Being a migrant worker, being able to say ‘no’ at work, and how nursing is exposing inequalities with Lloyd Nunag
Hello! Thanks for stopping by again. For my second Emotional Labour interview I’m turning my attention to nursing.
I come from a family of nurses. My mum and dad, my nan, several of my aunties – all are, or were, nurses from their teens. I spent hours after school unravelling bandages and playing with dressings in the back of the car while my mum worked as a district nurse. It was not uncommon to find a human torso stashed in a hallway cupboard (Resusi Annie. They’re horrifying).
Nursing was one of those jobs that people didn’t typically pay attention to, or admire, or ask questions about. There is very little status attached to being a nurse – until now. In the past six months, we’ve clapped for carers, we’ve had the government commission celebratory pin badges, and the UK advertising industry has switched to celebrating ‘our heroes’.
Whilst I’ve loved seeing kids embracing the NHS – with rainbows stuck in windows, and ‘Thank You NHS’ doodles chalked on pavements – and I didn’t get mad when my neighbour set his car alarm off every Tuesday night at 8pm to show his love for the national health service – I’ve felt uncomfortable about the government adopting this rhetoric too.
Because MPs clapped for carers on TV, but they’re not turning up for parliamentary debates on NHS wages, when a May YouGov poll found 77% of the UK population supports increased pay for NHS workers. England’s chief nurse, Ruth May, got dropped from a daily press briefing after she refused to support Dominic Cummings. They’re making pin badges for carers, but from 2021, introducing a points-based immigration system that will class many carers and healthcare workers as ‘unskilled’.
I wonder if the government has gotten behind the ‘hero’ language because heroes typically aren’t overtly political, or vulnerable. Heroes have unusual, superhuman strength. They save other people – they don’t need saving. No-one knows how Batman or Captain Marvel vote for a reason, because it ensures mass appeal.
And yet every nurse I know is a) a flesh-and-blood mortal, with zero magical abilities, and b) has a lot of thoughts and feelings on how the NHS is run. They’re human. From what I’ve learnt from nurses, you can be a caring person yet still demand accountability from the government. You can be proud of the NHS and still dissent, or ask questions about how it’s being run. Nurses also need money and sleep like the rest of us.
I’ve been talking to two frontline nurses over the past month – Dorcas Boamah, and Jose Maria ‘Lloyd’ Nunag. Both have been deeply involved in treating people infected with coronavirus during the pandemic; Dorcas as a Nightingale nurse, and Lloyd as a COVID-19 research nurse. Lloyd is first up!
Jose Maria ‘Lloyd’ Nunag is a clinical research nurse for the NHS in London, working on COVID-19 studies. He’s also studying for a Masters in Public Health at the London School of Hygiene and Tropical Medicine.
Olivia Gagan: Did you always want to be a nurse? What was your journey to where you are now?
Lloyd Nunag: I came to the UK in 2017. But before that, I trained as a nurse and worked in the Philippines for almost three years. I came here because there are better opportunities. And of course, aside from that, I also have to send money back home, like most Filipinos, and most immigrant workers.
I grew up in a poor family in the Philippines. Growing up, I had always been curious why my community or my family – or just Filipinos in general – have nothing on the same level of technology and healthcare that you have in rich countries like the UK. Understanding that as a child started my sense that quality healthcare starts with good and vigorous research. Which oftentimes, is non-existent in places like the rural Philippines, where I’m from.
So I think my personal experiences fundamentally shaped my interest in research, and in public health and nursing. Because at the same time as being a nurse and doing research, I have had the opportunity to dig deep into questions of inequality, injustices and stigma in healthcare, as I’ve witnessed it first-hand working as a nurse in the ward, both the Philippines and in the UK. I think that's it.
Olivia: You started your current job in January. How has your research changed between then and now? Has your focus completely changed? What was expected of you then, compared to now?
Lloyd: When I started in January, weren’t studying infectious diseases – we were mainly focused on cardiovascular diseases. But ever since the pandemic started, and then lockdown, all our regular studies have been suspended for COVID-19 research. There's research happening on AI, and research into different medications and vaccines. So there has been a lot of shifts – in funding, in resources, on our time. And aside from dealing with all those things, a lot of my workmates are sick, in self-isolation, or shielding. So we have more to do, but less people to do it.
Olivia: You must feel a lot of pressure. You guys aren't only being asked to pivot to completely different research areas immediately, but also it sounds as if this is under immense strain in terms of staffing levels.
Lloyd: Exactly. And I’m still new! I’ve only been in my role a few months.
Olivia: Are you largely behind a computer screen, or is it very much patient-facing work? How does a research nurse interact with patients?
Lloyd: Research nurses, most of the time, are recruiting patients for our studies. We’re screening potential patients, working through consent forms, and explaining the studies to the patients. We liaise with their next of kin if they're unable to consent, if they don't have the capacity. Then once the patient is enrolled in the research studies, the research nurses are the ones who do the follow-ups, if they're doing well, and if there's any adverse events, to check on the patients’ medications and their blood results. We have to follow strict protocols.
Olivia: So you've got patients who are already in a high stress situation – they're ill with coronavirus – and you're talking them through the research you’re doing as well. Do you have to really think about how you talk to patients, and how you explain the work you're doing with them?
Lloyd: You do – I realised that during the peak of the pandemic. If one patient tests positive for COVID-19, then the medical teams, and three or four different research studies are all approaching the patient at the same time. And the patient has just got diagnosed with COVID-19 – of course they're very upset, they’re worried.
So a lot of people will be approaching them. And not just regular people – people who are wearing scary outfits, in PPE. Aside from that, I have to introduce the patient to a lot of terminology for them to better understand what the research all about. And then we have to decide who to work with – ‘Should I enrol this person, or this one? It's difficult to be a patient in these times.
Olivia: Have you found yourself adjusting the way you communicate?
Lloyd: Yeah. Before, I just focused on the goal – recruiting the patient for our study. But now, I have more values and principles involved when it comes to my approach. Because it's a very difficult time, or an ‘unprecedented’ time, as everyone’s always saying…I think it’s made me grow, not just as a nurse, but as a person. Now, I’m always asking, "How are you?". Just trying to put a person to the nurse, a more human element.
Olivia: I know you're already well aware of this, but the HSJ [a UK nursing magazine] is reporting much higher levels of illness and death among BAME health and social care workers in the UK. And Filipino nurses are suffering hugely disproportionate levels compared to the rest of the healthcare community. Where are we going wrong here? Why do you think this is happening?
Lloyd: I think it's a lot of factors. It could be a complex combination of economic, social, and health related factors which can arise from structural racism, or it could be policies that haven't been made. At the same time, a lot of my colleagues, especially Filipinos, they’re all quite small and petite. They’ve been joking about it, but I think it's a fact that PPEs are made for a very large human being.
[OG note – there’s been a lot on this in the press – for PPE to work, it has to fit. But the available PPE for the NHS workforce, of whom 77% are women, is typically designed for tall men – or as this article put it, ‘6’3 men built like rugby players.’]
Lloyd: If they're wearing the suit, they can stumble, and if they're wearing the mask, it’s not properly fitted for smaller faces. I hope the government has learned a lesson because of this pandemic and all the lives that we have lost, that we should make the policies gender-sensitive, and responsive to race. Make things more inclusive. Especially in the NHS, where a lot of the workforce are from BAME backgrounds.
I also want to mention that, for me, for example, I depend on my NHS work permit to work in the UK, which also applies to a lot of migrant workers and Filipinos. And for some of them, if they're being asked by their manager to work in COVID-19 red zones, or on COVID-19 wards, it is very difficult for them to say, "no." Because saying "no" might mean risking their permit. It means risking being able to stay here in the UK and sending money back to the Philippines.
Olivia: I have to admit, I haven't ever thought of that. So if you're being asked to do a task, there's a real fear if you say no, that you're threatening your livelihood and your job.
Lloyd: Mm-hmm.
Olivia: So what are you doing to take care of yourself? Have you changed the way you work or your daily routines? How does a nurse take care of themselves when they're having to take care of a lot of other people at the same time?
Lloyd: Fortunately, some of the NHS Trusts, mine included, are offering psychological first aid and support, which I think should be available in all of the Trusts in the UK.
But I don't feel I have the privilege to be off sick anymore. In some of the studies, I’ve been the only one working in person on the wards – most of my colleagues are self-isolating. So I don't think I have the privilege to have a mental break, or to be off work. If I do that, when I come back, COVID’s still here, and the work has just piled up. So it’s better to face the working do my job, than have a day off and then come back to work with a lot of things piled up already.
Olivia: Which is not an ideal situation to be in, because obviously you need your rest, right? Can you still take holidays, are holidays still being honoured if you would request one?
Lloyd: Yeah. It's just I feel like I'm forced to be working everyday. The Trust is actually encouraging us to take our annual leave, especially during the pandemic – with the condition that there is proper staffing.
Olivia: So with no staff, you're in a tricky situation there.
Lloyd: Yeah.
Olivia: When this crisis abates, has it changed where you would like your research and work to focus on in the future?
Lloyd: I think working in nursing research has exposed me to a lot of the opportunities, and at the same time, a lot of injustices that the world is facing right now. We're doing the research – I know that already, there are a lot of promising candidates for a COVID-19 vaccine. What scares me is that without effective safeguards from the government, the big pharmaceutical companies could charge extortionate prices for these vaccines, which would prevent millions of people around the world from receiving it and allow the virus to spread further.
Olivia: So you’d want to ensure that vaccines and healthcare don't become profit-making enterprises.
Lloyd: Yeah. It’s funny – sorry, I have to mention this – this research we’re doing, it’s publicly funded. What we're doing right now, the money is coming from the government, from the NHS. Most of this research was started by the government. But since the government doesn't have the capacity or the money to manufacture the [eventual] medications or vaccines, they have to sell it, or give the opportunity for these big companies to profit from it. So, yeah, it's very problematic.
And I'm thinking about my family back in the Philippines. We don't have this sort of research and money to buy the vaccines that will be available from the big companies. I think decision makers need to ensure that any vaccine developed will be accessible and affordable worldwide, paying special attention to the needs of vulnerable groups. So, yeah, I think after my Master’s degree, I’d like to focus on health systems strengthening, and medications fair-pricing. Making sure there is equity and needs-based assessments, especially in a pandemic like this.
Olivia: The crisis is exposing, or has at least made people more aware, of systemic inequalities both within the healthcare system and just in society at large. What would you like to see change with the government's approach towards healthcare once the first wave of the crisis is over?
Lloyd: Well, I would like to commend the government. I think the applause was great. I appreciate the world is celebrating the work of healthcare workers in this pandemic. But at the same time, healthcare workers in the UK also need decent work and fair pay.
I'd also like to call on the government and the international community as a whole to protect healthcare workers, by giving them not just the right PPE – and that includes outside of a pandemic – but also fair pay. As a public health student, I know that investing in healthcare saves millions of lives and enhances global health security. Which results in massive economic and social returns in the long term. Investment in nurses or healthcare workers in general will only benefit society, and it is not a cost.
Olivia: There’s been clapping for carers. How, on a practical level, do you think the public can help influence the direction of travel for the NHS?
Lloyd: I think one concrete example of how to put more pressure on the government to be more accountable to the healthcare system, and to healthcare workers, is to write to your MPs. Me and my friends have done it before, and they actually do reply. It’s a way we can make them more accountable to their actions and to the promises they’re making. Collectively, if more people are doing that, MPs will know that there is actually a problem, that they should act on it and that it should be a priority – that a lot of people are talking about it, and a lot of people care, and a lot of people want change.
There you have it – people like Lloyd make me worry less about the state of the world, and he’s also educated me a lot on some of the pressures migrant workers in the NHS are facing. I am so grateful to Lloyd for taking the time to do this. He was talking with me on a Friday night, at the end of a long week of shifts – thank you Lloyd!