A Proud Nursing Heritage
Focus on the Philippines
(California Edition)
By Rebecca Ray
April 11, 2005
Elvie Magsarili, RN, will never forget the first time she came to the United States in the 1960s. Magsarili, who had earned her bachelor of science in nursing degree from Manila Central University, had never been outside the Philippines, and her port of entry that October — Alaska. Nothing had prepared her for the icy weather. Fortunately, she had thought to wear a wool cape. “If I didn’t have that,” she says, “I would’ve died.”
Today, Magsarili still lives in the U.S. The San Diego-area resident considers the U.S. her home and doesn’t plan on moving back to the Philippines.
Magsarili, who came to the U.S. on an H-1, or temporary work, visa, is part of the migration of Filipino nurses to the U.S. The Philippines, which is the world leader in nurse emigration, played a key role in helping the U.S. fill its nursing shortages over the last 55 years.
During the last four years, more than 50,000 Filipino nurses have found work in the U.S., according to an October 2004 study by the University of the Philippines National Institutes of Health. In The New Asian Immigration in Los Angeles and Global Restructuring, Paul Ong and Tania Azores estimate that at least 25,000 Filipino nurses migrated to the U.S. between 1966 and 1985.
Colonial link
This migration to the U.S. is linked to early twentieth-century U.S. colonialism in the Philippines, Catherine Ceniza Choy asserts in her 2003 book Empire of Care: Nursing and Migration in Filipino American History. Choy says U.S. colonialism in the early 1900s led to the creation of a Filipino labor force in the late twentieth century with the requisite skills, professional credentials, and knowledge of the English language to work in U.S. hospitals, as well as a labor force accustomed to the U.S. hospital work culture, due to the Americanized professional nursing training.
Nursing comes to the Philippines
Americans began training the first Filipino nursing students in 1907. Nursing students in the Philippines studied many of the same subjects as nursing students in the U.S. However, Choy says, the curriculum in the Philippines “was never a mirror-image reproduction of the American nursing curriculum” and involved more than a simple transfer of knowledge from American nurses to Filipino nurses. The first Filipino nursing students also studied subjects that were more relevant to their patients, such as “the nursing of tropical diseases” and “industrial and living conditions in the islands,” as described by Lavinia L. Dock’s 1912 book A History of Nursing: From the Earliest Times to the Present Day with Special Reference to the Work of the Past Thirty Years.
In addition, Filipino nursing students studied English; today, the Philippines is the third-largest English-speaking country in the world. However, Choy notes, Filipino nursing students didn’t lose their native language; Philippine schools of nursing believed the best way to promote physical health was to have a select few medical professionals spread their knowledge “in the dialects of their own people,” as described in the Philippine General Hospital School of Nursing Ninth Annual Announcement and Catalogue, 1915-1916.
Through the 1930s, Philippine schools of nursing continued to adopt those aspects of American professional nursing they deemed relevant and appropriate, such as higher admission standards and the specialization of public health nursing.
Training and practice at the hospital schools of nursing in Manila was “violently disrupted” when the Japanese occupied the Philippines in 1942, Choy says. However, U.S. colonial patterns in Philippine nursing education soon returned after the U.S. reclaimed the country in 1945 and even after the Philippines gained independence from the U.S. July 4, 1946.
Although American philanthropic organizations sponsored Filipino nursing graduates to study abroad in the 1940s, the Filipino nurses who traveled to the U.S. continued to be few in number, according to Choy.
First wave
That changed with the establishment of the U.S. Exchange Visitor Program in 1948. The goal of the program was to fill a post-World War II labor shortage, as well as promote a better understanding of the U.S. in other countries to combat the “hostile propaganda campaigns directed against democracy, human welfare, freedom, truth, and the United States, spearheaded by the Government of the Soviet Union and the Communist Parties throughout the world,” as Choy quotes from Senate reports.
The EVP contributed to the first wave of migration of Filipino nurses, with more than 11,000 Filipino nurses participating in the program between 1956 and 1969.
The 1965 Immigration Act included new occupational preferences, which enabled Filipino nurses to settle as permanent residents. By 1967, the Philippines had replaced European and North American countries as the world’s biggest exporter of nurses to the U.S., which was experiencing a nursing shortage of 125,000 vacant positions. With the passage of a U.S. public law in 1970, fewer exchange visitors had to meet a two-year foreign residency requirement to become permanent residents. Between 1966 and 1978, 7,495 Filipino exchange visitors amended their status to become U.S. permanent residents.
The Philippines also led other countries in the number of H-1 visa nurses entering the U.S.; between 1972 and 1978, 60% of H-1 visa nurses were from the Philippines.
But the U.S. immigration laws don’t tell the whole story. Choy also attributes the 1960s and 1970s migration of Filipino nurses to their desire for travel and adventure, low nursing wages and poor working conditions in the Philippines, heavy recruitment by U.S. hospitals and travel agencies, and the Marcos government’s shift to an export-oriented economy, among other things. The Philippine government exported laborers in an attempt to revitalize the Philippines’ economy in the hope that the laborers would deposit their earnings in Philippine banks.
A good fit
Magsarili, now a member of the San Diego County chapter of the Philippine Nurses Association of America, Inc., who owns a residential facility for adults with developmental disabilities, says it was “so easy” for her to adjust to working in an American hospital. Not only do Philippine students begin learning English at the kindergarten level, but the mode of instruction in Philippine nursing schools is the same as in nursing schools in the U.S.
The main difference is that Philippine nursing schools place more emphasis on bedside nursing and clinical training, while American nursing schools, particularly baccalaureate programs, seem to focus more on leadership and critical thinking.
Students in the Philippines complete more clinical hours than American students and receive year-round clinical exposure, with more concentration on areas like medical/surgical, OR, obstetrics, and labor and delivery, says Nelly Peterson, RN, MNEd, president of the Arizona chapter of the PNA. Peterson, a nursing faculty member at Phoenix College, received her BSN from the University of Santo Tomas in Manila in 1977.
Students have even delivered babies. When Gemma Rama-Banaag, RN, MSN, MBA, a member of the PNA San Diego, was attending what is now Adventist University of the Philippines in Cavite, she spent summers working in the obstetrics area so that she could complete the required 35 deliveries. Rama-Banaag, who graduated in 1987, was part of the last class in the five-year BSN program; after that, all BSN programs in the Philippines were cut to four years.
Peterson spent five weeks in L&D caring for patients for about 20 to 24 hours a week, while her students in the U.S. now spend 16 hours a week.
Marlon Saria, RN, MSN, OCN, an oncology clinical nurse specialist at University of California, San Diego Medical Center who graduated from the University of the Philippines Manila in 1998, says nursing students had to participate in a community health program that involved living with local families and working in a rural area for about two months without pay.
Saria, a member of the PNASD, says all of his textbooks in school were in English except his Tagalog, history, and civics textbooks. Students weren’t allowed to speak Tagalog, Rama-Banaag says, unless it was a Philippine subject.
Rama-Banaag’s mother even instituted “English Day”; each Thursday, Rama-Banaag and her cousins weren’t allowed to speak any Tagalog. The children would carry English dictionaries, hoping to catch one of the others using an English word incorrectly; if they did, they could fine the offender, on top of handing off a household chore.
In general, Filipino families value education, and parents begin saving money for their children’s education as soon as they’re born, say members of the PNASD. It is common for family members to provide financial support for each other’s education.
The educational attainment of Filipino-born Americans is generally higher than that of native-born RNs in the U.S., with 71.1% of the Filipino-born earning BSN degrees, compared with 30.7% of the native-born, according to Daisy Rodriguez, RN, MN, MPA, co-author of “Demographic Survey of Filipino American Nurses,” which appears in a 2004 edition of Nursing Administration Quarterly. In the Philippines, there is no associate nursing degree; the bachelor’s degree is the entry-level degree.
Opportunity to grow
Rama-Banaag, a clinical manager involved in business development at Paradise Valley Hospital in San Diego, came to the U.S. because there were more opportunities for nurses in administration and management. There were few management roles in the Philippines, where the highest position a nurse could achieve was director of nursing and nurse practitioners and case management didn’t exist, she says.
Rama-Banaag also saw how successful her two cousins were as nurses in Michigan and heard their stories of America. She says that in the Philippines, it’s common for family members to choose the same career.
Peterson predicts that with so many nurses leaving the Philippines, the country will soon experience a nursing shortage of its own. She says this poses an “ethical dilemma.”
Vicki Huber, RN, MSN, CHE, chief nursing officer at University Medical Center in Las Vegas, says UMC has stopped recruiting foreign-trained nurses because of her concern about luring them away from countries that need their skills. “I’d rather promote development of the profession through schools of nursing than to rob other countries of a precious resource,” she says.
Huber hopes that local nursing students rotating through the teaching hospital for clinical training will join UMC. Also, she says, many Filipino staff nurses are encouraging their children to become nurses, and some already have. “So that’s really what we’re trying to promote — one big extended family,” she says.
The problem of recruiting foreign-trained nurses has been exacerbated by tighter visa restrictions. In January, the U.S. Citizenship and Immigration Services announced it would no longer issue employment-based visas for workers in the Philippines and other countries that have exceeded their annual quota for green cards until new visas become available. Nurses whose employers petitioned after Jan. 1, 2002 must now wait more than three years to receive permanent residency. Previously, nurses who were sponsored by a U.S. hospital and received visa approval could become permanent residents in 18 to 24 months. The temporary visa program expired in 1995.
The PNASD is sponsoring HR 139, the Health Improvement and Professionals Act of 2005, introduced by Rep. Tom Lantos of California. The bill calls for the recapture of unused employment-based immigrant visas.
Rama-Banaag says she wants other nurses to realize that Philippine nurses are not in the U.S. to “take over,” but “to help address a need in the health care industry. We carry pakikisama [the spirit of trying to get along] with us. We want to be partners with everybody.”
Rebecca Ray is managing editor of NurseWeek, Mountain West edition. John Leighty contributed to this story.