owners and the government officials who failed to address problems that have long plagued nurses in the Philippines. Most Compliant nurses argued that the Philippine government had no right to force nurses to work during a pandemic, given that it had treated the profession so poorly in the past.

Yet, perhaps most striking was the fact that most Compliant nurses also had high aspirations to emigrate overseas (see Table 1). In this sense, the decision to enter the Philippine government's urgent hiring scheme was not borne out of a stronger investment in the country's healthcare system. Instead, Compliant nurses 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.

A time to gather clinical skill

Lester, a registered nurse since 2009, shared a story that was typical of other Compliant nurses we interviewed. Initially determined to emigrate to the US, Lester was eager to accumulate clinical experience in Manila's tertiary hospitals. Yet, after obtaining his license, the only job he could find was a volunteer position with the Philippine Red Cross. After six months with no income, his friends convinced him to apply as a cabin crew for a local airline. Lester got the job and stayed with the airline until 2019. When the Philippine government launched its urgent hiring scheme for COVID-19 hospitals, Lester grabbed the opportunity to return to his profession. Working for the government would allow him to “hit two birds with one stone.” He could finally practice nursing while earning a living wage.

As reflected in Lester's story, Compliant nurses left their nursing careers when they could no longer endure the lousy job market for nurses in the mid-2000s. To pay for daily expenses, they moved towards non-nursing professions in research, sales, and hospitality services. Three Compliant nurses were able to work abroad despite their lack of clinical experience, yet they were limited to allied health fields such as dentistry and physical therapy. As such, they could not build enough clinical experience to qualify for the hospital jobs they desired overseas. Jenine, a registered nurse since 2011, decided to work at a dermatology clinic in Saudi Arabia after failing to find a full-time hospital job in the Philippines. While the clinic paid well, Jenine was not satisfied with her experience. “It still was not a hospital set up, and the patients were not really sick, it was more on aesthetic procedures,” she said. “But at that time, it was better than nothing.”

These stories indicate that the COVID-19 pandemic provided a chance for Compliant nurses to re-enter the overseas career pathway they had initially imagined for themselves. Paradoxically, their decision to work in the Philippines’ COVID-19 hospitals was driven by a strong desire to emigrate rather than a lack of migration aspirations. Such was the case for Sarah, a registered nurse since 2016, who was working as administrative staff in a government office when she decided to apply for a position in a COVID-19 hospital.

I've always wanted to return to clinical work, but the problem was that I could never find a job that would pay me as much as my office job did. Now, the pay is better, and I get to help people … But my main purpose is to start gaining experience because I want to migrate with my daughter in the future.

When Sarah first started working after graduation, the closest she had gotten to hospital experience was a medical secretary job for a public hospital. At the time of our interview, she had already completed several intense shifts in the COVID-19 ward. She described the experience as tough but fulfilling,

In my first shift, all I did was check vital signs and blood sugar. But in my second shift, I really had to handle patients. I had to give the medication, things like that. It was scary and exciting at the same time. I guess I was excited because it was my first time to do this! I mean, I got my license in 2016, and since then, I never worked as a bedside nurse.

Like Sarah, other Compliant nurses were also candid about their motivation to accumulate clinical skills for future emigration plans. They still cared deeply about their COVID-19 patients, many of whom were coming to the hospital feeling scared and alone. However, it was the opportunity for skilling that made the task of treating COVID-19 patients “worth” the costs and risks. As Jenine shared, “If I could stay in the hospital, I will stay. I still want to learn new things. In my first week, we had to intubate two patients, and one of them died … One time I wanted to cry because I was so stressed, but I still want to learn more.”

Jenine's determination indicated that even as work in the COVID-19 wards intensified, Compliant nurses continued to view their jobs as an opportunity to learn clinical practices they had been deprived of experiencing before the pandemic. Jenine admitted that the work had been taxing, but she still hoped to renew her contract with the Department of Health.

A limit to service

While the pandemic allowed Compliant nurses to resume their career plans, they established clear limits to the time they would spend within COVID-19 hospitals. Several interviewees admitted that they only planned to work for two years, the minimum period of work experience required by some foreign hospitals. They had hoped that the time devoted to gaining clinical experience would pay off for their own careers in the future. In our interview, Jenine admitted that she had violated her contract with the dermatology clinic in Saudi Arabia when she decided to sign up for the Philippine government's hiring scheme. She took the risk because she knew that having hospital experience was attractive to potential employers in places like the US and UK.

Before the pandemic, I just felt trapped between my professional needs and my family's needs. I wanted to work in a hospital, but of course, you need to pay for the house, maintenance, and all that. It was a risk to give up my Saudi contract, but I talked to my family about it. I said that when I get this hospital experience, I can apply to more countries because they like nurses with hospital experience. Even if we have to suffer for a while, there will be more countries to apply for after the pandemic. We'll make up for the sacrifice.

In emphasizing the value of hospital experience, Jenine's statement revealed how Compliant nurses assessed the purpose of working within COVID-19 hospitals in the context of a migration trajectory that stretched beyond the present moment. The timing of the deployment ban in Jenine's career inspired her to take advantage of the opportunity to obtain clinical experience that she had been unable to access in the past.

However, it is important to note that the pandemic had also intensified an already dire need for nurses overseas, opening up opportunities for Filipino nurses to accelerate their progress towards emigration. In countries like the UK, government hospitals have reduced the duration of time required for clinical experience – with positions available even for those who had just obtained their professional license (Gillin and Smith, 2020). For some Compliant nurses, such changes shortened the amount of time that they had initially allocated to local service. Lorenzo, a registered nurse since 2007, explained,

I just really need the experience so I can get out of this country … I'm just so fed up with how they treat health workers … I really wanted to go to the US, so my initial plan was to work in the hospital so I could get the 2 years of clinical experience. But now, I think I'll probably leave after one year. I can look for another country that will give me an offer, and I'll just work there to lengthen my clinical experience before moving to the US.

Lorenzo's statement reveals how Compliant nurses' commitment to work did not blind them to the shortcomings of the Philippine healthcare system. While they willingly entered the COVID-19 wards, they saw this experience as a period they needed to endure to leave the country. If given the opportunity to leave earlier, Compliant nurses were also likely to shorten their tenure within Philippine hospitals.

In this sense, Compliant nurses were serious about their jobs and exerted tremendous effort in treating COVID-19 patients in the wards. Yet, they were clear that their compliance with the state's urgent hiring scheme was mainly a temporary investment and not a long-term commitment to Philippine healthcare. While Compliant nurses also faced the job demands and work stresses of Resistant nurses, their lack of clinical experience was an important factor that shaped their decision to work in COVID-19 hospitals. Rather than professional values or nationalist sentiment, Compliant nurses believed that working for COVID-19 hospitals would help them move forward with their migration plans. Resistant nurses did not share the same views.

Resistant nurses: clocking out of philippine healthcare

Resistant nurses had spent considerable time (2–7 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 and were much further ahead in the emigration process. As such, the prospect of entering the country's COVID-19 hospitals did not have the same value as it did for Compliant nurses in terms of accumulating relevant clinical experience. This difference stemmed from Resistant nurses' ability to obtain jobs in Philippine hospitals earlier in their careers, which allowed them to move further along the emigration process.

Unlike their Compliant counterparts, Resistant nurses were able to rely on family members and personal savings to sustain themselves while they worked in lowly paid (or unpaid) positions in local health institutions. These financial resources allowed them to avoid taking long career detours to non-nursing fields. However, not all Resistant nurses came from well-off backgrounds. While some could depend on family members, others took on second or third jobs to augment their meager salaries. Resistant nurses also maximized connections to hospital administrators who supported their applications. A few interviewees used family contacts to look for open positions in hospitals beyond the Philippines’ crowded urban centers. These networks provided an important advantage in competing with the thousands of other graduates desperate for clinical experience.

It is undeniable that Resistant nurses had certain privileges that helped them find hospital jobs before the pandemic. However, their time within Philippine health institutions left them tired and demoralized. This experience defined their decision not to heed the Philippine state's call for health workers.

Enough time for self-sacrifice

Similar to other developing nations, the Philippines has long struggled with an underfunded public health system, often overwhelmed with patients unable to afford hospital fees. Numerous studies have documented the heavy work of nurses in the Philippines and the lack of recognition for their labor (Guevarra, 2010; Authors, 2020). Resistant nurses had only stayed within the system to build the necessary experience for jobs overseas. Having completed this requirement, these nurses had clocked out of the Philippine healthcare and were determined never to return.

In this sense, the process of “clocking out” is different from the experience of a “job burnout” or a condition marked by both physical and mental exhaustion (Maslach et al., 2001). While burnout is a psychological syndrome that can happen without warning, we argue that clocking out is a more deliberate action that people use in reserving their energies for the next period of their careers. The Resistant nurses in our study had not burned out of their hospital jobs in the Philippines. However, they argued that they had “done enough” for their country as professional nurses, and it was time to move on with their plans to work abroad.

For most of our interviewees, this logic was difficult to convey to friends and relatives outside the profession. Chester, a registered nurse since 2014, complained that he often encountered questions as to why he refused to go back to work. Chester resigned from his job at a large government hospital when he received his work visa to the UK in March 2020. His agent was scheduling his flight to London when the COVID-19 pandemic shut national borders, and the deployment ban came into effect.

I know people must think I'm being selfish because I don't want to go back to work. But you know, I already served seven years here in the Philippines. Only now am I thinking of myself. Is that so wrong?

At the time of our interview, Chester had been unemployed for two months and was isolating himself at home. He was relying on his father and siblings for his daily needs. Chester understood that nurses had taken an oath to serve their patients. However, he also felt that it was time for others to respond to the government's call to service.

For other Resistant nurses, 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 our interviewees had worked as hospital staff for very low wages with no benefits or security. One nurse, Rachel, obtained her license in 2006, but only found a regular hospital job in 2016, when positions opened up at a private tertiary hospital in her city. Even then, Rachel had to go through a probationary period for six months before she was eventually “regularized” as a full-time nurse. During this period, she took on the same tasks as regular staff nurses yet was paid a measly salary of Php 6000 (125 USD) without health insurance or overtime pay. The only reason she managed to complete three years of work was because her mother, an immigrant in the UK, remitted money to finance her daily needs.

In many ways, Rachel was lucky. Other nurses with less financial resources juggled multiple jobs just to keep working in the hospital. Kevin, a registered nurse since 2010, worked for 2 years at a private hospital, first as a “volunteer nurse” for six months and eventually as a “reliever nurse” for two years. To sustain himself, he took another part-time job as a community nurse because it paid a higher salary. Now waiting to leave for Germany, he felt it was unfair for government officials to judge nurses like him as unpatriotic.

We have already served the country. For many years, we served the country, even when hospitals only accepted volunteers and there were no permanent contracts given to the nurses … I have been a nurse for many years, and I never saw the government give us any importance. I think that is enough exploitation for me.

Other interviewees echoed Kevin's sentiments, arguing that they could not return to the punishing caseloads that defined their previous jobs. However, the chronological time limit that Resistant nurses set for themselves varied widely depending on their subjective view of what was “enough” before they could move on with their emigration plans. Some Resistant nurses stayed only up to the minimum 2-year period for migrant nurses, while others worked in their hospitals for more than five years.

What remained consistent across all nurses was that once they clocked out, they could not work in Philippine healthcare any longer. All but one of the Resistant nurses said that they would rather leave the nursing profession than return to hospitals in the Philippines. “If I don't get to leave, I will stop being a nurse,” declared Marivic, a registered nurse since 2010. She had worked as a staff nurse for a provincial hospital for 5 years before resigning in February 2020. When her flight to the UK was canceled in March, the nurse manager at her former hospital called to ask if she wanted her old job back. Marivic declined. “It's not worth it. You risk your life, but no one cares about you. I will probably look for a job in another industry.”

Again, this refusal to serve was reinforced by the timing of the deployment ban. Given that Resistant nurses had already completed the required clinical experience and secured contracts with overseas employers, there was no strong reason for them to take on the risk of caring for COVID-19 patients. Most Resistant nurses were privileged enough to rely on family while they remained at home. However, even those who needed money were unimpressed by the Philippine government's incentives for nurses who serve in COVID-19 hospitals. Instead of responding to the state's call for service, they found jobs in call center agencies and private companies. Other set up home businesses selling snacks and milk tea. In many ways, their continued resistance indicates that once individuals clock out of a particular work period, they are unlikely to go back.

Time to move on

It is important to note that Resistant nurses were not unwilling to work because they were disillusioned with nursing work or had given up on their profession. Many of these nurses were conflicted about choosing not to join the government's urgent hiring scheme. As Rouella, a registered nurse since 2009, admitted, “To be honest, yes, I sometimes feel like I want to volunteer. I am an anesthesia nurse so when it comes to intubations, I can help out with people. But then, I feel like this is not right … They tell us to risk our lives … but they never cared about our lives! Where is justice in that?”

Rouella often shared these thoughts on social media, and she was surprised by the pushback she received from friends and strangers. For her, the most hurtful comments were those that accused her of being unprofessional. “I love my profession. I gave it my youth and my strength … But now, I think it is time for myself. Time for me to do something about myself.”

Another Resistant nurse, Sherilyn, was unwilling to enter the government's urgent hiring scheme. However, she couldn't resist but check in on colleagues in a private hospital where she used to work. While her hospital was not a designated center for COVID-19 patients, she worried that her friends were also facing a deluge of patients who were likely infected with the virus.

Actually, I called my friend in [my former workplace]. As a nurse, I know what it’s like to work in a hospital that's understaffed. I asked them if they really needed help, maybe I'll consider coming back. They said they are still doing okay. But they also said, “Don't you dare come back! Do you want to get COVID?”

Sherilyn's story reveals how the split between nurses inside and outside the COVID-19 ward did not reflect a clear difference in professional commitment. It is interesting to note that Sherilyn's friends who were still working in the hospital told her to stay away, acknowledging that she should move on with her dream of working abroad as she planned. Sherilyn shared that many of her former colleagues wanted to leave the country as well. However, when the deployment ban was declared, she was the one with a work visa and job waiting overseas.

Resistant nurses’ stories reveal how their refusal to work does not only draw from an assessment of current risks and benefits but a broader migration trajectory that includes years of tolerating poor treatment in Philippine hospitals to fulfill requirements for emigration. The concept of clocking out takes this perspective into account, providing a more nuanced view of how Resistant nurses assessed their commitment to serve during the pandemic.

Discussion and conclusion

The Philippines' decision to ban its nurses from working overseas exemplifies the intense pressures on health workers to fulfill their professional duties despite rising costs and risks. While there is extensive scholarship on the factors that impact health professionals' commitment to their work, few studies contextualize these issues within a wider career pathway that spans national borders. As Timmons and his colleagues (2016) argued, scholarship on professions has tended to either examine nurses’ experiences within one country or compare work contexts across two nations. Meanwhile, most migration studies have concentrated on the struggles of foreign nurses outside their countries of origin as they adjust to healthcare systems overseas. There remains a lack of research on how global opportunities associated with certain health occupations impact local perspectives of professional identities, values, and commitments. In this paper, we show how becoming a professional nurse places Filipinos on a migration trajectory directed towards leaving their home country for jobs overseas. This trajectory shapes how they define the responsibility and commitment they ascribe to their work.

Rather than simply professional values, we found that Filipino nurses' decision to work in COVID-19 hospitals depended on the timing of the deployment ban in their progress towards leaving the country. For Compliant nurses whose migration plans had been stalled for many years, clocking into local hospitals allowed them to begin the task of accumulating clinical experience that would restart their emigration journeys. In contrast, Resistant nurses at the final stages of the migration process refused to return to local hospitals, having clocked out of this difficult period of their careers. We argue that nurses’ position along their individual migration trajectories determined how they made sense of their professional obligations to working in Philippine hospitals. While both Resistant and Compliant nurses regarded their professional oath to service with the same value, the key difference was whether they had completed this phase in their emigration trajectories.

As such, this paper forewarns how the aggressive recruitment of foreign nurses in developed nations can impact poorer countries in need of their labor. As seen in the Philippine case, skills requirements in desired destination countries defined how much time aspiring migrants devoted to working within local healthcare institutions. Rising labor needs in wealthier countries may shorten the required length of clinical experience for foreign nurses, prompting aspiring migrants to either clock out of local service earlier or choose to build their skills elsewhere. For example, in 2018, the UK rescinded the requirement for all foreign nurses to have at least 12 months of clinical experience. Our findings reinforce the concerns of scholars who believe that such policies would affect source countries that already suffer from a large outflow of health workers (see Gillin and Smith, 2020). Given the ongoing COVID-19 pandemic, there is a need for further research on how efforts to rebuild healthcare systems may entail recruiting more foreign health workers earlier in their careers, thus depriving source countries of labor that is already short in supply. Further studies could also shed light on whether older nurses from source countries like the Philippines still consider emigration part of their professional trajectories.

Second, this paper emphasizes how scholars need to better recognize how individual perspectives of their professional commitments can shape retention issues among health workers. It is important to note that both Compliant and Resistant nurses expressed a dedication to the value of nursing care. Their desire to leave the country did not diminish their commitment to caring for their patients’ needs and well-being. However, we emphasize that Filipino nurses set clear limits as to how long they would continue to work under the exploitative conditions of Philippine hospitals. In many ways, the refusal to work among Resistant nurses is not simply a refusal to care. Instead, it is a decision to clock out of a difficult phase in a professional trajectory driven towards emigration. This aspect of professionalism is understudied in current scholarship on healthcare workers.

Lastly, we acknowledge that by focusing on the Philippine deployment ban, we had limited our analysis to a specific policy – one that the Philippine state eventually replaced with a “cap” on outgoing nurses towards the end of 2020 (Macaraeg, 2020). However, we believe that the deployment ban represents common assumptions that continue to drive state policies to retain health workers. By banning nurses from leaving the country, Philippine state officials assumed that they could simply be redirected to local hospitals, where an urgent hiring scheme would be enough to compensate them for their service. Nurses' widespread opposition to the ban and the emergence of Resistant nurses underline the limitations of such logic. Our paper's findings reveal 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. As our paper reveals, nurses subjected to poor working conditions within local hospitals will eventually clock out of the system and leave the profession instead.

Credit author statement

Yasmin Y. Ortiga: Conceptualization, Data-gathering, Writing; Michael Joseph Diño: Data-gathering, Reviewing, Editing; Romeo Luis Macabasag: Data-gathering, Reviewing, Editing.