Congratulations, Minority Nurse Scholarship Winners!

Another year, another record-breaking number of applicants, and another group of nurses and soon-to-be nurses that overwhelmed us with their determination, dedication, compassion, and intelligence. Choosing our scholarship winners has always been a difficult task, and this year was no exception. But after much deliberation, we are so proud and thrilled to introduce our winners to you! We hope their stories resonate with you just as they did with us.

And just as we reveal this year’s winners, we invite you to send in your applications for next year’s scholarship. To apply for the Minority Nursescholarship, you must:

  • Be a racial or ethnic minority.
  • Be enrolled (as of September 2013) in either the third or fourth year of an accredited B.S.N. program in the United States or an accelerated program leading to a B.S.N. degree (such as R.N.-to-B.S.N. or B.A.-to-B.S.N.) or an accelerated master’s entry program in nursing for students with bachelor’s degrees in fields other than nursing (such as B.A.-to-M.S.N.). Graduate students who already have a bachelor’s degree in nursing are not eligible.
  • Have a 3.0 GPA or higher (on a 4.0 scale).
  • Be a U.S. citizen or permanent resident.

We encourage you to apply for the 2013 scholarship and look forward to reading your application!

First-Prize Winner, Shylisa Hicks

Born in San Diego, Shylisa Hicks now lives in Bastrop, Louisiana, and attends Grambling State University. She belongs to a litany of nursing associations, volunteers her time, and has bright plans for the future.

But it is Shylisa’s life story, one of overcoming seemingly crushing adversity, that truly inspires. Her father was killed when she was five years old. Child Protective Services removed Shylisa from her mother’s home at 10 years old. She went to live with her grandmother, then aunt and uncle, where she stayed.

Originally two grades behind her peers, Shylisa persevered and eventually graduated high school early as an honors student. She continued her honors course work at Grambling State.

Bubbly and laughing, Shylisa says she calls her aunt and uncle mom and dad. “I wouldn’t be anywhere with out my parents,” she says. “I appreciate it all.” She also credits her success to her supportive husband—also her high school sweetheart. She hopes to one day have two children of her own.

“I really wanted a big family,” Shylisa says, and she grew up with three siblings. “I love kids . . . especially to make them feel better when they’re sick.” She currently treats children and families in their homes. “I just fell in love with it,” Shylisa says.

Shylisa plans to obtain a doctoral degree and become a certified Sexual Assault Nurse Examiner (SANE). “Somebody has to do it,” she says. “I want it to be me….I’ve had a rough life myself.”

“It’s been a bumpy road, but I love it,” Shylisa says of her nursing education. She is excited for the future, and she intends to go back to school to become a Nurse Practitioner, eventually going on to establish a pediatric clinic.

Runner-up, Sandrine Nankap

Now living in Winchester, Virginia, where she attends Shenandoah University, Sandrine Nankap grew up in Cameroon, on the West coast of Africa. Hundreds of people in her country live in poverty and die of AIDS due to lack of knowledge and resources, she says. Though she volunteered with children and teens to teach them about HIV/AIDS prevention, Sandrine wanted to do more.

The fourth of seven children, Sandrine says her parents could only afford to send one of them to school. “They put all their money on me,” she says. “They did their best to encourage me in everything I wanted to do.” In her culture only men are thought to deserve schooling, to lead a family, Sandrine says. “I had a lot of pressure to be a successful woman.”

Ranked high in her secondary school class, Sandrine wanted to educate others and make a difference in their lives, so she went to nursing school, graduating in 2004. In 2008 she was “blessed with the opportunity to come to America,” hoping to become a nurse educator, combining two professions in which she believed strongly.

But upon arriving in America, Sandrine found she did not have enough money to support the continuing education needed and her two young children. “As a single mom, I started to work as a coffee maker at Dunkin Donuts for almost one year.” She was promoted to assistant manager. “Working with that company, I kept some money that allowed me to go for my nursing assistant training.”

Within two months, Sandrine took a job as a nurse assistant. It was one of her lucky breaks, she says. The other nurses counseled her, taught her. “They helped me achieve my dreams,” she says. “I passed [the NCLEX] on the first try and today, after all this struggle and tears, I am proud to be a registered nurse.” She still wants to become a nurse educator, teaching both in the United States and Cameroon.

In five years, she’ll be pursuing her doctorate, Sandrine says, and she’s starting her master’s course work next year. “I like to learn. I love knowledge,” she says in a soft yet steady voice. “I worked so hard for everything that I have….I have a lot of ambition.”

Sandrine says she wants to send her younger siblings to schools as well. She sends them whatever money she can so they can come to America too. Sandrine also wants to return to Cameroon to help other young women become nurses. “I’m really grateful for this opportunity to be what I want to be in life,” she says.

Runner-up, Cerilene Small

“Every morning I wake up and begin my daily rituals of feeling the left region of my face,” says Cerilene Small. She keeps her eyes shut, afraid she will open them and be unable to see. It’s happened in the past, and because she has multiple sclerosis, it could happen again. Cerilene was diagnosed in 2009.

A competitive African dancer, Cerilene first knew something was wrong when she lost feeling in her body—but her mother thought it was due to her dancing all night. Then, after months of inconclusive tests, she learned she had MS.

“It was really hard” going into senior year, Cerilene says. She was scared of going anywhere, hopeful but cautious of what her future might hold. Originally from Brooklyn, Cerilene applied to New York University undecided, but after spending a month in the hospital, she says she realized she wanted to become a nurse. “My nurses really had a strong impact on my recovery,” Cerilenesays—so much so that she redid her college applications.

Now enrolled at NYU, Cerilene started classes in February 2011, and she had her first MS “flare up” not long after. She says she has about one flare-up each semester, but she’s trying and adjusting to the effects of a new treatment.

Being an honors student, a high school valedictorian, and a first-generation student, they all pale in comparison, Cerilene says, to being able to take advantage of every day “as a leader.” She mentors other first-generation students and one day hopes to open a youth health center offering free clinical services. She aspires to pursue a five-year dual degree (B.S.N./M.S.N.) in pediatric nursing.

Become familiar with the population you want to serve, Cerilene advises soon-to-be nurses. “Try to get involved before clinicals.” Know that the work is hard, but learn to “be a leader on your own.” After that, just “have faith,” she says. “You’ll do fine.”

English Language Learners: Uneven Odds

Professional nursing programs in the United States are rigorous and demanding, particularly for students whose first language is not English. Language, culture, and academic expectations are the most common areas of difficulty for those who teach multicultural students. According to recent research, early academic interventions, tutoring, and culturally sensitive educational practices can foster success and promote a more ethnically diverse nursing community.

Many nursing schools are admitting record numbers of students categorized as English Language Learners (ELL). In fact, the number of ELL students seems to be growing more rapidly than the general student population. The National Center for Educational Statistics reports the U.S. population grew 9% between 1993 and 2003; the ELL population increased by 65% during that same time. Now, ELL students comprise over 10% of all students.

Faced with completing assignments in a language they are not comfortable with, ELL students tend to score lower on standardized tests and receive lower grades than their English speaking classmates. Their teachers even sometimes perceive them to have lower academic abilities, according to research by Moss and Puma, 1995.

In 2002–2003, baccalaureate and graduate nursing program enrollment indicated that 21.6% of nursing students came from minority populations. However, there are no clearly outlined procedures for identifying ELL students in higher education. Determining the exact criteria for classifying the ELL student has been controversial. Poor classification of ELL students results in insufficient annual reporting and inadequate provision of student services.

There has been minimal research associated with the challenges experienced by ELL students. Some researchers have posited that one of the reasons may be that researchers do not have the patience to listen to someone with an accent. Increased diversity in our nation’s college classrooms and communities, including new immigrants from many different parts of the world, requires greater understanding of student education needs.

In order to accelerate nursing academic progress in the next decade, schools of nursing must consider recruitment, acceptance, and graduation of culturally diverse nursing students. This will require change in the current education system, with specific improvements to address challenges faced by international nursing students and students who speak English as a second language. The following research gives a voice to the obstacles encountered by the English language learner nursing student.

Achieving a higher education requires a partnership between student, teacher, and institution. The successes of each entity are interdependent. Ten ELL nursing students enrolled in two separate associate degree in nursing programs in San Antonio, Texas, were interviewed. The goal of the interview was to identify and describe unique challenges experienced by students who speak English as a second language. The group was representative of nine nationalities and fluent in a total of 15 languages. It was concluded that student success was based on four areas: student study habits, student distress, student support system, and student learning tasks.

Student study habits included a tedious, time-consuming approach to reading assignments. Often students reread an assignment several times in order to grasp its true meaning. Additionally, the students described their exam study habits. The single most helpful study method was reviewing the National Council Licensure Exam (NCLEX) practice questions. Personal study habits, including reading practices, note taking, small study groups, use of printed lecture PowerPoint handouts, and reviewing websites, were also described.

ELL students also reported an increase in stress related to their relationship with their instructors, lack of time to complete exams, and anxiety around approaching teachers with questions. More importantly, they felt unable to communicate clearly in English, resulting in a negative self-image.

The study demonstrated that participants had a strong desire for emotional support. First, ELL students valued a positive relationship with their nursing faculty. Second, students showed progress and confidence in the nursing program based on strong emotional support from their family and friends.

Student learning tasks comprised three areas: nursing vocabulary comprehension, confidence to speak publicly in English, and comfort level posing a question during class. The single most important point discerned was the students’ needs to comprehend nursing vocabulary. Use of study guides and Internet tools, along with repetitive verbalization of terms, developed both vocabulary as well as English language confidence. Posing questions in class is something English speaking instructors and students take for granted. ELL students are perceptive and sensitive about their ability to correctly pronounce English terminology. Inability to ask a question in class hinders a student’s learning experience. A silent suffering is taking place as it applies to English communication skills.

By the year 2020, non-white American citizenship is expected to rise by 50%, according to the U.S. Census Bureau, 2000. English Language Learners seek higher education, so institutions of higher learning, nursing instructors, and students must all come together to understand what processes are needed to create success for this group of students. ELL students will become a larger part of nursing classrooms, as is reflected in their demographic advancement.

Said one male participant from Burundi, Africa: “I came to study. And I believe that if I study, I can—I can succeed!”

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

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

Rosario May Mayor, MSN, RN.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 <a class=Kansas in 1966.” width=”330″ src=”/sites/default/files/articles/06-06-06-5c.jpg” />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.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. 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, CNORFilipinas 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


In Our Own Backyard

When she came to Houston, Texas, from Mexico four-and-a-half years ago, Martha Martinez was working in a laundry and getting by with limited knowledge of English, never imagining that she was just like hundreds of other foreign-trained nurses who had strong nursing skills and experience but lacked the tools to get a license to practice in the U.S.

Then she heard about a meeting for immigrant nurses at the Lyndon B. Johnson General Hospital in Houston, and she was thrilled to find that she was not alone.

Months later, with the support of her newfound friends in the Nurses Helping Nurses program, Martinez cleared the hurdles to become a licensed RN in Texas. Now she has a job in a family practitioner’s office and is helping other Spanish-speaking immigrant nurses follow the same path toward returning to the profession they had practiced at home.

“When I worked in the laundry, I was proud to be a nurse,” says Martinez. “People told me, ‘You’re nothing here. You don’t speak English. You’re nothing.’ But I told them, ‘I can do it, and I’m going to do it.’

“It’s good to belong to an organization like [Nurses Helping Nurses],” she adds. “You can help other people [who are in the same situation]. We can help each other instead of being part of the minority. Maybe someday we can be part of the majority.”

The Nurses Helping Nurses program is one of several efforts being conducted by local chapters of the National Association of Hispanic Nurses (NAHN) in different parts of the nation to help immigrant nurses from Spanish-speaking countries strengthen their English and the other skills they need to obtain U.S. licensure. NAHN (, headquartered in Washington, D.C., represents the interests of more than 40,000 Hispanic and Latino nurses and nursing students coast-to-coast.

An Untapped Resource

Jacqueline Crespo Perry, RN, an emergency room nurse at LBJ General Hospital and president of NAHN’s Houston chapter, got the idea for starting the Nursing Helping Nurses program a little over a year ago when she encountered a Mexican nurse who was serving up burgers at a local Jack-in-the-Box because she did not know how to go about getting credentialed to practice in the U.S.

Like most other parts of the country, Texas is struggling with a severe nursing shortage. Last June, for example, the LBJ emergency room where Perry works had to shut down temporarily because of inadequate RN staffing levels. Perry began to wonder how many other skilled and experienced foreign-licensed nurses were out there working low-paying jobs when they could instead be making a valuable contribution to the state’s urgent nursing-care needs.

In September 2000, Perry organized an open house at the hospital to gauge the number of new immigrant nurses in the Houston area. She expected that about 200 people would show up. Instead, 1,000 nurses came, including Martinez.

Perry and other NAHN chapter presidents who have organized similar programs in Dallas, Philadelphia and elsewhere point out that some hospitals spend thousands of dollars to bring foreign nurses to the United States to solve their staffing shortages, but they overlook a vast resource pool in their own backyards. With the right support and funding, licensing-preparation programs to help immigrant nurses who are already here can be started up easily anywhere in the country, they maintain.

“I found out that local hospitals are paying $30,000 to bring just one nurse over here from the Philippines,” Perry says. “Why spend that kind of money when you can invest in nursing talent right here in Houston? That’s beyond me.”

Measuring the Need

According to the Chicago-based National Council of State Boards of Nursing, Inc. (NCSBN) there is no way to measure exactly how many recently immigrated nurses from Mexico, Latin America, South America and elsewhere are working outside their profession in the U.S. But it’s easy to see the critical need for getting them into the RN workforce just by looking at a snapshot view of Houston.

The Greater Houston Partnership, an economic development group, is one of several local organizations that are providing funding for the Nurses Helping Nurses program because of concerns about the growing gap between the Hispanic share of the city’s population and the number of Hispanics employed in the health care sector.  The partnership conducted a joint study with the Gulf Coast Workforce Board and found that Hispanics currently make up more than 25% of Houston’s population. That number is expected to increase to more than 30% before 2010.

However, in 1998 only 12% of the city’s health care workers were Hispanic, and Hispanics accounted for only 6.5% of the local RN workforce.

Karen Love, health industry liaison for the partnership, says her group has provided a $20,210 grant to Nurses Helping Nurses to pay for the initial assessment of each of the 50 participants currently enrolled in the program.

“The assessment will tell us what assistance these nurses need in order to take the licensing exam,” Love explains, adding that those needs can range from “minimal brush- up classes” to extensive retraining for nurses who have not worked in the field for several years.

A Slow Process

Why are so many immigrant nurses washing clothes or serving fast food when they should be caring for patients? From learning the English language and American medical procedures to finding the money to pay for training courses, foreign-educated nurses have a number of hurdles to clear before they can become licensed, says Judith M. Pendergast, RN, JD, marketing and communications director for the Commission on Graduates of Foreign Nursing Schools (CGFNS) in Philadelphia. Moreover, those hurdles vary from state to state.

Part of the process in most states is successful completion of an English proficiency test, such as the Educational Testing Service’s Test of English as a Foreign Language (TOEFL) or the Michigan English Language Assessment Battery (MELAB).

In addition, says Pendergast, most states, including Texas, require nurses to hold a CGFNS certificate. This is obtained through passing a predicator test of nursing knowledge, validation of the license from the nurse’s native country, certification that the nurse’s education was comparable to that in the United States and passing an English proficiency test.

Some states, however, require the nurse to only have the certification of education comparability and license verification, according to Pendergast. Once those requirements are met, the nurse can take the NCLEX exam.

Because some states present foreign-trained nurses with more barriers to licensing than others, programs like Nurses Helping Nurses have helped some participant become “licensed by endorsement” to get around lengthy procedures in their states. Martinez, for example, got her license this May in Florida, which had fewer hurdles than Texas, and then submitted it to Texas to practice there.

Statewide in Texas, the number of licenses issued by endorsement has increased from 3,438 in fiscal year 2000 to 3,843 in FY 2001, says Bruce Holtzer, spokesman for the Texas Board of Nurse Examiners in Austin, although he could not break down how many of those licensees were foreign-educated nurses.

Even though this relicensing process is rigorous and lengthy, it’s necessary to insure against fraud, says Barbara L. Nichols, RN, MS, DHL, FAAN, chief executive officer of CGFNS. Because it’s easy to create fake paperwork in some countries, she explains, U.S. licensing organizations must make sure the person applying for licensure is really a bona fide nurse.

“Fraud is a problem in the international arena, and [lengthy licensing procedures] are the price to pay to protect the American public,” argues Nichols, who is African American. “I think what we have to tell [foreign-trained nurses] is that they have to start early and be patient, because it’s not going to happen quickly.”

Making It Work

Houston’s Nurses Helping Nurses is actually the newest of the NAHN-sponsored projects designed to help Spanish-speaking immigrant nurses achieve their goal of becoming licensed to practice in the U.S. Ada Granado, RN, BSN, president of the association’s Dallas chapter, has been spearheading a similar program in her city since 1998.

Granado, a respiratory care nurse at the Children’s Medical Center in Dallas, says that like Perry, she held a community meeting for potential participants and about 500 people showed up. She weeded out those who were not in nursing, such as doctors and pharmacists, narrowing the group to 60.

The next step was to ascertain how well each of the nurses spoke English. Eventually, 35 of them were determined to have a good enough grasp of the language to be enrolled in a class to prepare them to take the boards. The rest were advised to work intensively on their English and wait for the next year’s class.

The first course started in February 1999 and ended that July. The classes were taught in English by chapter members and other local nursing professionals, and the only cost to the students was a one-time fee of  $100 to cover copying and other expenses. The participants, who were natives of Peru, El Salvador, Mexico and Puerto Rico, were asked to sign a contract stating that they would finish the class–and all of them did finish it, even two students who had had babies during that period and one who was injured in a serious auto accident.

“That first graduation was so emotional,” Granado says proudly.

Following the success of the first course, a second one was held in 2000, this time with 23 students. “All the instructors were volunteers and were considered experts in their fields, such as pediatrics,” Granado notes. “We had major reviews for the different areas of nursing.”

Since then, Granado has forged a partnership with the Dallas-Fort Worth Hospital Council, which has held six meetings in the area to recruit participants for the next course. About 75 people showed up to each meeting, and that group has been whittled to 25 for a class to start in January. This class will be offered to the students completely free of charge.

“The secret to making it work is giving encouragement to these nurses and being available to them,” Granado believes. “When they have questions, you can’t forget about them. They want to know that they can reach you, in case they need help.”

For many of these immigrant nurses, she continues, the process of adjusting to a new country, language and culture can be very intimidating. Many of them come from cultures where women are expected to not be assertive, and having to work menial jobs instead of continuing their nursing careers takes a toll on their self-confidence. “They feel lost,” Granado explains. “I feel for them.”

Although Nurses Helping Nurses in Houston has been holding classes for only a year, Perry too reports that her students are doing well. In January 2001 her group started working with Houston Community College, which funded English classes with an emphasis on medical terminology.

“The students had to learn how do things like read a chart–anything having to do with medicine,” she says. In addition to attending classes twice a week for three hours a night, the students also got together to study on weekends.

Perry has nothing but praise for the nurses in her program. “They were excellent. At the end of each class, after they had finished with their instructor, they would get together in groups to tutor each other. They would take each part of the body and review it in English and Spanish.”

Now Perry has the support of the Greater Houston Partnership to help cover the cost of program’s next phase: the nursing review course to help students prepare for CGFNS certification. Other students who need extra help with their English will go to the University of Houston for courses, she says. The students themselves pay for their books and other classroom expenses through fundraisers, such as garage sales.

To help ease the students’ transition back into the nursing workplace, both Perry and Granado encourage program participants to try to find opportunities to work in health care-related fields, even if they have not obtained their licenses yet.

“One of the things I require is that you can be a volunteer, such as a nurse’s aide,” Perry tells students. “Where I want you is in a hospital, a clinic. You need to be in a medical environment so you can get to know how nurses work in America. Try to notice the major differences between our country and yours. Ask, ‘What do you call this in English? This is what I call it in Spanish.’”

From the Island to the Mainland

Meanwhile, in Pennsylvania, Maria Teresa (Tere) Villot, RN, BSN, president of NAHN’s Philadelphia chapter and women’s coordinator at the Veterans Administration Hospital of Philadelphia, started a program in 1992 to help immigrant nurses from Puerto Rico stay current with their licenses.

Since Puerto Rico is a U.S. territory, nurses from that country who work in the federal sector can apply for a permit to work as RNs in America under their Puerto Rican licenses for one year. But to continue working, they must take the NCLEX review after that year is up. If they don’t pass, they can retake the NCLEX once every 90 days.

Three-and-half years later, Villot’s program had expanded to also include nurses working in the private sector. Professors from area nursing schools volunteered to teach nursing reviews. Then members of the Philadelphia NAHN took over, providing coaching on how to pass the exam and, if necessary, assistance with English proficiency, such as referring the students to agencies where they could take English classes for free.

Initially, participants in the NAHN program only had to pay the $60 application fee to renew their license, and those who did not work at the VA paid an additional $5 for the course. However, Villot says, “We now have about four nurse practitioners in our chapter and they offer the classes for free.”

NAHN members also conduct mock job interviews for students, to improve their English skills in that area, she adds. “That has been really helpful for the students, because even though we speak their language, we pretend that we are supervisors. So there’s no Spanish allowed.”

In the early days of the program, the students also met at Villot’s home. One student would take a mock NCLEX review exam on Villot’s home computer while the others watched videos of local university professors giving tips on how to take the exam. Now, however, Villot makes copies of the test and videos, and the nurses study at their own homes.

The current class includes two Cuban nurses in addition to the Puerto Rican students. And the chapter is also reaching out to help people who are unable to take time off from their jobs to participate in the program—such as former nurses who are currently working in factories or as nursing assistants. “For those who can’t come to our courses, we try to identify agencies in the community where they can go to take English classes,” Villot says.

Slowly But Surely

Again, this is a long process that takes time and patience. But slowly these programs are beginning to make a difference. Since the Philadelphia project’s inception, for example, seven nurses have gotten their licenses and many others are still making their way through the program.

Although several dozen nurses have passed through the programs in Texas, Martinez is currently the only one in the Nurses Helping Nurses group who has become an RN. However, another student in Houston, Adriana Isaza, has passed the CGFNS. A nurse from the Dallas program has passed the NCLEX and moved to California. About five others in Dallas are now eligible to take the NCLEX, Granado says, but she wants them to brush up on their English skills first.


Isaza, who worked in dialysis and renal transplants for nine years in her native Colombia, says she studied for the CGFNS constantly–“with my daughter, in my house, in my car.” She hopes to get her license in June.

“I would tell others [in my situation] to study very hard, because it is possible to get the license in this country,” she advises. “You are a nurse, and this country needs nurses. I never lost hope.”

Minerva Betances, who came to the U.S. from Puerto Rico, took the first class that was offered by the Dallas group. She says her English is not fluent, but it’s enough for her to get by on. Her advice to immigrant nurses like herself: Be assertive about learning the language and the culture.

“Take a good English course,” she emphasizes. “And then try to look around and see where the people are who can help you. Don’t stay home waiting for someone to knock at the door and say, ‘Hey, are you a nurse?’”

Christina Escamilla, the nurse who works at the Houston Jack-in-the-Box, was a surgical assistant for six years in Mexico before moving to the United States. She’s also mom to two pre-school daughters and a baby boy, but she insisted on keeping up her studies in spite of family demands. Escamilla is taking an English class at Houston Community College and is working toward taking the CGFNS next year.

“I want to be in my profession,” she says. “I want the best future for my family.”

Often, says Perry, the students in her program have all the skills necessary to become credentialed to practice in America—they just need encouragement to push themselves to get their licenses. She says she had to prod Martinez to go for her license in Florida.

“She was saying, ‘I’m not ready for this,’” Perry recalls. “I told her, ‘What have you got to lose? You have to take the exam. You paid the money. If you fail it, you study again. What if you pass? If you don’t go at all, you’ll wonder for the rest of your life.’ I said, ‘Just leave it in God’s hands and He’ll decide what He is going to do.’ And she passed it!”

Giving Voice to the “Invisible Minority”

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
[email protected]