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Immigrant Filipino nurses in Western Canada : an exploration of motivations and migration experiences… Ronquillo, Charlene Esteban 2010

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 IMMIGRANT FILIPINO NURSES IN WESTERN CANADA: AN EXPLORATION OF MOTIVATIONS AND MIGRATION EXPERIENCES THROUGH ORAL HISTORY  by   Charlene Esteban Ronquillo  BScN, McGill University, 2007     A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING   in    The Faculty of Graduate Studies      THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   August 2010     © Charlene Esteban Ronquillo, 2010  ii  ABSTRACT   Over the latter half of the twentieth century, a steady increase in the numbers of immigrant Filipino nurses have been incorporated into the Canadian healthcare workforce, mirroring trends of international nurse migration to other Western countries. Yet, there is a paucity of information on the contexts surrounding the motivations and experiences of this group of migrants who work as registered nurses in Canada. This study aims to add a historical perspective in order to understand the historical contexts surrounding this phenomenon, to gain an informed understanding of past and current trends, and more importantly, to examine what surrounded and shaped the experiences of immigrant Filipino nurses. This study explores the oral histories of nine immigrant Filipino nurses in Alberta and British Columbia who migrated from 1974 to 2005, and aims to take the beginning steps in understanding this migration phenomenon in the Canadian context.  The findings revealed that the motivations and experiences of migrant Filipino nurses were significantly influenced by the lasting effects of the historical colonial relationship between the US and the Philippines. Other important influences, however, include familial pressures and societal constructs of Filipino culture, the structure of nursing education in the Philippines, and issues of racism. These factors also shaped the transition process of the registered nurses into the Canadian workforce. With more attention and resources currently being directed at addressing foreign nurse transition and work integration in Canada, findings of this study prompt a critical reflection on these current trends and includes in the conclusion important implications on policy development for future foreign nurse immigrants entering Canada. The study concludes that  iii  social and cultural factors as much as economic ones shape nurses desire to migrate as well as their transition into the Canadian nurse workforce.  iv  TABLE OF CONTENTS  ABSTRACT ................................................................................................................................... ii TABLE OF CONTENTS ............................................................................................................ iv ACKNOWLEDGEMENTS ....................................................................................................... vii DEDICATION............................................................................................................................ viii CO-AUTHORSHIP STATEMENT ........................................................................................... ix CHAPTER 1  INTRODUCTION ................................................................................................ 1 1.1 Background .................................................................................................................... 1 1.2 Problem Statement ......................................................................................................... 2 1.3 Research Questions and Study Objectives .................................................................... 3 1.4 Literature Review ........................................................................................................... 4 1.4.1  Global Nursing Migration ....................................................................................... 4 1.4.2  Migrant Nurses in Canada ...................................................................................... 6 1.4.3  Nursing, Colonialism, and Foreign Presence in the Philippines ............................. 9 1.4.4  Capturing Nursing Migration Experiences Through Oral History ....................... 11 1.5 Outline of Thesis .......................................................................................................... 12 1.6 References .................................................................................................................... 14 CHAPTER 2  BEYOND GREENER PASTURES: CONTEXTS SURROUNDING FILIPINO NURSE MIGRATION TO CANADA ................................................................... 16 2.1 Introduction .................................................................................................................. 16 2.2 An Oral History Perspective ........................................................................................ 18 2.3 Methodology ................................................................................................................. 19 2.3.1 Sample....................................................................................................................... 21 2.4 Immigrant Groups in Canada ..................................................................................... 22  v  2.5 Why Immigrate? ........................................................................................................... 24 2.6 The Culture of Migration ............................................................................................ 26 2.7 Nurse Survivors – Move It or Lose It .......................................................................... 31 2.8 It’s Nursing or Nothing – Family Dynamics and Cultural Pressures ....................... 35 2.9 Challenges in Co-creating and Interpreting the Narrative ........................................ 43 2.10 Conclusions .................................................................................................................. 44 2.11 References .................................................................................................................... 47 CHAPTER 3  LEAVING THE PHILIPPINES: ORAL HISTORIES OF NURSES’ TRANSITION TO CANADA .................................................................................................... 51 3.1 Introduction .................................................................................................................. 51 3.2 Oral History – The Method and Framework .............................................................. 52 3.3 Sampling and Recruitment .......................................................................................... 53 3.4 Participant Demographics ........................................................................................... 54 3.5 Transition of Global Nurse Migrants .......................................................................... 55 3.6 Nurse Immigration History: Race, Gender, and Identity ........................................... 58 3.7 Narrative Themes ......................................................................................................... 59 3.7.1 Get In Where You Can ............................................................................................. 60 3.7.2 Family First, Nursing Later ....................................................................................... 68 3.7.3  Nursing in Canada: Different Expectations .......................................................... 73 3.7.4  Being Foreign: Proving Self and Perceptions of Racism...................................... 78 3.8 Discussion and Future Directions ............................................................................... 83 3.9 Conclusions .................................................................................................................. 85 3.10 References .................................................................................................................... 86 CHAPTER 4  CONCLUSIONS ................................................................................................. 90  vi  4.1 Limitations .................................................................................................................... 94 4.2 Contribution to Field of Study and Potential Applications ........................................ 95 4.3 Future Directions ......................................................................................................... 96 4.4 References .................................................................................................................... 97 Appendix A  Invitation Letter ................................................................................................... 98 Appendix B  Ethics Consent Form ............................................................................................ 99 Appendix C  Demographic Questionnaire .............................................................................. 102 Appendix D  Oral History Interview Script ........................................................................... 104 Appendix E  Ethics Approval Certificate ............................................................................... 105     vii  ACKNOWLEDGEMENTS   I am indebted to my supervisor, Dr. Geertje Boschma, for her enthusiasm and constant support not only throughout this project, but also in my own development as a student and researcher. Thank you for your efforts, and for always keeping my best interests at heart. To my thesis committee, Drs. Linda Quiney and Sabrina Wong, thank you for your contributions and feedback which were instrumental in fine-tuning this work. It has been a pleasure and privilege to work with you.  To my parents, for their unconditional love and support. To my sisters, thank you for being amazing. To those I hold dearest, simply, thank you. I thank Sheryll Mah, Bellie Ronquillo, and Charisse Ronquillo, the nurses who facilitated recruitment of participants. This research would not have been possible if not for the willingness of the participants to share their stories with me, thank you all.  I gratefully acknowledge the financial support of the University of British Columbia‟s School of Nursing Katherine McMillan Director‟s Discretionary Fund, the Registered Nurses Foundation of British Columbia Research Bursary, and the British Columbia History of Nursing Scholarship, for this research.  viii  DEDICATION   Para de mi Aguela, Nana Oñang.  Tu el unica ya enseña con migo el mi mucho amor na prendida.  Tu el primera que bisa con migo, yo de pudi asir todo que yo quiere asi.  Tu estraño y te amo para siempre.    ix  CO-AUTHORSHIP STATEMENT   As first author, I conceptualized and designed the study, conducted the interviews and analysis, and wrote 100% of the manuscript. Chapter two entails a co-authored manuscript. Dr. Geertje Boschma, the second author, closely guided the study design, methods, and analysis, and editing of the manuscripts. Dr. Sabrina Wong and Dr. Linda Quiney, my committee members and following authors, both contributed in the analysis and interpretation of the data, and editing of the manuscripts for development into publishable papers. The second manuscript in chapter three is a single authored one by me, while I acknowledge the contribution of my committee members in the submission.  1  CHAPTER 1  INTRODUCTION 1.1 Background  Globalisation is reflected in the nursing profession through the increasing popularity of nurse migration throughout the world (Choy, 2010; Kingma, 2001, 2006). Although nursing migration is not a new phenomenon, the trends of nursing inflows and outflows, and traditional source and destination countries have changed in the latter half of the twentieth century (Choy, 2003, 2010; Kingma, 2006; Martineau, Decker, & Bundred, 2002). Historically, migration tended to be a means to seek adventure, and occurred primarily between different Western nations (Martineau, Decker, & Bundred, 2002).  As nursing migration grew in popularity over the following decades, there has since been a tendency for nurses from underdeveloped countries to migrate to Western nations (Connell, 2007; Kingma, 2006). In recent decades, the Philippines has grown to be a leading producer of nurses for export, and has been recognized for this fact, globally (Choy, 2003, 2010; Dumont, 2008; Kingma, 2006; Kline, 2003). The most popular destinations for nurses from the Philippines have been the United States (US) and the Middle East (Center for Migrant Advocacy, 2006; Emerson, Griffin, L'Eplattenier, & Fitzpatrick, 2008; Kline, 2003). More recently, the United Kingdom (UK) and Canada have also become a popular destination country for Filipino nurses (Brush & Sochalski, 2007; Buchan, Jobanputra, Gough, & Hutt, 2006; Dumont, 2008; Kline, 2003). Indeed, as Canada increasingly incorporates internationally educated nurses (IENs) into its healthcare workforce, the Philippines leads in numbers as a significant source country of IENs (Baumann, Blythe, Kolotylo, & Underwood, 2004).   2  1.2 Problem Statement  There have not yet been studies conducted that explore the personal histories and experiences of immigrant Filipino nurses in Canada. Current studies which include Filipino nurses as part of larger groups of IENs in Canada, focus primarily on statistical trends of inflows and outflows of nurses, policy analysis and implications of these trends, and  there is also a tendency to use primarily economic and policy analysis lenses (Brush & Sochalski, 2007; P. Kelly, 2003; P. F. Kelly, 2006; Ogilvie, Leung, Gushuliak, McGuire, & Burgess-Pinto, 2007; Sills, 2007). If present trends in IEN inflows to Canada are sustained, it is important to understand the roots and influences surrounding Filipino nurse migration, as Filipino nurses can be expected to grow as a significant group of nurses in Canada. The continued growth of the incorporation of IENs in the Canadian healthcare workplace will have important implications for nursing practice, and the evolution of the culture of nursing in Canada. In order to better understand and gain insight into these implications, an exploration of the histories of nurse migration in Canada then provides an important foundation of historical knowledge which might inform policy development. In this vein, this thesis research employed a historical framework, to add a complementary historical perspective to existing economic and policy analyses of global nurse migration. As there is little information available currently about this group in Canada, this research provides the beginning steps in knowledge development, examining the life histories of a group of immigrant Filipino nurses in Canada. This study contributes to the body of research informing nursing history and culture in Canada, nursing recruitment and retention, and work place dynamics.   3  1.3 Research Questions and Study Objectives  The overarching goal of this study is to provide and examine oral accounts of the immigration experience of Filipino nurses, from their own perspective, and in their own words. In addition to providing rich descriptions of the immigration experience, this study employed an analysis of these histories using oral history methods.  To gain contextual understanding and lay a foundation of knowledge from which to build on, this study sought to first examine and synthesize existing literature discussing: 1) the history of global nursing migration; 2) nursing immigration history in Canada; 3) nursing, colonialism, and foreign presence, in the Philippines; and 4) the importance of the oral history method in contributing to migration studies. The oral history interviews were conducted concurrent with the exploration of the literature. Participants‟ accounts of their migration experiences were then analyzed in context of the larger societal and cultural influences, and in light of what was known in the literature. The specific questions this study sought to address were: 1. What do these Registered Nurses‟ (RNs) oral histories tell us about the context and larger influences at play in the decision to emigrate from the Philippines? 2. How were the motivations to migrate and transition experience to life and work in Canada remembered by these RNs? 3. What was the relationship between larger influences and migration trends in the literature, and each individual‟s experiences of immigration? For example, were larger trends reflected in, or did they differ greatly from each individual‟s experiences? 4. In light of this study‟s findings, what new issues and questions should be asked more broadly with regard to foreign nurse migration to Canada?  4  1.4 Literature Review  To provide background information to the phenomenon of Filipino Registered Nurse migration to Canada, I review in the following section the literature instrumental to the development of this thesis. Although I use the general term nurse throughout this thesis, my focus is specifically on registered nurses. Therefore, if I use the term nurse without further specification, it should be read as Registered Nurse (RN). First, a broad overview of global nursing migration will be discussed; focusing on historical trends of nurse migrant flows, and changes in patterns over time. Within this topic I will discuss the push and pull factors of migration, issues traditionally discussed in the migration literature. The next topic will review nursing immigration history in the Canadian context. Specifically, I will discuss groups of nurse migrants who had arrived in Canada in the earlier part of the twentieth century, and points of contention experienced by foreign nurses. Thereafter, I will discuss the Philippines, specifically the history of nursing and its relationship to colonialism, and subsequent official adoption of migration into Filipino culture. Finally, the contribution of the oral history method to migration history will be discussed, and why it is appropriate given the goals of this study. 1.4.1  Global Nursing Migration  For the purpose of this thesis, global nursing migration refers to the movement of nurses from one country to another. Global nursing migration is not a new phenomenon. Seeking adventure or new experiences were some reasons nurses travelled from one country to another in nurse migration history (Kingma, 2006; Martineau, Decker, & Bundred, 2002). For example, it was not unusual for new graduate nurses from New Zealand and Australia in the 1960s and 1970s to travel through Europe and North America on working holidays (Martineau, Decker, &  5  Bundred, 2002). However, a shift in the trends for sending and receiving countries has occurred over time. Trends reflected how exchanges of migrant nurses historically occurred less frequently between Western nations, and there has instead been a growing tendency for nurses from developing and “poorer” nations to migrate to Western or other “wealthy” nations (Connell, 2007; Kingma, 2006).  Kingma observed that while nursing “has been advertised as a „portable profession‟ and nurses have always moved from town to town, city to city, and country to country, never has nurse migration been the mass phenomenon we see today” (Kingma, 2006, p. 2).  Indeed, the migration of health care workers comprises an increasingly large component of total global migration (Connell, 2008; Kingma, 2006). Why has global migration grown to be such a popular option within the nursing profession? Common arguments for the reasons behind the popularity of nursing migration are the social and economic inequities between different nations, the difference in quality of life and status of nursing in different countries, in short, the “push and pull” factors of migration which arguably drive the movement of nurses around the globe (Blythe, Baumann, Rheaume, & McIntosh, 2009; Center for Migrant Advocacy, 2006; Kingma, 2006; Kline, 2003).  The push and pull factors of migration are defined in the literature as the aspects of donor and receiving countries which drive the migration of individuals to and from these locations (Kingma, 2006; Kline, 2003). Push factors are defined as the often negative characteristics of the home or origin country that make the option of immigration to another country desirable. These factors include poor working conditions, unemployment and underemployment, poor economic conditions and quality of life, and political and social instability (Blythe, Baumann, Rheaume, & McIntosh, 2009; Brush & Sochalski, 2007; Center for Migrant Advocacy, 2006; Kingma, 2006;  6  Kline, 2003). In contrast, pull factors are defined as more positive aspects of certain countries which make them attractive as migration destinations. These include improved financial conditions, opportunities for education and professional development, secure social and political environments, and opportunities for better conditions for their families (Connell, 2007; Kingma, 2006, 2009; Kline, 2003). These factors explain the trend of nurse migrant flows from relatively poorer countries to relatively richer countries. Discussion of the push and pull factors of migration and their role in the exacerbation of inequalities between rich and poor nations has traditionally dominated discourses surrounding global nurse migration and continues to do so. 1.4.2  Migrant Nurses in Canada  For the majority of the twentieth century, nursing in Canada had been the preserve of White and Canadian-born women (McPherson, 1996). The progression of the century saw increased ethnic heterogeneity in the country, however, the nursing profession and health care administration in Canada maintained beliefs of racist hierarchy, and firmly resisted the incorporation of non-White nurses into the Canadian healthcare workplace (McPherson, 1996). Reasons for the resistance to the entry of non-White nurses to Canadian nursing included social constructs of their inability to maintain the appropriate gentility and morality required of bedside nursing, the lack of appropriate educational preparation, as well as assumed expectations of their inability to adapt to the English language, colder weather, and Western culture (K. Flynn, Feldberg, Ladd-Taylor, Li, & McPherson, 2003; McPherson, 1996). Registration in nursing colleges and licensing bodies thus remained extremely limited for non-White immigrant nurses, as these values were upheld by the Canadian nursing profession overall (Calliste, 1993; McPherson, 1996).  7   In the post-World War II era however, these restrictions were challenged as a result of the severe shortage of required nursing services during that time (Calliste, 1993; Shkimba, Flynn, Mortimer, & McGann, 2005). To alleviate the shortage, one approach taken was to introduce more liberal immigration policies, that eased the immigration process for foreign nurses (McPherson, 1996). These policies were initiated with Europeans in the early 1950s, and were followed by the migration of small numbers of Black Caribbean nurses in the same decade (Calliste, 1993; K. Flynn, Feldberg, Ladd-Taylor, Li, & McPherson, 2003; Shkimba, Flynn, Mortimer, & McGann, 2005). There was a notable contrast between the reception of White nurses of European descent and Black nurses from the Caribbean to the nursing profession in Canada. Whereas White European nurses were admitted to Canada as permanent residents on the basis of their general admissibility, Black Caribbean nurses were only admitted on the basis of their nursing education, experiences, training, and had to be deemed “cases of exceptional merit”. Consequently, this often meant that Black Caribbean nurses who were granted entry to Canada exceeded the experience and education requirements of their White counterparts (Calliste, 1993; McPherson, 1996). The resistance to the incorporation of non-White nurses into Canadian nursing and the preference for White nurses is also evidenced by the lack of questioning of foreign nurses‟ ability to adapt to the English language and North American culture (McPherson, 1996). For example, the migration of Greek nurses was actively encouraged and their credentials and capabilities never questioned or scrutinized, despite their greater difficulties with the English language, in stark contrast to the experiences of Caribbean nurses, including those who had obtained their education in the US (K. Flynn, Feldberg, Ladd-Taylor, Li, & McPherson, 2003).  8   Difficulty in entering Canada was only the first of the challenges Caribbean nurses faced in their migration. Upon arrival in Canada, Caribbean nurses faced problems in securing employment as nurses, as most healthcare institutions did not hire non-White applicants as nurses (Calliste, 1993; K. Flynn, Feldberg, Ladd-Taylor, Li, & McPherson, 2003). As a result, many nurses experienced deskilling, and worked as domestics or in other services jobs. Often they became “trapped” in such positions by institutional policies which prevented them from seeking other work or further education (Calliste, 1993). For Caribbean nurses who were able to work as nurses in Canada, the workplace has been described as filled with tension between White and Black nurses (K. Flynn, 1998). Further difficulties identified by Caribbean nurses in their migration to Canada included racism, sexism, homesickness, culture shock, and alienation from their families back in their home countries (K. Flynn, 1998; Karen. Flynn & Henwood, 2000). Despite the generally racist attitude of the Department of Citizenship and Immigration, some medical and nursing organizations displayed more tolerant attitudes. The Canadian Nurses Association (CNA) for example, was willing to include Caribbean nurses in the nursing profession and opposed discrimination, fuelled by concerns of a nursing shortage, and also as a result of its increasing international involvement (K. Flynn, Feldberg, Ladd-Taylor, Li, & McPherson, 2003). Notably, despite their experiences of the racist structures of immigration, Caribbean nurses did not express regret with regard to their decision to migrate to Canada (K. Flynn, 1998). Instead, most expressed appreciation for the opportunities they were offered in Canada via nursing, and having enjoyed greater social prestige within the Caribbean community (K. Flynn, 1998).  With the increased numbers of immigrant nurses arriving in Canada over the last few decades, there has been renewed attention to the experiences of migrant nurses in the literature.  9  Yet, since the initial historical work exploring Caribbean immigrant nurses, there has been little further exploration of the histories of other immigrant nursing groups in Canada. This thesis addresses this gap in knowledge, and provides an additional historical context through which current nursing immigrants‟ experiences can be explored. 1.4.3  Nursing, Colonialism, and Foreign Presence in the Philippines  The Philippines is a country familiar with foreign influences, having experienced centuries of colonial occupation by the Spanish from the 1500s to the late 1800s, followed by occupations by the Japanese and Americans in the closing years of the nineteenth and early twentieth centuries (Choy, 2003; Martin, 1993; Schirmer & Shalom, 1987). Resulting from these foreign ties is a longstanding history of overseas migration of Filipino people, including to Mexico, Hawaii, and California (Center for Migrant Advocacy, 2006; Martin, 1993; Schirmer & Shalom, 1987). In 1946 the Philippines achieved formal independence from the US, but remained closely linked to the US both economically, and through military collaboration (Schirmer & Shalom, 1987). Historian Catherine Choy‟s scholarship on the history of Filipino nurses in the US is currently the authority on the topic. She argues that the colonial relationship between the Philippines and the US was crucial in fostering and maintaining the enthusiasm for migration among Filipino nurses (Choy, 2003). This thesis also argues that this colonial relationship was instrumental in the creation and propagation of the “culture of migration” that has been widely popularized and internalized by Filipino people throughout the twentieth century. Nursing has become a strategic stepping stone for the pursuit of emigration from the Philippines.  10   During the US colonial occupation in the early twentieth century, an American-based nursing education system was established in the Philippines, in an attempt to professionalize and legitimize the profession in the country, as well as to produce Americanized nursing leaders (Choy, 2003). Part of this effort was the active encouragement of Filipino nurses to pursue postgraduate training in the US, facilitated by the establishment of the Exchange Visitor program (EVP) in 1948, in order to train and then return them to the Philippines to perpetuate American nursing trends (Choy, 2003). Migration to the US was advertised widely as a transformative and prestigious route for Filipino nurses, and encouraged young Filipino women to enter the profession in hope of going abroad, through the EVP (Choy, 2003). Facilitated by the EVP and successful US migration campaigns, the first wave of mass migration of over 11 000 Filipino nurses overseas took place between 1956 and 1969 (Choy, 2003, p. 64; Damasco & Knowles, 2008).  In the Philippines, formal support for overseas migration was incorporated as government policy through the Labour code, by then President Marcos‟ government in the 1970s (Center for Migrant Advocacy, 2006; Choy, 2003; Lan, 2000; Schirmer & Shalom, 1987). Recognizing the potential of the Philippines as a global labour exporter, formal specialized government bodies were established through the 1990s to manage and bureaucratize the immigration process, and to further encourage migration as a means to bring foreign currency into the country through to the 1990s (Center for Migrant Advocacy, 2006; Choy, 2003; Lan, 2000; Martin, 1993). Mass waves of Filipino migration to numerous global destinations then followed (Center for Migrant Advocacy, 2006; P. F. Kelly, 2006; Samonte, 2003). Thus, the culture of migration was born and fostered in the Philippines. The literature describes the culture of migration to be a pervasive common desire, an attitude which reaches all levels of society (Connell, 2008; Garchitorena,  11  2007; Sills, 2007). Unlike the earliest wave of migrant Filipino nurses, whose desire to migrate can be traced back to US efforts, this thesis argues that in recent decades there has been an internalization of the culture of migration. Given the history of foreign presence in the Philippines and the adoption of the migration culture by the Philippine government, this thesis offers some explanation of why this construct has been so embraced by Filipino nurses. 1.4.4  Capturing Nursing Migration Experiences Through Oral History  Oral history, both as a method and a framework, was instrumental in the design development, data collection, and critical analysis of this thesis. The goals of this study include the exploration of immigrant Filipino nurses‟ memories of their migration experiences, with all the nuances, inconsistencies, and richness that they contain. Additionally, this thesis seeks these experiences as they are remembered by individuals in their own words. On consideration, the oral history method best fits this study. Biedermann argues that “oral history has the advantage over more traditional historical sources, in that the oral sources, or the narrators, can interpret events, personalities and relationships within the interview in ways that may not be possible to reproduce in written histories with the same lucidity” (2001, p. 61).  Indeed, the oral history approach provides one with an understanding of how events were experienced at the individual level and how participants interpreted their experiences, providing insight as to the nurses own understanding and biases of the situation. For example, an oral history account of an event deemed significant by the researcher may not in fact be recalled as important by the person who actually experienced the event. Additionally, oral history provides the opportunity for the “smaller, everyday” figures in history to have a voice, including groups which have been overlooked in history, including women, children, and ethnic groups (Boschma  12  et al., 2008). Finally, the oral history method used in this thesis is in line with recommendations of Catherine Choy. Choy argues that “through international frameworks attentive to the lived experiences of migrant nurses, nursing historians can bring nuance, historical context, and human interest to current discourses of the international migration of health professionals” (2010, p. 15). In Chapters 2 and 3 I introduce a further discussion of the oral history approach. 1.5 Outline of Thesis  This thesis is comprised of four chapters. Following this introduction, Chapters 2 and 3 comprise the body of the thesis, each one a separate manuscript. Chapter 2 has been submitted for publication in a peer-reviewed journal, and Chapter 3 will be submitted for publication at a later date in the year 2010. The research questions outlined in Chapter 1 are addressed largely in Chapters 2 and Chapter 3, with the difference being the themes discussed in each chapter.  Chapter 1 gives an overview of topics central to the development of the research question, methods, and analysis of the data. It provides an introduction to the history and trends in global nursing migration, immigration within the Canadian context, nursing and colonialism in the Philippines, and the contributions of the oral history method to migration history. There are a number of topics beyond the four described in this chapter that are explored further in the analysis and interpretation in the thesis, which will be introduced and described in subsequent chapters.  Chapter 2 examines the themes arising directly from the oral histories, focusing on experiences prior to emigration from the Philippines. This chapter discusses in greater detail the culture of migration and the state of nursing in the Philippines. This chapter also introduces the role familial and cultural constructs and societal pressures play in the decision to migrate, as well  13  as other relevant concepts. I also discuss in this chapter my role as a researcher and its potential effects on the study.  Chapter 3 addresses the migration experience, and issues encountered in transition to life and work as a nurse in Canada. This chapter introduces the themes of opportunity-seeking, the centrality of the family in Filipino culture, changes in nursing autonomy, and experiences of racism. The themes that arise are tied to historical concepts such as the history of women and the experiences of early migrant nurses in Canada.  Chapter 4 summarizes and concludes the thesis, and discusses the appropriateness of the methods to the research purposes. This chapter examines the thesis results as a whole, its overall contributions, and potential for the future direction of nursing migration research.  14  1.6 References Baumann, A., RN, PhD, Blythe, J., PhD, Kolotylo, C., RN, PhD, & Underwood, J., RN, MBA. (2004). Immigration and Emigration Trends: A Canadian Perspective. Ottawa, Ontario: The Nursing Sector Study Corporation. Biedermann, N. (2001). The voices of days gone by: advocating the use of oral history in nursing. Nursing Inquiry, 8, 61-62. Blythe, J., Baumann, A., Rheaume, A., & McIntosh, K. (2009). Nurse Migration to Canada: Pathways and Pitfalls of Workforce Integration. J Transcult Nurs, 1043659608330349. Boschma, G., Scaia, M., Bonifacio, N., Roberts, E., Lewenson, S. B., & Herrmann, E. K. (2008). Oral History Research. In Capturing Nursing History: A guide to historical methods in research (pp. 79-98). New York, NY: Springer Publishing Company LLC. Brush, B. L., & Sochalski, J. (2007). International Nurse Migration: Lessons From the Philippines. Policy, Politics, & Nursing Practice, 8(1), 37-46. Buchan, J., Jobanputra, R., Gough, P., & Hutt, R. (2006). Internationally recruited nurses in London: a survey of career paths and plans. Human Resources for Health, 4(1), 14. Calliste, A. (1993). "Women of exceptional merit": Immigration of Caribbean nurses to Canada. Canadian Journal of Women and Law, 6(1), 85-103. Center for Migrant Advocacy, P. (2006). Working paper on overseas migration (pp. 11). Quezon City, Philippines: Center for Migrant Advocacy Philippines. Choy, C. (2003). Empire of care: nursing and migration in Filipino American history. Durham: Duke University Press. Choy, C. (2010). Nurses across borders: Foregrounding international migration in nursing history. Nursing History Review, 18(1), 12-28. Connell, J. (2007). Local skills and global markets? The migration of health workers from Caribbean and Pacific Island States. ¿Mano de Obra Local Mercados Globales? La Emigración de Trabajadores del Sector Salud de los Estados Insulares del Caribe y del PacÃfico., 56(1/2), 67-95. Connell, J. (2008). Niue: Embracing a Culture of Migration. Journal of Ethnic and Migration Studies, 34(6), 1021 - 1040. Damasco, V. G., & Knowles, J. G. (2008, 2008). Life history research and discovery of a newfound history through emotions: The immigration of Philippine-trained healthcare professionals to Canada. Paper presented at the ESREA Life history and biographical research network conference. Dumont, J. (2008). International mobility of health professionals and health workforce management in Canada: Myths and realities (Report). Paris, France: Organisation for Economic Cooperation and Development. Emerson, E. E., Griffin, M. Q., L'Eplattenier, N., & Fitzpatrick, J. (2008). Job Satisfaction and Acculturation Among Filipino Registered Nurses. Journal of Nursing Scholarship, 40(1), 46-51. Flynn, K. (1998). Proletarianization, Professionalization and the Caribbean Immigrant Nurses. Canadian Women's Studies Journal, 18(1), 57-60. Flynn, K., Feldberg, G., Ladd-Taylor, M., Li, A., & McPherson, K. (2003). Race, the state, and Caribbean immigrant nurses, 1950-1962. In Women, health and nation: Canada and the  15  United States since 1945 (pp. 247-263). Montreal and Kingston: McGill-Queen's University Press. Flynn, K., & Henwood, C.-L. (2000). Nothing to Write Home About: Caribbean Canadian Daughters, Mothers and Migration. Journal for the Association for Research on Mothering, 2(2), 118-129. Garchitorena, V. P. (2007). Diaspora philanthropy: The Philippine experience (pp. 31). Manila: The Philanthropic Initiative Inc. and The Global Equity Initiative, Harvard University. Kelly, P. (2003). Canadian-Asian transnationalism. Canadian Geographer, 47(3), 209-218. Kelly, P. F. (2006). Filipinos in Canada: Economic Dimensions of Immigration and Settlement (Vol. CERIS Working Paper No. 48). Toronto: Joint Centre of Excellence for Research on Immigration and Settlement. Kingma, M. (2001). Nursing migration: global treasure hunt or disaster-in-the-making? Nursing Inquiry, 8(4), 205-212. Kingma, M. (2006). Nurses on the Move: Migration and the Global Health Care Economy. Ithaca, NY: Cornell University Press. Kingma, M. (2009). The international workplace: Challenges and solutions. Nursing Workforce: a Special Issue, 46(7), 879-883. Kline, D. S. (2003). Push and pull factors in international nurse migration. Journal of Nursing Scholarship, 35(2), 4. Lan, P.-C. (2000). Remapping identities across borders and at Home: Filipina migrant domestic workers and Taiwanese employers. Paper presented at the Conference Name|. Retrieved Access Date|. from URL|. Martin, P. L. (1993). Migration and Trade: The Case of the Philippines. International Migration Review, 27(3), 639-645. Martineau, T., Decker, K., & Bundred, P. (2002). Briefing note on international migration of health professionals: leveling the playing field for developing country health systems. Unpublished manuscript, Liverpool. McPherson, K. (1996). Bedside matters: The transformation of Canadian nursing, 1900-1990. Ontario: Oxford University Press. Ogilvie, L., Leung, B., Gushuliak, T., McGuire, M., & Burgess-Pinto, E. (2007). Licensure of Internationally Educated Nurses Seeking Professional Careers in the Province of Alberta in Canada. Journal of International Migration & Integration, 8(2), 223-241. Samonte, E. L. (2003). Filipino International Migration: A Continuing Saga. In L. L. Adler & U. P. Gielen (Eds.), Migration: Immigration and Emigration in International Perspective (pp. 251-270). Westport, CT: Praeger Publishers. Schirmer, D. B., & Shalom, S. R. (1987). The Philippines reader: A history of colonialism, neocolonialism, dictatorship, and resistance. USA: South End Press. Shkimba, M., Flynn, K., Mortimer, B., & McGann, S. (2005). In England we did nursing: Caribbean and British nurses in Great Britain and Canada 1950-1970. In New directions in the history of nursing (pp. 141-157). London: Routledge Taylor & Francis Group. Sills, S. J. (2007). Philippine labour migration to Taiwan: Social, political, demographic, and economic dimensions. Migration Letters, 4(1), 1-14.    16  CHAPTER 2  BEYOND GREENER PASTURES: CONTEXTS SURROUNDING FILIPINO NURSE MIGRATION TO CANADA 1  2.1 Introduction  The past fifty years have seen an increase in the ease and popularity of nurse migration around the globe. The presence of “supplier” and receiving countries is not new to nursing, and it is not surprising that migration occurs mostly between developing countries with poor conditions and large numbers of workers who want to leave, and developed nations with apparent nursing shortages and aging populations (Flynn, Feldberg, Ladd-Taylor, Li, & McPherson, 2003; Kingma, 2006, 2009). Canada‟s nursing sector continues to see a steady rate of nurse migration into the country (Canadian Institute for Health, 2008) with evidence of increased international nurse migration in Canada through the 1990s (Blythe & Baumann, 2009). Of the approximately 8% of registered nurses in Canada who graduated from an international program, the majority of individuals attended programs in the Philippines (31%) or the United Kingdom (17%) (Canadian Institute for Health, 2008). Indeed, skilled professionals including nurses make up over a third of all migrant deployment in the Philippines (Burgess & Haksar, 2005). In turn, these deployments play an important role in remittances received, making up over nine percent of the country‟s gross domestic product and placing the Philippines as the second highest remittance-recipient country worldwide (Burgess & Haksar, 2005; Chami et al., 2008). A recent study examining the implications of international migration of health care workers suggests that migration of health professionals to industrialized countries can be expected to increase in the future (Bach, 2003) with Canada being part of this trend. On a global scale, chief supplier countries of nurses include  1 A version of this chapter has been submitted for publication. Ronquilllo, C., Boschma, G., Wong, S., and Quiney, L. (2010) Beyond Greener Pastures: Contexts surrounding Filipino nurse migration in Canada.  17  the Philippines along with India, and other South Asian countries (Blythe & Baumann, 2009) but the Philippines has been identified as the largest source of registered nurses working overseas (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Bach, 2003).  The significant presence of Filipino nurses within healthcare is evident from recent statistics on internationally educated nurses in Canada. In 2002,  nurses from the Philippines made up the largest group, 27%, of all immigrants in the Canadian workforce, followed by the UK with 25%, and the US in third place with 8% (Baumann, Blythe, Kolotylo, & Underwood, 2004). Recruitment strategies such as those deployed by Saskatchewan‟s government for targeting Filipino nurses additionally illustrate the growing popularity and numbers of this group in Canada (Saskatchewan, 2008). This study examines the life histories of nine immigrant Filipino nurses, living and working in Alberta and British Columbia from 1974 onwards, employing the use of oral history methods to provide a regional case study of their migration experience. This paper will illustrate how larger social pressures and cultural constructs were experienced at the individual level (McPherson, 1996; Grypma, 2005) through the oral histories of these nurses. This paper will focus on the period in the lives of the Filipino nurses interviewed prior to their emigration, addressing the overarching questions: (1) Which social contexts in the Philippines (e.g. economic status, foreign influence, educational trends, family context) shaped the migration experiences of Filipino nurses and how did they affect individual migration decision-making, and (2) beyond an economic motive, what other factors were perceived to affect decision-making related to migration of Filipino nurses?  My interest in immigrant Filipino nurse experiences evolved from my own first year of work as a registered nurse in Canada. Being of Filipino origin, but having completed my education and training in Canada, my curiosity deepened as I found myself increasingly  18  surrounded by, and working with, colleagues who had emigrated from the Philippines to work as nurses in Canada. In the Philippines, nurses constitute the largest group of professional workers both at home and abroad, with migration patterns that can be traced back to the 1950s (Galvez Tan, 2005). Due to domestic and foreign demand, the Philippines has seen a rapidly growing nursing education sector comprised of some 460 nursing colleges offering baccalaureate nursing programs, which graduate approximately 20 000 nurses annually (Commission on Higher Education, 2006). With increasing numbers of new immigrant Filipino colleagues, I sought to examine their experiences surrounding the apparent popularity of immigration for Filipino nurses. Moreover, my goal was to explore through the oral histories of immigrant Filipino nurses how they remembered their experiences and gained an understanding of how the larger social trends and historical context for Filipino immigration was reflected in their individual stories. While I expected financial and economic reasons would be identified as important reasons for immigration, after completion and analysis of the interviews, I argue that there are also important subtle influences at play which shape migration decision-making and eventual migration experiences of immigrant Filipino nurses.  I argue that the popularity of immigration for Filipino nurses is not driven solely by economic motives but is also fuelled by cultural pressures, the desire for status, and an internalized desire to migrate. 2.2 An Oral History Perspective  Despite Canada being a major receiving country of nurses migrating from the Philippines, there is a paucity of information on the history of this migrant group (Damasco & Knowles, 2008). However, an extensive history of Filipino nurse migration to the United States (US) was undertaken by historian Catherine Choy, and subsequently became a standard work in the field (Choy 2003). The conceptual frameworks and perspectives Choy uses in her historical  19  analysis serve to inform and guide the conceptual base and interpretation of this study. Choy argues the need to go beyond the traditionally dominant method of looking at migration history of Filipino nurses from a narrow economic perspective. Presently, the global migration of nurses examined in the existing literature employs economic and health policy as the most dominant contextual frameworks (Calliste, 1993; Choy, 2003; Connell, 2008; Damasco & Knowles, 2008; Dumont, 2008; P. Kelly, 2003; P. F. Kelly, 2006; Kingma, 2006, 2009). To provide a richer account of Filipino nurse migration, Choy also highlights the importance of life stories in understanding nurses‟ individual experiences (Choy, 2003, 2010). She argues that “through international frameworks attentive to the lived experiences of migrant nurses, nursing historians can bring nuance, historical context, and human interest to current discourses on the international migration of health professionals” (Choy, 2010). It is precisely through a similar exploration of life histories that this study uncovers contexts surrounding the immigration of Filipino nurses to Canada that extend not only beyond economic and financial factors, but also beyond the traditional push and pull factors that shape global migration. 2.3 Methodology  This study uses oral history both as a framework and a method to capture personal stories and elicit new sources of evidence. Exploration of individual nurse migration experience, and the memories of this experience, generate sources where little other documentation exists (Boschma et al., 2007). In these stories, larger social trends and how they were experienced on an individual level can be explored (Boschma et al., 2007). Oral history focuses on day to day experiences of ordinary people, in contrast to the powerful and influential (Boschma et al., 2007; Burke, 2001; Thompson, 2000). Biedermann (2001, p. 61) states that “Over the past 20 years, research using oral history method has played a significant role in retrieving and recording  20  historical experiences of „non-elite‟ nurses and their patients who have no record of their lives or historical documents” . Given that many traditional histories often focus on individuals who have made great contributions to nursing, this study will contribute another perspective on the question raised by nursing historian Sioban Nelson who asks, “What does nursing history begin to look like minus its great women?” (Nelson, 2002). Kirby (1997) discusses how oral history can be used to illuminate areas (e.g. childhood, nursing) and facets of experiences that are often not represented in archival collections. Similarly, this study will provide a voice for a professional and cultural group otherwise underrepresented in the literature.  Relying on interdisciplinary analytic frameworks drawn from history, sociology, psychology, and cultural studies, oral history has grown to be a complex and critically developed methodology with extensive discussion in the literature (Anderson, 2006; Boschma et al., 2007; Chamberlain, 2006; Grele, 2006; Perks, 2008; Ritchie, 2003; Yow, 2005).  The goal of this study is not to provide an objective, positivistic account of events, but rather to elucidate how experiences are remembered and reconstructed by individuals through the process of recollection (Sugiman, 2004). The narrator and interviewer engage in the dynamic co- construction of the narrative, and their relationship over the course of the interview affects how the story is told and requires careful interpretation (Perks & Thomson, 2006; Sangster, 1998; Boschma et al., 2007). Field notes were written to serve as documentation of personal observations and impressions of each interview, and a place to note details that might influence data analysis and interpretation (Polit & Beck, 2008), and in an effort to capture aspects of the interview that would not be apparent from reading the transcribed interviews (Speziale & Carpenter, 2003). Review of the field notes was instrumental to the interpretation, with special attention paid to the interviewer‟s role in the structuring of the narrative. Analyses of narratives  21  were done concurrently with the analysis of written documentation (Yow, 2005), and were ongoing with data collection to facilitate continuous comparison between narratives as they were produced. Continuous comparison between narratives and the existing migration literature further aided in understanding emerging themes and placing the findings in the broader social and historical context. 2.3.1 Sample  A total of nine interviews were conducted. Given the provincially based structure of Canadian health care, this study provides an important regional understanding of the history of immigrant Filipino nurses in the Western provinces. Participants consisted of female registered nurses currently residing and practicing in Calgary, Alberta and Vancouver, British Columbia. All participants completed their nursing education in the Philippines; eight had baccalaureate degrees and one trained at a hospital school of nursing. The dates when participants emigrated from the Philippines range from 1974 through 2005. All but one participant had an existing connection or network in Canada prior to migration, which aided in migration. Five participants immigrated directly to Canada from the Philippines. Of the five, one worked as a registered nurse on international cruise ships for five years prior to migration. Four first worked as registered nurses in other countries prior to arriving in Canada including the United Kingdom, Austria, Saudi Arabia, and Dubai. Two nurses entered Canada through the Live-In Caregiver program, five were sponsored by either an agency or family already residing in Canada, and two arrived as independent immigrants. Snowball sampling was used to facilitate access to networks of Filipino nurse immigrants, wherein existing participants referred other potential participants to the study (Polit & Beck, 2008; Speziale & Carpenter, 2003). Recruitment was through third  22  parties with whom the author had an established connection. All participants signed a consent form and chose pseudonyms to be used in the analysis of prevalent themes in the narratives. 2.4 Immigrant Groups in Canada  Preliminary exploration of Canadian literature on Filipino nurse migration in Canada found little beyond basic statistics on migrant nurses in Canada. There is, however, a nascent historiography examining migrant nurse groups of other visible minority backgrounds, and of Filipino migrants of non-nursing professions in Canada. Extensive work exploring the immigration of Caribbean nurses to Canada by Calliste (1993) and Shkimba et al. (2005) discuss the process of immigration control in Canada in the post-World War II period. Both authors discuss the roles race, class, and gender played in Canadian migration policies affecting immigrant nurses. The incorporation of immigrant nurses from visible minority groups in the Canadian health care system is argued to be a result of the severe shortage of health care workers Canada experienced in the post-World War II period and subsequent changes to the immigration policies (Calliste, 1993; Shkimba, Flynn, Mortimer, & McGann, 2005). Initial resistance to the acceptance of visible minority nurse migrants was felt by these nurses in their experiences with Canadian immigration policies, employers and colleagues, the experience of deskilling, and their racialized treatment in their transition to life in Canada (Shkimba, Flynn, Mortimer, & McGann, 2005).  Other literature examining Filipino non-nursing workers similarly discuss the effects of immigration policies on experiences of migrant groups which include studies on Canada‟s Live- in Caregiver program (Cohen, 2000; Oxman-Martinez, Hanley, & Cheung, 2004; Pratt, 1999). Canada‟s Live-in Caregiver program is an immigration program designed to recruit domestic workers from overseas. This program forms an important entry point to Canada for Filipino  23  immigrants, especially for unskilled women who would not otherwise be able to enter the country through the points system (Cohen, 2000; P. F. Kelly, 2006; Oxman-Martinez, Hanley, & Cheung, 2004). Cohen (2000) outlines the negative impact of immigration policies on the familial relationships of Filipino‟s participating in the Live-in Caregiver program. The Live-in Caregiver program was examined in a number of metropolitan centres in Canada, including a study of job descriptions and demographics of live-in caregivers in Montreal (Oxman-Martinez, Hanley, & Cheung, 2004), an analysis of the Live-in Caregiver program‟s role in deskilling Filipino immigrants with professional backgrounds, a study of the stereotyping of  Filipino domestic workers in Vancouver (Pratt, 1997, 1999), and a description of  experiences of live-in caregivers in Toronto and Montreal (Grandea & Kerr, 1998).  While there is a wealth of information on the live-in caregiver group of Filipino immigrants, studies examining the experiences of skilled Filipino immigrants have only recently been conducted. Studies of skilled migrants tend to focus on immigration policies, statistics, patterns of movement, and demographics of skilled migrants (Akbar & Devoretz, 1993; Antecol, Cobb-Clark, & Trejo, 2003; Iredale, 2000). While these perspectives provide important information about the immigrants in Canada, viewing immigrant groups solely through an epidemiological lens and international migration policies actively dehumanizes global migration as a phenomenon, and denies recognition of the migrants' life experiences.  Numerous studies that do explore lived experiences of skilled migrants to Canada primarily focus on deskilling experiences of migrants upon their arrival in Canada (Calliste, 1993; Gardiner Barber, 2008; Gillian & Brandy, 2009; Man, 2004; McKay, 1999; Mojab, 1999). The deskilling of immigrants is an important issue in global migration, however one must be cautious not to view migration experiences solely through this lens. A focus on deskilling is  24  prominent in the literature, as is the dominance of economic influences. As a result, it is easy to develop a preoccupation with negative perspectives of migration experiences when in fact both are only examples of the numerous issues that comprise the migration experience as viewed by Filipino nurses themselves. 2.5 Why Immigrate?   Economic “push and pull” factors figure importantly in the literature on nurse migration and are identified as powerful influences in the decision to pursue immigration (Center for Migrant Advocacy, 2006; Kingma, 2006; Kline, 2003), and they were also a recurrent theme in the interviews. Important push factors which surfaced in the interviews included poor working conditions for nurses in the Philippines, the inability of the Philippine nursing profession to provide financial stability, and dissatisfaction with living conditions and aspects of the social climate in the Philippines. Conversely, aspects that “pull” these nurses towards pursuing the immigration journey to Canada included better working conditions for nurses, an improved standard of living, access to continuing education and potential for professional advancement, and realizing the dream of finding “greener pastures”. These push and pull factors are important aspects of migration and a common theme in the migration literature (Center for Migrant Advocacy, 2006; Kingma, 2001, 2006). A careful analysis of the interviewees‟ stories, however, suggests that it is important to move beyond these traditional themes of migration, due to another pervasive aspect which I frame as a “culture of migration”, a concept also discussed in the literature (Connell, 2008; Garchitorena, 2007; Sills, 2007).  The existence of a prominent „culture of migration‟ and its dominance in the Philippines surfaced as a persistent and pervasive theme, and will be discussed in detail in both an historical and contemporary context. The rise of a culture of immigration began with the first efforts of the  25  United States to popularize and facilitate the immigration of Filipino nurses to the United States in the 1940s (Choy, 2003). This culture of migration subsequently resulted in an attitude of fervent promotion of labour export spanning all levels of society (Sills, 2007). Campaigns were aimed at increasing the allure and prestige of emigration, encouraging Filipino nurses to immigrate to the United States to seek educational and professional advancement, then return to the Philippines as leaders in the profession (Choy, 2003). In this period, the core of the initial relationship between immigration and nursing in the Philippines was clearly established. Conversely, my interviews revealed that the culture of migration and the desire to emigrate persevered, and dominates the thoughts of Filipino nurses to the present day, although no longer traceable to a specific catalyst. The sentiment that “of course, everybody wants to get out” of the Philippines with emigration as the primary vehicle of this goal was a shared consensus among the participants. As part of the popular culture of migration in the Philippines, the nurses also discussed the potential improvement in social status they imagined they would achieve if able to successfully emigrate. The rise in social status associated with emigration was identified from the perspective of the participants as another important factor influencing the culture of migration in the Philippines. As a result, a booming industry in nursing education continues, and in the Philippines there is fierce competition in gaining employment among nursing graduates. An internalization of the desire to migrate was particularly evident in the interviews, as few interviewees were able to articulate specifically the motivations behind their desire to leave the country. Overarching pressures created by family dynamics and cultural expectations further coloured migration decision-making. Nurses faced tacit but unyielding pressure from their families to pursue nursing and to emigrate, regardless of their personal aspirations. Acting in concert with these pressures were cultural expectations of obedience and obligation to family,  26  further diminishing the sense of freedom and personal choice in determining career paths and future endeavours. The intersection of these motivating factors in individual immigration experience was revealed in the oral history. 2.6 The Culture of Migration  The culture of migration evolved from the Philippines‟ long history as a “sending nation” (Abella, 1993; Martin, 1993; Tan, 2001). This history can be traced to the late 1800s when Filipinos emigrated to Europe, Mexico, and the United States, propelled by the political, linguistic, and cultural ties of the Philippines with Western nations (Sills, 2007). One important outcome of the these close ties to the United States was the implementation of a “Westernized” system of nursing education in the Philippines in the early twentieth century, through which the US sought to train “better” nurses and provide a “more sophisticated” nursing and medical education (Choy, 2003). Unique to this training was a deliberate Americanized model of education which included a significant English-language component, the use of American textbooks, and a sole focus on Western medical knowledge (Choy, 2003). This model of nursing education developed into an important precondition for the mass waves of nursing migration that took place in the later twentieth century (Choy, 2003; Kingma, 2006). Indeed, in the following decades and to the present day, the marketability of Filipino nurses for global export can be distinguished from other ethnic groups, both because of their Western-based nursing education and a strong command of the English language (Choy, 2003; P. F. Kelly, 2006; Kingma, 2006) . United States‟ campaigns and efforts launched in the Philippines through the 1940s aimed at promoting the immigration of Filipino nurses to the United States, and are at the root of  the initial connection between migration and nursing (Choy, 2003). Images of the transformative potential of work abroad, and the prestige of immigration, prompted Filipino nurses not only to  27  emigrate to the United States, but also to pursue nursing in order to achieve this goal (Choy, 2003).  The migration of Filipinos overseas has come in three waves since the early 1900s and remained relatively small until the third wave of migration in the early 1970s (Center for Migrant Advocacy, 2006; Garchitorena, 2007; P. F. Kelly, 2006). The declaration of Martial Law by President Marcos in 1972, and the promotion of overseas labour export as an economic development strategy to relieve nationwide unemployment, fuelled the huge outflow of migrant workers in this era (Garchitorena, 2007; P. F. Kelly, 2006; Lan, 2000). Filipino nurses were especially targeted by those policies, and consequently hailed as national heroes in their ability to bring in much needed foreign currency (Choy, 2003). The continued investment of the Philippine government in migration has resulted in emigration becoming entrenched in the economic and political cultures of the present day, and as an important influence in the evolution of the social dimensions of everyday Filipino culture.  The narratives demonstrate clearly the absorption of immigration ideology into the national culture and how it has become so deeply embedded that immigration is no longer viewed as an option, but instead as an obvious aspiration for all Filipino people: Interviewer: In the Philippines, the US is very popular, and wanting to go to the US. Why do you think that is, a lot of people’s first choice is to go to the US? What’s your opinion on why that is?  Linda: Hmm...it’s, I think, it’s the status? Or like, I don’t know, because people there in Philippines like when I was in college, all we knew is only America, I want to go to America.  Interviewer: Okay.  Linda: Yeah, like that. Nobody’s, “Oh I want to go to Canada”, it’s recently only. It’s recently only. So yeah, so, it’s kind of, status…I think.   28  Interviewer: And how do you think it got so popular? America?  Linda: Umm...maybe of the currency? I don’t know. I think it’s the currency, it’s higher than here (Canada).  It was notable to observe the amount of consideration and uncertainty that went into answering the question: “What are your thoughts on why immigration and nursing are so popular in the Philippines”. With the exception of financial reasons, the goal of leaving the country was described almost as a means to an end, and nursing as being an essential piece in facilitating this goal. Additionally, along with the increasing incorporation of the culture of migration into mainstream Filipino society came the development of the prestige and social status associated with immigration to a foreign country. Carmen: Well Philippines is a 3rd world country, you know? And you’re always, you’re always aspiring to go abroad.  Interviewer: And why do you think, that’s so popular there? For you why was that an aspiration?  Carmen: Hmm, just like I said, it’s a prestige you know? And it’s one way...and honestly now, nursing is a good stepping stone to get out of the country.  Amy echoes similar thoughts: Interviewer: And you said you wanted adventure?  Amy: Yes. Yeah.  Interviewer: And what was that coming from?  Amy: And nursing in the Philippines at that time is when uh, it’s the prestige, you know? They think highly of the nurses at the time. So that was one thing.   29  Even within Philippine nursing schools, it was not unusual for the allure of immigration to be presented as an end goal students should aspire to, and as a justification for their chosen area of study. Tess described:   Tess: […] So that’s how I decided nursing. Also like in the back of my head, you know I’m also thinking. You know nursing is like an exportable job. Eventually I want to go to Canada as well with my mum. And, I feel like at that time, that’s what they tell us. Like with nursing you can work anywhere. Any part of the world, you won’t have any problem […]  Interviewer: So you were saying that’s what they tell you, that it’s exportable. Who’s they? Who was “they” for you?  Tess: Um, school.  Interviewer: The university?  Tess: Yeah, a lot of our professors are like…a lot of them came from the States. They practiced, I don’t know how long in the States. Most of them are from the States and the UK and came back to the Philippines to teach.  Interviewer: And they’re Filipino nurses?  Tess: They’re Filipinos, they’re Filipino nurses. And they’re like, it’s amazing, there’s a lot of opportunities.   With nursing widely recognized as an effective stepping stone out of the country, its popularity among Filipino‟s continued to grow, particularly with the presence of recruiters. Alida described the popularity of nursing among her classmates: Interviewer: And what was the popularity of nursing with your classmates?  Alida: A lot of my batchmates actually took nursing because…I remember late 80’s and early 90’s, there were like. If you turn the pages on the local newspaper there will be like Saudi Arabia, US, they’re like…  Interviewer: Recruiters?  Alida: Recruiting nurses from US and you can see them from local newspapers and I haven’t seen that before.  30   Similarly, as Lillian‟s responses indicate: Interviewer: So maybe we’ll start with, if you could tell me what made you interested in becoming a nurse in the first place.  Lillian: Oh! To get more money! It’s a fad before you know! [laughing]  Interviewer: Okay, around what time was that?  Lillian: Oh that was, 19...no, 1970...1974? No. Maybe, 74 I think I graduated, I’m not so sure. 75 or 75, yeah.  Interviewer: Okay, and it was a fad? And what made it so popular?  Lillian: Because maybe I’m going, to go abroad!  Interviewer: And for you, what made you want to go abroad?  Lillian: Oh...to earn more money!  Interviewer: Why was that something you wanted to do?  Lillian: Oh! Nursing, I went to nursing because I don’t know, I don’t know what to take [laughing]   Although Lillian names financial reasons as motivations for immigration, her response mirrors that of other participants who offer little questioning of other  personal motivations for migration, and a notable uncertainty in her response. The interview continued: Interviewer: And when you decided to pursue nursing, did you plan it so you can leave the country? Or was nursing and immigration separate decisions for you? Or did you do one in order to do the other?  Lillian: Uh, no! Nursing was not really my...because I came from a small town. I want to like…every time I see an airplane I said to myself, I want to become a flight stewardess! [laughing] But the time that I was in Saudi, I had the opportunity to be a flight stewardess, but I did not go because I was scared already of the airplane [laughing]. They recruited there for Saudia Airlines, but I was telling, I’m scared of, what do you call that. What do you call when you are in the airplane, up, up, up already? When the airplane moves a lot?    31   The anecdote Lillian describes is one example of the integration of the concept of immigration within Filipino culture. Even with limited knowledge of airplane travel and what the journey entails, the ingrained desire to leave the country seemed to take hold of her thoughts very early, despite lacking the knowledge of what immigration and leaving the country would actually mean for her. From Lillian‟s story, one could interpret that the airplane symbolizes a way out of the country, and something to aspire to by any means, without doubt of question. Continuing promotion, organization, and bureaucratization of labour migration overseen by dedicated governmental groups served to further solidify the importance of migration in the Philippines and added to the already widespread equating of migration with a better life (Martin, 1993; Sills, 2007). The popularity of immigration and using nursing as a stepping stone to achieve this goal continued to gain great momentum from the 1970s. Filipino nurses make up a significant portion of exported labour groups and continue to be hailed as part of a group of “modern day heroes” by the Philippine government, garnering much praise from media and fellow Filipino citizens (Sills, 2007). The adoption of immigration for Filipino nurses developed out of distinct roots in the United States‟ campaigns in the 1940s, evolving on inextricable linkage to the everyday way of life in the Philippines. The narratives further demonstrate other important facets of this phenomenon, namely the complete acceptance of the potential for a rise in prestige and status associated with overseas migration. 2.7 Nurse Survivors – Move It or Lose It  With the enormous production of nursing graduates in the Philippines, it was not surprising to hear participants speak of the increased competition for nursing positions in hospitals. What was surprising however, was the degree of fierce competition for these positions, as Ning described:  32  Ning: Yeah so during my time during the orientation we have what we call like elimination stage? Like you know, I remember like I think there were 15 of us and I think what happened is like 10 left, and then 7 left...  Interviewer: Is it competitive then?  Ning: Yeah. So they trimmed down all this, they trimmed down...that’s only the orientation part. And then the orientation part has no fee. You don’t have any...the hospital is not paying for you.  Interviewer: You don’t get paid?  Ning: You have to go there by your own expense. And you were informed, really informed that hey um, we don’t guarantee you that we’re going to hire you. Just come over and be part of the orientation. But before you go into the orientation you still have to undergo an examination and interview. And this is already like, they strain (stress) you well. You know?  Interviewer: How long is the orientation period?  Ning: Orientation is like 3 weeks, and volunteering is like 3 months. So volunteer, and then if you pass the orientation stage, you have to get in the next stage which is the volunteering work. So you have to volunteer. You’re already practicing as a nurse, RN, you have already the patient assignment, but you are not paid. You come over there, you work 8 hour shift regardless of day, evening, or night shift, but you are not paid. Volunteer is full time […]  The “volunteer” period of nursing was described by all participants who had first practiced as nurses in the Philippines as an expected requirement if they wanted to gain employment at Philippine hospitals. I understood the volunteer period to be a period of “limbo”, where one had the potential for securing employment, yet no real promise of a paid position or any attempts at compensation were made. These nurses were expected to work full-time using their full capacity and responsibilities as nurses simply in hope of eventually gaining a position. Lydia echoed the challenges involved in gaining employment as a nurse in the Philippines: Interviewer: And how did you find like school and all that? Learning nursing and working in nursing?   33  Lydia: Well before I was like...because back home before, I tried applying back in the States when I graduated. And then I kind of, that was the time that they stopped the H...the H-1 something. That immigrant visa, the working visa in the States. So I was kind of stuck.  Interviewer: Around what year was it?  Lydia: That was around 94. So that was the peak where they stopped.  Interviewer: The working visa?  Lydia:  The hiring. The hiring again, back in the States. So I was kind of stagnant then I didn't know what to do and plus there is no work in the Philippines. After that so I have to go to, you know I have to apply and work. Like I was a Med rep, I was a…I did everything, just any job.  Interviewer: What part of the Philippines are you from?  Lydia: I'm from Pampanga. So yeah. I didn't go, I was planning to go to Manila for my college but there was one near my place so I just, graduated in Pampanga.  Interviewer: So it's hard to find jobs in Pampanga?  Lydia: Yeah! You know, and even Manila, it’s hard. And I even volunteered for two years without pay. As a nurse just to get experience.  Interviewer: Wow. In Pampanga?  Lydia: Yeah, in Pampanga. And  I even took my CGFNS [Commission on Graduates of Foreign Nursing Schools ]at that time. And then still. Nothing. Still no hire. So it's been like I think since 94 […]  The amount of time each nurse spent volunteering in hospitals in order to gain experience in hope of eventually securing a position varied with each individual. The “volunteering nurse” phenomenon has not yet been explored in the literature. From the interviews, it was difficult to determine the details of this process such as the average length of time for volunteering, variations in practice between different hospitals and regions, among other aspects. Lydia‟s mention of working in different fields, just for the sake of being employed, was repeated in other  34  narratives. Indeed, the volunteer period was identified by participants as a significant barrier that kept many graduate nurses from pursuing careers in nursing, as Patricia described: Interviewer: You were mentioning also that because of the pay, the financials, you have to volunteer - that affects people’s decision to stay in nursing.  Patricia: Oh yeah like, some of my classmates would be, I think they didn’t practice nursing at all because they couldn’t handle not being paid for 6 months. Some of them went to work in fast food restaurants. And some even do like uh, you know selling stuff, like go to their own business kind of thing.  Similarly, Alida‟s story revealed experiences of volunteer nurses, and described the differences between the nursing careers she and her sister pursued. While Alida chose to pursue immigration, her sister opted to stay and work as a nurse in the Philippines. The following excerpt illustrates the implications of volunteering, as well as the idea that even those who have already established nursing careers in the Philippines are similarly tempted to leave the profession. Alida describes: Alida: They made a schedule for you too once you volunteer for them.  Interviewer: That’s full-time right?  Alida: Mm-hmm.  Interviewer: So how did you, and other nurses starting like that, how do you support yourself during that time?  Alida: Like financially or? Oh I lived with my parents. For…until I left you know, the Philippines. I lived with them for 4 and a half years’ time. It didn’t bother them though, that I lived with them or something. Because my salary is like 5000 [pesos] a month.  Interviewer: When you started getting paid?  Alida: Yeah. Until for the next 4 years, that’s all I got. That’s why like, I’ve been out of the country for 10 years and my sister’s salary is just 8000. That’s why she’s saying like, mama I’m just going to go transfer to a call centre because they get paid 17000 […]    35   Due to the continued increase of nurses produced by the Philippines, it is reasonable to suggest that these issues are ongoing, and the phenomenon is likely to continue. From the narratives in this study, one can see that the difficulty in finding employment as a nurse and potential for exploitation by hospitals are other aspects which drive Filipino nurses to seek employment overseas. This study provides a beginning overview of the volunteer nurse phenomenon and is an area that will benefit from further exploration. 2.8 It’s Nursing or Nothing – Family Dynamics and Cultural Pressures  Pursuing a nursing career was not a first choice for many participants. In each interview, I began by asking what it was that attracted the participant to study and pursue the nursing profession. It was a revelation to learn that a nursing career was a decision made by the families of seven of the participants, and not an independent choice. One nurse opted for nursing because, as she described, it was “a fad” at the time. Another pursued nursing because she admired her aunts who were nurses in the United States. Despite not having a choice in their career selections, these nurses cited no conflicts that arose as a result of their parents taking full control of this early career decision. Interestingly, even in cases where there was blatant disregard for the participants‟ own wishes, these nurses described no resistance or animosity. My interview with Lucita illustrates: Interviewer: So maybe you can tell me a bit first about what made you interested in nursing?  Lucita: Actually I’m not interested in nursing. I applied in Manila to get a...nursing is out of my mind.  Interviewer: Okay.  Lucita: And I actually want to be a technician. A med tech. But my father enrolled me to nursing, while I’m med tech so I’m...   36  Interviewer: Oh really?  Lucita: [laughter] You know how, you know how it is back home? You want to please your parents so you just flow...  Interviewer: Follow along?  Lucita: Follow what they want. And I’m not sorry now, because I love nursing now. You know, that’s all...I never think about changing careers since I’ve been nursing here. Maybe if I’m nursing in the Philippines I might. [laughing] And I won’t be here (Canada) if I’m not a nurse.  Interviewer: So you were already registered as a student in med tech? And then...  Lucita: Uh yeah, I was trying to go to med tech but he enrolled me to nursing. Actually I’m about two weeks behind already you know? [both laughing]  Interviewer: Oh really? And then they told you...  Lucita: And I had no choice! No you’re going to be a nurse so, there you go!  Interviewer: What did you think of that at the time?  Lucita: Uh [pause], not really, no, I’m not really so disappointed, you know.  Interviewer: You were okay with it?  Lucita: Yeah, I’m okay with it. As long as I’m in school. And they’re supporting me in school. [laughter].  This excerpt reflected the common experience of lack of power over decision-making in the nurses‟ earlier years and notably, an almost nonchalant response to the experience. In one of the more striking stories of parental control with regard to the decision to pursue nursing, Tess described her experiences: “[…] I have no idea so I thought like I kind of excelled in like English, like languages. So I thought, oh maybe I should take journalism, something to that area. And so when I was applying for school I was taking a journalism program, whatever, or broadcasting. I can’t remember. The whole summer of 1996 […] I was working on that like March-April, and then my mum came to the Philippines. She’s working here already in Canada as a caregiver. She was a patient care aide, and she’s supporting us in our education. So we rarely see her. Like, the last time I’d seen her at that time was in 5th grade. Then the next  37  time she came back here is high school graduation. Almost 4 years […] and then anyway, so she came home to attend our graduation ceremony for high school. And she said, no, no, no, no! You’re not taking journalism, you’re not taking broadcasting, not any of this! You’re taking nursing. It’s practically, like decided for me and my sister […] It’s not that I hated it. I also was interested in it but I just thought with my evaluation or assessment in school […] my strength was in the English language […] so that’s why I chose that. But from my mum it’s like no. You’re taking nursing, you’re going to this university. Which is not any of the universities that I applied for! She wanted me to go to the University of Santo Tomas which is in Manila. And they’re known for their nursing program there. And this is like, a month before school starts again in June. We didn’t have a lot of time, there’s a lot of exams. So both my sister and I like, went to the city, went to Manila one day between May and almost June. Took the exam with no preparation, no nothing. And then just hoped for the best […] so anyway, we passed and so it was set! She (her mum) has the dorm, she already like bought stuff, bed sheets, anything, toiletries […] So that’s how I decided nursing.”  It was common for participants to justify their acceptance of the career decision made for them by reflecting on the personal, career, and financial successes they could potentially and eventually did achieve as a result. It was also notable that despite their desire to pursue a different career path, having the decision to pursue nursing made for them by parents and family was remembered as being an uncomplicated event and without mention of conflict. Influence of extended family was also identified as important to the career decision-making of a number of participants. Linda remembered her mom's influence. She stated: “So the thing that encourage me to go to nursing? It’s mostly my mom. I listen to my mom. I think she was so pertained because she really wanted to be a nurse as a child and she just like passed it to us like as a kid. She just like mentally brainwashed us I think.  You have to be a nurse, you have to be a nurse.”  The powerful influence of parents‟ aspirations acted in conjunction with the exposure to successful family members in the nursing profession to steer individuals towards nursing.  Interviewer: So first maybe you can tell me what made you interested in nursing to begin with?   38  Amy: Um, well just like every other little girl says you know. I just want to follow the footsteps of, of my aunts. So there’s quite a few in the family that are nurses. And most of them are retired now. [laughing]  Interviewer: And so, why was that something you looked up to as a kid and made you want to follow?  Amy: Yeah well, I think it’s always. You know back home. Like [pause], um, I think that’s what I’ve seen. And to be honest, you know, probably at the back of my mind I really want to, for adventure! I really want to get out of the country as well. Because my aunts, the 2 of them, went to Canada, you know. They’re one of the pioneers here.  Interviewer: Okay, so were they already here when you were still young? So that’s a lot to look up to.  Amy: Mm-hmm. Yeah. And I never changed. I thought at first on an early age you know, because I really like to get in, I really liked politics. So I really like to be a lawyer. I always say I want to be a lawyer. But when I was in high school, I said, I want to be a nurse. And that’s it. I changed my mind.  Interviewer: Oh yeah? Okay, so how come, how did you go from lawyer to nurse?  Amy: To nursing? Well [pause], well you know how it is in....I remember your teacher always say, what do you want to be? Even at early age, what do you want to be, when you grow up? And I, and those are the only 2 profession that I really want to be. Either a lawyer or a nurse. Yeah. And I think, for the nurse, pretty well will be influenced by my relatives.   The narratives reflected perceptions of some that although a career was chosen for them by their families, ultimately, they still could have disagreed and pursued their own ambitions. However, and this is reflected in the responses of many, the response of “you know how it is”, and “you want to please your parents” as mentioned in an earlier excerpt, were common responses when asked about reactions to their loss of decision-making power. The cultural value of obedience to the wishes of parents and elders seemed expectations that were generally not argued against, as demonstrated by a study in California involving interviews with children of Filipino immigrants:  39  “…most of the undergraduates we interviewed were involved in majors that would lead to a job or to a graduate degree in a field chosen by their parents. Parental expectations were central and there did not appear to be any rebellion or rejection of parental desires for fear of confronting and disappointing them, and for fear of sanctions.” (Wolf 1997, p. 464)  Participants did not discuss the potential consequences of disobeying their parents, but there was a palpable sense of obligation in the narratives. The motivating factors for migration appear to be absolutely intertwined, namely the culture of migration with the cultural expectation of unquestionable obedience to please parents. The literature on Filipino culture and personality describes childrearing as “overprotective, as emphasizing deference and obedience rather than self-reliance, and as minimally concerned with early or excellent task performance” (Domingo, 1977; Guthrie, 1966; Nydegger, 1963). Medina (2001) provides a more contemporary overview of Filipino family culture, describing the importance of strict parental discipline and child obedience as part of traditional parenting norms. The concept of the family is central to identity as a Filipino, and a high value is placed on loyalty and the cohesiveness of the family as a unit (Wolf, 1997). Also important to consider is the dominance of religion in the Philippines, with eighty-five percent of Filipinos being of Catholic faith (Sanchez, 2007) placing further emphasis on the importance of family cohesiveness and obedience.  It is particularly interesting to note the negotiation for parental approval Linda described in the following excerpt: Interviewer: Okay, so why don't we start with, if you could tell me about what made you interested in becoming a nurse, in pursuing nursing?  Linda: Well actually this is not my first choice to study nursing, my first choice was, I don’t know if you'll believe me, it is to be a nun.  Interviewer: Really?  Linda: Yes, and then the second choice what is this? Business and management.  40   Interviewer: Okay. And this is the last choice. [both laughing] Then how did you make a decision about what you were going to study?  Linda: Um...because my parents that time didn't agree with me to study business and management and they don't agree with me to become a nun. And then, they asked me to study as a teacher and I said no I don't want to. They said okay. So I choose this one, I choose this as the last one.    Part of the shared sense of obligation described by participants was the desire to look after and “repay” their parents in some way. A common thread running through the narratives was how their feelings of obedience and obligation originated from the feeling that they “owed” their parents for financing their education. This important trait known as utang na loob, is described as “an abiding and eternal debt of gratitude for favours extended to a member of the family” (Sustento-Seneriches, 1997). A study examining adolescent‟s perceptions of family obligations found that among a number of other minority groups, Filipino youths placed the greatest importance upon familial respect, and also put a greater emphasis on their future obligations (Fuligni, Tseng, & Lam, 1999), indicating the deep roots of this trait. The importance of family as a core social value, and expressions of respect, loyalty, and sacrifice in Filipino families, similarly make up the concept of filial-piety, that is discussed in the literature with regard to Chinese and Korean cultures among other Asian backgrounds (Sung, 2000). Additionally, expectations for children to be obedient and respectful of parents‟ desires are components of the filial-piety concept (Li, 1985). Recent studies illustrate changes in perceptions of filial-piety, for example, elderly parents being less reliant on adult children and taking up common American values such as independence (Lan, 2002; Wong, Yoo, & Stewart, 2005) and more generally, a movement towards integration of the origin and host cultures (Wong, Yoo, &  41  Stewart, 2006). In this study, it is notable that obedience as a link between participants and parents are described as being of core importance, regardless of the length of time participants have been settled in Canada. This link is evidenced, and in a sense confirmed, by ongoing financial and other support these nurses provide to their parents and other family members.  Nursing education in the Philippines is costly and financed solely by individuals. All the participants interviewed, with the exception of one who was awarded a full scholarship, had parents fully finance their nursing education. Provision of full financial support by the parents well into adulthood was a situation common to most participants. This involved adult children residing at home through post-secondary education, with some remaining in the parental household well after completing their nursing education and being employed. Patricia described her financial status early in her nursing career: Interviewer: Right and then, financially, [what was it like] working as a nurse?  Patricia: As a nurse back home, I think I only earned about one uh between 150 to 200 dollars a month. And then at the beginning in order for you to be in the payroll of that hospital, you have to work like you have to volunteer for 3 to 6 months. So the first 3 months you don’t get any pay at all. And then the next 3 months I think I was paid about 12 dollars a month. That’s the allowance.  Interviewer: So then your family becomes really important in helping support you during that time.  Patricia: Oh yeah for sure. Back home it’s different too right? Like the parents support the kid. And the kid even though you’re done school you still live with your family so not like here, like at 18 you can go. Like back home, they don’t…[stop] support[ing] you until you can be on your own.    Reflecting the financial difficulties their parents endured to put them through school, the participants‟ narratives illustrate both the sentiments of obligation, and a desire to repay these  42  obligations. Nursing and emigration facilitated the feasibility of fulfilling this responsibility, and was cited as further motivation for pursuing the path of emigration as Ning described: “I should say my goal in abroad is like to help my parents. Because we are 9 in the family and then my mum said my dad’s getting sicker. So I said, okay mum I’d like to help. So then if I’m going to stay in Manila in the hospital, my salary is not enough. There would still be a little amount left for me because my salary was increased to like 14 000 pesos? So it’s like 7000 twice weekly right? So then what happened there is like I said to my mum I can help you. If I’m going to go abroad then I can help you. You know [there would be]more than enough for myself, and you know, for me to help them. So then it became strong, the need to go abroad, became stronger, so then I applied. I got 2 applications now, the cruise ship, and then London. So I applied […]”.  Providing financial support to family members, both in the Philippines and in Canada, was the common obligation of six participants. Of the remaining three who indicated they do not provide financial support, two had the majority of their family members residing in Canada. Indeed, this was one reason that despite the lack of freedom in choice in their career path, not one participant mentioned any regret in following the plans made for them. Despite the challenges and hurdles they faced along the way, there was a shared sense of contentment among the participants with regards to the career paths they chose, which ultimately allowed them to reach the “greener pastures” they had aimed for. Tess‟ reflection illustrated this: Interviewer: You mentioned most people’s reason for coming [to Canada] is a better future. What does that mean for you? What is a better future?  Tess: Hmm. My mum has emphasized to us that you know, for example if I have my own family. She said that she doesn’t want me to have the kind of life that we did […] we were basically working hard to even get by. […] We can’t afford to go on vacation, we can’t afford to go like swimming, or like go on trips. You know, like occasionally Christmas we get to like buy clothes, but not just a part of what we do as a family. In here [Canada] I feel like we all work hard but everybody has an equal opportunity. I mean I know that initially we stayed in a 2 bedroom apartment. Then a year after that when I got a job, my sister got a job, we were able to buy a house right away. Back home, our house is like actually owned by my grandparents and it’s an extension of their house. […] And we can’t afford to buy our own there. And you know with that income, with our situation, it’s just hard. So in here I feel like right away you get to see the result. You work hard, yeah, but at  43  the same time you know you can reap your hard work right away. You can see it’s visible, it’s tangible.  As illustrated in these narratives, the effect of cultural and societal influences on the motivations of immigrant Filipino nurses is complex and powerful. It is important to bear in mind that the analysis in this paper examines only a fraction of Filipino cultural and familial relationships and pressures. Also, it is important to note the degree to which all of these factors are intertwined, so much so that distinguishing between the catalysts and the outcomes is almost impossible. Regardless, cultural pressures emerge as important factors influencing the motivations of Filipino nurses both in pursuing the nursing profession and their eventual immigration. 2.9 Challenges in Co-creating and Interpreting the Narrative  Given that I myself am a Filipino nurse, I found the oral history methodology particularly challenging. In the planning of the study, I was acutely aware of my own knowledge, experiences, and assumptions about Filipino nurse migration and how these might affect the conduct and interpretation of the interviews. Navigating through the initial interviews proved particularly complex as I was unsure of whether I should approach the interviews from a neutral position as a researcher, or to present myself to participants as a fellow Filipino nurse. A neutral position seemed best suited to the goal of producing the most genuine interpretation of each narrative, while minimizing the introduction of concepts and biases that coloured my own experience and knowledge. There were two issues with this approach. First, it would be disingenuous to deny my personal connection with the topic, and try to portray a completely neutral stance that would be convincing to participants. Through an active detachment of my own background from the participants and the interview process, I felt I would introduce a more complex problem of presenting a false image, as it is obvious that I share the same ethnic  44  background. This approach had potential to alienate participants and create difficulty in establishing rapport.  The second issue with an alleged neutral approach was that it would fail to take advantage of the existing familiarity of the interviewer with the participants. Despite the risk of introducing bias, by being part of the same ethnic and cultural origin, as both a nursing colleague and Filipino, I automatically claimed a basis for connection with participants. In addition to facilitating a rapport with the participants, this connection also had potential to elicit narratives that participants may not otherwise have shared. It is important to consider however that despite my relation to the participants, there was still a distancing between us. This resulted from participants‟ perceptions that I “grew up Canadian” while they did not, and therefore would not be able to understand their more authentic experiences as native Filipinos. Located in this “in between” place of being familiar yet different, the decision as to what position to take during interviews was determined for me. In this position as an "in-betweener" I was able to conduct the interviews from an objective perspective with regard to a number of the topics, yet I was able to capitalize on a shared familiarity in establishing a trusting and comfortable relationship with participants, which arguably freed them to discuss more intimate memories. Furthermore, to account for my role as co-creator of the resulting narratives, both the written field notes and the continuing comparison of the narratives with existing migration literature proved instrumental in both the analysis and interpretation of the narratives. 2.10 Conclusions  Exploration of the biographical histories of Filipino immigrant nurses provides a new perspective from which to view global nursing migration. Oral history facilitates the incorporation of frameworks beyond the traditional lens of economic and policy analyses, from  45  which much of global migration is viewed. In contrast, narratives produced in the course of this study provide an intimate and detailed look at the cultural and familial influences that shaped their desire to emigrate from the Philippines. The creation of the widely popular culture of migration, fierce competition surrounding nursing employment at home, familial obligations and cultural pressures, all contributed to the motivations of Filipino women to pursue the nursing profession and international migration. How these nurses recall and describe their experiences provides insight into how the decisions to pursue nursing and immigration were experienced first-hand and offers details of their experiences before leaving the Philippines. For these nurses, the culture of migration had a significant influence on the internalization of the desire to migrate. The initial establishment of a popular culture of migration stemmed from the United States‟ efforts in recruiting Filipino nurses by presenting migration as a prestigious and highly desirable goal. Conversely, the narratives in this study demonstrated that more contemporary reasons to immigrate have latterly become fully ingrained in these individuals, detached from historic roots. There was a sense of uncertainty in participants‟ responses when questioned about personal reasons for wanting to migrate. Indeed, participants often were unable to pinpoint specific motivations, but instead alluded to migration as being an „obvious‟ desire of most Filipino people. As a result of the great number of nurses produced by the booming nursing education industry in the Philippines, nursing jobs are scarce and competition is fierce. The phenomenon of the “nurse volunteer”, working as a fully-fledged and fully-responsible nurse without compensation in the effort to secure a hospital position, was a common narrative. The immense competition in securing employment as a nurse in the Philippines also arose as an important influence, effectively redirecting nurses to seek employment overseas, or in other professions altogether. Although on appraisal, basic economic gain stands out as the most  46  obvious reason to migrate, nuances revealed by the narratives illustrate more subtle implications. The narratives reveal a complex web of family obligations and expectations that proved extremely influential in shaping motivations to migrate. Cultural and familial expectations of obedience and family loyalty have shown these nurses to have had little choice in the decision of career pursuits and life choices. A desire to “pay back” and to take care of their parents in turn, provided examples of the profound sense of obligation described by participants.  Examining the experiences of Filipino immigrant nurses prior to coming to Canada, this study provides a first glimpse into the history of this group of nurses in Canada. The themes that emanated from this study moved beyond economics and the traditional push and pull factors frequently discussed in nursing migration literature, and highlight the importance of broader social and cultural pressures as well. While many details of the migration of Filipino nurses to Canada are still to be explored, this study reveals how a life history perspective sheds light on the more subtle aspects of identity formation and the power dynamics in decision making, giving an identity to the often faceless statistics of migrant nurses.  47   2.11 References Abella, M. (1993). Labor mobility, trade and structural change: The Philippine experience. Asian and Pacific Migration Journal, 2, 249-268. Aiken, L. H., Buchan, J., Sochalski, J., Nichols, B., & Powell, M. (2004). 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(2005). Examining types of social support and actual sources of support in older Chinese and Korean immigrants. International Journal of Health and Human Development, 61(2), 105-121. Wong, S. T., Yoo, G. J., & Stewart, A. L. (2006). The Changing Meaning of Family Support Among Older Chinese and Korean Immigrants. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 61(1), S4-S9. Yow, V. R. (2005). Recording oral history: A guide for the humanities and social sciences. Walnut creek: AltaMira Press.    51  CHAPTER 3  LEAVING THE PHILIPPINES: ORAL HISTORIES OF NURSES’ TRANSITION TO CANADA 2   3.1 Introduction  Between the years 2000 to 2002, the United Kingdom (UK) and Philippines were the main source countries of registered nurse (RN) immigrants to the Canadian workforce, with the Philippines taking the lead from the UK in 2001 (Baumann, Blythe, Kolotylo, & Underwood, 2004). To provide some context, the percentage of immigrants to the Canadian RN workforce in 2002 was approximately twenty-seven percent for nurses from the Philippines, the UK with twenty-five percent, and in third place is the US with eight percent (Baumann, Blythe, Kolotylo, & Underwood). More recent statistics show that of the approximately eight percent of RNs graduating from an international program, nurses from the Philippines make up the largest group (thirty-one percent) (Canadian Institute for Health, 2008). The Philippines is often identified as the leading producer of nurses for global export (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Bach, 2003), and with the predicted shortage of nurses in North America in the coming years, it is reasonable to anticipate an increase in the migration of health professionals (Bach), with Canada being part of this trend . Yet despite these growing numbers, there remains a paucity of information in Canada about this immigrant group (Damasco & Knowles, 2008). As Canada can be expected to remain a popular destination country for immigrant Filipino nurses, a historical study of this group and the context surrounding their experiences is important and timely. It will allow an anticipation of potential challenges in the transition and integration process and a better understanding of the transition process.  2 A version of this chapter will be submitted for publication. Ronquillo, C. (2010) Leaving the Philippines: Oral histories of transition to Canada.  52   Existing work on the history of immigrant Filipino nurses in the United States (US) reveals the importance of the historical colonial relationship between the US and the Philippines as a precursor to the popularity of immigration and nursing as a career choice for Filipinos (Choy, 2003). Choy‟s seminal work is the authority on this history, and emphasizes the importance of an oral history perspective in providing a detailed look at the life histories of this group to complement dominant economic and policy analysis perspectives of global health worker migration (Choy, 2003, 2010). In line with the recommendations Choy presents and the goals of this study, this chapter examines the history of Filipino nurse migration, specifically through the exploration of the lived experiences of a small group of immigrant Filipino nurses currently living and practicing in Canada. It provides a regional and personal illustration of migration as voiced by those who experienced it first-hand.  The period of transition to Canada and the process of integration into the Canadian nursing workforce and life in Canada is the focus of this chapter. The social historical concepts of gender, race, and identity are central to the analysis and interpretation (Boschma et al., 2008; Choy, 2010). 3.2 Oral History – The Method and Framework  Given the goal of this study to provide a detailed examination of larger social, cultural and historical influences at play in the migration of Filipino nurses and how they evolve at the individual level, oral history is a valuable source of evidence to capture the experiences of immigrant Filipino nurses. Oral history research involves conducting interviews with a selected group of individuals – those with first-hand knowledge of the event or time period under study – and producing a narrative of each individual‟s past experiences in the context of the topic under study (Boschma et al., 2008). As both a method and framework, oral history allows  a shift in perspective to a “bottom-up” view, highlighting the experiences of ordinary people in everyday  53  life (Boschma et al., 2008; Burke, 2001; Thompson, 2000). By affording the opportunity for individuals to tell their stories in their own words, oral history provides a voice for groups and individuals who may not otherwise be heard, or have no written histories (Biedermann, 2001; Kirby, 1997). Capturing past experiences as they are presented by participants is sought, complete with their ambiguities, disorganization, complexities, and possible inconsistencies (Boschma et al., 2008). In the narratives the focus is shifted from a chronological and concrete telling of history to how it was experienced, interpreted, and remembered by individuals (Sugiman, 2004). Oral history focuses less on the events themselves, and instead seeks to explore the meaning speakers place on their own experiences and how they view their relationship to their history (Boschma et al., 2008; Portelli, 1998). Through an examination of how events are recollected over time, we gain insight into how these events shaped and coloured the individual perspectives of the experiences encountered. 3.3 Sampling and Recruitment  This study examines interviews with nine female Filipino nurse immigrants. Five interviews were conducted in Calgary and four in Vancouver. Given the provincially-based healthcare structures in Canada, this chapter provides a regional look at the experiences of Filipino nurse immigrants in Western Canada. Additionally, British Columbia (BC) and Alberta (AB) are two of the leading three provinces with rapidly increasing numbers of new RN registrants from abroad, with numbers doubling in BC, and a fivefold increase in AB from 1999 to 2002 (Baumann, Blythe, Kolotylo, & Underwood, 2004). Participants were recruited by purposive and snowball sampling, as the study required individuals who have undergone particular experiences and are willing and able to share them. Purposive sampling is targeted recruitment and inclusion of participants who would most benefit the study (Polit & Beck, 2008).  54  Snowball sampling was also used wherein early informants were asked to make referrals to other potential participants (Polit & Beck, 2008). The author has an extensive network of nurse colleagues in Vancouver, as well as relatives who are nurses in Calgary and Edmonton. Volunteer third parties from this network initiated contact with potential participants and facilitated the recruitment process. Ethics approval was granted by the University of British Columbia‟s Behavioural Research Ethics Board in the fall of 2009. All interviews were conducted by the author and audio recorded. An open-ended script was used to guide the interviews, however precedence was given to the stories participants wished to speak about. Participants were encouraged to speak freely and openly about their experiences and the interviewer minimised her intervention. Pseudonyms are used in this paper to refer to participants. 3.4 Participant Demographics  All participants were currently practising female RNs in Canada, except for one participant who was on medical leave.  All participants had completed their nursing education in the Philippines. Seven female participants whose ages ranged from the early thirties to the late fifties had baccalaureate degrees in nursing, and two graduated from hospital-based schools of nursing. Dates of departure from the Philippines ranged from 1974 to 2004. Immigration to Canada occurred after 2000 for five participants, two arrived in the 1990s, one in the early 1980s and one in the early 1970s. Four participants first lived and worked as RNs in other countries prior to arrival to Canada. These include England, Austria, Saudi Arabia, and the United Arab Emirates. One nurse was employed on a cruise ship prior to migration to Canada. Five migrated with other family members and four as individuals. Seven migrated with the aid of a sponsor, and two of those who arrived by sponsor entered Canada through the Live-In Caregiver Program.  55  Two nurses migrated independently, without aid from a sponsoring person or agency. Five participants indicated that they provide financial support to family in the Philippines either regularly or according to their family‟s needs. Two indicated they did not provide any financial support, while two did not provide a response to the question. 3.5 Transition of Global Nurse Migrants   With the rapid increase in numbers of migrant nurses, transition issues, for example acculturation to working and living in the host country, have received much attention in the literature.  A number of studies explore the transitional experiences of migrant nurses in the UK and the US, with Filipino nurses included as part of larger migrant groups (Alexis, Vydelingum, & Robbins, 2007; Allan, Larsen, Bryan, & Smith, 2004; Daniel, Chamberlain, & Gordon, 2001; Emerson, Griffin, L'Eplattenier, & Fitzpatrick, 2008; Matiti & Taylor, 2005; Withers & Snowball, 2003).  Few studies on the experiences of immigrant Filipino nurses have been conducted in Canada (Blythe, Baumann, Rheaume, & McIntosh, 2009; Nelson, 2005). In the US and UK, transitional programs have been implemented with the aim of facilitating the adaptation and transition process of IENs to their new host countries. A systematic review of transitional programs for IENs in the US illustrates that many studies focus on the effectiveness of transitional programs that have been implemented (Zizzo, 2009). Yet, little attention has been paid to the experiences and voices of the immigrant nurses themselves, constituting a gap in knowledge that may inform such transitional programs. In the National Health Service (NHS) in the south of England, a number of studies have explored the experiences of migrant nurses (Alexis, Vydelingum, & Robbins, 2007; Allan, Larsen, Bryan, & Smith, 2004; Daniel, Chamberlain, & Gordon, 2001; Withers & Snowball, 2003) including those that found white UK-based nurses were supportive of Filipino nurses (Daniel, Chamberlain, & Gordon, 2001),  56  while others described receiving limited support from their UK counterparts (Alexis, Vydelingum, & Robbins, 2007; Matiti & Taylor, 2005). A metasynthesis of the experiences of immigrant Asian nurses working in Western countries found four overarching themes in the literature which include: (1) the daunting challenges of communication, (2) marginalization; (3) discrimination and exploitation; and finally, (4) cultural differences and differences in nursing practice (Xu, 2007). The challenge presented by the disconnect between the expectations and the actual experiences of migration and working as a nurse overseas is discussed in several studies (Dicicco-Bloom, 2004; Matiti & Taylor, 2005; McGonagle, Halloran, & O'Reilly, 2004).  An important theme is their frustration with a lack of  recognition for educational preparation and work experience in their home countries, and a sense of feeling devalued upon starting their work in the host country (Alexis, Vydelingum, & Robbins, 2007; Matiti & Taylor, 2005). Language was often presented as an important challenge for immigrant nurses (Matiti & Taylor, 2005; Salma, 2009; Withers & Snowball, 2003; Xu, 2007). It is notable that these studies, primarily preoccupied with the integration and transition process, are being conducted currently. The voices of immigrant nurses participating in transitional programs are being solicited primarily to provide feedback to inform decisions surrounding the design of these programs. The focus on these transition issues illuminates the increasing globalisation of nurse migration and its growing importance in healthcare systems globally.  Studies discussing transition experiences of internationally educated nurses (IENs) in Canada are emerging, and early work shows challenges similar to those discussed in the UK and US literature. In a study examining workplace integration as part of the transition process of thirty-nine nurse migrants to Canada, language and communication is also identified as one of the critical barriers to workplace integration (Blythe, Baumann, Rheaume, & McIntosh, 2009).  57  Two master‟s theses completed within the last five years explore the transition experiences of IENs in Canada. Nelson (2005) explores the experiences of thirteen IENs (primarily from Australia, Britain, and the Philippines) employed in the Greater Vancouver Regional District. Findings from this study include IENs misconceptions about relocation and ease of registration, difficulty with the bureaucracy of the licensing process and education upgrade requirements, and challenges with taken-for-granted logistics of immigration (e.g. obtaining a driver‟s license). Personal transition experiences discussed in Nelson‟s thesis includes the perception by IENs that Canadian nurses felt threatened by their employment, the first six to eight months as the most difficult periods of transition, adapting to a different culture of nursing in Canada, adapting to a multicultural environment, feelings of being devalued, and the importance of personal and professional support during the transition process (Nelson, 2005). Salma‟s (2009) thesis explores the experiences of IENs, focusing on those who migrated to Alberta. This study identifies challenging areas,such as the cultural differences in nursing practice which includes a difference in task delegation, nurse autonomy, and responsibility (Salma, 2009). The study also discusses frustrations with the lack of recognition for previous experience, and feelings of deskilling and devaluing (Salma, 2009). Canadian studies similarly reveal the difficulty in becoming registered in Canada as a significant challenge for IENs and misinformation in the amount of time and effort required to complete the process (Blythe, Baumann, Rheaume, & McIntosh, 2009). It is not unusual that this underestimation of the resources required to register in Canada serves as barrier to some nurses in pursuing their careers (Blythe, Baumann, Rheaume, & McIntosh, 2009).  58  3.6 Nurse Immigration History: Race, Gender, and Identity  Canadian historian Franca Iacovetta (1997) suggests that early studies of ethnic migrant groups are often rife with cultural stereotypes, and there is a tendency toward homogenizing immigrant experiences. Additionally, she underscores the tendency to neglect work specific to women, for example housework, childbearing and rearing, in studies exploring Canadian ethnic communities (Iacovetta, 1997). Coupled with the history of nursing being inextricably linked to women‟s historical roles, exploration of immigrant nursing history in Canada has been relatively limited. The exploration of nursing immigration history in Canada has been analyzed within the frameworks of gender, identity, and race, in an attempt to understand immigrants‟ experiences. For example, the historiography examining the immigration of Caribbean nurses to Canada by Calliste (1993) and Shkimba et al. (2005) discuss the roles race, class, and gender played in controlling immigration in Canada in the post-World War II period. Nursing historians have argued that a perceived shortage of nurses in Canada in the mid-twentieth century prompted changes in immigration policies to facilitate immigration of foreign nurses, and incorporation of these nurses into the Canadian healthcare workforce (Calliste, 1993; Shkimba, Flynn, Mortimer, & McGann, 2005). Notably, race played a prominent role in shaping the recruitment of foreign nurses. For example, Calliste (1993) illustrates this through exploring the differing immigration policies, dependent on the nurses‟ race and country of origin. For examples in the 1950s and early 1960s, white nurses‟ general admissibility was sufficient to be admitted to Canada as permanent settlers. In contrast, Caribbean nurses were admitted only „as cases of exceptional merit‟, and on the basis of their nursing qualifications (Calliste, 1993) Additionally, Calliste (1993) argues that the changes in Canadian immigration policies were also implemented in order to further Canada‟s trade interests in the British Caribbean.  59    Exploration of the experiences of immigrant Filipino nurses in Canada is emerging, however an analysis of the critical role of the historical background that shaped their experiences is lacking. Nursing education and practice in the Philippines in particular, is influenced heavily by its colonial ties with the US in the mid-twentieth century, and such an historical context is essential to facilitating the analysis of Filipino nurses‟ experiences (Choy, 2003, 2010). In the US, historian Catherine Choy‟s extensive work on the history of Filipino immigrant nurses in the context of the Philippines‟ colonial relationship with the US, is the authority on the topic (Choy, 2003). Current analyses of the global migration of nurses often focus on economic and health policy issues as the most dominant contextual frameworks (Calliste, 1993; Choy, 2003, 2010; J. Connell, 2008; Damasco & Knowles, 2008; P. Kelly, 2003; P. F. Kelly, 2006; P. F. Kelly & D'Addario, 2004; Kingma, 2006, 2009). Choy argues that there is a need to look beyond these dominant perspectives and incorporate the voices of nurses themselves, in order to provide a more complete and rich account of the immigrant nurse‟s experience (Choy, 2003, 2010). She highlights life stories as instrumental in understanding the individual experiences of these nurses in the context of larger social and historical influences (Choy, 2003, 2010). This study adds to this historical perspective, through the analysis of oral histories, to complement ongoing work for this group of migrant nurses. This oral history study endeavours to illustrate how each individual narrative fits within the larger social influences, and how larger overarching factors are experienced at the individual level. 3.7 Narrative Themes  From the oral histories, four prominent themes arose which were common to the majority of participants. First, I will discuss the Filipino nurses‟ opportunistic attitude toward pursuing migration and how this is related to the broader development of the culture of migration in the  60  Philippines in recent decades. A discussion of family cohesiveness as a central value in Filipino culture follows in relation to the issues this brings about for immigrant nurses. Next, I will explore the contrast between training as a nurse in the Philippines and the expectations of greater autonomy upon their entry to the Canadian health care system. Finally, the concept of having to prove self and the participants‟ perceptions of racism will be reviewed. 3.7.1 Get In Where You Can  The narratives illustrate that the final destination was unimportant and did not seem to stem from any personal desire to live and work in a particular country. These destinations were pursued solely because they were the opportunities for migration that became available. More importantly, these migration opportunities were perceived as having a high probability of success. This often led to an indirect path to immigration to Canada. It was common for nurses to first work and live in other countries prior to what they consider “settled” immigration in Canada. Reasons given for first working as RNs in other countries include the relative ease of the immigration and registration process in those countries; as compared to the perceived “closed borders” of Canada. Recruitment agencies were often mentioned as directing efforts towards recruiting nurses from the Philippines and facilitating the immigration process for many. Complementary to these efforts was the increasing popularity of immigration as a goal for many Filipino nurses. Alida Sanchez described the popularity of recruitment agencies: Sanchez: A lot of my batchmates actually took nursing because…I remember late 80’s and early 90’s. If you turn the pages on the local newspaper there will be like Saudi Arabia, US, they’re like…recruiting nurses from US. You can see them from local newspapers and I haven’t seen that before […] I got connected to an agency and they said, there’s a direct hiring from the UK. The employers are coming, they’re going to go and interview you guys and meet up in a hotel. So we applied and had our interview. I think within 6 months we flew […] I think there were like, in the intensive care unit [in the Philippines], there were about 20 staff.  About 4 or 5 went to the [United] States, and the rest went to the UK.  61   Interviewer: Who did you hear [about the recruiters] from? Was it another co-worker?  Sanchez: Another co-worker of ours. She was a floor senior nurse and she goes around, “Oh I heard there’s an interview this and that, you go”. So we went there and interviewed – there’s a lot of nurses there! Probably we were around 50 to 200.  Sanchez remembered that hiring to the US “pretty much stopped” after 1995, and by 2000 most of the hiring was by the UK. Sanchez‟ story illustrates the speed of the process of immigration to the UK with the aid of a sponsoring agency when she first emigrated from the Philippines in 2000. The ease and high probability of success in immigrating is discussed in many narratives as instrumental in determining migration decisions, including the eventual destination country.  The Middle East was a popular destination as described in the narratives, and this study included two participants who first migrated to there prior to arriving in Canada. Both participants described the popularity of Middle Eastern countries and the effortlessness of their migration experiences. Lillian Villa described how only three months after graduating from nursing school, she was hired as an RN in Saudi Arabia.  She recalled the experience:  Interviewer: After you passed your board exam, what was your next step?  Villa: Work. I went to abroad right away! [laughing] I went to Saudi [Arabia] right away!  Interviewer: So you didn’t work as an RN in the Philippines?  Villa: No.  Interviewer: And what made you apply so soon, or so quickly after?  Villa: Because before there were lots of, what do you call that? Hiring for Saudi Arabia. Nurses. It’s just in Manila. I just heard it from one of my classmates. Maybe, 10 of us I think applied right away. 10 of us left like 1982. In March we had the board exam and we graduated. After that we went to Manila in May. May, we took the board exam. And June, yeah June I think we left. It was too fast!   62  It is noteworthy that those who experienced relatively trouble-free immigration processes did not expand on the details of their immigration process. This strengthened the perception that their experiences of first leaving the Philippines to work as RNs in other countries were straightforward and facilitated by their direct recruitment by the host country.  Linda Samala illustrated this point with a very succinct description of how she came to work in Dubai:  Interviewer: And what happened after that [graduation]? You were working as an RN in the Philippines, and then?  Samala: Then a friend of mine, she called me one day. She told me there's a hiring for Dubai. So I applied. And then I got the job. I worked there for almost 11 years in Dubai.    The narratives reflect the recognition of the opportunity for a successful migration presented to them. The participants did not seem to consider their own desires when deciding on a target country for migration. Instead, migration opportunities were taken as they were presented, regardless of the destination. The goal to emigrate was conveyed clearly throughout the narratives, and this goal was pursued by any means available.  While some described the relative ease of their attempts to immigrate, others encountered numerous obstacles in their migration journey. Nurses‟ experiences of either ease or difficulty with the migration process appear to be related to the human resource needs and recruitment efforts of host nations. Nurses sponsored by other individuals or who immigrated independently directly to Canada, encountered more challenges as compared to their actively recruited counterparts. The immigration process to Canada is described by many as more difficult, leading two nurses to enter Canada through the Live-In Caregiver program to facilitate their entry. Although one nurse was aware of what this program entailed and its consequence of delaying her ability to work as an RN in Canada, another nurse, Ning Pascual, came through this program  63  without her knowledge. After working in the Philippines for a few years, Pascual easily found an RN position on a cruise ship. In her work on the ship, she cared for an elderly Canadian couple, Tom and Jane, who became determined to “help her out” by insisting on sponsoring her immigration to Canada. After discussing this option, Tom processed the required documents to facilitate the migration process and Pascual was on her way to Canada. Pascual described:  Pascual: Yes [the process was] so quick, it was like eight months. Before that we were exchanging e-mails and he said he went to the College of Registered Nurses of British Columbia. There’s registration for me to start and they start processing the papers […] so before I arrive I’m already set and everything is ready and all my profiles were in place. The first day I arrived we went to CRNBC […]They assessed all my papers, but you see the truth was, when we looked up my category, I'm under a live-in caregiver program […] He applied [for] me in the cancer clinic and they said they accept me right away. But looking back at the paperwork, the human resources told me, “Your visa is not a working visa. It's a caregiver visa”. I was shocked on that. I said, so, what am I going to do now Tom? […] So then the saddest part of my story is like I arrived November 18, and he passed away December 24. So now I feel like I'm an orphan of the country. [That was in] 2004. So it's like oh my lord what's happening to me right now? The agency with whom he placed my paperwork, I have to go back to them and say, so they said I’m a caregiver. I said, I think I’m not clear with that before. So what can I do? I promised the old man not to go back, but I have the option to go back […]  Ultimately, Pascual opted to remain. For two years she was a caregiver in Canada, until she was finally able to register as an RN. Although her story illustrates one of the more dramatic experiences of struggle and confusion as part of the migration process to Canada, it serves as an example of unexpected challenges some migrant nurses encountered. Pascual had to weigh the importance of pursuing migration, with all the problems and rewards it would include. Echoing the other narratives, the choice to follow-through with the decision to immigrate was pursued by Pascual, as an opportunity that could not be wasted, despite the difficulties it included. In contrast to the other narratives however, her journey to Canada, which did not involve direct hiring or recruitment from the host country, was a more tumultuous experience.  64   Like Pascual, Patricia Reyes also facilitated her entry to Canada by first entering as a caregiver. Reyes recalls that it was her uncle who sponsored her through the Live-In Caregiver program. She described how this option was attractive since it was relatively “faster and easier”, with a higher probability of success and a shorter wait time in entering Canada, compared to independent immigration. Unlike Pascual, Reyes was aware of the professional limitations presented by entering the country under the Live-In Caregiver program. Despite having to relinquish her nursing identity for a time, Reyes considered the opportunity to emigrate as more important. She recalls that her experience entering Canada through the Live-In Caregiver program was not difficult in and of itself. The challenges however, came with the requirements of the program, namely the required twenty-four months or 3900 hours of full-time work as a caregiver (Citizenship and Immigration Canada, 2010). Completion of these requirements subsequently allowed her to apply as a permanent resident and pursue nursing work in Canada. The caregiver work requirement delayed her ability to register as an RN in Canada, caused her to lose nursing skills, and made it more challenging to complete the refresher course required to eventually apply for RN registration in Canada. Reyes‟ experiences echo those of Pascual‟s, wherein more challenges were encountered as a result of not being directly recruited and hired by the host country.   Issues and delays encountered in the immigration process of those sponsored by other individuals or migrating independently was common for participants in this study who arrived in Canada from the mid-90s to the 2000s. It was notable however, that two participants who migrated to Canada in 1974 and the early 1980s, an independent immigrant and the other sponsored by her grandparents, did not recall their immigration experiences in Canada as difficult. Instead, for them the challenges came later, in their attempts to register as RNs in  65  Canada. Carmen Torres was sponsored by her grandparents, already residing in Canada at the time. She provided only a brief account of her immigration process, and recalled that obtaining a visa and entering Canada as a sponsored migrant was not a problematic experience for her. Similarly, Lucita Cruz, who arrived in Canada in the early 1980s, described:  Cruz: We didn’t really migrate here [Canada] first. We, me and my sister went to Vienna, Austria and did some nursing there. That was [19]74. I graduated in 74 so I hardly work in Philippines actually. I went straight to Vienna, Austria […] You just apply to them [the agency], present your registration. And that offer is quite nice because you don’t have to spend anything. They work for all the papers you need. They did everything for you and then they just call you and you’re going!  Interviewer: Oh wow. So that was right after you graduated?  Cruz: Right after, I probably worked about a few months in the Philippines […]  Interviewer: So then after Vienna...  Cruz: That’s the time we immigrated here [Canada]. Because you always think it’s better somewhere else so... [both laughing]  Interviewer: And why Canada for you?  Cruz: Canada is open, at that time. And the US, they don’t accept application from out of the country. So Canada is the only way you can go.  Cruz only briefly described her immigration experiences to Austria and Canada, providing the perception that the process was relatively trouble-free. Cruz noted that she was able to work as an RN in Vienna right away, largely as a result of being hired directly. In Canada however, similar to Torres, her challenges came later with the frustration of being unable to register and work as an RN after her arrival.  From these narratives it appears the desire to immigrate led nurses to first practice as RNs in a number of other countries, for example the UK, the US, and the Middle East, because they perceived direct entry to Canada as more difficult. Alternate ways of entry to Canada, including  66  the Live-In Caregiver program or sponsorship by other individuals, were perceived by Filipino nurses as viable options to enter the country. Despite the limitations and challenges of the indirect routes, the probability of success in immigration was described as outweighing any temporary struggles. For participants who arrived in Canada in the 1970s and 1980s, the migration process in and of itself was not remembered as particularly difficult. The narratives illustrate that the valuing of the migration opportunity far outweighed any personal desire to relocate to any particular country, or any anticipated challenges involved with the migration journey.  Inconsistent documentation has made it difficult to track inflows and outflows of nurse migration between different countries. Likewise, information available on the demographics of immigrants entering countries through various points of entry (e.g. educational training and credentials of Live-In Caregivers in Canada) is scarce. Given this paucity of information, an examination of the historical contexts of immigrant Filipino nurse migration, as well as other migration trends in Canada, contributes important information to the interpretation of the study results.  Historian Catherine Choy argues that it was the historical colonial relationship between the US and the Philippines that laid the foundation, in the mid-twentieth century, for the mass migration of Filipino nurses that continues to the present day (Choy, 2003). The “culture of migration” is a concept described in the literature as the pervasive desire to immigrate, and the enthusiastic promotion and pursuit of migration among people as a means to improving social and economic status (Choy, 2003; Cohen, 2004; John Connell, 2008; Garchitorena, 2007; Sills, 2007). I argue that the historical relationship between the US and the Philippines and early successes in foreign migration, laid the foundation for the propagation of the culture of migration  67  in the Philippines, and subsequently, fostered an opportunistic attitude towards pursuing overseas immigration. Given the legitimization and acceptance of the immigration option as a path to social and economic well-being, it is not surprising that any means necessary to achieve this end is pursued. Filipino nurses hold an especially advantageous position, as nursing is a very transportable profession. Filipino nurses have a great potential to significantly improve their social and financial situations if able to work successfully overseas. A problem then arises in determining a successful point of entry to the country. I argue further it is this problem that leads Filipino nurses to pursue immigration to seemingly arbitrary locations. From the study results and historical trends, it seems that the destination country holds little significance for migrant Filipino nurses. Instead, it is the foreign policies regulating entry to the host countries and within the Philippines that become most important. For example, the first major wave of migrants to the US came after 1948 with the establishment of the Exchange Visitor Program (Choy, 2003; Martin, 1993). After 1965, US immigration laws allowed more people from the Philippines and Asia to immigrate; in the 1970s, labour export of Filipino workers became government policy in the Philippines (Aguilar, 2000; Martin, 1993; Sills, 2007; Tan, 2001). These complementary policies then resulted in a large outflow of Filipino nurses to the US during those years. Additionally, mass migration to the Middle East occurred during this time (Samonte, 2003). Arguably, this is still happening today – immigrant Filipino nurses pursue opportunities to immigrate through the means they deem will most successful. In the narratives, this was reflected by the variety of host countries to which the nurses first emigrated, and the different means of entry to Canada. Some participants also expressed how changes in US immigration policies determined their decisions regarding which migration route to follow. Current trends illustrate this opportunistic tendency. For example, numbers of Filipino nurses are declining in the US and  68  increasing in the UK (Kingma, 2009; Kline, 2003), where immigration policies have been more liberal than in the US during the last few years (Aning, 2010). 3.7.2 Family First, Nursing Later  The concept of the family is central to identity as a Filipino, with loyalty and cohesiveness comprising important aspects of this concept (Wolf, 1997). The importance placed on the value of the family as a unit was conveyed clearly in each nurse‟s story. The desire for family cohesiveness often took priority over any personal professional goals for these nurses. For some, the potential to reunite with family members was one reason for choosing Canada as a destination country. A consequence of placing central importance on the family was a delay in the process of obtaining RN registration in Canada.  Many participants remembered that the RN registration process in Canada was a lengthy one in comparison to their experiences in other countries. They described being unaware of the amount of additional time and education required to register and work as a nurse in their new country. RNs who had first worked in other countries where their Philippine nursing education and experiences were deemed equivalent were particularly frustrated upon trying to register in Canada. They expressed feelings of being devalued and disbelief that their previous RN experiences were not recognized. After graduating from nursing school in the Philippines, Cruz was recruited to work as an RN in Vienna where she remained for two years. After working in Austria, she describes her experiences of arriving in Canada: “When you get over here you’re not registered. You have to pass the board exam. But we were considered registered in Vienna. You don’t have to take a board exam or anything. In Vienna, once you’re registered in the Philippines, you’re registered there. But when you get over here, that’s a different story. You have to do it all over again. So, me and my sister worked as nursing attendants for a while.”   69  Cruz described how she first worked for four years as a nursing attendant in Canada before being able to obtain her RN registration. Cruz recalled feelings of frustration with Canadian accreditation and an inability to understand why there was such a difference in the registration process between Vienna and Canada. Having to first work for a number of years as a care aide or nursing attendant was common among participants.  The long delay in gaining RN registration was recalled by many as an exasperating process. This delay was further compounded by the valuing of their family‟s needs as superseding any professional goals. Many remembered that their time of entry to Canada coincided with periods in their lives when they began to buy property and to start building a family. Consequently, they recalled that it was “comfortable” to continue working as care aides or nursing assistants indefinitely, as they valued supporting their families above their career pursuits. Carmen Torres was sponsored to Canada by her grandparents, and arrived during a period when nursing standards and reciprocity for IENs in Canada were beginning to change. Upon her arrival in 1974, she was able to obtain a graduate nurse position in a small town in Alberta. After taking a year or two to start a family, she found the situation for IENs in Canada had changed:  “ I moved back to Calgary and settled. And that’s when I started a family at an early age, I had a baby. And after that, when I’m ready to come back, I can’t come back as a graduate nurse anymore […] I worked as a nursing aide. And actually I worked for a long time as a nursing aide. I was really like comfortable you know, having a family and that, you never really think of [going back to school]. Until I got a call from [the registrar in] Edmonton, and they’re saying, oh what are you going to do? Are you going to still take your exam or what?”   70  Torres recalls that the registrar‟s persistence in encouraging her to pursue nursing registration in Canada. Once given the push to pursue her RN registration in Canada, Torres described how she managed the process:  “ I didn’t quit working so I did night shifts, and then I’d just do some review in between that. So fortunately I made it! […] And I always tell everybody, you know you don’t have to study all day. Only have at least 2 to 3 hours, even just 2 hours a day that you can read. And it doesn’t have to be reading. You tape, you can listen, even when you’re doing your kitchen. […] The thing is, I don’t waste time. If I’m only younger? I’d like to do all! I want to pursue my career, you know? Because once you start doing it and you’re reading, you’re really going to get into it. That’s just how I felt at the time. I go to the doctor’s office, wherever that I have to wait. I always have something with me that I wait with. I have either some clippings or some literature, or a case study, or whatever! Just something. And I said, make use of it. I said even when I’m going to the washroom! […] That’s how I did. I work the night shift and then I will only sleep for a couple of hours after. I cook dinner so when the kids come home they have something to eat. Then by one o’clock I’m at the library […]  Torres worked as a graduate nurse and nursing aide from 1975, completed a refresher course in 1990, obtained her RN license a year later, and much later obtained a position as a nursing manager. She emphasized that when re-entering the workforce after having her baby, she wanted to complete the RN registration process immediately. However the demands of her new family took priority. This excerpt from Torres‟ story mirrors the experiences of many of the other nurses. Starting a family, and attempts to establish their nursing careers in Canada, were often at odds. Many expressed how this was a result of the numerous requirements, for example refresher courses and written exams, to register as an RN in Canada.  Along with voluntarily overlooking their professional goals, a number of nurses expressed how familial relationships were the reason they immigrated to Canada. For many, the choice to come to Canada came as a result of circumstance – the family members sponsoring their immigration were residents of Canada. As previously discussed, being provided with such  71  an opportunity was reason enough for many to pursue migration to Canada. However, those who actively chose Canada as a destination country often did so in order to bring their families together. Lydia Alvarez recalls how she came to Canada: “Well my husband actually got his immigrant visa here. He applied when he was single, so I was waiting to be a citizen back in the States.  It would take at least three more years before we can be together. Because we have a son eh…so I have to sacrifice that thing [her US citizenship]. I was able to bring my son [to the US] but I don't have any babysitter and stuff like that. Basically because of my husband, that’s why I came here. We migrated together here.”  Alvarez expressed how despite her initial sacrifice, she hoped to return to the US. She acknowledged that having an extensive network of family members in the US was a key reason for this desire, as well as her frustration with having to “start from the bottom” upon her arrival in Canada. Echoing other nurses‟ frustrations, the lack of recognition of both her Philippine education and other international experience, was voiced by Alvarez as having a significant impact on her job satisfaction and desire to remain in Canada.  Similarly, the hope of joining her sister was what Alida Sanchez recalled as the reason she pursued migration to Canada. Sanchez worked as an intensive care nurse in the UK and when her sister in the Philippines decided to apply for immigration to Canada, she decided to apply to join her. Other than hopes of joining her sister, Sanchez made no mention of any personal desires to come to Canada. In the midst of Sanchez‟s migration process, her sister opted to cancel her application as it meant leaving her family behind in the Philippines. Sanchez expressed how she agreed with her sister‟s decision, since it would have been a long and difficult process to bring the rest of the family to Canada. Still, she recalls disappointment that her sister would not be joining her, and expressed the challenges she faced: Sanchez: Losses would be…a lot also. Being away from the family. Alone. Loneliness. You can never handle it. I’ve been away but you never get used to loneliness, I guess. It’s  72  always going to be there. Also [pause] depression. I got depression when I got here […] Losses is not being able to be there for your family. But the gain is being able to financially support them. And yeah, the loneliness too. Being away and being alone.   Despite the difficulties and loneliness Sanchez encountered, she reasoned that the ability to provide for her family made her struggles worthwhile. These narratives illustrate the importance of family cohesiveness in the lives of Filipino nurses. Despite having to make sacrifices or placing their own goals on hold, the family is always an important influence in decision-making.  The family as a loyal, cohesive unit is of central importance in the Filipino culture (Oxman-Martinez, Hanley, & Cheung, 2004; Wolf, 1997). Therefore it is not surprising in the narratives that family cohesiveness was often cited as an important influence in migration decisions, and the transition process to life and work in Canada. Participants often mentioned the concept of sacrifice – either postponing pursuit of their RN careers in Canada, or choosing Canada as a destination country despite their own wishes, in order to please and put the family first. As immigrants and women, the concept of sacrifice described in the narratives, link both to women‟s historical roles in the family, the cultural constructions of Filipino women and the expectations associated with those ideals. Historically, women‟s roles have been shaped by expectations of successfully managing domestic, reproductive, and economic responsibilities (D'Antonio, 1999). Cultural norms that define “good mothering”, include as a core value the expectation for women to sacrifice personal gains for the good of the family, and placing familial responsibilities as the most important priority (Milkie & Peltola, 1999; Mintz & Kellogg, 1988). The historical roles of women described here are based mostly on Western cultural constructs (Prentice et al., 1988). However, it is reasonable to suggest that these influences are also significant with regard to Filipino women, as aspects of cultural constructions that constitute  73  “proper” roles as wives and mothers, and share commonalities with different cultures. For example, similar ideals of women such as dedication to family, availability to children, and other roles ascribed by male members of the community, are described in a study of domestic roles in the Black community in the late 19 th  century (Sharon, 1990). A study on immigrant Caribbean nurses similarly describe the social expectations of women to provide for their families despite sacrifices they would have to make (Karen. Flynn & Henwood, 2000).  Cultural values that place the family as of central importance, reinforce the expectations for individuals, especially women, to place their own needs below those of the family. The period of postponement in their pursuit of RN registration in Canada was time which most interviewees devoted to their families. Participants were expected to juggle multiple roles as a wife, mother, and nurse successfully, while placing family cohesiveness as the main priority. Although there was no mention from participants of explicit expectations communicated to them by their husbands and families, I argue that the narratives shared by these Filipino nurses reflect the deep roots of the traditional roles as women and as Filipinos, that are no longer actively recognized, and seem instead to have been internalized. 3.7.3  Nursing in Canada: Different Expectations  North American nursing culture emphasizes the importance of critical thinking to facilitate a certain level of autonomy in decision-making among RNs, (Boychuk Duchscher, 1999; Higgs & Jones, 2000; Profetto-McGrath, 2003). In contrast, the narratives portray a very different nursing culture in the Philippines where the nurses were educated. What is considered an “old-fashioned” hierarchical relationship between physicians and nurses in Canada was described by participants to be the norm in the Philippines. Expectations and experiences of  74  autonomy were divided among those who first nursed in other countries prior to Canada and those who came directly to Canada from the Philippines.  Nurses who directly immigrated to Canada from the Philippines indicated their need for some time to adjust to new expectations of critical thinking and expanded decision-making, as well the significant difference of their working relationships with physicians. For some, there were initial reservations, beginning with a shift in how nurses address physicians in Canada. Reyes, who arrived in Canada in 1999, recalled her experiences:  Reyes: Back home, doctors, they’re like gods. You can’t even talk to them without…you know you have pay respect because of the because of the long years they spend in the hospital and school right. Like, you can’t be on a first name basis there.  Here, like oh my gosh! The doctors, they don’t have any…they treat the nurses better and they treat nurses here with respect. They acknowledge that nurses have good knowledge of what they are doing, and they’re not just there saying yes to whatever they want. They accept suggestions and you know you could tell them what you’re thinking. Back home we can’t do that.  Interviewer: And how did you find that of change in environment when you started working?  Reyes: It was hard! Up to this point I never go on a first name basis with the doctor even though I know them. I’ll always say doctor and say the last name. They’ll say Reyes, don’t call me that, you can call me by my first name. And I say oh sorry, I can’t help it. I’m never comfortable, even though they treat you nice and all that I never assume we’re equal because I was always taught that you were always…one step under them. You’re not…you know.  Despite initial reservations however, the increased expectations and less hierarchical relationships between nurses and physicians were described as a welcome change from the nursing culture they had encountered in the Philippines. Samala reflected:  “Oh Philippines and Dubai is almost the same. You're just following what the doctor said. We cannot decide. Unlike here we can decide on our own. We have our own nursing. Yet there it’s different […] I enjoy [here in Canada] because you can decide before calling a doctor. You can decide. You have your own judgment. Instead of calling the doctor right  75  away…because they [the doctors] don't like it also. I like [that] you have independence here.”  Cruz, who graduated from nursing school in the Philippines in 1974, echoes the positive change in relationships between nurses and doctors , she recalled: “It’s quite different [in Canada]. Like once you know the doctor, they want you to call them by their first name. You never call them, back home, with their first name. And you know back home, like when the doctor comes around, you like stand up. But here it’s different. And the thing I like here too is that the doctor listens to you. If you say something to doctor, like this patient has a problem, they listen to you. And if patients complain about nurses too, the doctor is going to back you up too. So, I like that.”  The consistency of the nurses‟ perceptions of physician-nurse relationships in the Philippines, whether they attended nursing school in the 1970s or the 1990s, is notable. Also consistent was the participants‟ reflections that the change in professional relationships between nurses and physicians was perceived as very positive. Nurses expressed feelings of being valued and respected by physicians in Canada, in contrast to their experiences of being treated as inferior and subservient to physicians in the Philippines. The focus on professional relationships between nurses and doctors is described in the narratives as poignant aspects of change in their nursing practice in Canada, as these relationships are inextricably linked to nurses‟ capacity for autonomy. This positive change is described as bolstering confidence to increase autonomy, as well as encouraging critical thought and interdisciplinary teamwork, regardless of their background training. A period of acclimatisation was needed to fully accept the increased expectations for these nurses. However the sense that sharing their knowledge and expertise is not only valued but expected, has been described as one consequence that has made their experience of nursing in Canada remarkable and rewarding.  76   In contrast, Alida Sanchez shares a different story of her transition to Canada where she described feeling her autonomy was reduced. Sanchez first worked as an RN in the UK prior to arriving in Canada. Sanchez recalled that the combination of decreased autonomy and a greater focus on documentation were challenges in her transition to practice. Sanchez noted the differences: Sanchez: Work is, way, way, too different from the UK. I was already complaining of the paperwork there! But it’s not a lot of paperwork. The patients there are sicker, so you need more attention to them. They’re needier [...] Here it’s, you know, a lot of wastage. A lot of paperwork that takes you away from patient care. A lot of things that can be simplified, but it can’t be simplified […] Everything will be under the nurse’s discretion. We don’t have RTs [respiratory therapists] there. If the patient is bubbly and chesty, put a naso tube down, suction through the nose. If not put a mouthpiece, and then suction. That’s it. Everything will be at the discretion of the nurse. Start IV fluid, that’s it.  Interviewer: How did you find nursing autonomy? What’s it like in comparison?  Sanchez: More. More there. And they will not question you. There’s a lot of equipment there. I think because of the nursing autonomy you do more for the patient there in a way. Like the ECG. Patients complaining of chest pain, you do the ECG right then and there [...] You do everything for the patient there. Here you have to call the technician. I think you got stuck more in the paperwork. I know there nobody even cares about the paperwork. Like for example the discharge thing [at her current workplace], like there’s a checklist – nobody does that! Who has the time?!   Although Sanchez‟s story is unique in that she experienced a decrease in autonomy, her story still illustrates the challenges of transitioning to a different “culture” of nursing practice. Reflecting on their experiences as nurses in the Philippines, participants expressed initial discomfort regarding the different expectations of nurses in Canada. Many described first being apprehensive about the increased autonomy, and more collegial relationships between nurses and physicians in Canada. Once able to acclimate to their new surroundings however, they viewed these changes as largely positive. Narratives illustrated that nurses felt not only greater  77  appreciation of their knowledge by physicians, but also felt that being a more active and dynamic participant in patient care plans was expected of them in Canada.  The literature examining nursing education in the Philippines focuses primarily on its role in producing mass numbers of nurses for export (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004; Brush & Sochalski, 2007). Yet, there is a paucity of information on the structure of nursing education, and the development of the nursing curriculum in the Philippines, since the establishment of the US-based model of education in the early 1900s. Historically, Western nursing education has undergone numerous transformations over the years (Elliott, Stuart, & Toman, 2008; McPherson, 1996; Mortimer & McGann, 2005). From custodial care provided by untrained and uneducated matrons, to the professionalization of nursing, contemporary nursing baccalaureate programs now emphasize the importance of critical thinking skills (Boychuk Duchscher, 1999; Profetto-McGrath, 2003; Simpson & Courtney, 2002), and the ability to work as active members of interdisciplinary teams (Baldwin, 2007; Heller, Oros, & Durney-Crowley, 2000; Larson, 1995). Despite the Philippines‟ nursing education system being modelled according to Western standards, the narratives illustrated an important difference. Namely, that there is a seemingly unchanged relationship between nurses and physicians in the Philippines, subsequently resulting in the need for a period of acculturation to the Canadian nursing structure. Physician-nurse relationships in the Philippines are described in the narratives as hierarchical and one-sided, and reflect values no longer overtly held in Canadian nursing practice. The fact that participants expressed appreciation for this change in relationship and increase in autonomy, suggests that there are shared aspects of nursing that extend beyond cultural boundaries.  Notably, one nurse‟s comparison of her experiences working as an RN in the UK and in Canada, mirror the experiences of Caribbean nurse migrants. Caribbean nurses were one of the  78  first migrant groups to enter Canada after the Second World War, with most having first worked in the UK (Calliste, 1993; K. Flynn, 1998; Shkimba, Flynn, Mortimer, & McGann, 2005). A historical study of Caribbean nurses‟ entry to Canadian practice, revealed that challenges in transition to nursing practice included restrictions on nursing autonomy, and scope of practice in the new host country (K. Flynn, 1998; Shkimba, Flynn, Mortimer, & McGann, 2005). Through concurrent examination of participant narratives with nursing education and migration history, it is made clear that the transition experiences described are not experienced in isolation but rather, products of social constructs with deep historical roots. 3.7.4  Being Foreign: Proving Self and Perceptions of Racism  The narratives described a common positive perception of the changes in the relationships between physicians and nurses. In contrast, experiences of adapting to work in Canadian hospitals and attempts to integrate into Canadian nursing culture varied among individuals. Some remembered their entry to practice as RNs in Canada in the context of being surrounded by very supportive nursing colleagues, managers, and support staff. Alternatively, some recalled their experiences as being far more challenging. The theme of having to “prove self” was consistent within the narratives. Lydia Alvarez first worked in the US for a number of years. Upon arriving in Canada, she recalled being struck by the fact that she was the only Asian person attending the regional orientation. Alvarez described feeling that she was constantly being tested, because she did not complete her education in Canada. Alvarez recalled:  Alvarez: Most of them tried to kind of test you? How good you are […] So I have to prove myself to them by saying that, “Yeah, I'm a graduate nurse for now, but I have experience back in the [United] States. I've been a nurse back home [the Philippines].” They tried to test your abilities, I think. But when they see you how you work, then they will try to be more accepting. That's what I feel [...] Even in this unit the first time I started, most of the  79  senior ones they're saying that “Oh! Filipino nurses are different because their curriculum is not is not the same as the one that they have here.” […] I can still feel it.  I've been on the unit for a year now. So most of them, they know me. Before they kind of don't talk to you and now… we have to work with everybody. We have no choice. It's not that I'm saying that I am a good worker or something like that.   Although she does not explicitly mention race, her narrative gives the impression that it is precisely her ethnic background that shaped her perceptions of being perceived as “different”. But most of us Filipino nurses, we kind of get the respect of the people working there because they know how hard-working we are […] Well you're working in a foreign country hey, so what do you expect? You have to live to their expectations […] You have to prove yourself all the time, because you're not "a graduate here" or something like that.  The choice of words in statements like “how hard-working we are”, seem to be an attempt at legitimizing “we, as Filipinos” as equally competent to their Canadian counterparts, and suggests that racism was indeed experienced. Additionally, it is arguable that had she been a Caucasian nurse from the UK for example, she would not have experienced the same questioning of her education and abilities. Alvarez later noted that although her initial experiences were unsettling, she was not surprised by them. Many participants described “feeling foreign” and “having to prove yourself”, upon their entry into Canadian practice. Participants expressed that they expected to encounter this hurdle simply because they were foreign. Samala shared a similar perspective:  Samala: Yes, there is discrimination. That is everywhere. Even in Dubai there’s discrimination. Because you are a foreigner. For me so far, I didn't experience. But I can observe. Yes, there is discrimination. For example here in Canada if you work, they will ask you. In your unit they will ask you, where you're from, you’re graduated from Philippines, how you got an RN right away. Then they will expect you more. That's what I observed. They expect you more.  Interviewer: So you feel like you have to work harder? As a foreigner, to prove yourself?   80  Samala: No, not harder. Just, just to prove to them that you are an RN. But not to work harder, no.  It is important to clarify that for participants, “work harder” meant to physically put in more work, or to work overtime – something they did not necessarily relate to proving oneself. Defining exactly what had to be done in order to prove they were equals to Canadian nursing colleagues proved elusive. In review of the narratives as a whole, it seems that the ability to prove self for these nurses meant the ability to prove themselves as competent, experienced, well-qualified, and most importantly to earn the respect of their colleagues. These qualities could not be achieved simply by working more, but developed over time through demonstration of their nursing skills, abilities, and knowledge.  For many, the feeling of being foreign coloured perceptions that colleagues did not view them as equal, spurring the need to prove oneself. It is notable that although most participants did not explicitly identify racism as being an important transition issue, “feeling foreign” consistently arose as an important issue. Tess Benitez illustrated this:  Interviewer: And how did you feel coming in as a foreign nurse? How were you received?  Benitez: Hmm, in [hospital name] I felt like I was a foreigner. I felt like an outsider. I felt most of them are the older Caucasian group. So I really felt like, not that I’m not welcome, but I’m just different from all of them. I’m young, and then I’m not Canadian. But I didn’t feel any discrimination. I didn’t feel like they don’t value my assessment...because I was also doing like charge nurse role at that time. I have students with me. So I thought that since I was brand new, I was different, they won’t give me these opportunities. But we were all given equal opportunities, which was good.  Although Benitez described feelings of isolation as a result of feeling foreign initially, she also spoke at length of feeling welcomed and supported by her workplaces. Commending workplaces as sources of support was also common in the narratives. Cruz described her experiences of racism and in her work as an RN in Canada:  81   Cruz: And of course being a foreigner, they [patients] might think you’re not capable of doing what other nurses do. So you just have to prove yourself that you can do what they really do […] Being a foreigner is kind of...you can’t avoid prejudice. And you can sense that when you’re taking care of the patient. So sometimes you just have to ignore that and do what you can.  Cruz remembered feeling unjustly treated by a patient, which she perceived to be discriminatory. After a particularly difficult shift, she recalled her supervisor‟s response to the situation:  Cruz: […] Well everybody knows, even my head nurse knows. I’m in tears and this patient giving me a hard time. And the next day my supervisor backed me up. So she talked to the patient she said, “Do you know that she’s the best nurse I have! And you’re giving her a bad time and she’s threatened to quit and because of you...” [laughing].  Interviewer: So you got lots of support.  Cruz: So yeah that’s the only thing. They give you lots of support here, they don’t let it just go by. And there are some people, some patients that you know, they’ll discriminate you […]  Narratives revealed the participants‟ acknowledgement that discrimination and racism were unavoidable issues that would arise at one point or another. Despite claims that racism and discrimination were not issues upon their transition to practice, narratives consistently illustrated the significance of “feeling foreign” as an issue in transition. The distinction between racial experiences and simply feeling different remained vague and unclear in this study. The majority of nurses described feeling largely welcomed and supported upon their entry to the Canadian nursing practice. The narratives shared, revealed that despite feeling foreign and as a result feelings of having to prove self, the reception of these nurses as fellow RNs was primarily positive and conducive to successful integration to Canadian nursing practice.  Perceptions of racism were mixed and vaguely described by participants. It is significant that feeling foreign was consistently noted within the narratives, despite denials of experiencing  82  racism. It was common among participants to attribute feelings of being judged and having to prove self, to being foreign. This suggests that often there may not be a realization of experiencing racism by immigrant Filipino nurses, similar to Caribbean immigrant nurses who only recognized discriminatory experiences after recalling their experiences decades later (K. Flynn, 1998). In terms of explicitly described instances of racism, the stories illustrated that experiences of Filipino nurse immigrants also mirror those of Caribbean nurse migrants, wherein perceptions of racism varied. While there were those who remembered experiencing racism first- hand, others remembered learning about it from the media and other people‟s experiences (Shkimba, Flynn, Mortimer, & McGann, 2005). A contrast in experience between Filipino and Caribbean immigrant nurses seems to be in the reception and support provided by the workplace. Arguably, the racially hostile Canadian nursing environment Caribbean nurses entered was during a time of less diversity and tolerance in Canada as a whole (Calliste, 1993; McPherson, 1996). Filipino migrants on the other hand began to arrive in larger numbers in Canada decades later, starting from the 1980s (P. F. Kelly, 2006). An important aspect to consider is the massive numbers of Filipino migrant nurses that have arrived in Canada may have eased the transition process for many as they may potentially have felt support from other Filipino nurses in the workplace. Additionally, over time, professional culture in Canada has grown to be more tolerant, and indeed, diversity has become a distinguishing and accepted ideological characteristic of the country, as a result of which overt racial attitudes are frowned upon. This aspect of Canadian culture, often referred to as „multiculturalism‟ (Vandenberg, (in press)) arguably is what contributes to the more subtle experiences of racism as described by participants, along with the vagueness and uncertainty in their recollection of discriminatory experiences. Despite undergoing racist or discriminatory experiences however, these groups  83  shared the common appreciation for the upward social and economic mobility provided by immigration (K. Flynn, 1998). Although the transition period sometimes became difficult, most recalled that they did not regret the choices they have made, and that their pursuit of immigration has afforded them opportunities they otherwise would not have. 3.8 Discussion and Future Directions  The number of emerging studies which focus on transition programs for foreign nurses is notable, and suggests a preoccupation with the integration of internationally educated nurses in their host country. This preoccupation is evidenced by the increase in the number of transition programs for internationally educated nurses as part of hospital work orientations or specialty education programs in many colleges and universities of recipient countries. Arguments for implementation of such programs include addressing gaps in knowledge and training of foreign nurses in their new host countries, and facilitation a smooth integration into the healthcare system and life in the new country, particularly in the face of increasingly growing numbers of migrant nurses (Edwards & Davis, 2006; Ryan, 2003). In Canada, commitment to facilitating workplace integration of nurses include prior learning assessment and recognition (PLAR) programs such as that by the College of Registered nurses of British Columbia (CRNBC) (College of Registered Nurses of British Columbia, 2006), and the Creating Access to Regulated Employment (CARE) program for nurses (Centre for Internationally Educated Nurses, 2006), among numerous other programs. Although the preoccupation with evaluating transition programs in Canada does not yet appear to be as popular as it has been in the US or UK, it is reasonable to suggest that Canada will see a similar phenomenon. Given current trends, it is arguable that the focus on foreign nurses‟ transition in Canada will continue to increase and has potential to reach a national policy level. The dominant view of transition programs seem  84  genuinely concerned with helping foreign nurses facilitate the entry to Canadian nursing practice, particularly since Canada sees continually increasing numbers of foreign nurses. However, it can also be argued that this preoccupation may also have ulterior purposes. Is the concern truly to facilitate the transition of foreign nurses? Or perhaps the development of formal programs and regulations are meant to police and assert greater control of the entry of foreign nurses to Canada?  In the case of Filipino nurses, I make three important points to consider with regard to transition programs. First, Filipino nurses have been immigrating, and more importantly, successfully integrating to life and work in Canada for a number of decades now, albeit in much smaller numbers. From the findings in this study, it seems that integration of Filipino nurses in Canada has been successful in the past, without the aid of formal transition programs. Secondly, the value of family and cultural cohesiveness and tendency to immigrate to existing overseas networks, indicated that an evaluation of available social support is done by these nurses beforehand. That is, Filipino nurses have migrated to places where they had already some connection, arguably to facilitate their anticipated transition to the receiving country. Indeed, historian Mirielle Kingma observes this phenomenon of “chain migration”; that is, the “tendency of successful past emigration to encourage more future emigration” (Kingma, 2006, p. 14). In considering this, it is then questionable how Western-based transition programs are truly perceived by foreign nurses, and whether they are found to be genuinely helpful. Lastly, this study found that the registration process in Canada of Filipino nurses was often delayed, for months and years for some. It was then after a period of settlement into life in Canada that these nurses were finally able to enter the healthcare workforce as registered nurses. If Canada then chooses to follow suit with the US and UK in incorporating “transition to life in the new  85  country” components of transition programs, there then seems to be a disconnect with the situations of Filipino nurses such as the participants of this study, who had already been residing in Canada for a number of years. Although it is beyond the scope of this study to address these points, it is nonetheless important to bring attention to them, and to question alternate motives, in order to encourage critical views of current trends in Canadian nursing. 3.9 Conclusions  Throughout the entire immigration journey: from determining an point of entry to Canada, to integrating into Canadian nursing practice, immigrant Filipino nurses encountered a number of challenges in transition, but also achieved a number of successes. With the culture of migration as the foundation of the desire to immigrate, these nurses pursued opportunities to migrate through any means they had. Often this resulted in relocating to a variety of countries or entering Canada through recruiters, individual sponsors, or the Live-In Caregiver program. The challenges that come along with the transition process are numerous, yet the focus on family loyalty and cohesiveness, shaped by cultural and societal constructs, remain a central value in these nurses stories. The narratives describe a seemingly unchanged hierarchical relationship between physicians and nurses in the Philippines; a welcome challenge in transition within Canadian nursing culture‟s emphasis on interdisciplinary care and critical thinking. Another notable issue in transition to practice was that of racism, often subtle and unrecognized by participants. Through exploration of oral histories, this study provides a rich account of how larger social and cultural influences were experienced at the individual level. This study places into historical context the experiences of a group of immigrant Filipino nurses in Canada and adds to the migrant nursing history literature in Canada.  86  3.10 References Aguilar, F. (2000). Nationhood and transborder labor migrations: The late twentieth century from a late nineteenth-century perspective. Asian and Pacific Migration journal, 9, 171- 198. Aiken, L. H., Buchan, J., Sochalski, J., Nichols, B., & Powell, M. (2004). Trends In International Nurse Migration. Health affairs, 23(3), 69-77. Alexis, O., Vydelingum, V., & Robbins, I. (2007). Engaging with a new reality: experiences of overseas minority ethnic nurses in the NHS. Journal of Clinical Nursing, 16(12), 2221- 2228. Allan, H. T., Larsen, J. A., Bryan, K., & Smith, P. A. (2004). 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O., & O'Reilly, O. (2004). The expectations and experiences of Filipino nurses working in an intellectual disability service in the Republic of Ireland. Journal of Learning Disabilities, 8(4), 371-381. McPherson, K. (1996). Bedside matters: The transformation of Canadian nursing, 1900-1990. Ontario: Oxford University Press. Milkie, M. A., & Peltola, P. (1999). Playing All the Roles: Gender and the Work-Family Balancing Act. Journal of Marriage and Family, 61(2), 476-490. Mintz, S., & Kellogg, S. (1988). Domestic revolutions: A social history of American family life. New York: The Free Press. Mortimer, B., & McGann, S. (2005). New directions in the history of nursing. New York: Routledge. Nelson, L. J. (2005). The transition to practice in Canada - The experiences of nurses educated outside of Canada. University of British Columbia, Vancouver. Oxman-Martinez, J., Hanley, J., & Cheung, L. (2004). Another look at the live-in-caregivers program: An analysis of an action research survey conducted by PINAY, the Quebec Filipino Women's Association with the Centre for Applied Family Studies (pp. 1-29). Montreal: Centre de recherche interuniversitaire de Montréal sur l‟immigration, l‟intégration et la dynamique urbaine. Polit, D. F., & Beck, C. T. (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia, PA: Lippincott Williams & Wilkins. Portelli, A. (1998). What makes oral history different. In R. Perks & A. Thomson (Eds.), The Oral History Reader (pp. 63-74). New York: Routledge. Prentice, A., Bourne, P., Brandt, G. C., Light, B., Mitchinson, W., & Black, N. (1988). Canadian women: A history. Toronto: Harcourt Brace Profetto-McGrath, J. (2003). The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Journal of Advanced Nursing, 43(6), 569- 577.  89  Ryan, M. (2003). A Buddy Program for International Nurses. Journal of Nursing Administration, 33(6), 350-352. Salma, J. (2009). Career Advancement and Education Opportunities: Experiences and Perceptions of Internationally-Educated Nurses. University of Alberta, Edmonton, AB. Sharon, H. (1990). For the Good of Family and Race: Gender, Work, and Domestic Roles in the Black Community, 1880-1930. Signs, 15(2), 336-349. Shkimba, M., Flynn, K., Mortimer, B., & McGann, S. (2005). In England we did nursing: Caribbean and British nurses in Great Britain and Canada 1950-1970. In New directions in the history of nursing (pp. 141-157). London: Routledge Taylor & Francis Group. Sills, S. J. (2007). Philippine labour migration to Taiwan: Social, political, demographic, and economic dimensions. Migration Letters, 4(1), 1-14. Simpson, E. R. N., & Courtney, M. R. N. (2002). Critical thinking in nursing education: Literature review. International Journal of Nursing Practice, 8(2), 89-98. Sugiman, P. (2004). Memories of Internment: Narrating Japanese Canadian Women's Life Stories. The Canadian Journal of Sociology / Cahiers canadiens de sociologie, 29(3), 359-388. Tan, E. (2001). Labor market adjustments to large scale emigration: The Philippine case. Asian and Pacific Migration journal, 10, 21. Thompson, P. (2000). The voice of the past: Oral history. Oxford, UK: Oxford University Press. Vandenberg, H. ((in press)). Culture theorizing past and present: Trends and challenges. Nursing Philosophy. Withers, J., & Snowball, J. (2003). Adapting to a new culture: A study of the expectations and experiences of Filipino nurses in the Oxford Radcliffe Hospitals NHS Trust. Nursing Times Research, 8(4), 278-290. Wolf, D. L. (1997). Family Secrets: Transnational Struggles among Children of Filipino Immigrants. Sociological Perspectives, 40(3), 457-482. Xu, Y. (2007). Strangers in Strange Lands: A Metasynthesis of Lived Experiences of Immigrant Asian Nurses Working in Western Countries. Advances in Nursing Science, 30(3), 246- 265. Zizzo, K. A. (2009). Post-Hire Transitional Programs for International Nurses: A Systematic Review. Journal of Continuing Education in Nursing, 40(2), 57-64.    90  CHAPTER 4  CONCLUSIONS   As a whole, this thesis research has explored the history of immigration of Filipino nurses to Canada, via the life histories shared by a group of Filipino migrant nurses who arrived in Canada from the 1970s onwards. Division of this thesis research into two manuscripts as presented in Chapters 2 and 3 provided the advantage of examining and analyzing in detail, the two distinct and important periods of time in the nurses‟ migration journey: the pre-migration period, and the transition period in the host country. Along with facilitating a better organization of the thesis, this division also allowed for a broader examination of multiple aspects of the literature relevant to the themes in each time period – a task that would be difficult to achieve in a singular broader analysis of the narratives as a whole.  This study employed a continuous comparison between the oral history narratives and the historical and contemporary literature on the topics of global nursing migration, immigration in Canada, the colonial history and cultural traditions of the Philippines. Through this continuous comparison, this thesis was able to contextualize the individual experiences of these nurses, and place them within the larger historical, social, and cultural influences which ultimately shaped their experiences. Concurrently, the analysis in this research work also successfully illustrated how larger social and cultural trends, and historical relationships, were experienced at the individual level by this group of Filipino nurses.  The introduction of key topics in Chapter 1 provided the reader with the contextual understanding of the research problem, how it was developed, and the proposed approach for tackling the research questions. Additionally, each of Chapter 2 and 3 provided more detailed discussion of the current state of knowledge and literature on topics specific to each chapter.  91   The use of oral history as the primary method and framework for understanding directed this study toward a specific course. In addition to illustrating the main themes that arise from the narratives as is done in many qualitative studies, the oral history framework required the presentation of the results in the context of the historical background and other larger social and cultural influences at play. One goal of this study was to determine how motivations to migrate and the transition period in Canada were remembered by nurses. The narratives produced in the oral history interviews successfully illustrated these memories, in the voices of the nurses themselves (Anderson, 2006). By examining not only what, but how memories were recalled, some insight was provided as to what influences were important to individuals at different points of the immigration journey (Anderson, 2006; Boschma et al., 2008; Passerini, 1992). The nurses having shared these memories in their own words were censored only by their own thoughts and reservations, providing further “clues” as to the significance of the events they experienced and the influences surrounding these experiences (Boschma et al., 2008; Sugiman, 2004).  One research question in this thesis asked what the oral histories uncover about the context and larger influences at play in the decision to emigrate in the Philippines. Chapter 2 thoroughly addresses this research question by focusing on the pre-migration period in the life histories of these Filipino nurses. This chapter argues for the need to look beyond the traditional economic and policy analysis lens often used in analyzing migration history. The prominent themes discussed in the narratives in this period of time focused on the unquestioned desire to emigrate and the weight of cultural pressures and cultural constructs faced by individuals to pursue migration. A thorough examination of the literature was conducted in this chapter and each topic discussed corresponded with a theme that arose from the narratives. The literature reviewed focused on the topics of the history of immigrant groups in Canada, “push and pull”  92  factors traditionally discussed in migration literature, the development of the culture of migration with relation to the historical colonial relationships of the Philippines, and the Filipino cultural values of obedience and family cohesiveness. Through continuous comparison of the oral histories with available literature, this research provided evidence of the deep historical roots of the seemingly contemporary phenomenon of immigrant Filipino nurse migration to Canada (Boschma et al., 2008). Indeed, Chapter 2 illustrates the significance of overarching historical roots and social and cultural constructs, in shaping the experiences of each nurse interviewed. Concurrently, examining the stories together demonstrated that the migration experiences existed as part of the common larger trends reflected in the literature.  Chapter 3 followed with a detailed examination of the transition period in the new host country. A similar method of continuous comparison to relevant literature was employed in this chapter; however, the themes and issues that arose from the narratives differed from those revealed in Chapter 2. Subsequently, the literature that needed to be examined for Chapter 3 also had to extend beyond the topics relevant to the pre-migration literature. Topics included expanded discussion of global nursing migration history, trends, and related challenges (e.g. racism), women‟s historical roles, the history of nursing education and professionalization, and Filipino cultural and familial values. The culture of migration discussed in the pre-migration period also proved to be a significant influence in Chapter 3, and is argued to be a driver of the opportunistic attitudes toward migration often taken by these nurses. Additionally, family as a central value in Filipino culture is further reinforced in the transition period, as illustrated by the nurses‟ delay in obtaining their nursing registration in Canada, in order to prioritize the needs of their families above their own professional ambitions. The difference between priorities of nursing education and training in the Philippines versus Canada was highlighted by the oral  93  histories. Particularly, the challenges encountered in adapting to the greater autonomy and expectations as a member of the health care team in Canada, was linked to the difference in the historical development of nursing education in the Philippines and Canada. Lastly, Chapter 3 paralleled these Filipino nurses‟ perceptions and experiences of racism to those of earlier nurse immigrants to Canada: Caribbean nurses. From the narratives, it was shown that perceptions of racism remained mixed among nurses. One notable difference between the experiences of Filipino and Caribbean migrant nurses however, is the change in the perceptions of blatant racism that was experienced. Studies on early immigration of Caribbean nurses to Canada illustrated that Caribbean nurses‟ stories of racism often involved unconcealed racially-motivated treatment by institutions. I argue that Filipino migrant nurses on the other hand, experienced a more subtle form of racism; so subtle that it was difficult for the nurses themselves to identify these experiences as a form of racism. Nurses often referred to “feeling foreign” and “having to prove themselves”, yet denied having experienced any form of racism. This dissociation between their feelings and statements is what I argue to be an attestation of their experiences of racism. Also considering the contemporary attitudes of anti-racism in Canada and most of the Western world, it is reasonable that although blatant racism is viewed as unacceptable, more subtle forms of it remain, and this is what was experienced by these Filipino migrant nurses. Chapter 3 ends by introducing important questions regarding recent preoccupations with immigrant nurses transition in Canada, Specifically, it questions whether recent preoccupation with planning transition programs for foreign nurses is truly meant to help this group, or whether these efforts are simply attempts to exert control over the already difficult entry of foreign nurses to Canada.  This thesis illustrates that the experiences of migrant Filipino nurses explored in this study were not individually-experienced and temporally-isolated phenomena. Instead, this  94  research demonstrates that they are linked to deep historical roots that were responsible for largely shaping the contexts from which their experiences stemmed from. This thesis illustrates a complete picture of the immigration journey of a group of immigrant Filipino nurses in Canada, from the pre-migration period to transition to life and work in Canada. Despite the different decades from which these nurses began their migration journeys, this study shows a notable consistency between each nurses‟ experiences, further testifying to the shared overarching historical, social, and cultural influences that are not immediately obvious. 4.1 Limitations  As with any oral history research, particular attention must be paid to the interpretation of the shared life histories by participants (Borland, 1998; Bornat, Henry, & Raghuram, 2009; Boschma, 2007). Although the interpretation is in theory guided primarily by available literature and knowledge of the historical background, the potential for introducing personal biases should always be considered. Particularly, being a fellow Filipino and a fellow nurse provided me with an intimate connection with this topic. 3  In this regard, it was especially important for me to maintain reflexivity during the interviews, in analysis of the narratives, and in connecting themes that arose from the narratives to available knowledge on corresponding topics (Sugiman, 2004). Recording field notes of my thoughts, ideas, and perceptions of each interview, written immediately after each interview, and reviewing these prior to each following interview, was one way in which reflexivity was maintained (Anderson, 2006; Boschma et al., 2008). Additionally, discussion of the interviews and arising themes with my supervisor was another means through  3 In Chapter 2, I provide a detailed discussion of how these characteristics of myself as a researcher was handled for the purpose of this study.  95  which reflexivity was maintained. This allowed for the exploration of ideas surrounding the interviews that were outside of my own perceptions, and provided alternative perspectives from which to view and analyze the narratives with.  Due to time constraints and inability of participants to meet in person, a number of interviews were conducted by phone, posing a limitation in the richness of the narratives that could have been potentially produced. Without the person-to-person connection during the interview, it can be argued that participants may have been limited in the memories they shared. In addition, the researcher misses non-verbal cues that are telling of an individual‟s true feelings about a subject, adding richness and sometimes contradicting participant‟s statements. 4.2 Contribution to Field of Study and Potential Applications  This thesis provides a comprehensive examination of the life histories of a group of immigrant Filipino nurses in Canada. This thesis work can be viewed as a case study, providing a snapshot of the history of this growing and significant group of nurse migrants in Canada. It provides the first historical study of the experiences of immigrant Filipino nurses in Canada, in the context of larger societal, cultural, and historical influences. This thesis reflects growing scholarship in global nursing migration, and touches on issues that will grow in relevance with Canada‟s increasingly diversifying nursing population. This research is also an important addition to Canadian nursing and migration historical literature.  Findings of this study can inform foreign nurse migration policies in Canada, as well as foreign nurse transition programs that are gaining growing attention in the country. Additionally, this thesis presents important questions to consider particularly with recent growing preoccupation of transitioning foreign nurses to life and work in Canada.  96   Finally, this thesis demonstrates the value and importance of the contributions of oral history to migration and nursing history. The nuances and richness gathered from these stories were captured through the detailed story-telling of these nurses, an advantage afforded by oral history. Consideration of not only what, but how experiences were remembered, provided this thesis with insight as to the more subtle influences at play in the individual life stories. Another advantage of the oral history method is that its flexibility allows it to be translated to use with a myriad of historical topics. 4.3 Future Directions  Potential for building from the findings of this study are numerous, particularly in the field of foreign nurse immigration in Canada. The participants in this study varied widely in their time of arrival in Canada: from 1974 to 2005. Similar future studies may benefit from examining Filipino nurse migrants according to their decade of arrival in Canada. It would be valuable to determine whether migration experiences among this ethnic group has remained consistent over the decades, or if they have changed significantly, in order to have a better idea of correlations to immigration policies, for example.  Findings of this study also lead one to question the role of the Live-In Caregiver program with regard to Filipino nurse migration to Canada. Although there are a few studies that focus specifically on this program and involve nurses-turned-caregivers, there has not been attention paid to the extent of involvement of nurses with this program. A basic descriptive study examining the numbers of current RNs in Canada that entered through the Live-In Caregiver program would be valuable in determining the true extent and popularity of immigration among Filipino nurses, as well as question the impacts of this program on foreign nurse entry to Canada.  97  4.4 References Anderson, K. J., D.C. (2006). Learning to listen: interview techniques and analysis. In R. T. Perks, A. (Ed.), The oral history reader (Vol. 2nd ed., pp. 129-142). London: Routledge. Borland, K. (1998). 'That's not what I said': Interpretive conflict in oral narrative research. In R. Perks & A. Thomson (Eds.), The Oral History Reader (pp. 320-332). London: Routledge. Bornat, J., Henry, L., & Raghuram, P. (2009). 'Don't mix race with the specialty': Interviewing south Asian overseas-trained geriatricians. Oral History, 37, 74-84. Boschma, G. (2007). Accommodation and resistance to the dominant cultural discourse on psychiatric mental health: Oral history. Nursing Inquiry, 14(4), 266-278. Boschma, G., Scaia, M., Bonifacio, N., Roberts, E., Lewenson, S. B., & Herrmann, E. K. (2008). Oral History Research. In Capturing Nursing History: A guide to historical methods in research (pp. 79-98). New York, NY: Springer Publishing Company LLC. Passerini, L. (1992). Introduction: Memory and totalitarianism. (Vol. 1). Oxford: Oxford University Press. Sugiman, P. (2004). Memories of Internment: Narrating Japanese Canadian Women's Life Stories. The Canadian Journal of Sociology / Cahiers canadiens de sociologie, 29(3), 359-388.        98  APPENDIX A  INVITATION LETTER    The University of British Columbia  School of Nursing  T201  2211 Wesbrook Mall  Vancouver BC Canada V6T 2B5 Invitation to Participate in a Research Study: The History of Immigrant Filipino Nurses in Western Canada from 1970 to 2000 Principal Investigator: Dr. Geertje Boschma, PhD, UBC  (604) 822 7457 Co-Investigator: Charlene Ronquillo, RN, MSN Student  Your participation is requested!  The purpose of this study is to explore and find out more about the history of immigrant nurses in Western Canada, particularly from the point of view of Filipino nurses. Little information is currently available that looks at the history of the motivations and impacts of Filipino nurse migration in Canada. Yet, as nurses, we can observe the changing ethnic makeup of our health care workplaces, and the significant numbers of Filipinos that practice as registered nurses. As part of my Master‟s thesis at the University of British Columbia, I hope to contribute to nursing history by providing a voice for Filipino nurses to share their experiences. Specifically, I would like to know about how you have chosen your career path into nursing, what made you interested in immigrating to Canada, and what your experiences have been like along that journey.  To participate in this study you must be age 19 or older, currently practicing as a registered nurse or have recently retired in Canada, have emigrated from the Philippines originally, and be willing to share your experiences. You will be asked to participate in 1 tape-recorded interview that will last about 1 to 1.5 hours, and perhaps contacted again by phone for a few brief follow-up questions or to clarify certain parts of the interview. Your participation will help in contributing to nursing and migration history in Canada, as well as provide an understanding of the immigration experience for Filipino nurses. Participation is completely voluntary, and you will not be paid for participation.  If you are interested in participating or have any questions, please contact me at: Charlene Ronquillo Phone: xxx-xxx-xxxx Email: xxxx@email.com  The contact persons for this study are registered nurses: In Vancouver Xxxx Xxxx and Xxxx Xxxx In Edmonton Xxxx Xxxx In Calgary Xxxx Xxxx  99   APPENDIX B  ETHICS CONSENT FORM    The University of British Columbia School of Nursing T201  2211 Wesbrook Mall Vancouver BC Canada V6T 2B5 CONSENT FORM : The History of Immigrant Filipino Nurses in Western Canada 1970 - 2000  Principal Investigator: Dr. Geertje Boschma, PhD, UBC  (604) 822 7457 Co-Investigator: Charlene Ronquillo, BSN, RN, MSN Student  Purpose: The purpose of this study is to explore the experiences of immigrant Filipino nurses in Western Canada. I am especially interested in the point of view of nurses from the Philippines who have already immigrated and are currently practicing in Canada, and registered nurses residing in the Philippines who have plans or are in the process of immigration. There is currently little Canadian information that explores this topic and I hope that this study will contribute to the history of immigrant nurses in Western Canada. I am especially interested in the experiences of Filipino immigrants as they are a growing presence in the practice of nursing in Canada. In the study I hope to explore what motivates the desire for migration and what impacts it has had by talking with immigrant Filipino nurses.  Study Procedures: I am requesting one face-to-face interview lasting about 1 to 1.5 hours. After the interview, I may contact you by phone to answer a few brief follow-up questions or to clarify certain parts of the interview. The follow-up telephone call is not expected to last more than 15 minutes. The interviews will be tape recorded and typed. The information you share with me may be used in this study. It may be published. The interview can be conducted at a time and place of your choice. This study is being done as a Master‟s thesis of a student in the Master of Nursing program at the University of British Columbia. The study provides no direct benefits to you; however, you may find you enjoy sharing your experiences. Additionally, the information you share will help  100  contribute to historical nursing knowledge in Canada, and help bring to light the experiences of migration of Filipino nurses. There is a small risk that the interview may bring about feelings of discomfort when sharing personal memories, though this is not expected to be more than what you would experience during a typical stressful situation. You may choose to decline to answer any questions, change the topic, or stop the interview at any time without consequence. There are no other expected risks associated with participating.  Confidentiality: Any personal information (telephone number, email) and identifying information will be kept private and be only accessible to the researcher and her supervisor. Confidential information will only be collected in person or over the phone by the researcher. You will be acknowledged for any information used in the study. You may choose not to have your name identified. However, there is still a slight chance readers may recognize you through the information shared. Therefore, anonymity cannot be guaranteed entirely. The information you share is of historic value and may be used by future researchers interested in this topic. Your information can be accessed by future researchers with the appropriate ethical approval. It will be stored in a locked, secured location for five years upon the completion of the study. After those five years, information you have provided will be sent to the archives of the University of British Columbia with your permission.  Renumeration/Compensation: Participation in this study is completely voluntary and you will not be paid to participate.  Contact for information about the study: If you have any further questions, wish to clarify any part of the study, or wish more information, you may contact Charlene Ronquillo at (xxx)-xxx-xxxx or at xxxx@email.com in Vancouver.  Informed Consent: Your participation in this study is completely voluntary. You have the right to refuse to participate or withdraw from the interview at any time. (1) Do you agree to have your name identified in the study?   Yes No (2) If you answered No, do you understand that every effort will be made to keep your information confidential but that anonymity may not be guaranteed entirely?  Yes  No (3) Do you agree to have your interview tapes and transcripts deposited into an archive for future use after five years?        Yes No  (4) May we contact you again for future research projects of the researcher?  101            Yes No  (5) For participants in the Philippines: Do you understand that the study is not affiliated with Canadian immigration and that your participation will not affect the process of my ongoing or planned immigration.        Yes No  Your signature below indicates your agreement to the terms of the study and that you consent to participate in this study.  Printed Name of Participant   Signature   Date  If you wish to receive a copy of the final report, please provide your mailing address below:  102  APPENDIX C  DEMOGRAPHIC QUESTIONNAIRE  Demographic Information for Participants The questions on this form are asked in order to provide a general picture of the participants in the study. No identifying information will be included or linked to your individual interview. Please do not write your name on this form. Please fill out as much as you can, but you are free to leave blank questions you may be uncomfortable with answering. Please write in answers or mark one answer from the check box choices for each question. 1. Self-assigned family role: 2. Number of people in your immediate family: 3. Number of people in your household: 4. Relationships to people living in your household:  5. Languages spoken at home: 6. Your neighbourhood and city of residence: 7. Level of education (e.g. university, trade school, etc.): 8. Citizenship status: 9. Year, city, and province you immigrated to in Canada: 10. City and province you are from in the Philippines: 11. Migration route to Canada (e.g. Philippines to UK to Canada):  12. Migrated as:   Individual   With Dependent Family  Other (please write in details):  13. Was your migration aided by a sponsoring agency/family?   Yes  No 14. Yearly Household Income:  less than $20 000  $20 000 - $40 000  $40 000 - $60 000  $80 000 or more 15. Number of individuals in the household contribute to finances: 16. Do you provide financial support to family in the Philippines?  Yes No  103  17. If you answered yes to the previous question, please give the approximate amount of your contribution (please indicate if weekly, monthly, yearly, etc.):  Thank you for completing this demographic form. The information you‟ve provided is very valuable to this study!  104  APPENDIX D  ORAL HISTORY INTERVIEW SCRIPT  The following questions will serve as a flexible guide for oral history interviews.  1. Can you tell me about what made you interested in pursuing nursing?  2.   What were your nursing school experiences like? What were your experiences when you first started working as a nurse?  1. Can you tell me about some of the reasons why became were interested in immigrating? What was that process like for you?  2. How did you choose where you were going to immigrate to?  3. Can you tell me about some of your expectations of what immigration in general would be like? Of your expectations of what it would be like to work as a nurse in Canada?  4. Can you tell me about the similarities and differences you noticed between nursing in the Philippines and Canada?  5. Can you tell me about what experiences have stood out the most for you in the course of your nursing career and your experiences with immigration?  6. What would you say are some of the gains and losses you have experienced throughout your nursing career?  105  APPENDIX E  ETHICS APPROVAL CERTIFICATE    The University of British Columbia Office of Research Services Behavioural Research Ethics Board Suite 102, 6190 Agronomy Road, Vancouver, B.C. V6T 1Z3  CERTIFICATE OF APPROVAL - MINIMAL RISK  PRINCIPAL INVESTIGATOR: INSTITUTION / DEPARTMENT: UBC BREB NUMBER: Geertje Boschma  UBC/Applied Science/Nursing  H09-02531 INSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT: Institution Site UBC Vancouver (excludes UBC Hospital) Other locations where the research will be conducted: subject's home  CO-INVESTIGATOR(S): N/A  SPONSORING AGENCIES: N/A  PROJECT TITLE: The History of Immigrant Filipino Nurses in Canada from 1970 to 2000 CERTIFICATE EXPIRY DATE:  September 29, 2010 DOCUMENTS INCLUDED IN THIS APPROVAL: DATE APPROVED:   September 29, 2009 Document Name Version Date Protocol: Proposal: History of Filipino Nurses in Canada 1.0 September 18, 2009 Consent Forms: Letter of consent N/A September 18, 2009 Advertisements: Letter of invitation N/A September 18, 2009 Questionnaire, Questionnaire Cover Letter, Tests: Interview script/Questionnaire N/A September 18, 2009   The application for ethical review and the document(s) listed above have been reviewed and the procedures were found to be acceptable on ethical grounds for research involving human subjects.   Approval is issued on behalf of the Behavioural Research Ethics Board and signed electronically by one of the following:  Dr. M. Judith Lynam, Chair Dr. Ken Craig, Chair Dr. Jim Rupert, Associate Chair Dr. Laurie Ford, Associate Chair Dr. Anita Ho, Associate Chair 

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