Philippine Nurses in The U.S. - Yesterday and Today

During the mid 20th century, thousands of nurses from the Philippines migrated to the United States in search of the American dream. Today a whole new generation of nurses is following the trail they blazed.
By Barbara Marquand

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

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

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

A Historical Perspective

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

Exchange student Josephine Villanueva (second from left) at the University of Kansas in 1966.The first big wave of nurses from the Philippines came after 1948, as part of the Exchange Visitor Program. This program allowed people from other countries to come to the U.S. to work and study for two years to learn about American culture. Originally the program didn’t target the Philippines or nurses specifically but was created to combat Soviet propaganda during the Cold War by exposing foreigners to U.S. democracy, Choy explains. But because of the strong relationship between the two countries, a large percentage of the exchange visitors came from the Philippines, and many of them were nurses.

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

Another big upsurge in migration from the Philippines occurred after 1965, when U.S. immigration laws—which had favored northern European countries—were changed, allowing more people from the Philippines and Asia to immigrate. The new law also allowed nurses to come here on tourist visas even without prearranged employment, says Reuben Seguritan, JD, a Filipino American attorney who is general counsel to the PNAA.
Meanwhile, entrepreneurs in the Philippines set up more nursing schools to meet the demand, and the number of nursing graduates soared. In the 1940s there were only 17 nursing schools in the Philippines, compared to 170 in 1990 and more than 300 today, says Choy.

Easing the Transition

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

Exchange student Josephine Villanueva being greeted at the airport by KU nursing students.“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.
Exchange student Josephine Villanueva posing with KU roommate Debbie Hardman. Some newcomers from the Philippines working in U.S. health care facilities feel embarrassed to talk and ask questions, says Cheri Nievera, BSN, RN, a staff nurse in the cardiothoracic ICU at Barnes-Jewish Hospital in St. Louis. Homesickness can be a problem, too, she adds. “Emotionally it’s very challenging being alone and away from their families.”

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

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

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

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

Filipinas Lowery, MA, RN, CNORFilipinas 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 the 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. (See sidebar.) And now a growing number of physicians trained in the Philippines are switching to nursing to take advantage of the opportunities abroad. An estimated 4,000 Filipino physicians are currently enrolled in nurse training, according to Rey Rivera, MA, EdM, RN, CCRN, CNAA, BC, ANP, senior director of nursing at The Brooklyn Hospital Center in New York and education chair of the PNAA.

As president-elect of the PNAA, Mayor is in beginning talks with the World Health Organization about the need for initiatives that would encourage return migration. These issues were also addressed at a joint conference held in January by the PNAA and its counterpart in the Philippines, the Philippine Nurses Association. And nursing leaders are working on creating more structured visiting programs for U.S.-based nurses traveling to the Philippines.
Although the brain drain is a serious problem, Philippine nurses’ desire to leave their homeland in pursuit of the American dream is, then as now, understandable and even inevitable. There aren’t enough jobs at home for all the nurses who graduate from universities in the Philippines, Lowery points out.

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


Barbara Marquand is a free-lance writer based in Reno, Nevada.