This striking, colorful graphic was created by a Minority Nurse reader named Kimberly Repollo, BSN, RN, a 22-year-old Filipino nurse who lives in Canoga Park, California. “I’m a nurse and I love making art,” Kim writes. “I’d love to be able to combine my love of nursing and drawing. Here’s one of my drawings… How I wish I could see this design on a set of nursing scrubs!” To learn more about the work of this talented nurse artist, contact her at [email protected].
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
Rosario May Mayor, MSN, RN.
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
Exchange student Josephine Villanueva (second from left) at the University of Kansas in 1966..
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
Exchange student Josephine Villanueva being greeted at the airport by KU nursing students.
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.
Exchange student Josephine Villanueva posing with KU roommate Debbie Hardman.
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).
Filipinas Lowery, MA, RN, CNOR
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.
Compared to other RNs of color practicing in the U.S. nursing work force, Filipino nurses are something of a “hidden minority.” Most of the statistical information available about them is lumped into the general category of “Asian nurses.” For example, the Health Resources & Services Administration’s National Sample Survey of Registered Nurses—the profession’s most frequently consulted source of statistics on nursing’s racial and ethnic demographics—does not give Filipino RNs a separate grouping.
Yet Filipino and Filipino-American nurses have their own unique ethnic identity and a rich cultural heritage. As the number of Filipino nurses working in the U.S. continues to increase, this group is quickly becoming an important part of our nation’s health care system.
Formally known as the Republic of the Philippines, this small island nation became independent from the United States on July 4, 1946. However, the Philippines retain close ties with America. English is taught in Filipino schools, including nursing programs, and widely spoken throughout the country. In recent years, large numbers of nurses trained in the Philippines have immigrated to America in search of better career opportunities. In turn, U.S. health organizations continue to actively recruit nurses from the Philippines, a practice that has increased in recent years as a result of the current nursing shortage.
“Since the 1960s, there has been an exodus of nurses and physical therapists from the Philippines,” comments Hilda Sadio, RN, BSN, OCN, RNC, a nursing case manager for Covenant Health System in Lubbock, Texas. “They come to America because there are not enough jobs for them in the Philippines.”
After receiving her nursing diploma from a school in Dagupan City, Pangasinan, Philippines, Sadio completed her bachelor’s degree in nursing at Manila’s Far Eastern University in 1969. Three years later she came to the United States, where she has worked in a wide variety of different nursing units within the hospital setting. She spent 17 years in oncology nursing, first as a nurse manager and then as a coordinator.
Sadio’s extensive experience enables her to mentor newly immigrated Filipino nurses and help orient them to an unfamiliar cultural environment—both professional and social. Learning to bridge the cultural gaps, she believes, is vital to these nurses’ success.
Life in America
Learning about a new culture can be a challenging, exciting experience, but it can also be a frustrating one. When Filipino nurses move to the United States, they not only have to learn about American customs and lifestyles but also about this country’s nursing practices.
“Nurses who have recently come here from the Philippines need to learn new technologies, like computerized charting and reading vital signs via monitors,” explains Magdalena A. Mateo, RN, PhD, FAAN, associate professor in the School of Nursing at the Bouvé College of Health Sciences, Northeastern University, Boston. “They also need to have a firm grasp of the language and understand the need to obtain licensure as an RN. They need to learn about visa status, employment contracts, salaries and benefits.” Mateo speaks from experience: She is a Filipino nurse who has lived in the U.S. for 25 years.
Bringing newly arrived Filipino nurses up to speed about American culture and the work environment takes time and effort on the part of both the nurse and the employer. Many large health care organizations in the U.S. that recruit nurses from the Philippines provide on-the-job training as well as orientation programs focusing on what to expect in America.
“The process of acculturation does not happen overnight,” comments Marie F. Santiago, RNC, EdD, associate professor of community/public health nursing at The College of New Rochelle School of Nursing in New Rochelle, N.Y., and founder of the Philippine Nurses’ Network.
“In the Philippines, we have different value systems,” adds Santiago, who has lived in the U.S. since 1967. “It took me a while to become comfortable in this country. For instance, when I first started to work here as a nurse, the tone of voice some Americans used wasn’t what I was used to. But once I became acculturated, I was fine.”
After new arrivals from the Philippines have adjusted to the logistics of their nursing jobs and received training in new technologies, the next hurdle is gaining an understanding of the American social structure and the priorities of American employers.
“Filipinos are very laid-back, easy-going, serene people,” Santiago explains. “The U.S. workplace is very competitive, but we’re not aggressive people. Sometimes that quality can be a hindrance to Filipino nurses’ career advancement.”
Another problem is that some Filipino cultural characteristics and beliefs may be misinterpreted in this country. For example, in the Philippines people show deference for their elders and for people who outrank them in terms of experience or position level. Sadio says she has overheard physicians say of Filipino RNs, “They are very good, hard-working nurses and you can rely on them, but they are very timid.”
The reality, Sadio argues, is more complex. What may seem like diffidence stems from the fact that Filipino nurses’ cultural and religious beliefs have taught them to persevere and not complain. Because they come from a Third World country, she continues, these nurses view the opportunity to work in the U.S. as a chance to prove themselves and to achieve a better life for themselves and their families. Therefore, they tend to work very hard without complaining. Often they take more than one job so they can send money back to their families in the Philippines.
Even after nurses from the Philippines have found their bearings in America, there is still the issue of whether they will want to stay in this country. Family loyalty often causes them to want to return to their homeland. Sadio believes that strong professional support networks can play a key role in determining whether or not Filipino nurses choose to remain on American soil.
“Right now, I have four Filipino nurses living with me until they find a place of their own,” she says. “It’s important for us to support each other and help each other make the cultural adjustments.”
Bringing Cultural Gifts
One of the most valuable qualities Filipino and Filipino-American nurses bring to America’s health care table is their unique understanding of Filipino languages and culture, enabling them to provide culturally sensitive and linguistically competent care to patients who share their ethnic heritage.
“Back when I was a young nurse working in the ICU, a nurse colleague asked me to help her put restraints on a patient because he was confused,” recalls Katherine Abriam-Yago, RN, EdD, associate professor at San Jose State University School of Nursing in California. “As I entered the patient’s room, I realized he was a Filipino man who was speaking in Ilocano, a Filipino dialect, and that he was in pain. I explained this to the nurse and told her that she did not have to restrain him. The patient had received pain medication, but it was not working. I told the nurse to call the doctor and ask for another pain medication order. Restraining the patient would have been an inappropriate intervention.”
Adds Mateo, “Filipino nurses, including those who are born in the U.S., are familiar and adept with Filipino culture and traditions. Filipino-American nurses who were born here learn Filipino customs and traditions through their parents or grandparents. When they are growing up, they are encouraged to participate in cultural and religious activities where they socialize with other Filipino-American children.”
This strong cultural grounding makes Filipino nurses highly attuned not only to Filipino patients’ needs but to those of the patients’ families as well. “Family values are an important part of Filipino culture, resulting in unique health care issues and beliefs,” Mateo says. “For example, Filipino children traditionally care for elderly and sick family members. This custom could be challenging when a patient has a communicable disease. Filipino nurses can play an important patient-education role by addressing ways of preventing the spread of a disease among family members.”
While many Americans openly express their emotions, particularly regarding pain, Filipinos tend to be less vocal about discomfort, Santiago explains. Therefore, Filipino patients’ expressions of pain are often muted or stoic. Nurses who are familiar with this cultural characteristic are more likely to realize that even if the patient doesn’t complain or appear to be in pain, he or she may still need medication or some other treatment.
“Often these patients will suffer in silence and will try to bear the pain as much as they can,” says Sadio. “Many Filipinos are Catholic and are taught to sacrifice and suffer. We rely heavily on spiritual healing; religion is very important to us.”
Another area in which Filipino nurses can make a vital cultural contribution is nutrition, Santiago notes. The traditional Filipino diet is high in red meat and fried, high-fat, salty foods, all of which contribute to coronary artery disease and hypertension, as well as ailments such as gout. Because Filipino patients already understand the diet of their people, they have an edge in communicating with these patients about the connection between diet and health.
Back to School—American-Style
The typical educational level of nurses who emigrate to the U.S. from the Philippines is a bachelor’s degree in nursing. Once they arrive in this country, they often quickly realize that continuing their professional education is important to their careers. While some of these nurses rely on self-education, such as reading or taking a few classes, many begin pursuing advanced degrees or training as nurse specialists at U.S. colleges of nursing.
However, some Filipino nurses working in America encounter obstacles that make it difficult for them to return to school. Nursing education in the Philippines involves extensive clinical experience, making Filipino nurses especially well prepared for jobs requiring direct patient contact. Therefore, because of the urgent nursing shortage in the U.S., many Filipino nurses may remain in these positions for years. Abriam-Yago is concerned that this prevents Filipino nurses from moving up into management roles, nursing education and research.
In addition, strong family ties and the need to send money home to their families in the Philippines can also prevent these nurses from advancing in their careers. Some Filipino nurses work more than one job in order to make enough money to support themselves and their loved ones. As a result, they may not have time to further their nursing education.
Nevertheless, graduate programs at American nursing schools are making an active effort to recruit and retain Filipino nurses. Abriam-Yago says that her academic role at San Jose State University includes advising new Filipino nursing students.
She recalls an experience when a Filipino graduate student told her that she came to San Jose State University specifically because of all the support she would receive there. “She reviewed different types of nursing programs, but they did not offer the support she needed to be successful. We offer a comprehensive student retention program with tutoring, peer and professional mentoring, membership to ethnic nursing students’ associations and financial support.
“I was the founder of San Jose State’s Filipino Nursing Students Association, which was formed in 1998 with support from the Philippine Nurses Association of Northern California,” Abriam-Yago continues. “In 1999, we established the first Philippine Nursing Students Association of America and held our first annual national conference in February 2000.”
With so much to offer, both to their patients and their profession, Filipino and Filipino- American nurses deserve to be recognized as unique and significant contributors to the American health care system. As the number of nurses who come to this country from the Philippines continues to grow, so do opportunities to learn from them and ensure that Filipino patients and their families are provided with culturally and linguistically sensitive care.
You’re Not Alone: Professional and Networking Resources for Filipino Nurses
Philippine Nurses Association of America
Contact: Rosario May Mayor, President
Rosemarie Jeanpierre remembers the cruel comments as if she heard them yesterday. She was riding a crowded bus to work in Los Angeles when a perfect stranger got on and said, “move over, fatso,” as they all jostled for more standing room. Feeling ashamed, she wanted to get off the bus immediately, but kept riding, all the way to her job as a treatment nurse at Western Convalescent Hospital.
At the time, Jeanpierre weighed 220 pounds, and at 5’2″, she was considered obese. In 2003, her doctor told her she had pre-diabetes, a condition of elevated blood sugar and a harbinger for a diabetes diagnosis down the road. She had been overweight her whole life. As a girl in the Philippines, she learned the habit of overeating for emotional comfort. She had the classic symptoms: her blood sugar was “out of control,” yet she felt hungry all the time. She felt short of breath, propping up pillows at night to breathe while sleeping. And her co-workers told her she looked stressed.
“My doctor got upset with me,” Jeanpierre, L.V.N., recalls. “She said, ‘You’re only 39 and you’re a nurse!'” Being scolded by her physician was upsetting, but not nearly as traumatic as dealing with her father’s death of a massive heart attack a few years before. He had been a diabetic and suffered from high cholesterol and high blood pressure as well.,
“That gave me a big realization that I needed to do something about my health,” Jeanpierre says. “I said to myself, ‘I’m a nurse, and I want to set a good example for my patients.'”
In a dramatic reversal of fate, Jeanpierre lost half her body weight in 18 months through a disciplined regimen of exercise and dietary changes. She forced herself to reduce her daily caloric intake from 6,000 to 1,800. The trips to McDonald’s and a local bakery stopped. What began with 45-minute walks on the treadmill gradually morphed into an abiding passion for running. Jeanpierre ran her first marathon in 2005 at the urging of her nephew. Now, she routinely wins shorter distance races in her age division and plans to run the Nanny Goat 100-mile race this year.
Jeanpierre’s story is exceptional, yet could have turned out much differently if she hadn’t found the willpower to change her behavior. Diabetes, heart disease, and hypertension are chronic diseases and are among the leading causes of death in all populations, but more acutely strike minority groups: African Americans, Latinos, Native Americans, and certain Asian ethnicities. They also happen to be diseases where behavioral changes can reverse—or at least mitigate— their impact.
Nurses possess greater knowledge of these illnesses than the average person, but are no exception. In addition, researchers have recently discovered nurses may be particularly vulnerable to developing key risk factors.
Diabetes: bad for our blood vessels
If not properly managed, diabetes sets the stage for poor heart health. Grim statistics prove cardiovascular disease is the leading cause of death among people with diabetes. Two out of three people with diabetes die of heart disease or stroke; a middle-aged person with type 2 diabetes has as much of a chance of having a heart attack as someone without diabetes who has already had one heart attack, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
“Diabetes is a risk factor for cardiovascular disease, and any diabetes education program must include information about heart disease,” says Cristina Rabadán-Diehl, Ph.D., M.P.H., Deputy Director of the Office of Global Health at the National Heart, Lung, and Blood Institute.
In fact, researchers have come up with a special name for the cluster of traits that make a person prone to both diabetes and heart disease: metabolic syndrome, meaning he or she has three out of the following five conditions.
- Excessive abdominal fat
- High levels of triglycerides
- Low amounts of HDL, or “good,” cholesterol
- Fasting blood sugar level of 100 milligrams per deciliter
So how exactly does diabetes compromise cardiovascular health? By adding stress to our circulatory system, which carries blood and oxygen to vital organs and tissues.
In type 2 diabetes, cells become resistant to insulin, the hormone needed to extract sugar from the blood and metabolize it into energy. Having excess sugar, or glucose, in the blood contributes to the deterioration of blood vessels, but researchers have yet to pin down glucose’s specific role in this process.
“Glucose exacerbates the action of other risk factors, [and] the process of atherosclerosis gets accelerated,” says Rabadán-Diehl. Atherosclerosis is the process by which arteries become clogged and hardened by plaque, a waxy substance made of cholesterol, fat, calcium, and cellular waste, thereby narrowing the channel through which blood can flow.
According to Rabadán-Diehl, excess blood sugar could also “stimulate the production of fatty acids, and makes plaque a bit vulnerable.” By producing fatty acids, glucose potentially destabilizes pieces of plaque, moving them through our arteries to potentially form blood clots.
“Glucose likely contributes to the formation of plaque and might also contribute to the instability of plaque, causing particles to drift,” she says.
The narrowing and blockage of blood vessels is the root cause of all major cardiovascular problems, from stroke (caused by blockage of arteries leading to the brain) to coronary heart disease (blockage of arteries leading to the heart) to peripheral arterial disease (blockage of arteries leading to the legs). In addition, more pressure is felt by the arterial walls because of the constricted space through which blood can flow, giving rise to hypertension.
Why nurses are vulnerable
Nurses shoulder a unique burden among health care providers. Not only are they the primary caregivers and conveyers of health information to their patients, but they are often expected to be role models of healthy behaviors. Among nurses who care for diabetic or cardiac patients, the burden is greater since risks for both can be mitigated by behavioral changes like weight loss, dietary modifications, and exercise.
Sally K. Miller, Ph.D., F.N.P.-B.C., and clinical professor of nursing at Drexel University, has studied obesity rates among nurses and their ability to provide weight management counseling to their patients. She links a nurse’s own health status to her credibility among those in her care: “‘Do as I say and not as I do’ is not very effective. People in general put more weight on advice from someone who is modeling that behavior and has been successful in that behavior.”
Yet how easy is it for nurses to maintain a healthy weight and avoid chronic metabolic disorders? Not terribly, according to two studies published last year.
At the University of Maryland School of Nursing, postdoctoral fellow Kihye Han, Ph.D., R.N., and professor Alison M. Trinkoff, Sc.D., M.P., B.S.N., R.N., F.A.A.N., found that nurses who worked long shifts were more likely to be obese than underweight or at a normal weight. Their results, published in the November 2011 issue of Journal of Nursing Administration, show that among the 2,103 female nurses surveyed, 55% were obese and reported less physical exertion and movement in their jobs.
“Long hours affect circadian rhythms,” Han and Trinkoff wrote in an e-mail interview. “Disrupted day/night cycles have detrimental effects on sleep quality and quantity, which are important independent risk factors for obesity, more important than even physical inactivity and high fat intake.”
Han and Trinkoff conclude that nurses who work long shifts might not have the time and energy to participate in regular exercise and that sleep deprivation also stimulates the appetite, forcing nurses to snack during shifts when healthy food choices might not be available.
Nutrition researcher An Pan, Ph.D., goes a step further by solidifying the connection between nurse’s shift work, obesity, and a dispensation towards type 2 diabetes in a study published in the December 2011 issue of PLoS (Public Library of Science) Medicine.
Pan and his colleagues at the Harvard School of Public Health analyzed responses from 177,184 nurses surveyed over a span of two decades. They discovered that a nurse’s risk of developing type 2 diabetes grew in direct proportion to the number of years she worked night shifts. A nurse working night shifts for three to nine years had a 20% chance of becoming diabetic, while that risk jumped to 58% if a nurse worked night shifts for over 20 years.
Weight gain became inevitable after years of working nights, says Pan in an interview: “Women who worked rotating night shifts gained more weight and were more likely to become obese during the follow-up.”
Nurses also say they have a tendency to turn a deaf ear to warnings about their own health, opting to take care of everyone else—patients, spouses, children—first. Eva Gómez, M.S.N., R.N., C.P.N., and a staff development specialist at Children’s Hospital in Boston, waited 13 years before following up on a diagnosis of a heart murmur she received in her 20s. In 2010, she found out she had a misshapen aortic valve, causing her aorta to bulge with backed-up blood. She scheduled valve replacement surgery for later that year and says if she had waited any longer, her aorta could have burst.
“At one point, I said, ‘That cannot be me; that’s something that happens to patients. I take care of people who have this,'” says Gómez, a national spokeswoman for the American Heart Association’s Go Red Por Tu Corazón campaign. “It never occurs to you that it could happen to me.”
Why certain races and ethnicities are at risk
Nurses face serious occupational challenges when it comes to managing their weight and stress level, and those who belong to certain racial and ethnic groups face even steeper barriers.
Latinos, African Americans, and Native Americans are at particular risk for becoming diabetic, while cardiovascular disease remains the #1 killer of all populations, despite race. While genes play a role that researchers are only beginning to understand, lifestyle, socioeconomic, and environmental factors have been the focus of most public health campaigns.
Relying on staples like rice, beans, and bread products and cooking techniques like deep frying, many Latin American cultures eat “diets that are richer in carbs and fats,” says Maria Koen, F.N.P., C.D.E., a bilingual nurse practitioner and diabetes educator at the Joslin Diabetes Latino Initiative in Boston. In addition, “they’re not necessarily having regular exercise as part of their lifestyle [or] making it a priority.”
Getting patients to eat more fruits and non-starchy vegetables remains a challenge, and fast food is perceived as a reward in certain communities. “Going to a fast food restaurant is considered to be aspirational; it’s a treat” among Latinos, says Marleny Ramirez-Wood, Communication Manager of the AHA’s Go Red Por Tu Corazón campaign. “We want to focus our message…in terms of cooking traditional meals, how they can make them healthier, [and] how they can incorporate physical activity into what they’re doing.”
For many ethnic groups, questions about access and affordability arise in conversations about eating healthier, since the corner markets in their neighborhoods may offer nothing more than liquor, cigarettes, and lottery tickets.
“Access to fresh fruits and vegetables is not available in certain communities we’re talking about,” says Lurelean B. Gaines, R.N., M.S.N., Chair of the Department of Nursing at East Los Angeles College and President-elect, Health Care & Education, of the American Diabetes Association. “If it’s not there and you don’t have the means, and with gas prices what they are, you’re not going to drive out of your community to get better food.”
A diabetes educator at the Mattapan Community Health clinic in Boston, Sharon Jackson counsels Haitian immigrants and African Americans from the neighborhood, many of whom work multiple jobs, have no time for exercise, and struggle to manage their disease.
“There isn’t a two-hour stretch where a person who is conscientious isn’t trying to take care of their diabetes,” says Jackson, M.S., R.D., C.D.E., a clinical research program manager at the Joslin Diabetes Center. “Taking care of diabetes is a full-time task…[it] becomes a luxury when you’re in a lower socioeconomic level.”
Managing the deadly three
A nurse’s hectic schedule is often beyond his or her control, especially early on in the career. Scarfing down meals on the go, never getting a decent night’s sleep, working crazy hours to make ends meet, and juggling the demands of work and family life is the norm for many.
These habits take their toll, yet are not simply a matter of individual nurses making bad choices. Institutions play their part in either discouraging or promoting a culture of health for nurses.
One hospital is taking an aggressive approach in helping nurses and other hospital staff get control over chronic diseases like diabetes, heart disease, and hypertension. For the past decade, the Cleveland Clinic has offered its staff disease management programs as part of its employee health plan. Employees are assigned case managers who help them set and reach specific goals related to their condition, says Patricia Zirm, B.S.N., R.N., M.P.H., Senior Director of Employee Health Plans at the clinic.
The clinic is known for its culture of wellness, with nine different fitness areas scattered among its 12 hospitals, reimbursement of gym memberships, a ban on regular soda in vending machines, and healthy food choices in its cafeterias.
Of more than 30,000 employees enrolled in the health plan, approximately 18,000 have one of the diagnoses for which the clinic has a disease management program, and roughly 8,000 are already enrolled in a disease management program.
In 2010, the clinic started to incentivize employee health through a program called Healthy Choice, which ties participation in one of six disease management programs to lower monthly premiums. The six programs are focused on diseases, including diabetes and hypertension, where behavioral changes in diet and exercise deliver a huge impact.
Healthy Choice is a three-tiered system of insurance premiums where the highest level of discount (gold) is awarded to employees who are complying with their disease management goals. In the case of a diabetic, one goal is to maintain a blood sugar level of less than 7%. The silver rate is for employees participating in disease management, but aren’t completely meeting their goals; the bronze rate is the standard rate, where an employee is insured but not enrolled in disease management.
Attaching health outcomes to an employee’s paycheck seems to be a smart strategy. Since 2010, Healthy Choice participation among the staff has tripled. Over the past year, 17% of clinic employees went from the standard rate to the gold rate, and employees are making fewer trips to the ER and are being admitted less frequently to inpatient care, says Zirm. These are all signs of progress, yet work remains to be done.
“Anybody who is doing shift work is more prone to stress, diabetes, and heart disease,” says Zirm. “The clinic tries to do a [favor] of addressing these issues related to shift work…we’re trying to remove barriers, but the fact remains, because of the nature of the job, we can’t fix it for everybody.”
In a year when the Philippine Nurses Association of America is proudly celebrating its 30th anniversary as an important and highly respected presence in our nation’s nursing landscape (see Directing Our Destiny), it might seem strange that the immigration of Philippine nurses to the U.S. could still— after all these years—continue to be a source of controversy. But consider this email I recently received from a reader named Janet Christian:
“I have one important question on behalf of all nurses who graduated from American nursing schools by taking out lots of loans and making a significant difference in the U.S. economy,” she writes. “Why should they do so when hospitals want to hire or import nurses from [outside the U.S.]? Hospitals in the state of New York are filled with Philippine nurses. [People] who are stakeholders for NCSBN (the National Council of State Boards of Nursing) and CGFNS (the Commission on Graduates of Foreign Nursing Schools) have special interests, and hospitals have their own interests, but what about the future of our children, who want to be nurses but [can’t find jobs] because hospitals are looking for cheap labor from overseas?”
It would be easy to dismiss this as just the grumbling of one disgruntled nurse who may be having a tougher than usual time trying to compete in a recessionary job market. But some remarkably similar comments surfaced this past August during the National Black Nurses Association’s 2009 annual conference in Toronto, Canada—the first-ever NBNA convention to be held outside the U.S. After a presentation on international nurse migration and global health by CGFNS chief executive officer Barbara Nichols, someone in the audience who introduced herself as a faculty member at a nursing school in California complained that “foreign nurses are being hired for jobs that should be going to my BSN graduates.” Someone else pointed out that even President Obama has said he wants to reduce America’s dependence on foreign-educated nurses.
Nichols’ response to these comments was—as they say on the public radio quiz show “Whad’Ya Know?”—well-reasoned and insightful. (As the barrier-breaking first African American president of the American Nurses Association, Nichols knows a thing or two about territorial prejudices in nursing.) And since Janet Christian, as well as other nurses who share her sentiments, were presumably not there to hear it, Minority Nurse is happy to pass it along. First of all, Nichols argued compassionately, nurses in the U.S. must be careful not to scapegoat nurses from the Philippines, Africa, India and elsewhere who come to our country in search of a better way of life for themselves and their families. These nurses have every right to arrive here in pursuit of the American dream, just as so many previous generations of immigrants have done. The foreign nurses themselves are not the problem, Nichols emphasized; the real problem is that certain U.S. health care employers must stop hiring nurses from overseas simply because they can pay them less than American nurses.
There are other reasons why some hospitals in this country prefer to fill their staffing needs with foreign-educated nurses rather than U.S. nursing graduates, Nichols continued. Nurses from overseas are more likely to have BSN-level education than American nurses, as well as more work experience. Secondly, many of today’s newly graduated U.S. nurses are reluctant to pick up and move to where the jobs are—such as rural and underserved areas. And some hospitals have learned the hard way that many of these new grads— unlike “imported” nurses—tend to not stick around for more than a year or so once they’re hired.
These are all issues that nurses can work toward addressing, both collectively and individually. Through nursing unions, professional associations and political activism, nurses can try to influence health care employers to adopt fairer hiring practices. And some individual nurses may need to take an honest look at how they can increase their marketability to employers—e.g., by advancing their education. Together, nurses can find some viable answers to Ms. Christian’s “one important question.” But blaming foreign-educated nurses shouldn’t be one of them.