Philippine Nurses in the U.S.—Yesterday and Today

Rosario May Mayor arrived in New York City one cold morning in March 1971, a 22-year-old with “adventure in her veins,” yearning to experience the America portrayed in the television shows and movies she had watched while growing up in the Philippines. “The draw was a different setting, a different country with lots to offer–opportunities for education, travel and to be independent,” she recalls.

The young immigrant nurse took full advantage of all those opportunities. Over the years, she grew to become a top nursing professional and a national leader. Today Rosario May Mayor, MSN, RN, is a health systems specialist to the director and chief of staff of the Bronx VA Medical Center. She is also president-elect of the Philippine Nurses Association of America (PNAA).

Mayor is one of thousands of nurses from the Philippines who migrated to the United States in the 1960s and ‘70s and became an integral part of the health care system here. For decades the Philippines were the number one source of foreign-trained nurses in the U.S., and the trend has continued into the 21st century. In 2005, out of the 21,500 foreign-trained registered nurses who sat for the Certification Program Nurse Qualifying Exam, administered by the Commission on Graduates of Foreign Nursing Schools (CGFNS), 55% were educated in the Philippines.

Today, as a severe nursing shortage grips the U.S. health care system, a whole new generation of Philippine nurses is coming to America to seek educational and career opportunities unavailable in their homeland. This newest wave of immigrant nurses faces a more complex health care system and stricter immigration rules than their counterparts of 30 or 40 years ago. But many of the challenges of adjusting to a new culture, as well as the drive to seek a higher standard of living, have hardly changed at all.

A Historical Perspective

The former colonial relationship between the United States and the Philippines laid the foundation for the mass migration of Philippine nurses to this country in the latter half of the 20th century, according to Catherine Ceniza Choy, associate professor of ethnic studies at the University of California, Berkeley, and author of Empire of Care: Nursing and Migration in Filipino American History (Duke University Press, 2003). Before the Philippines became independent in 1946, the United States sponsored nurse training there, including the study of English, that was comparable to the work culture and training of nurses in America.

The first big wave of nurses from the Philippines came after 1948, as part of the Exchange Visitor Program. This program allowed people from other countries to come to the U.S. to work and study for two years to learn about American culture. Originally the program didn’t target the Philippines or nurses specifically but was created to combat Soviet propaganda during the Cold War by exposing foreigners to U.S. democracy, Choy explains. But because of the strong relationship between the two countries, a large percentage of the exchange visitors came from the Philippines, and many of them were nurses.

With the cycle of nursing shortages after World War II, the exchange program became a recruiting vehicle for U.S. hospitals. Many Philippine nurses hired through the program had positive experiences, but some nurses were exploited, Choy says. Because the exchange program was intended as a learning opportunity, nurses were paid stipends instead of full salaries. But in some instances, hospitals used the program simply to fill positions and gave the most unfavorable shifts and jobs to the exchange visitors.

Another big upsurge in migration from the Philippines occurred after 1965, when U.S. immigration laws–which had favored northern European countries–were changed, allowing more people from the Philippines and Asia to immigrate. The new law also allowed nurses to come here on tourist visas even without prearranged employment, says Reuben Seguritan, JD, a Filipino American attorney who is general counsel to the PNAA.

Meanwhile, entrepreneurs in the Philippines set up more nursing schools to meet the demand, and the number of nursing graduates soared. In the 1940s there were only 17 nursing schools in the Philippines, compared to 170 in 1990 and more than 300 today, says Choy.

Easing the Transition

American life and culture have undergone many changes since the days when Philippine nurses of Mayor’s generation migrated to the United States. But even though Motown, disco and “All in the Family” have given way to hip-hop, iPods and “The Simpsons,” many of the challenges that confront newly arrived nurses from the Philippines aren’t all that different today. One of the biggest difficulties is simply adjusting to a new environment and cultural landscape.

“The weather was so cold,” remembers Josephine Villanueva, MA, RNC, associate nurse executive and chief nurse at the VA Long Beach Healthcare System in California, who first came to the U.S. in the 1960s as part of a student nurse exchange program between the University of the Philippines and the University of Kansas. She arrived on a frigid day in January. “Our American roommates met us at the airport and said, ‘Let’s go to Dairy Queen and have ice cream!’”

Like many other new arrivals to the U.S., Villanueva had to adjust to the nuances of American culture. For example, she says, Americans are more independent than Filipinos, whose lives are more centered around family. The Filipino culture values sensitivity and gratitude, while Americans are more frank.

Language differences are another source of culture shock. Even though nurses trained in the Philippines speak English, they often have trouble deciphering the varied American accents and idiomatic expressions. Villanueva recalls looking out the window in alarm one day when a roommate said it was “raining cats and dogs.” She laughs when she remembers puzzling over a store clerk offering her a “rain check” coupon.

Some newcomers from the Philippines working in U.S. health care facilities feel embarrassed to talk and ask questions, says Cheri Nievera, BSN, RN, a staff nurse in the cardiothoracic ICU at Barnes-Jewish Hospital in St. Louis. Homesickness can be a problem, too, she adds. “Emotionally it’s very challenging being alone and away from their families.”

Many PNAA chapters offer mentoring programs and acculturation classes to help these new immigrant nurses make a smooth transition into American life. In the 1990s, the New York chapter collected turtlenecks, jackets and other warm clothing for nurses who had just arrived and were not prepared for the difference in climate. The chapter also sponsored a seminar called “Managing Effectively in a Different Environment,” a program Mayor would like to resurrect during her term as president of the national association.

In 2000 Nievera coordinated an initiative at Barnes-Jewish Hospital called “Bridge to the Pacific” to ease the transition of new cardiology nurses from the Philippines. The project came about after concerns were raised publicly about the new Filipino nurses’ educational background, clinical competency and communication skills. Nievera traveled to the Philippine Heart Center in Manila to meet with the nursing director, educators and staff and review standards of care, treatments and equipment. She learned that the nurses there met rigorous qualifications, administered the same medications and treatments as their U.S. counterparts and met comparable standards of care. The equipment was older, but the nurses treated the same conditions, she says.

Nievera reported back her findings to put the concerns at rest, and her insights were used to shape the orientation and cultural integration of the new nurses. She also worked with the St. Louis chapter of the PNAA to send needed equipment back to the Philippine Heart Center.

Something Old, Something New

Unfortunately, another aspect of Philippine nurse migration that has not changed much over the years is the potential for nurses to be exploited by unscrupulous employers and recruiters eager to profit from the nurses’ desire to achieve a better standard of living in America.

Filipinas Lowery, MA, RN, CNOR, one of the founders of the PNAA, recalls how some recruiters in the 1980s collected fees from hospitals to bring in Philippine nurses, then charged the nurses fees and held their passports until the nurses paid up. At that time, Lowery was president of the New York PNAA chapter. She and others from the chapter worked with the New York State Nurses Association to put a stop to the unethical recruiting practices.

Today, immigrant nurses are still vulnerable, but it’s difficult to say how often exploitation occurs. Lowery, now a nurse consultant in New York, believes such practices are more likely to occur in remote areas of the U.S. where international recruiting efforts are relatively new. “We hear about it from time to time, but we don’t have the documentation [to prove it],” she says.

While some of challenges faced by immigrant nurses from the Philippines are the same now as they were 20 or even 50 years ago, others are completely new. Today’s new arrivals encounter a much more complex work environment than that of a generation ago, including new high-tech equipment, paperless records, increased regulation, utilization review guidelines and new disease management concepts, to name just a few.

There are also more barriers to immigration, Seguritan says. These days, foreign-educated RNs applying for an occupational visa must obtain a visa screen certificate. This certificate is issued by the Commission on Graduates of Foreign Nursing Schools, an international authority on credentials evaluation of health care professionals worldwide.

The visa screen is an immigration requirement, not a license to practice in the United States. It determines whether the nurse has the equivalent of a U.S. license and education, can speak and write English adequately and has adequate medical knowledge. To get the visa screen, nurses must pass either the CGFNS certificate exam or the National Council of State Boards of Nursing’s NCLEX-RN® exam.

The problem is, only the CGFNS exam–a pre-qualifier for the NCLEX–is administered in the Philippines. Outside the U.S., the NCLEX, which is required for licensing, is administered only in Hong Kong, London and Seoul, South Korea. Philippine nursing leaders on both sides of the Pacific are lobbying for the NCLEX to be administered in the Philippines to make the immigration process easier.

Meanwhile, the Philippine nursing “brain drain”–the loss of the country’s best nurses to the U.S. and elsewhere–remains a concern. And now a growing number of physicians trained in the Philippines are switching to nursing to take advantage of the opportunities abroad. An estimated 4,000 Filipino physicians are currently enrolled in nurse training, according to Rey Rivera, MA, EdM, RN, CCRN, CNAA, BC, ANP, senior director of nursing at The Brooklyn Hospital Center in New York and education chair of the PNAA.

As president-elect of the PNAA, Mayor is in beginning talks with the World Health Organization about the need for initiatives that would encourage return migration. These issues were also addressed at a joint conference held in January by the PNAA and its counterpart in the Philippines, the Philippine Nurses Association. And nursing leaders are working on creating more structured visiting programs for U.S.-based nurses traveling to the Philippines.

Although the brain drain is a serious problem, Philippine nurses’ desire to leave their homeland in pursuit of the American dream is, then as now, understandable and even inevitable. There aren’t enough jobs at home for all the nurses who graduate from universities in the Philippines, Lowery points out.

Rivera, who taught psychiatric nursing in the Philippines, immigrated to the U.S. in 1986 to complete his master’s degree and ended up staying in America and working in critical care, says the issue is complex and goes beyond just the nursing profession. It’s natural for people in developing countries to want to immigrate to other countries where there are better opportunities. “It’s economics,” he emphasizes. “We need to improve the economic conditions in the Philippines.”

An Innovative Response to the Nursing “Brain Drain”

Six years ago, a Minnesota state representative concerned about the state’s growing nursing shortage asked international trade expert Todd Bol to explore recruiting foreign-trained nurses. But after meeting with nursing leaders in the Philippines, Bol became convinced that the typical one-way recruitment practices of the last several decades were not the way to go.

Rather than draining countries like the Philippines of their best nurses, Bol set out to create a sustainable model that would help replenish the global nursing supply. Working with leaders such as Sister Remy Junio of St. Paul’s University in Manila, he founded the Global Scholarship Alliance (GSA).

A private company based in Cincinnati, GSA facilitates cultural exchange programs and provides scholarships for qualified international nurses to receive graduate education and academic training at universities and hospitals in the United States. Nurse-scholars participating in the four-and-a-half-year program receive fully funded MSN scholarships and part-time work experience at alliance hospitals during their study.

But here’s what’s unique: After completing the program, the nurses must return to their home countries for at least two years to work as clinical instructors, nurse leaders or administrators to help train the next generation of nurses.

The two-year service requirement is one way to help ensure sustainability, says GSA Executive Vice President Ty Nelson. Last year, the Office of the Press Secretary in Manila reported that Philippine nursing schools could produce only one nursing graduate to replace every three trained and experienced nurses who leave the country every year for jobs overseas.

“As nurse educators, GSA alumni can have a huge impact on the quality of nursing education in their home countries,” Nelson explains. “Many of them will have MSN degrees with concentrations in education. And they will have four-plus years of work experience with inarguably the most advanced health care system in the world.”

After the nurses complete the two-year service requirement, they may apply to return to the United States. As an incentive to complete their home-country service, GSA will help with the green card process, says Nelson. “Of course, we prefer that they stay in their home country, but we recognize that the economic forces at work are difficult to resist from the nurses’ perspective,” he adds.

Currently, 91 GSA nurse-scholars are studying in the U.S. and about 138 more will arrive in the next year, Nelson reports. Together they constitute about $10 million in scholarships. More than 90% of the nurses are from the Philippines, but they also come from Zimbabwe and India. When the next wave of nurse-scholars arrives, more African, Middle Eastern, Southeast Asian and British Commonwealth countries will be represented.

The GSA promotes its program as “creating a variety of win-win relationships” in which U.S. universities and hospitals benefit as much as the foreign nurses. The program always involves a partnership between a hospital and a nursing school. The university usually sponsors the nurse-scholar’s visa; the hospital directly employs the nurse-scholar. GSA recruits the scholars, based on the experience levels and specialty skills desired by the participating institutions.

According to Nelson, international health officials are excited about the sustainable model. And U.S. hospitals are pleased because they can replace high-cost travel nurses and agency nurses with their own employees while increasing the quality of patient care with BSN-trained and MSN-candidate nurses.

For more information about the Global Scholarship Alliance, visit www.globalscholarship.net.