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Home>Service> Awardees of Fervent Global Love of Lives Award> 19th Fervent Global Love of Lives Award 2016> Facilitator of Total Care – Chaw-Fang Chou
Facilitator of Total Care – Chaw-Fang Chou
[Defend Care ˙ Guard Patients]
As long as what I do is right and meaningful, I will always make every endeavor, stick it out, challenge the limit and never give up in the hope that the "total care" I devote my life to promoting – allows Taiwan to join the rank of global civilized health care.
– Chaw-Fang Chou
Forge ahead with the Banner of Total Care
        Chaw-Fang Chou, Adjunct Associate Professor of School of Nursing of NTU, has stuck on as always for more than 50 years since she wore the nursing uniform in 1964. She started as a medical caregiver and grows into a pioneer in defending the interests of nursing, and into a guardian committing herself to evaluating hospital health care. Besides, she opens up a brilliant page of Taiwan nursing diplomacy, and takes the first step of total care in Taiwan.
        In the domestic nursing sector, Chaw-Fang is known as a veteran and served as Director of the Nursing Division of National Taiwan University Hospital, Assistant Administrator of En Chu Kong Hospital, President of New Taipei City Nurses Association, Deputy Executive Manager of Taiwan Joint Commission on Hospital Accredation, Supervisor of Taiwan Nurses Association, Director, Taiwan Union of Nurses Association, ad Director and Managing Supervisor of Psychiatric Mental Health Nurses Association. Also, she helped the establishment of National Taiwan University New Building, Buddhist Tzu Chi Hospital, Lotung Poh-Ai Hospital, and En Chu Kong Hospital, from equipment procurement to integration.
        In the foreign nursing sector, she is a recognized nursing ambassador. She assisted Saudi Arabia to establish the National Hospital and facilitated the exchanges on nursing between the medical staff with Natioanal Taiwan University Hospital and those from the United States, France and South Africa. Meanwhile, she contributed all the resources with her husband Rong-chi Chen, who is a dean of hospital – offering long-term and free assistance to the Viet Duc Hospital to make it a first-class hospital in Vietnam.
        Regardless of home and abroad, As long as what she does is right and meaningful, she will always persevere and fight to the end. In particular, in order to allow Taiwan to join the rank of global civilized health care in the globe, she devotes herself to facilitating "total care" as always for more than 50 years by comparing the patients in Europe and America. Hospitals should be fully responsible for medical treatment and care in case of hospitalization, and comprehensively enhance the quality of medical care so as to erase the shame that Taiwan hospitals are like vegetable markets.
        From this, she undertakes life-long learning (despite 77 years old, she learns Japanese every day, has a vegetarian diet and reads Buddhist sutras. Besides, she throws herself into the campaign led by Prof. Hai-guo Hu and aimed to promoting mental health of the public, and assists Master Jian-shi to offer impoverished students access to education). She defends nursing all her life, guards patients and never retreats, so she is worthy of the "Facilitator of Total Care". Among the 2459 nominees for the medal, Chaw-Fang Chou has been award the 19th Global Fervent Love of Lives Medal by the Chou Ta-kuan Foundation.
Assist the Establishment of the National Hospital in Saudi Arabia
        In 1964, when first working in the National Taiwan University Hospital (NTUH), Chaw-Fang, though as a teaching assistant, needed to work shifts with nurses.
At that time, Taiwan and Saudi Arabia had diplomatic relations, and entered into a 10-year contract that NTUH appointed doctors and nurses to Saudi Arabia to assist the establishment of a national public hospital. Her teachers also led a team to Saudi Arabia.
        In order to enable care and contact of the medical staff in Taiwan and Saudi Arabia, in 1979, she worked as an acting director of nursing for 7 years. Coupled with her 8-year service, she retired until 1992. She acted as a nursing director and was promoted to be a supervisor at a very young age of over 30 years old. Her husband and classmates felt exceedingly surprised about her career, since "those serving as the nursing director or supervisor must be quite old", she explained smiling.
        A total of 230 doctors and nurses needed to be sent to Saudi Arabia with the first group reaching 90 people. In order to meet the enormous demand for manpower, she had to recruit a group of people immediately, and must teach them nursing skills and Arabic within two weeks.
        "It was really like a war, because a group of people needed to be temporarily dispatched within two weeks", she recalls. She even went to the Department of Arabic Language of National Chengchi University, and requested the teachers to teach this group of people Arabic in NTUH.
        Although she was only responsible for backup and did not fight in the "front line", something proud happened. In order to receive the medical staff from Taiwan, the Saudi Arabia's Prince personally welcomed them. "We nurses were very proud at that time!" she said.
Facilitate Exchanges with Medical Staff from France, South Africa and the United States
        In addition to helping Saudi Arabia, from 1979 to 1981, the exchanges between the medical staff with NTUH and those from the United States, France and South Africa were increasingly frequent. She was still responsible for the exchanges.
        Each year, France would send 2 to 3 people to visit the operating room of NTUH. The two sides learned from each other and exchanged views. Also, NTUH would send medical staff to pay a visit to France, so those medical staff also needed to learn French. South Africa would send people to visit ICU and TSCU of NTUH to learn from each other.
        The reason why Taiwan could have groundbreaking exchanges with so many countries was, she said modestly, by chance. But it is undeniable that the nurses were widely recognized between 1971 and 1981.
Protest Unfair Salary and almost Stage Demonstration on the Streets
        Serious Chaw-Fang led the protest against unfair salary and almost staged demonstration on the streets in 1985 and 1986. Suddenly, she became a focus of the newspapers. "I was really indignant and felt terribly unfair and hence formed a team for demonstration", she said.  
        The reason for the protest was to fight for pay. Compared with pharmacists and medical laboratory scientists, the salary of nurses was relatively low. Furthermore, in spite of promotion and pay rise, the pay reached a certain cap finally. In case of working in the hospital for 10 years, the pay of nurses was only half of that of pharmacists and medical laboratory scientists. "I am the fifth graduate of the School of Nursing of NTU. The previous fourth graduates had resigned, leaving me alone to continue to take care of patients as a nurse", she signed.
        Therefore, she intended to take the initiative to contact reporters and hold a press conference in order to voice unfairness. Meanwhile, she also repeatedly visited the Ministry of Education, Ministry of Civil Service and Directorate-General of Personnel Administration. But these authorities passed the buck. Even though Director General of Civil Service received her and was willing to report her complaint, no further actions were taken after one or two weeks.
        To allow the senior government officials and the public to understand the unfairness, she decided to convene a press conference, and the director of Ministry of Rehabilitation also came to support her. She expressed that at that time, everyone's salaries were cut, including nurses, pharmacists and medical laboratory scientists. Based on the original different base salaries, the pay of nurses saw the greatest decrease, followed by the pharmacists with the highest salary initially. At last, the pay of nutritionists was unexpectedly the highest.
        Through her efforts, she strove to deliver her petition to the Ministry of Civil Service. Also, some legislators expressed concern and held a public hearing in the Legislative Yuan. However, eventually, the Office of the President cracked down on this policy.
        Some people did not agree and said that the pay of NTUH nurses was higher than that of Veteran General Hospital, so why did NTUH nurses fight for a pay rise? "In fact, the pay of Veteran General Hospital was visibly low and invisibly high".  
        "Visibly" meant the pay of the medical staff with the public hospitals like NTUH was issued by the Ministry of Civil Service and Ministry of Education, while "invisibly" meant the pay of the medical staff with Veteran General Hospital was subsidized by the Veteran Affairs Council at that time. Director General of Civil Service told her frankly that it was beyond his duty. "Since NTUH was at a disadvantage invisibly, we need to fight for visible fair treatment", she said indignantly.
        Later, after coordination and compromise, the government listed all the positions with the Chinese character of “师” as the eighth grade, including pharmacists, medical laboratory scientists, nurses, nutritionists, etc. Thus, the salaries of the medical staff with NTUH were the highest among all hospitals nationwide.
        Such a result was under fire. "I only ask for a fair salary but not the highest one. Moreover, the then salary of nurses was generally low, which occurred not only in NTUH but across the country."  
Pay no Regard to Titles and Modify Organization Chapters
        Fighting for salary continuation is one of the most stressful events in her tenure as director of nursing. Yet, another event associated with fighting for title also imposed tremendous pressure on her.
In NTUH, originally head nurses had salary increase, but if promoted to a supervisor, they did not have salary increase. After promoted to a supervisor, one head nurse complained to her that her salary was substantially cut after promotion, which was "visible promotion and invisible salary decrease".
        At first, Chaw-Fang did not know such a thing, so she personally inquired the Ministry of Personnel Administration and Department of Health before knowing that the true title of NTUH's supervisor was "supervisor", while the supervision title of the Tri-service General Hospital was "head supervisor". Subsequently, the Department of Health issued a document to the National Taiwan University, explaining that since the supervisor was not the head supervisor, so no pay rise was offered. "Actually, the work content and function between the two titles are exactly the same, but due to the difference of one word, the pay is much less," she said calmly.
        Since the authorities could not help, she could only commence modifying the organization rules and regulations of the hospital, and visited the Chancellor of NTU and the Dean of NTU Medical School. The Chancellor of NTU explained that in order to improve the situation that promotion resulted in pay cut, the supervisor in the organization rules and regulations must be modified to head supervisor.
        To eliminate unfairness, "Back then, I was really determined to stage demonstration on the streets. I would rather not serve as a director, but would lead all our nurses to dress in white and stage demonstration on the streets. Furthermore, the Ministry of Civil Service and the Office of the President were adjacent to our hospital." She said was resolute. Even if the newspapers warned her that nurses should have ethics, and could not put the patients aside for demonstrations. Nonetheless, she disagreed by stating that only when nurses can work in peace can they take good care of the patients, which is good for the patients.
Knowledgeable Young Nurses, but Their Clinical Skills to be Improved
        She recalled that when she attended the school of nursing, only NTU Medical School and National Defense Medical Center ran the school of nursing. However, as the medical environment changes rapidly, a growing number of nursing schools are set up. But when these new nursing students interned in the hospital, she found that the young nurses had excellent academic performances and great capacity and were well-educated, but their ability of adaption, technique and absorbing new knowledge was inferior to that of the nurses in the past.
        According to her, she began working at the age of 22. Even if she was on night shift alone and needed to take care of 60 and 70 patients, she could handle it properly, since many previous nurses acted in this way. Now, she sees that many young nurses will cry due to great pressure on night shifts, which she cannot bear.
        Although lamenting that the young nurses now acquire sound knowledge about care but with poor clinical techniques, she analyzed the possible reason was that teachers could not pay enough attention to all students due to the large number. Every student can have the opportunity to learn and can master the clinical techniques, but some nursing students do not know how to give an injection and the doctors need to teach them.
        During the service of Yan-shi Chiang as the Minister of Education, she promoted the teaching evaluation of nursing schools, in which Chaw-Fang also participated. She found that many nursing schools running five-year program recruited many students, but only hired 3 teachers. As a result, the students were left unattended. Therefore, at the first evaluation, De Yu Nursing College was categorically shut down.
According to the explanation of Chaw-Fang, since the board of De Yu Nursing College ran away with money, the dormitories were dilapidated, the teachers did not get paid for half a year, and the principal was locked up. Even in interviews with students during the evaluation, the students cried that they did not have uniforms to wear though paying the uniforms.
        When the students of De Yu Nursing College took internship in the hospital, some patients and family members criticized, "What can you students learn since your teachers ran away?" As a matter of fact, the quality of students from De Yu Nursing College was better than that of the nursing school students in central and south Taiwan, and they often can be admitted by NTUH and Veteran General Hospital as nurses. Yet, unfortunately, the school was closed.
        The Ministry of Education required De Yu Nursing College to close for a year. In the second year, only one class of students were enrolled and normal enrollment resumed until the third year.
Comprehensive Hospital Accreditation to Identify Hospital Defects
        Chaw-Fang found that the students interning in the hospital was simply left unattended and were treated as cheap labor. They were arranged to take night shifts and hence could not learn something useful. Besides, the work which the nurses did not feel like doing was left to the students. As a result, the subsequent teaching evaluation also required a visit to the students' internship sites, which also forced the Ministry of Education to urge the Department of Health must carry out hospital accreditation of the hospitals where the students interned.
        The early hospitals were of poor quality. Especially the small-scale hospitals had uneven quality and did not have standard operating procedures. Furthermore, their operating rooms were like general wards without sterile facilities but with sterilizers only. The medical care equipment was too simple, and the only first-aid equipment was an oxygen cylinder. Chaw-Fang claimed that such hospitals were extremely terrible. Also, she was worried about the care patients received after admission, because pollution might take place in each link and step. Especially in the countryside, many people did not see an ambulance at all.
        It was via this comprehensive hospital accreditation that plenty of hospitals were found to hire unlicensed nurses, many of whom just graduated from junior high school and high school, and started working only after short-term training. In a hospital run by a legislator, Chaw-Fang inquired the head nurse about from which nursing school she graduated. Yet, unexpectedly, this head nurse made an excuse to avoid answering. Later, the legislator said this head nurse did not attend any nursing school.
Tension between Doctors vs. Nurses
        Since many hospitals and clinics did not employ licensed nurses, after the evaluation, Chaw-Fang urged the Ministry of Health and Welfare and the Ministry of Education to require hospitals and clinics at all levels to hire licensed nurses. Unexpectedly, this requirement gave rise to physicians' protest, so Chaw-Fang again became the focus of media.
        Pursuant to the provisions of Article 37 of the Nurse Practitioner Act, hospitals must employ licensed nurses, and only the licensed nurses can perform nursing services, including injection, medication, intubation and other invasive behaviors. However, many physicians expressed that they could not hire nurses. The event evolved into the opposition between the Physicians' Association and the Nurses' Association.
        After consultations, Bo-ya Chang, the then Minister of Health, ruled that the implementation of the Nurse Practitioner Act was postponed for two years. Besides, she formulated Article 52 of the sunset clause concerning Article 37, so the physicians and nurses were temporarily at peace for two years. Also, the Nurse Practitioner Act was also adopted.
        However, after a two-year grace period, the physicians fought again, and required the implementation of the Nurse Practitioner Act to be delayed for two more years and prevented Article 37 from taking effect through the joint signature of DPP legislators. Consequently, the nurses flooded in Chaw-Fang's office to discuss countermeasures.
        As excessively angry she was, Chaw-Fang kept cool and decided to defeat the legislators of all parties. On the day when the legislators would convene a meeting, she found a couple of nurses to stand in front of the entrance of the Legislative Yuan, separately found and communicated with the legislators present in the joint signature and stopped them from entering the Legislative Yuan. Additionally, Chaw-Fang filed her petition to local legislators via the nurses' association in counties and cities, and mobilized all nurses' association nationwide to besiege the Legislative Yuan.
        She said that when gathering in front of the Legislative Yuan, she met the then DPP chairman Ming-teh Shih, and begged him to talk legislators out of attending the joint signature. "I told him if the implementation of the Nurse Practitioner Act is delayed again, the unqualified nurses are allowed to care for the patient, which will jeopardize the patients' rights. The implementation as scheduled is in the interest of patients across the country." 
        At the same time, she spent one night to call the nurses across the country, and summoned about 200 people to go north by taking sightseeing bus. "Although the crisis was resolved in front of the Legislative Yuan, the nurses were indeed very united," she said movingly.
        Although the opposition between the doctors and nurses took place, she said that doctors and nurses should cooperate with each other. In fact, the hospitals in the United States and Europe concentrated on nursing. Only in Japan and Taiwan, doctors had the highest power and their doctors were often deemed to be "imperial edict."
        Furthermore, doctors were only responsible for the treatment, and nurses took full charge of nursing. If the doctors were mean to the nurses, the latter might be uncooperative and delay performing the tasks assigned by the doctors. Therefore, the doctors' work would be counterproductive. Once a NTUH doctor started business and told her that he found it extremely hard and nervous to double as doctor and nurse. This was because once a patient suffered from urinary swelling for more than 20 hours, but no nurses were available and he had to personally look after the patient and dared not to run around.
Moved by Hard Work of Nurses
        She is immensely grateful for the hard work of the nurses. A few years ago, when China Petroleum Corporation (CPC) conducted offshore oil exploration in Hsinchu, though there was a male nurse on the exploration ship who could perform surgery and prescribe medication, medical manpower that could offer emergency back-up was required who could carry patients to hospital by helicopters.
        Therefore, CPC contacted NTUH to ask for support. She felt increasingly worried as the talk went on. Besides, a helicopter happened to crash in the Taiwan Strait, killing one physician with the Tri-service General Hospital, rendering her more concerned about the safety of the task.
        Nonetheless, she still announced this task in the nursing department. It turned out that two nurses took on the task voluntarily who had experience in ICUs and emergency rooms. "I really appreciated them, but I was also dreadfully worried about their safety." She was so hesitant about whether to allow them to undertake the task that she could not sleep for several nights.
        "Because the lives of these two people were controlled by me, and this task was exceedingly dangerous." Finally, she decided to report to the hospital president, hoping that this task could be canceled. The president also agreed with her, and wrote a letter to CPC to refuse the request.
Promote Total Care to Lighten the Burden on Families
        Chaw-Fang, who has always taken nurses and patient's families into account, served as Assistant Administrator at the invitation of En Chu Kong Hospital in 1997, and was the first to promote total care. The hospitals hired caregivers, care workers, nurse aides and patient assistants, and provided rigorous training and supervision. In this way, these assistants could help take care of patients, while the burden on families could be lightened, and the families did not need to spend extra money hiring care workers.
        Vendors extended gratitude to Chaw-Fang, because total care allowed him to properly continue to make money and earn a living. Also, a first-time father was also grateful to her, since he had never touched a newborn, and did not know how to care the mother. But total care freed him from worry.
        According to her, in fact, in advanced European countries and America, family members only needed to visit and comfort the patients in the hospital during visiting time, and did not need to stay in the hospital to take care of the patients. Or care workers and caregivers were hired to be in charge of hospital care.
        Therefore, the purpose of promoting total care is to recover the work which should not be undertaken by the families, such as force-feeding, medication and other risky behaviors. Thanks to her effort, the former Taipei Mayor Ma Ying-jeou immediately promised to implement total care in ten branches of Taipei City Hospitals, including Zhongxiao, Renai, Heping, Yangming, Zhongxing, Fuyou, Linsen, Songde, Chinese Medicine, and Kunmin, which was well-received by all walks of life.
Delighted to See Flourishing Total Care
        Taipei City Hospital's successful experience made it a reference for other government units. Mei-na Huang, the then Director of the Bureau of Nursing and Health Services Development and the Department of Health advocated that public hospitals should promote total care and hoped that the Hospital of Department of Health (the Department of Health was upgraded to the "Ministry of Health and Welfare" in 2013) began to promote total care. Also, Chaw-Fang was invited to serve as a consultant to assist discussion about problems, review of the sources of funding raised by hospitals and other matters.
        The total care was promoted from municipal hospitals to department hospitals. Chaw-Fang was optimistic about its success, but also reminded Mei-na Huang that the budget would be key to the success of the pilot. The Department of Health decided that the hospitals which wanted to run the pilot project should propose solutions to their own financial problems at the expense of the patients or of the hospitals themselves.
        In 2006, the Department of Health budget allocated the budget of 6.26 million NTD and commissioned National Cheng Kung University Hospital (CKUH) and Taipei Veterans General Hospital to implement the total care pilot scheme. The subsidies for the Bureau of Nursing and Health Services Development were to cover the costs of the pilot hospitals on training, recruitment and management of caregivers, but excluded the caregivers' salaries. CKUH adopted the model of patients at their own expense to pay the caregivers' salaries, while Veteran General Hospital took the measures of expenses of the Veteran Affairs Council.
        To help veterans and their family dependents, the Veteran Affairs Council set up a vocational training center to assist the veterans and their family dependents to receive vocational training. Chaw-Fang pointed out that the Veteran Affairs Council once established a care unit so that the veterans' family dependents, who sought employment, were assigned to the Veteran General Hospital and served as a nurse. This approach not only could take care of veterans' family dependents and offer them job, but could enable the Veteran Affairs Council to gain profit. Cuo-chian Yin, the then Director of the Nursing Division of Veteran General Hospital hoped that the Veteran Affairs Council, apart from reaping profit, could return the human needs of total care pilot scheme in the Veteran Affairs Council. Therefore, the contract provided that the care companies must offer one free service for each 30 shifts. The total number of beds in the Veteran General Hospital was nearly 3,000. Back then, a total of 500 to 600 nurses were needed. Therefore, the Veteran Affairs Council needed to promote more than a dozen volunteers as care workers. As a result, the Veteran General Hospital set an example to a certain extent. In the Koo Foundation Sun Yat-Sen Cancer Center with the highest ratio of caregivers and beds, all patient care was undertaken by nurses but not by the caregivers or families. Other hospitals, such as Hualien Hospital and Nantou Hospital patients, asked the patients to assume the costs on caregivers.
        "In fact, many hospitals are willing to undertake total care, but the key to whether the total care can be continued lies in the sources of this additional cost." Chaw-Fang hit the nail on the head and indicated the biggest bottleneck of promoting total care for so many years.
Work together to Create Win-win Total Care
        In the Chaw-Fang's blueprint of total care, volunteers constitute an important puzzle. The caregivers probably must look after patients in different wards, and the service gap in the cross-ward services is inevitable. To maintain the patients' safety, she hopes that the volunteers can take on the responsibility of the cross-ward services. The volunteers do not directly take care of the patients, but substitute the caregivers when the caregivers cannot be present in each ward.
        Once, a hospitalizing old lady wanted to get out of bed, but the caregiver happened to serve in other wards. The old lady did not know she could ring for the caregivers. When she wanted to get out of bed by directly crossing the bed rail, she was spotted by Chaw-Fang who was inspecting the wards. Worrying that the clumsy old lady might be in danger, she hurried to the bed and let her get out of bed by removing the bed rail.
        By including volunteers into the architecture of total care and making the hospital social worker responsible for recruiting and managing volunteers, the implementation of total care will be bettered. Aside from the patients' access to more professional care, for the families, their job is not affected and they do not need to operate some unfamiliar medical equipment, nor worry that they will be infected. Meanwhile, the care expenses can be reduced. For hospitals, if no caregivers live in the hospitals around the clock, this not only can reduce the extra cost of utilities and the amount of waste nor worry that the clothes not washed by the caregivers will cause infection. The hospital management is streamlined, thereby creating a win-win situation. Nevertheless, currently, many hospitals remain resistant to total care. There is still a long way to go if the target of total care is to be attained.
Invest in Hospital Evaluation to Enhance the Quality of Care
        Chaw-Fang, dedicating herself to nursing, has two daughters. Like her, the eldest daughter attended the NTU School of Nursing, but later changed her profession out of the interest in computers. However, the two daughters have inherited her good voice and love singing. Every time she attended her daughter's choir competitions, someone cried: "Star mummy is coming. Happy mother is coming!"  Outstanding performance of her daughters also frees her from worries and commits herself to working for the domestic nursing sector. Her little son retired from military service, and acts as a research assistant of NTU.
        Since she got involved with hospital accreditation in early years, Chaw-Fang chose to serve as deputy chief executive in Taiwan Joint Commission on Hospital Accreditation and promoted the improvement in hospital quality, including quality control circle and TQIP. To help establish standardized and consistent working processes, she still enthusiastically explains to hospitals in Taiwan.
        She was exceedingly concerned about the development of event that the nurse with Beicheng Hospital performed wrong injection, so she headed for the hearing, and even offered explanations when the judge collected evidence in the hospital. Her greatest wish is that the errors of medical personnel can be changed from criminal liability to civil liability by legislation in the future.
        Since in the SARS event, the media's coverage of the nurses in Ho-Ping Hospital was unfair and pointed out that many nurses "ran away" out of fear of SARS, she stepped forward bravely and argued that those resigning were the temporary staff, while none of the full-time nurses left. "I am convinced that via the SARS event, the public can finally understand the contributors behind who look after the patients are, in fact, the nurses."