THE LIVED EXPERIENCE OF FILIPINO REGISTERED NURSES SEEKING TO MIGRATE OVERSEAS Berzenn Urbi RN BSN, MAdvPrac A thesis submitted in fulfilment of the requirements for the degree of Master of Philosophy School of Nursing and Midwifery, Faculty of Health Institute of Health and Biomedical Innovation Queensland University of Technology Brisbane, Australia 2018
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THE LIVED EXPERIENCE OF FILIPINOREGISTERED NURSES SEEKING TO
MIGRATE OVERSEAS
Berzenn Urbi RN BSN, MAdvPrac
A thesis submitted in fulfilment of the requirements
for the degree of Master of Philosophy
School of Nursing and Midwifery, Faculty of Health
Institute of Health and Biomedical Innovation
Queensland University of Technology
Brisbane, Australia
2018
The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas i
Keywords
authentic Filipino, authenticity, driver for migration, economic migrant, economic migration, Filipino nurse migration, global nurse migration, Heideggerian, identity, intention to migrate, interconnectedness, lived experience, remittances, self, socio-cultural drivers, utang na loob
ii The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas
Abstract
Global nurse migration is a growing phenomenon as the recruitment of overseas
nurses continues to grow in response to global nursing shortages. The Philippines play
a key role in this area, as the country is considered the major exporter of nurses to the
world. However, despite the significance that Filipino nurses play in this phenomenon,
little is known about their experiences working in the Philippines and prior to
migration.
This thesis explores the experiences of Filipino nurses working in the Philippines
and intending to migrate overseas. Using a Heideggerian phenomenological approach,
five Filipino registered nurses (RNs) were interviewed about their reasons for wanting
to migrate overseas. Discussions focused on their experiences working as RNs in the
Philippines, their motives for wanting to migrate, and expectations related to getting
an overseas nursing job.
The results of this study show that Filipino nurses’ motivations to migrate were
associated with living out Filipino socio-cultural values that concentrate on giving
back to family and maintaining family ties. This study challenges research knowledge,
which argues that Filipino nurses are only economically motivated to leave family and
migrate overseas. It provides deeper insights into the motives of Filipino nurses
intending to migrate, and explores the socio-cultural factors fundamental to their lived
experience that influenced participants’ decisions to migrate. Although participants
expressed their hopes for better remuneration, their desire to maintain family and
social affiliations remained the primary focus of intention to migrate and their life
journey.
The migration of Filipino nurses in this study was greatly influenced by Filipino
values of helping family and not merely about wanting to achieve better remuneration.
This challenges the economic migrant label so often applied to Filipino nurses, and
offers useful information for policy makers, workforce planning, and further
investigation of nurse migration.
The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas iii
Table of Contents
Keywords ................................................................................................................................... i Abstract ..................................................................................................................................... ii Table of Contents ..................................................................................................................... iii List of Figures .......................................................................................................................... vi List of Tables .......................................................................................................................... vii List of Abbreviations ............................................................................................................. viii Statement of Original Authorship ............................................................................................ ix Acknowledgements................................................................................................................... x
Chapter 1: Introduction ...................................................................................... 1 1.1 Introduction .................................................................................................................... 1 1.2 Introduction to the phenomenon..................................................................................... 1 1.3 Philippines: A country of emigrants ............................................................................... 3
1.3.1 The rise of an industrialised country .................................................................... 4 1.3.2 Philippine culture of migration ............................................................................ 6
1.4 Philippine nursing employment...................................................................................... 8 1.5 Research question and aims ........................................................................................... 9 1.6 Significance of the study ................................................................................................ 9 1.7 The researcher as a reflective practitioner ...................................................................... 9 1.8 Scope of the research .................................................................................................... 11 1.9 Structure of the thesis ................................................................................................... 12
Chapter 2: Literature Review ........................................................................... 15 2.1 Introduction .................................................................................................................. 15 2.2 Human migration: A natural phenomenon ................................................................... 15 2.3 Global nurse migration: A reality ................................................................................. 16 2.4 It’s all about the money: The economic motive of nurse migration ............................ 19 2.5 Impacts of global nurse migration ................................................................................ 20 2.6 The ethics of global nurse migration ............................................................................ 23 2.7 Filipino nurse migration: a global phenomenon........................................................... 24 2.8 The post-migration experience of Internationally Educated Nurses ............................ 26 2.9 The post-migration experience of Filipino RNs ........................................................... 28 2.10 The experience of Filipino RNs pre-migration ............................................................ 31 2.11 Summary ...................................................................................................................... 35
Chapter 3: Methodology .................................................................................... 37 3.1 Introduction .................................................................................................................. 37 3.2 Phenomenology as a methodology ............................................................................... 37
iv The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas
Chapter 5: Results .............................................................................................. 65 5.1 Introduction ................................................................................................................... 65 5.2 Living an Indebted Life: A Socio-cultural Lived Experience ...................................... 66
5.2.1 The experience of living an indebted life ........................................................... 67 5.2.2 Sense of indebtedness: An obligation and a need to reciprocate........................ 69 5.2.3 Kagandahang loob: the value of reciprocation ................................................... 71 5.2.4 How favours are reciprocated ............................................................................. 72 5.2.5 Summary............................................................................................................. 74
5.3 Anticipating Liberation: The Hope to be Released From Socio-cultural Constraints .. 75 5.3.1 Anticipating liberation through release from socio-cultural constraint .............. 76 5.3.2 The hope to becoming self-determined .............................................................. 80 5.3.3 Summary............................................................................................................. 82
5.4 Maintaining close family ties: Living an inter-connected life ...................................... 82 5.4.1 Family as a support system................................................................................. 83 5.4.2 Family as part of life decision making ............................................................... 83 5.4.3 Family as a top priority....................................................................................... 84 5.4.4 Maintaining close family ties beyond the physical ............................................ 85 5.4.5 Summary............................................................................................................. 88
Chapter 6: Discussion and Conclusion ............................................................. 91 6.1 Introduction ................................................................................................................... 91 6.2 Family as Central to Filipino Inter-connectedness and Being ...................................... 91
6.2.1 Sacrificing for family is part of being Filipino ................................................... 96 6.2.2 Providing more for family is more than being altruistic .................................... 97
The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas v
6.3 Filipino Nurse Migration: It’s More Than Just Economics ......................................... 99 6.3.1 Challenging current nurse migration literature ................................................ 100 6.3.2 The ‘economic migrant’ label: a deeply rooted prejudice ............................... 103 6.3.3 Remitting money as a lived experience ........................................................... 105
6.4 Migration as Living a Life That is Authentically Filipino ......................................... 107 6.4.1 The authentic Filipino life ................................................................................ 109 6.4.2 Misperceptions towards immigrants’ identity: A cultural blind spot .............. 112
6.5 Reflections on the Research ....................................................................................... 114 6.5.1 Limitations of the research ............................................................................... 114 6.5.2 Potential researcher bias................................................................................... 115 6.5.3 Recommendations for future research ............................................................. 115 6.5.4 Contribution of this research ............................................................................ 115
vi The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas
List of Figures
Figure 1.1 Total emigrant populations by country, mid-2013 estimates .................... 4
Figure 2.1: Push and pull theory of nurse migration ................................................. 19
Figure 4.1: Seven-stage process of data analysis ...................................................... 56
The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas vii
List of Tables
Table 4.1: An audit trail sample for this study ........................................................... 63
viii The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas
List of Abbreviations
DOH Department of Health GDP Gross Domestic Product IENs Internationally Educated Nurses MMC Makati Medical Center NCLEX National Council Licensure Examination RNs Registered Nurses WHO World Health Organization
The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas ix
Statement of Original Authorship
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the best
of my knowledge and belief, the thesis contains no material previously published or
written by another person except where due reference is made.
Signature: QUT Verified Signature
Date:
Berzenn Urbi
13 May 2018
x The Lived Experience of Filipino Registered Nurses Seeking to Migrate Overseas
Acknowledgements
Family: this is who I am.
I would never have been able to come this far without my family: people who
inspired, motivated, and challenged me to go as far as I could. The people who taught
me to value life and the life of others. I am grateful to my parents, for without them I
would not be here and I would not be me. I am also grateful to my brothers for always
being there, even without uttering words, I know that they are always ready to support
me, especially in this endeavour.
To my research supervisors; Dr Alan Barnard and Dr Yvonne Osborne, I was
blessed to be standing on the shoulders of giants. I have never regretted a minute of
my research journey with these two experts. Alan taught me a lot about critical
thinking, enhanced my writing skills, how to present better arguments, and to always
think like a phenomenologist. Yvonne was a source of wisdom, encouragement, and
her kind words never failed me. In fact, her encouragement helped me complete this
thesis, despite all the inevitable obstacles research students face.
I would also like to thank professional editor, Kylie Morris, who provided
copyediting and proofreading services, according to university-endorsed guidelines
and the Australian Standards for editing research theses.
Furthermore, I am grateful for the Lord Almighty for giving me the wisdom I
needed to complete this study, the passion to know more, and the strength to create
change through this work.
Chapter 1: Introduction 1
Chapter 1: Introduction
1.1 INTRODUCTION
This thesis explores the lived experiences of Filipino registered nurses (RNs)
working in Metro Manila, Philippines and seeking to migrate overseas. This chapter
presents the background of the phenomenon under investigation, justifies the study,
sets out the research question and aims, and situates the role of the researcher. The
chapter concludes by outlining the scope and structure of the thesis.
1.2 INTRODUCTION TO THE PHENOMENON
The migration of Filipino RNs is a worldwide phenomenon that has attracted
attention, criticism, and debate due to its consequences for both receiving countries
(countries that recruit or are common employment destinations of Filipino RNs, such
as the United States of America (USA), United Arab Emirates, United Kingdom (UK),
Canada, and Australia) and within the Philippines (Aiken, Buchan, Sochaiski, Nichols,
& Powell, 2004). One group that has expressed alarm about the phenomenon is the
World Health Organization (WHO), that issued a warning statement in 2002 noting
that “if the world’s public health community does not correct this trend, the ability of
many health systems to function will be seriously jeopardized”. Despite the warnings
by the WHO in 2002, the migration of Filipino RNs is still an ongoing phenomenon.
Studies have explored the experiences of Filipino RNs who have migrated
overseas, mainly to developed countries, such as the USA and the UK (Alexis,
There is not a one-size-fits-all solution to the global nursing shortage, but
developed countries will continue to resort to recruitment of overseas nurses. Global
nurse migration will clearly continue and there is an immediate need to tackle issues
surrounding the phenomenon. Better understanding of the phenomenon is strongly
warranted.
Chapter 2: Literature Review 19
2.4 IT’S ALL ABOUT THE MONEY: THE ECONOMIC MOTIVE OF NURSE MIGRATION
Researchers, such as Nicholas and Campbell (2010), Alonso-Garbayo and
Maben (2009), Kline (2003), and Mejia, Pizurki, and Royston (1979) have often used
the push and pull theory of migration by Lee (1966) to try to create meaning related to
overseas nurse migration. The push and pull theory explains that there are push factors
for nurses to leave their country, such as political instability, war, or economic crisis,
whilst moving to another country is encouraged by pull factors such as a perceived
better life, political stability, and security (Dywili, Bonner, & O’Brien, 2012; Kline,
2003). The theory has been used prominently in nurse migration literature (Lorenzo et
al., 2007, p. 1412) (See Figure 2.1).
Figure 2.1. Push and pull theory of nurse migration
Many researchers have accepted the assumptions associated with the push and
pull theory in order to establish meaning associated with nurse migration overseas, and
this has led many authors to conclude that economic drivers are one of the major
Push Factors
Economic: low salary at home, no overtime or hazard pay, poor health insurance coverage.
Job related: work overload or stressful working environment, slow promotion.
Socio-political and economic environment: limited opportunities for employment, decreased health budget, socio-political and economic instability in the Philippines.
Pull Factors
Economic: higher income, better benefits, and compensation package.
Job related: lower nurse to patient ratio, more options in working hours, chance to upgrade nursing skills.
Personal/family related: opportunity for family to migrate, opportunity to travel and learn other cultures, influence from peers and relatives.
Socio-political and economic environment: advanced technology, better socio-political and economic stability.
Adopted from Lorenzo et al. (2007).
20 Chapter 2: Literature Review
reasons for nurse migration. For example, in a systematic literature review into the
reasons why nurses desire to migrate overseas Dywili et al., (2013) found that
economic factors were the major reason for movement. Although other reasons were
identified as to why nurses migrated, the desire for better and higher income was
demonstrated to be the strongest motivator. Authors believe that economic motives are
not only evident for nurses migrating from developing to developed countries, but even
between developed countries (Dywili et al., 2013). Sixteen out of seventeen articles
included in Dywili et al.’s (2013) review pointed to the phenomenon being
economically driven, and that nurses are leaving their country and family behind for
economic gain. Dywili et al. (2013) concluded that, “this literature review found that
economic factors dominated the reasons nurses migrate. Developed countries are able
to attract nurses with higher salaries and better benefit packages and poorer countries
cannot compete with these” (p.518). In another similar systematic review of literature
by Newton, Pillay, and Higginbottom (2012), economic factors played the biggest role
in decisions to migrate. The authors summarised their findings arguing that “the
primary reason for immigration is economic advantage” (Newton et al., 2012, p. 537).
Willis-Shattuck et al. (2008) also previously concluded in their review that “almost all
(90%) of studies discussed the importance of financial incentives on health worker
motivation” (p. 4). Economic motives for nurse migration are consistent also with Gray
and Johnson (2008) who earlier argued that “economic factors strongly influenced
migration decisions” (p.46). What is common throughout the literature is the fact that
researchers commonly accept and use the push and pull theory to explain the nurse
migration phenomenon, which positions motives of personal gain as the major
motivation for migration.
2.5 IMPACTS OF GLOBAL NURSE MIGRATION
There have been positive impacts of nurse migration identified by scholars,
especially related to remittances sent by migrants back to their families as a strategy
to ease unemployment and poverty. Remittances are believed to have direct and
indirect effects, including stabilisation of social and economic conditions for migrants’
families, as well as an effect on decreasing public health care spending, since families
who receive remittances are able to afford food, improve housing, and access better
education (International Centre on Nurse Migration [ICNM], 2014). Consequently,
remittances have the potential to reduce or alleviate poverty rates, stabilise a country’s
Chapter 2: Literature Review 21
economic conditions, and generally improve the wellbeing of participants, families,
and their communities (ICNM, 2014). For instance, although somewhat alarming due
to the questionable sustainability of remittances for families and a country, the
Philippines generates at least 10 percent of its economic GDP from remittances, which
is money returning to the country from Filipino migrants working and living overseas
(Khaliq, Broyles, & Mwachofi, 2008; World Bank, 2016). A recent report of the World
Bank (2016) regarding remittances received by developing countries noted that money
remitted by overseas migrants reached up to $431.6B in 2015. India, China,
Philippines, Mexico, and Nigeria topped the list, with remittance records of $69B,
$64B, $28B, $25B, and $21, respectively. Reports also indicate that total remitted
money by overseas migrants has now exceeded the total amount of global development
aid (Khaliq et al., 2008; WHO, 2016). However, the effects of remittances on home
countries has not been assessed. Scholars remain uncertain as to how remittances are
utilised by families, as well as the medium and long term economic benefits to the
home country (Bach, 2006).
Additionally, the Philippines views migration as an economic and political
strategy to ease unemployment in the country (Lowell & Findlay, 2002). Other
countries have been following a similar path to the Philippines, including China and
India, who, for example, are training nurses in an expectation to send them to work
globally (Khaliq et al., 2008). There is a clear political agenda to creating jobs for their
people through migration.
Nurses who leave their country are often the “cream of the crop” and are highly
skilled (Lowell & Findlay, 2002). Countries that receive highly skilled nurses benefit
greatly, as they accumulate the brightest and specialist nurses who have acquired
advanced knowledge, skills, and experience. This brain gain for receiving countries
comes at the cost of brain drain from another. However, on the other hand, if the same
nurses decide to return to their home country, they bring with them better nursing skills
and wider knowledge and experience (Khaliq et al., 2008; Mayr & Peri, 2008). The
potential to share improved nursing skills and ideas in a home nation would be a brain
gain, but there must be strategies to accommodate and encourage the behaviour.
Despite the potential positive impacts, there are significant negative implications
that currently arise from global nurse migration. Although a direct relationship
between nurse migration and poor health indicators has not been unequivocally
22 Chapter 2: Literature Review
established, proxy measures support claims that, for example, reduction of access to
health care and overburdening of the existing workforce weakens healthcare services,
its delivery, and the overall health of the population (Kingma, 2007). Although only a
claim, there are studies that show a direct relationship between health worker
availability and the health status of a community, for example, the WHO guideline of
2.5 health workers per 1,000 population has been linked directly to positive health
outcomes (Anand & Baernighausen, 2004). Furthermore, nurse migration has been
linked to increased workload and increased nurse to patient ratios in sending countries
(Aiken et al., 2004; Lorenzo et al., 2007). Increased workload is directly linked to
nurse burnout, which further encourages them to leave their workplace, creating a
vicious workload, workforce, and staff retention downward cycle (Khaliq et al., 2008;
Kingma, 2007). The workforce that is left in the country as a result of nurse migration
consists of fewer, less experienced staff dominated by novices, unable to meet the
standard of quality health care delivery.
Philippine data shows that 15 percent of the RN population are working in their
country and the rest are overseas (Aiken et al., 2004; Larsen et al., 2005; Masselink &
Lee, 2012; Prescott, 2016;). Out of this 15 percent of all Philippine educated RNs, only
58 percent (more than 193,000 Filipino RNs) were professionally active in 2003,
whilst data on the 42 percent was inconclusive as to whether they were working, were
under-employed, or had left the profession (Larsen et al., 2005). This situation is
believed to be one factor in why the Philippines has faced high levels of patient
mortality (Larsen et al., 2005); the country deals with its health problems without
adequate medical attention due to a system staffed by inexperienced health workers.
In the study by Lorenzo et al., (2007), 70 percent of Filipino patients died without
seeing a doctor or a nurse, which was believed to mainly be caused by health worker
inadequacy(ies) and their migration (p.1414). This scenario is also mirrored in sub
Saharan Africa. Kinfu, Dal Poz, Mercer, and Evans (2009) found that “in 10 of the 12
countries studied, current pre-service training is insufficient to maintain the existing
density of health workers…With current workforce training patterns it would take 36
years for physicians and 29 years for nurses and midwives to reach WHO’s recent
target of 2.28 professionals per 1000 population for the countries taken as a whole –
and some countries would never reach it” (p.225). The migration of nurses from
Chapter 2: Literature Review 23
countries already suffering a delivery crisis, quality issues, and accessibility to health
care services is not the proper way to solve and address global health.
2.6 THE ETHICS OF GLOBAL NURSE MIGRATION
The migration of health workers, including nurses from Africa, severely limits
the abilities of health care workers to combat HIV/AIDS spread and is detrimental to
the achievement of Millennium Developmental Goals (Scott, Whelan, Dewdney, &
Zwi, 2004). In defence of a global response to solving ethical dilemmas related to mass
health worker migration, a WHO Global Code of Practice on the International
Recruitment of Health Personnel was drafted and adopted by WHO member states in
May 2010 (WHO, 2010a). The code directs member states to ethically recruit
internationally educated health care workers, of which the majority are nurses. The
code is being achieved through bilateral agreements aiming to avoid or minimise the
recruitment of health care workers from health care vulnerable countries. The code is
voluntary to its member states and does not negate the right of every individual to
move, but rather recognises the complexities of health worker migration. It is a policy
oriented approach aimed at addressing the negative impacts of health worker
migration, such as brain drain, whilst observing the individual’s right to move (Buchan
et al., 2015).
People have the right to move and immigrate despite the realities of the right of
another to maintain health (Buchan et al., 2015). Gostin (2008) argued that “global
justice requires a fair allocation of benefits to source countries, destination countries,
and nurses” (p.1828); whilst on the other hand, Delucas (2014) argued that “nurses, as
participants, have the right to migrate and earn better salaries, enjoy improved working
conditions, and experience professional development” (p.80). These types of
conflicting ethical dilemmas are directly relevant to the issue of Filipino nurse
migration. Although authors such as Brush (2010) have argued that Filipino nurses
have the right to exercise their choice to move from their country, leaders such as Mary
Robinson, the former UN High Commissioner for Human Rights, have affirmed the
importance of the challenges of such movement and stated “health workers have a
clear human right to emigrate in search of a better life. Yet people in source countries
hard hit by the exodus of health workers also have a right to health in their own
countries” (as cited in Blake, 2010, p.19).
24 Chapter 2: Literature Review
The reality is that despite the WHO (2010a) releasing an ethical code for
recruiting health professionals, there is no definitive global consensus as to the
challenges raised by authors or nations. Despite attempts at ethical management of
global nurse migration, developed countries continue to recruit nurses from countries
that are vulnerable and suffer in their delivery of quality health care. Although ethical
dilemmas are continuously raised with regards to active recruitment of RNs from
vulnerable countries, according to Buchan et al. (2015) these concerns insufficiently
justify the creation of an objective and rigorous management policy towards
addressing negative effects of nurse migration. Buchan and colleagues (2015) argued
that policy makers need to shift perceptions from nursing as a problem to be solved
towards nursing as an essential part of properly managing nurse migration. These
authors argued that policy makers and countries suffering nurse shortage should focus
on enhancing the skills of their local nurses and the advancement of their careers
through reinforcement of advanced practice roles. This will effectively meet the health
care demands of populations, as well as providing career options to retain nurses in
their profession (Buchan et al., 2015). Although this would not entirely solve the
problem, the leveraging of nurse potential would ease the need to recruit more RNs
from countries such as the Philippines.
2.7 FILIPINO NURSE MIGRATION: A GLOBAL PHENOMENON
The Philippines is a world leader in the global exportation of nurses. For decades
the country has been consistently supplying countries like the USA and Saudi Arabia
with nursing staff. In recent years, the UK and Ireland have been added to the list of
typical nurse destinations (Lorenzo et al., 2007).
The global movement of Filipino RNs can be traced back to the 1950s. At that
time, the objective of a nurse going to the USA was to study and obtain advanced
training in order to return to the Philippines to improve the quality of life of Filipinos
through health care services. However, by the beginning of the 1960s, countries in the
Middle East and North America had started recruiting Filipino nurses to address
employment shortfalls. Many nursing students who had gone to America subsequently
stayed and became migrant workers, later often gaining permanent residency
(Corcega, Lorenzo, Yabes, & De la Merced, 2000). By the late 1990s, in response to
international competition, the USA had made recruitment offers even more attractive
and permanent, thus creating even stronger reasons for Filipino nurses to migrate to
Chapter 2: Literature Review 25
that country (Lorenzo et al., 2007). The situation created an increasing flow of foreign
currency back into the Philippines (Tiongco-Cruda, 2009) and major destinations like
the USA, Saudi Arabia, and the UK now offer clear advantages as a result of financial
compensation, better working conditions, and career advancement. At various times,
these countries have offered incentives to migrate, which have been major pull factors
for Filipino nurse migration (Alonso-Garbayo & Maben, 2009). Whilst unemployment
and low salary are major push factors for migration, it is the level of political instability
and scarcity of economic opportunity that continues to make migration a realistic
option to the relatively poorer quality of life and poor working conditions for those
remaining in the Philippines (Alonso-Garbayo & Maben, 2009; Lorenzo et al., 2007).
Emigration booms have a deleterious effect on the quality of health care and on
the supply of experienced nursing staff in the Philippines (Severino, 2006). Even today
there are no definite figures as to whether the Philippines has a nursing surplus or
deficiency because reports are conflicting. Some consider the Philippines to have a
surplus of graduate registered nurses (Department of Health, 2005; Lorenzo et al.,
2000). In a report written by Finch (2013), the Director of the Human Resource
Development Bureau of the Philippine Department of Health, argued that the
Philippines has always had a surplus of nurses. The excess registered nurses in the
country are the ones that migrate and seek overseas jobs (Finch, 2013). Finch (2013)
tried to debunk reports that the Philippines is suffering from a brain drain, arguing that
an oversupply was due to many nurses being unable to secure nursing jobs in the
country. Around 287,000 Filipino nurses were looking for nursing employment in the
Philippines in 2011 (Crisostomo, 2011).
However, other reports have demonstrated that a Philippine nursing shortage has
caused many health institutions to shut down due to an inability to find skilled nurses
to fill local vacancies. Nursing shortages were the reason given for almost 200
hospitals in the Philippines closing down in 2005, and at the same time 800 hospitals
shut down selected clinical departments for the same reason (Philippine Hospital
Association, 2005 as cited in Lorenzo et al., 2007). In 2004, there were accounts that
almost 30,000 nursing positions were unfilled in the country (McKenna as cited in
Clark, Stewart, and Clark, 2006). In the same year, the Philippines recorded a total of
346,247 nurses working overseas (ILO, 2005).
26 Chapter 2: Literature Review
Conflicting reports by different agencies and lack of availability of data from
government organisations such as the Philippine Overseas Employment
Administration (Finch, 2013) have resulted in an absence of systematic monitoring
of Filipino nurses in the country and of those who migrated. It is difficult to account
for each Filipino nurse who has migrated, especially if they have moved without going
through the government’s recruitment agencies and proper migration channels. The
reality is that the Philippine health care system continues to struggle to provide quality
and accessible health care and services to its citizens. For example, during 2013 in
Davao, the third most populated city in the Philippines had only one state doctor who
covered a catchment area of 200,000 Filipinos (Finch, 2013). The WHO standard
requires nine state doctors. In addition, there were only six nurses covering 10,000
people, which fell grossly below the standard of 20 nurses per 10,000 (Finch, 2013).
These scenarios are common in the Philippines, especially in rural areas and the
southern islands.
There have been efforts by the Philippine government to improve the condition
of health care delivery in rural locations within the country, such as through the
establishment of Nurse Assigned in Rural Service Program by the Department of
Health, Department of Labor and Employment and Professional Regulation
Commission. This program aims to send unemployed nurses to the 1,000 poorest
municipalities in the country (Republic of Philippines Department of Labor and
Employment [DOLE], 2013). It was developed to help resolve health status inequity
and improve health care access for Filipinos (Dimaya, McEwen, Curry, & Bradley,
2012). Inequity and access are the two top health problems in the country. For example,
health inequities are rampant in the country, as evidenced by a life expectancy for
Filipinos who live in richer provinces (urban areas) being ten times higher than those
living in poorer and often rural areas (WHO & DOH, 2012).
2.8 THE POST-MIGRATION EXPERIENCE OF INTERNATIONALLY EDUCATED NURSES
Interpretive research has examined the experiences of internationally educated
nurses (IENs) after leaving their home country, many of which have included RNs that
were educated in the Philippines. Studies by Moyce, Lash, and Siantz (2016),
Ronquillo (2012), Ma, Griffin, Capitulo, and Fitzpatrick (2010), Humphries, Brugha
and McGee (2009), and Brunero, Smith, and Bates (2008) have concentrated on the
Chapter 2: Literature Review 27
experiences of IENs (including Filipino RNs) in host or migration destination
countries; however, there has been far less focus on the pre-migratory experience.
The experiences of IENs after graduation is not as perfect as many might hope.
IENs often encounter difficulties with immigration regulations and obtaining
registration as nurses in destination countries. A recent systematic review of literature
by Moyce et al. (2016) related to the lived experiences of IENs found that many
struggle to become registered in their destination country(ies) and experience
confusion related to their migration visa privileges. Migrants report misinformation
from recruitment agencies about their immigration status, the nursing registration
process, and their working rights whilst awaiting registration. The situation causes
confusion and frustration for many, especially as the nurses have generally paid
substantial amounts of money in order to emigrate.
Entry visas commonly restrict them from working whilst waiting for their
nursing registration, which can be delayed for many months (Blythe, Baumann,
Rheaume, & McIntosh, 2009). These experiences lead to despair, feelings of
hopelessness, and significant delays to employment (Blythe et al., 2009). Although
many IENs wait for long periods, others do manage to change their visa and obtain
different employment options, though often in workforce sectors requiring low skills.
Some give up the waiting process and never apply for registration (Humphries,
Brugha, & McGee, 2008), whilst some even decide to go back to their home country.
These experiences are consistent with a study of migrant nurses in New Zealand by
Walker (2008), who found IENs experienced difficulty being recognised as registered
nurses because of intensive and strict assessment processes. These struggles create
frustration for many nurses, as recruitment agencies not only give inconsistent
information, but also blatantly incorrect information related to what lies ahead for an
IEN after migration.
Language and communication barriers are identified as common problems for
IENs transitioning to a new country (Moyce et al., 2016). Understanding colloquial
language and medical terminologies in a host country can be a struggle (Ma et al.,
2010; Sherman & Eggenberger, 2008). IENs sometimes attribute language difficulties
to a perception of an inability to deliver care. In a study of IENs by Blythe and
colleagues (2009), overseas nurses believed communication struggles lead people to
perceive them as slow workers, and only able to deliver a low quality care. Beriones
28 Chapter 2: Literature Review
(2014), Walker (2008), and Smith (2011) also found similar struggles of migrant
nurses in their nurse migration studies and this affects how IENs feel about themselves
and how they value their work.
IENs experience racism at work (Alexis & Vydelingum, 2009) and
discrimination based on skin colour, language, or accents. Discrimination can come
from multiple sources, including patients and their families, colleagues, and
supervisors (Larsen, 2007). They can experience social isolation because of
discrimination and poor treatment (Ma et al., 2010; Larsen, 2007), which can take
different forms and include overt criticism of work and various forms of harassment,
such as verbal and physical harassment from patients, workmates, or supervisors
(Moyce et al., 2016). Studies by Tregunno, Peters, Campbell, and Gordon (2009), Xu,
Gutierrez, and Kim (2008), and Larsen (2007) have demonstrated that many IENs who
have migrated face emotional and psychological stress from discriminatory struggles,
which often cause hindrance to successful transition and adaption in their new home
country.
IENs also experience difficulties acculturating to their new home country (Ma
et al., 2010; Xu et al., 2008). IENs can commonly experience culture shock and
struggle to understand and embrace new things in their destination country. However,
acculturating to a new culture in their destination country is essential “as nurses
navigate new surroundings, find housing, learn new cultural norms, manage finances,
and seek to find a sense of belonging” (Moyce et al., p.185). Importantly, if IENs
attend formal orientation programs they tend to be more acculturated and less likely to
leave the country or their employing organisation (Ma et al., 2010).
Experiences of difficulty becoming registered, language barriers, discrimination,
and adapting to a new culture are post migration experiences that centre on the
struggles of IENs as they progress along their migration journey. There is a need to
address and support immigrants with these struggles, as many encounter the same
experiences upon migration (Moyce et al., 2016).
2.9 THE POST-MIGRATION EXPERIENCE OF FILIPINO RNS
Filipino nurses migrating to developed countries such as the UK or Ireland often
have high expectations. They expect better and higher developed technologies, better
living standards, and better infrastructure. However, Filipino migrant experiences after
Chapter 2: Literature Review 29
migrating often report that these experiences do not meet pre-migratory expectations.
A study by Daniel, Chamberlain, and Gordon (2001), who interviewed 24 nurses from
the Philippines working in the UK, identified that their initial expectations and
experiences working in London did not equate with their actual experience. Their
expectations were that UK hospitals would be “high-tech” institutions and that nursing
workloads would be lighter compared to their home country. For instance, Filipino
migrants expected patient’s relatives and healthcare assistants would perform basic
nursing care for patients, and that they would be less involved in basic nursing. In
reality, their work in the UK showed this to not be the case. Nurses were expected to
carry out basic nursing care, such as bathing and toileting for patients. Their nursing
roles and workloads in the UK were not any less than working in the Philippines.
Differences between pre-migration expectations and actual experiences are common
in the literature and are believed to mainly be due to failure to properly orient Filipino
nurses to the working conditions in their destination countries. Daniel et al. (2001)
recommended the need to properly educate potential and expected nurse emigrants to
help the nurses mentally prepare and also to confirm whether they really want to be
where they would be working. Withers and Snowball (2003) interviewed Filipino
nurses working in Oxford Radcliffe Hospitals NHS Trust about their experiences and
expectations in England. Their study revealed differences between nurses’
expectations of working and living in the UK. The majority described how their
financial expectations were unmet and it was concluded that participants had
excessively high expectations about their ability to earn money and obtain a higher
standard of living. More importantly, their desire to advance professionally was often
unmet, leading to job dissatisfaction and lack of retention in the workplace.
Experiences were noted to affect behaviour and work attitude (Withers & Snowball,
2003). McGonagle, Halloran, and O’Reilly (2004) also interviewed Filipino RNs who
had migrated to Ireland. Respondents described difficulties with the infrastructure of
the country, including difficulties with transportation, and were shocked by the high
cost of living and taxation in Ireland. The level of technology, including the telephone
system, was not as advanced compared to their home country, and overall their
expectations were unmet.
The Philippine government has previously moved to implement a pre-departure
orientation seminar aimed at preparing Filipinos who are migrating, including nurses,
30 Chapter 2: Literature Review
about what to expect in their country of destination (Dinglasan, 2012). However,
recent reports claim that the implementation of the seminar, as well as the content of
the modules used, does not live up to the intent of the program to properly orient
overseas Filipino workers on their working rights and what to do in their country of
destinations in cases of emergency (DOLE, 2014). Barsbai, Steinmayr, Yand,
Tiongson, and Licuanan (2014) argued that there is no rigorous evidence to support
the effectiveness of such a program or the usefulness of the modules being used to
orient potential Filipino migrants.
Hughes (2008) studied the experiences of Filipino nurses in the US within five
years of their initial phase of working. The study showed Filipino nurses struggled
with feelings of being devalued and being discriminated against. Respondents felt
people were looking for their mistakes, and that they were judged by preceptors and
some colleagues who were narrow minded. Participants felt devalued working in the
US health care system. One participant described their experience in terms of not being
“in the place where I was accepted, that I can be productive, where I can excel…”
(Hughes, 2008, p.95). Discrimination against Filipino nurses and other IENs has
seldom been a topic for debate. It is a neglected health management issue in the US
despite the negative consequences for Filipino and other overseas nurses. The situation
affects their physical and psychological wellbeing, and can eventually affect the
quality of care they deliver (Baptiste, 2015).
Language and communication barriers have also been identified as common
struggles for Filipino nurses (Ma et al., 2010; Moyce et al., 2016; Sherman &
Eggenberger, 2008). Hughes (2008) explained that communication struggles in the US
often revolved around a lack of acquaintance with medical terminology and American
slang used by nurses and doctors, and differences in the cultural context of
communication. In her study, Filipino RNs tended to value not speaking up against
colleagues even if patient safety was at risk. Filipino RNs would feel embarrassed
delegating tasks to workmates and remained modest in speech, which lead to
compromises in patient safety because they tended to avoid hurting other people’s
feelings (Hughes, 2008). There have been similar struggles for Filipino nurses who
have migrated to Australia. Many Filipino nurses experience frustration understanding
different accents and slang, often leading to difficulties performing their role (Marcus,
Short, & Nardi, 2014). Communication struggles have been identified as a barrier to
Chapter 2: Literature Review 31
integrating and socialising with local groups due to fear of not being understood, and
not being able to communicate well due to cultural context differences in
communicating (Marcus et al., 2014).
Literature demonstrates that Filipino and overseas nurses’ often struggle upon
All the interviews or texts are read for an overall understanding Interpretive summaries of each interview are written. A team of researchers analyses selected transcribed interviews or texts. Any disagreements on interpretation are resolved by going back to the text. Common meanings and shared practices are resolved by going back to the text. Relationships among themes emerge. A draft of the themes along with exemplars from texts are presented to the team. Responses or suggestions are incorporated into the final draft.
Adopted from Diekelmann, Allen, & Tanner (1989) as cited in Polit and Beck (2013, p. 310).
Chapter 4: Methods 57
and interpretations of what it meant and based on its holistic meaning, noting
its contextual relevance, the whole life story of the participants, any pre-
conceived knowledge of the researcher about the phenomenon, and what the
literature described about the phenomenon. At this stage, the researcher also
began noting categories of meanings or themes based on repetition,
emphasis of meaning, stories, and relevance to the experience of migrating
overseas.
• Stage 3: This was the stage where the researcher started forming
meaning/themes as a single story, similar to putting small pieces of a jigsaw
puzzle together to create a whole. After determining possible themes, the
researcher met regularly with his supervisory team to (re)analyse
interpretations. This stage was where the researcher’s interpretations were
explained and became clearer through his supervisors’ assistance, such as
debate, discussion, justification, and explanation in order to merge and
confirm each interpretation.
• Stages 4 and 5: Deep analysis and interpretation of meaning were explored
by the researcher by going back to the data many times to reconfirm and
check whether there were other texts that were overlooked that could
support a meaning, or refute what was interpreted. Themes selected by the
researcher were regularly challenged by his supervisors to confirm
interpretation. This was done through constant feedback from his
supervisors and critiquing of data interpretation as a team. The researcher
always made sure those interpretations were supported by participant data.
• Stage 6: The researcher began to compare the formed themes and explore
their relationships, noting similarities and differences. This was the stage
where further critique and thought strengthened interpretations made during
the process.
• Stage 7: The analysis chapter was then commenced and drafts were
submitted to supervisors for (re)checking and (re)confirmation. When
supervisors provided questions or feedback about how the data was
interpreted, the researcher went back to stage 4 to investigate and strengthen
arguments by going back to the data or texts. Excerpts in the form of texts
or phrases were looked at from a holistic perspective; that is, the purpose
58 Chapter 4: Methods
was to glean meaning, not from a phrase or text itself, but its relationship to
the person’s whole story or narrative. Following this rigorous process, the
data analysis and the chapter were completed.
4.9 ETHICAL CONSIDERATIONS
Ethical approval was obtained from the Human Research Ethics Committee of
the Queensland University of Technology (see Appendix A) and an approval letter
from Makati Medical Center, Metro Manila, Philippines (see Appendix B) was sought
before data collection was conducted. Ethical frameworks are required when dealing
with issues such as privacy of participants (Patton, 2002); thus, these became an
essential component of this qualitative research study. The need to have ethical
frameworks in interpretive study was due to the close interaction and relationship
between the researcher and the study participants, as well as the semi-structured, yet
unpredictable nature of qualitative research methods (Liamputtong, 2009; Mishna,
Antle, & Regehr, 2004; Morse, 2007).
4.10 CREDIBILITY OF THE RESEARCHER
Heideggerian phenomenology recognises the involvement of the researcher in
the conduct, interpretation, and presentation of data collected. It is vital that some
information about the researcher is included (Whitehead, 2004) in data interpretation.
It is noted that the ability of the researcher to describe and interpret their experience is
an integral part of the research process (Guba & Lincoln 1989). The researcher in this
study was aware of the potential effects of his personal and social characteristics on
data collection and analysis. Therefore, the researcher’s background was disclosed in
Chapter 1 of this thesis (see Section 1.7). This process improves the openness and
credibility of the research in relation to intellectual rigour, professional integrity, and
methodological competence, and the influence of experience and background on the
researcher’s approach and analysis. The researcher understood and became carefully
aware of his personal biases due to his experience being a Filipino educated nurse. He
made sure as much as possible that data interpretation and the meaning of participants’
lived experience were answerable by the texts and not merely by his own
preconceptions. This was ensured through presenting data analysis to his two
supervisors, who were able to question and (re)check the data analysis and the process
of his data interpretation. Although the researcher has known biases, they were
Chapter 4: Methods 59
disclosed as part of the data analysis and are supported by the text and presentation of
participant excerpts in the results chapter. Although, it should be noted that
Heideggerian phenomenology relies on self-awareness of the researcher and recording
of influences, the analysis was driven primarily by participant text and supported by
the researcher’s understanding of the phenomenon, socio-cultural factors, and other
relevant information. This is clearly presented in the results chapter using participant
excerpts as much as possible to explain the lived experiences of the study participants.
Importantly, the researcher kept a reflective journal in which the content and process
of interactions were noted. The journal acted as a record of events and assisted to
clarify how prejudices may have developed, while providing material for personal
reflection (Koch, 1994). Some reflections written by the researcher were:
• May 6, 2012: I am currently in the initial stages of data analysis. I am very
unsure of the process of doing it and I have re-read many times the data
analysis framework of Diekelmann et al. (1989), but it is still not making
sense to me at all. What I have done so far is to descriptively categorise or
code significant experiences, find meanings of these, but I also understand
that this research is interpretive and not merely to describe participants’
experiences. I am feeling frustrated that I am unsure and do not have full
understanding of how I am supposed to properly conduct my data analysis.
I have questioned myself many times whether what I am doing is the right
analysis. My frustration also comes from my writing style. Research and
academic writing requires succinct and concise presentation; however, my
background as a literary writer is becoming a hurdle. Trying to follow the
research format is difficult to achieve, as this requires giving up my literary
writing skills. My supervisors’ comments on my previous works reflect a
descriptive analysis and need to move to better explain the experiences of
participants supported by their lived accounts.
• June 26, 2013: I have three themes approved by my supervisors, however,
my writing skills are still a work in progress. My supervisors’ recent
comments were: to consider better language in explaining participants’
experience; the need to form an argument, not just claims; and the need to
build an analysis of lived experience. I have been doing this analysis chapter
for more than a year now and am still struggling to find the appropriate
60 Chapter 4: Methods
words and structure to explain the participants’ experiences. Also, building
an argument is frustrating me so much, as this is the opposite to being a
literary writer. I am still struggling to write cohesive, concise, and succinct
ideas. After meeting with my language advisor, he always says that
phenomenological language and the art of argument or presenting ideas
phenomenologically is a process itself, which means it takes time. I love
seeing progress, and progress that is significant. Yet, for my writing, this
seems that it is taking forever. I have been reading recommended resource
materials to help me improve my writing skills and meeting regularly with
my language advisor for writing training and advice.
• Feb 05, 2014: Personal circumstances are taking a toll on my research
progress. Family issues that are inevitable are restraining me from
progressing in my writing the way I expected. I have applied for another
extension for my program and needed to work full time to supplement
family responsibilities. I have to prioritise family after all. There is no
question or discussion about it. If I have to choose between my studies or
family, in a heartbeat, my family trumps. These past months, I have not
progressed in my writing. Although, I don’t feel despair at all because my
supervisors understand my situation. I am thankful that my supervisors are
very supportive.
4.11 METHODOLOGICAL RIGOUR
Koch (1996) emphasised the importance of demonstrating research as
trustworthy and believable, and proposed that researchers should “select or develop
the most appropriate criteria for their particular study” (p.178). The following
strategies were used to ensure methodical rigour and ethical integrity.
1. Credibility: To ensure that the explanations of research fit the description
and whether the description was credible, genuine, and reliable, participants
were purposely and carefully selected for their knowledge about the
phenomenon (Liamputtong, 2009). Moreover, an audio recorded interview
was used to ensure that the transcribed texts were genuine. The researcher
also used reflexive journaling and discussions with supervisors at all stages
of data analysis.
Chapter 4: Methods 61
2. Transferability: To ensure transferability, a simultaneous literature review
was conducted throughout the research process and a purposive criterion
based sampling was adopted in choosing participants in this study.
Moreover, the context of the data collection and the participants’
characteristics and selection criteria for the study were provided (refer to
Section 4.4) so that readers of this study and its results can determine
potential applicability to other settings. These strategies are known to
enhance the transferability of a qualitative study (Shenton, 2004).
3. Dependability: This was achieved by using an audit trail of the data coding.
The researcher documented the method of data collection in detail and
showed linkages and coherence between the data collected and the results.
Moreover, the researcher recognised his key role in how the data were
shaped and analysed, which is considered essential in Heideggerian
phenomenology (Carpenter & Sutto, 2008). An example of audit trail
conducted by the researcher was when Brenda mentioned “I have to leave
because I plan to take my parents abroad, it’s my payback time”. This phrase
was initially coded as paying back parents. This code was then reflected
back to Brenda’s entire story. Her intention to migrate overseas was all
about what she could do for her parents. For example, when she mentioned,
“If I’ll be thinking about myself only, I’m satisfied with what I am doing
here”, she meant that the reason she was leaving for overseas migration was
for her parents and not for herself. The reasons why Brenda decided to
migrate were informed by a desire to engage in a selfless act. In the final
stage of coding, many participants expressed intentions to payback parents.
Hence, this intentionality was categorised as ‘paying back parents’.
However, upon further interrogation of the texts and their contextual
meanings, paying back is a Filipino socio-cultural value. There is an
accepted norm amongst Filipino people to financially give back or help
parents once they are able to generate income for themselves. This is when
the socio-cultural understanding of the researcher influenced how the texts
were given meaning. Meanings given by the researcher were tested back
using the participants’ whole narratives and the other texts mentioned by
Brenda during her interview. The researcher made sure that the texts would
62 Chapter 4: Methods
speak by themselves when writing the analysis or explanation of lived
experience. The coding of ‘paying back’ was finally categorised under the
first theme of this study ‘living an indebted life’, which is a Filipino socio
cultural lived experience. Table 4.1 provides other examples of coding or
audit trails performed by researcher.
4. Confirmability: The findings and results of the study did not come solely
from the researcher’s imagination, but rather are demonstrated to have clear
and cohesive links to the data (Padgett, 2008; Tobin & Begley, 2004). This
was achieved and further affirmed by using an audit trail throughout the
research process. The audit trail consisted of a recording of research
activities by the researcher to clearly demonstrate the process of data
analysis and the generation of outcomes.
Chapter 4: Methods 63
Table 4.1: An audit trail sample for this study
Transcript Initial coding Thematic coding Brenda: “Because I am single and I just have my parents with me, with what I'm receiving, all the benefits, the salary and the hospitalisation, and the discounts that I'll be receiving…” “I have to leave because I plan to take my parents abroad. It's my payback time.” “I just want to give them a better life before they leave.” “Because if I'll be thinking about myself only, I'm satisfied with what I'm doing here.” “So, I'm just worried about my parents that's why I'm leaving.” “I plan to give them a better life, so there.”
Brenda was financially supporting her parents. Nursing remuneration was insufficient to help parents, (i.e., medical expenses). Brenda wanted to pay back her parents. Brenda desired a better life for her parents. Brenda was not thinking about things she can achieve for herself, but rather for her parents. Brenda thought about the future of her parents. Brenda desired to give a better life to her parents.
Financial provision as payback to parents. Desire to financially support family as an expression of utang na loob: a driver for Brenda’s migration. Desire to send parents overseas as an expression of utang na loob: a driver for migration. Living an interconnected life: Brenda anticipated a better life for her parents. Also, mirroring the effect of living an interconnected life. Living an interconnected life: selflessness. Living an interconnected life: selflessness. Living an interconnected life: Brenda anticipated better life for her parents. Also, mirroring effect of living an interconnected life.
64 Chapter 4: Methods
4.12 SUMMARY
This chapter presented the recruitment procedure, how participants were
selected, and the participants’ backgrounds. The rationales for choosing the sample
size and sampling design were also presented. Moreover, the process of data analysis,
transcription, and ethical considerations were discussed.
The following chapter presents the study results and their related explanation, as
produced by the analytical process of interpreting the lived experience of participants.
Chapter 5: Results 65
Chapter 5: Results
5.1 INTRODUCTION
This chapter presents the three major themes to arise from the research about
experiences of seeking to migrate overseas. First, participants were motivated to seek
overseas migration to fulfil Philippine socio-cultural values related to reciprocating
sacrifices their parents had made for them to succeed in life. Reciprocation would be
achieved through better remuneration from working overseas, which would offer
increased capacity to assist parents. They hoped for financial provision for parents, to
cover parental medical expenses, to send family members to school, or provide an
overseas holiday for the family. This lived experience was described as living an
indebted life and was a major motivator for overseas migration.
Second, participants anticipated a liberated life and a release from constraints
imposed upon them through living out Filipino values. Each described a constrained
life when it came to pursuing personal hopes and dreams in the Philippines, often
because they were living a life of indebtedness. Their desire to provide financial
assistance to parents and family members limited their capacity to pursue personal
aspirations, such as becoming a business owner or pursuing a career in academia.
Migrating overseas was anticipated to bring a degree of release from the constraints of
living Philippine socio-cultural values, and participants wanted to experience a
liberation from that life. However, a liberated life for participants did not mean
relinquishing the socio-cultural expectations of significant others, especially
associated with helping family, rather it was characterised as having an ability to live
out socio-cultural values while achieving an ability to pursue life goals that they deeply
desired for themselves.
Lastly, migrating overseas was an expression of living a life of inter-
connectedness. Participants were motivated to seek overseas migration because of the
potential it offered to fulfil close family ties. They anticipated receiving better
remuneration upon migration, which meant each individual would have the
opportunity to help other members of their family, such as supporting a sick brother to
continue his medical treatment, or supporting the educational needs of a niece. By
desiring to make the lives of other people better, they believed they were making their
66 Chapter 5: Results
own life better. This inter-connectedness with family and significant others meant
migrating and leaving their family in hopes of securing a better life for everyone.
Although this goal was expressed as a difficult ambition as they prepared their journey
to migrate, many were more than willing to accept the fate of migrating for the sake of
hoping to change and improve the lives of their family. Being inter-connected did not
stop due to physical boundaries, but was simply an extension of connectedness and an
anticipation of improving the lives of the people that mattered to each individual.
5.2 LIVING AN INDEBTED LIFE: A SOCIO-CULTURAL LIVED EXPERIENCE
Participants in this study expressed personal accounts of living an indebted life
that motivated them to seek overseas nursing migration. Living an indebted life was a
direct emotional and action orientated response to a need to demonstrate socio-cultural
traditions associated with gratitude. Gratitude for Filipino people extends beyond
uttering a simple ‘thank you’, and is lived out through acts of reciprocation (the act of
returning favours). Reciprocal acts are demonstrated after receiving ‘pabor’ or favours
that are construed as good will or benevolent deeds. This expression of gratitude is
vernacularly termed as ‘utang na loob', and is a value deeply embedded within the
Philippine socio-cultural tradition; it is the result of receiving favour and reciprocating.
The act of reciprocation is embodied as both internal and external factors that are
dictated by an individual’s own cultural beliefs, as well society’s standards and
expectations. In this study, utang na loob was the combination of feeling a great sense
of indebtedness to the favour-provider, as well as undertaking acts of reciprocity.
Utang na loob as a lived experience carries an emotional response that emerges
when perceived favours are given to an individual; either due to an internal need to
reciprocate or as a result of a felt obligation. Each participant grew up in the
Philippines with people practising and observing the socio-cultural value of utang na
loob. This Philippine value is inherently embedded within each person’s inner being
as a result of assimilating themselves into Philippine society. Each individual clearly
felt a need to reciprocate favours and had embraced and internalised the concept of
utang na loob. There was an expectation that because participants were members of
Philippine society, and consider themselves Filipinos, they would conform to
practising utang na loob. Their experiences were expressed as socio-cultural
obligations felt by participants largely due to living in the Philippines and being
Chapter 5: Results 67
Filipino. Hence, whenever a favour was received, the emotional response of
participants was to either feel an internal desire to return the received favour, or feeling
obligated to express reciprocation. In the act of reciprocating, what was being returned
was not only a material favour, or an act of kindness, but also the kagandahang loob
enclosed within it.
Kagandahang loob is goodwill, benevolence or literally translated “good inner
self” that is present in every perceived good action or favour. Kagandahang loob is
the “goodness” that comes from the metaphysical inner being of someone performing
good acts. Socio-culturally, kagandahang loob or good inner self is what someone is
trying to reciprocate, not the actual favour, action or thing that was used in rendering
favour(s). Reciprocating the goodness of the person who performed the good deed is
what utang na loob is all about. This is why utang na loob pertains to feeling a great
sense of indebtedness to the favour-provider, which later becomes an embodiment of
being Filipino, which is rightfully accepted as a central value amongst Filipinos and
the Philippine society in general.
Utang na loob therefore not only pertains to an emotional desire to reciprocate,
it has to be carried out through reciprocity, an act of returning favour. How an
individual should reciprocate favour(s) is influenced by both external (society’s
standards and expectations) and internal (individual’s own cultural beliefs and values)
factors. A society and/or individual’s perception of reciprocating favour dictates what
reciprocal act(s) needed to be carried out. The reciprocal act has to fit into the
participants’ life circumstances, such as the need to provide better housing for families,
supporting siblings’ educational needs, and so on. Each individual in this study
considered what acts of reciprocity were appropriate for them to carry out, as well as
whether they would be relevant to the favour-provider(s). Thus, utang na loob was an
emotional response as well as an undertaking of reciprocal acts that assisted
participants to live an indebted life. Consequently, it is an influence on individual
intention(s) when seeking overseas nursing employment.
5.2.1 The experience of living an indebted life
Living an indebted life was expressed by participants during discussions about
their intention to seek overseas nursing employment. They appreciated favours from
their parents as a result of the sacrifices they had made to bring participants to where
they were at that time. Favours were considered good sacrificial actions, such as
68 Chapter 5: Results
financing their nursing education, bringing them up to be a good person, and providing
for their basic needs. Each participant expressed gratitude for parental favours
received, and as a result of utang na loob, they felt a need to live an indebted life to
their parents.
Brenda defined her life at the moment as payback time to her parents. During her
interview, she described how her life was focused on achieving reciprocity for all the
favours she received from her parents. She stated that what motivated her to go to work
overseas was: “…the better things that I can provide for my parents [as payback]
because this will be my ticket to success. To achieve [these] plans, basically…”.
Brenda aimed to achieve overt and tangible reciprocal actions for her parents. Brenda’s
life and intention to migrate centred on how she would fulfil her desire to payback her
parents, as demonstrated as living a life of being indebted.
Living an indebted life was a huge motivator for all participants. All of the
favours accumulated from parents needed to be reciprocated by participants, as this
was part of the socio-cultural expression of being grateful. Reciprocal actions as
responses for favours given by parents included willingness to move outside their
country to work as a nurse. They desired to migrate and work overseas because of an
anticipation that through migration they would receive a better salary compared to
what they were getting in the Philippines. The desire to receive a financial reward for
their labour was part of living a life of indebtedness, because a higher wage would
mean an ability to financially support their parents and significant others.
Ellen’s efforts at reciprocity for her parents were associated with a plan to enable
them to stop working, whilst at the same time financially providing for them, and this
desire to see her parents retire from work would be achieved overseas. She anticipated
that a better salary overseas would mean she would be able to financially support them.
She explained that one of her future plans upon migration was that she would:
…be asking them [parents] to stop working. I just want to pamper our
parents… [as payback because] I believe they’ve suffered much of how they
raised us up… Well, for example, bringing us to a good school [where] the
tuition fee is too much…
Similarly, Brenda was seeking overseas migration as she hoped that a “better
salary” would help her achieve reciprocity with her parents. She explained that
working overseas meant an ability to save for her parents so she, “…can provide a lot
Chapter 5: Results 69
more for them…”. She wanted to save money because of medical problems her parents
were suffering, and she also wanted to prepare herself financially for what would
happen to them in the future. Saving money would mean being able to support her
parents’ ongoing and future medical expenses, as well as having finances to cover their
inevitable death. She explained that working overseas meant that, “I will be also
investing for their health, for their memorial plan…”.
The motivation to seek a higher salary overseas was identified as a ticket to
achieving life successes. Being able to help and provide for her parents’ medical
expenses, as well as saving up for a good funeral service when her parents were gone
were descriptors she used to explain how she was living a life of indebtedness. The
experience was similar for each participant, and although expressions of payback were
different for each, all focused on a desire for better remuneration through overseas
migration, which was part and parcel of a path to fulfilling a life of indebtedness for
their parents.
5.2.2 Sense of indebtedness: An obligation and a need to reciprocate
Sense of indebtedness, as expressed by participants, was demonstrated both as
an obligation and a desire to reciprocate. Obligation to reciprocate was informed by
socio-cultural expectation to express utang na loob, whilst the desire to reciprocate
was a result of assimilation of the socio-cultural values that originated from their
backgrounds in Philippine society. Each participant explained how financial reward
for parents is a common reciprocal act in living an indebted life. Being able to
financially support parents was seen as a socio-cultural obligation that most working
Filipino children express through the giving or sending of money to parents, financing
medical expenses, or as saving for future expenses. Obligation to support parents is
often also expressed in implicit, indirect, and non-verbal ways. There is a common
understanding and expectation that it is what Filipino children have to do, and that
discussions surrounding specificities of paying back are rarely undertaken.
Deborah shared how her mother expected financial support even though
Deborah had her own child. Although her mother’s expectations were not
communicated directly, failure to meet them affected their relationship. When Deborah
became pregnant when doing her nursing degree, this was interpreted by her mother
as a failure for the whole family, and it weakened their mother-daughter relationship.
70 Chapter 5: Results
Deborah explained that she would have arguments with her mother and conversations
would end up with Deborah feeling:
…that she [mother] is really expecting so much from me [including the
obligation to financially support her]. I feel like she sees all of us, even my
siblings, as bank accounts that will give her a good life when we graduate but
since I gave birth, I had a child at 21, I think she’s really disappointed.
Deborah was expressing reactions to an obligation that is strong in society.
Living in the Philippines where parents are often financially looked after by their
children, her mother embraced the idea that Deborah would perform that duty. It was
not verbally discussed, but there was already an instant and a common understanding
between her and her mother. This became apparent in arguments where Deborah’s
mother would vent out her frustration regarding her low salary. Due to Deborah’s
priority to finance her child, her ability to support her mother was reduced. Deborah
shared that:
… her expression of love, it’s different with my siblings and me. [Her mother
often says], ‘O, manager ka nga, wala ka namang pera.’ [Yes, you are working
as a manager, but you do not have enough money].
Deborah’s commitment to migration goals would not only satisfy her mother,
she also saw this as redemption of her public image. Supporting her mother upon
migration would mean that people in Filipino society would label her a good daughter.
This is commonly expected by most Filipino people as the right and good thing to do.
There is a moral obligation for a child to support parent(s) no matter what they are
going through in their own life. Success for Deborah overseas would be shared with
her family, including her mother. Deborah explained the experience as, “When I’m
there [overseas] my plan is like, I just give her money…”.
Obligation to reciprocate as a societal standard was also expressed by some
participants as an indebtedness to their employer, for example, the chief nurse.
Working in the Philippines, Anna did not want to bring work home; however, because
of her sense of indebtedness to her chief nurse, she felt an obligation to complete
delegated tasks given to her by her superior. As a result, she often ended up bringing
work home, despite feeling opposed to the task. She shared that, “[I bring work
home like] the paper work of my chief nurse, of my manager… I really don’t want to
bring work home. I just want to relax at home…”.
Chapter 5: Results 71
Anna’s account demonstrated her sense of obligation to her chief nurse and her
sense of indebtedness to hospital management. Although she was personally opposed
to bringing work home, she uttered no remorse or objection when the work was given
to her. She accepted the added work, explaining that she did this because “You are
also helping your management. Try to help them also to unload. They have so many
things to do”.
Conforming to social expectations through reciprocating favours such as
agreeing to bring work home is a typical behaviour. Living in the Philippines means
living with pre-understanding of utang na loob as an expectation, or as Heidegger
termed it, as ‘flow’ in responding to requests from favour-providers, such as Anna’s
work manager. The flow parallels social morality associated with feeling self-
righteous and moral good as a result of doing such actions. Carrying out an obligation
to reciprocate by agreeing to take some work home was something participants did as
a spontaneous act.
Reciprocity was also influenced by internal desire. For example, Brenda and
Ellen desired to financially reward their parents and Brenda explained how migrating
would help her save money for her parents’ medical expenses. She explained that being
able to financially provide for her parents in the future for their medical needs would
reduce her worries about them, “…the medications here, the treatments, my mom is
already 65 and my dad is 62, so basically, sooner or later they will say hello to God”.
For Ellen, despite her parents telling her not to financially care for them, she still
felt the need to give back. She explained, “I just give [my parents], like, a certain
amount deducted from my salary”.
Brenda and Ellen were not being coerced by their parents to financially provide
for them. There was no question for each of them that it was the right thing to do. They
would automatically reciprocate some of the many favours their parents had provided
for them. Indebtedness was expressed as an obligation to reciprocate, which was a
result of socio-cultural norms, as well as an internal desire to assist significant others.
5.2.3 Kagandahang loob: the value of reciprocation
Reciprocal actions are pursued by each individual, but the central goal is not
achieved so much through material favour, nor the actual act of kindness, but more as
a result of the kagandahang loob (the goodness that is enclosed in the favour received).
72 Chapter 5: Results
For example, Brenda desired to come back to her hospital after migrating and share
whatever she would gain overseas in terms of nursing knowledge and skills. She
explained, “…I planned to come back…”.
For Brenda, the desire to come back and share knowledge was in response to the
kagandahang loob or goodness of her employer (including hospital management and
chief nurses) that she received whilst she was working with them. The patience of
nurse trainers in the hospital to train her and the opportunities she was given to develop
her skills were some of the ‘good things’ she encountered working in that hospital.
The kagandahang loob of the good people she had worked with was what Brenda was
trying to reciprocate when she desired to come back to her hospital after working
overseas. The lived experience of reciprocity was not understood in terms of an apple
for an apple, but rather the internal or inner goodness she received from her colleagues
and hospital management that continued to drive Brenda to come back to her hospital
and share skills and knowledge gained overseas.
On the other hand, Ellen was seeking to reciprocate not only financial expenses
given to her by her parents, but their kagandahang loob embedded in providing
finances for her nursing degree. She explained that she completed her nursing degree
despite her parents’ salary barely keeping the wolves from the door. She mentioned
that, “the tuition fee is too much… ‘parang kinaya na lang talaga nila’ [they had given
all of their best]… just to give us good stuff”.
The kagandahang loob of Ellen’s parents in sacrificing to financially support her
so she could finish her nursing degree was what she was trying to return, and this was
a similar experience for each participant. They were enacting reciprocal acts in
response to favours received because they wanted to return the goodness enclosed in
each received favour. This need to express the same kindness and live out a life of
genuine expression of similar goodness towards important others was the central
purpose of their actions. The emphasis was less about the actual provision of a gift,
but rather the intentionality embedded in one’s inner desire and to live a life where the
same perceived deep sense of giving is embedded in all actions.
5.2.4 How favours are reciprocated
Each individual desired to reciprocate sacrifices. Most participants had
witnessed or heard how their friends, relatives, and people within Philippine society
Chapter 5: Results 73
reciprocated through financial giving and felt compelled to live out a similar response.
Anna explained how her friends working overseas were able to return favours for their
parents in the form of financial support. Her friends gave her feedback explaining that,
“… they were able to save for themselves and then give part of them [finances] to the
family [parents and significant others]”.
Anna felt a need to conform to social expectations through expressions of
reciprocity. In doing so she not only perceived an appropriateness to her actions, she
also felt that she belonged or ‘fitted in’ with socio-cultural norms. However, Deborah’s
reciprocity to her mother was influenced, not only by her mother’s expectations and
social norms, but also by the role modelling she observed from colleagues, friends,
and relatives who were trying to fulfil their obligation through working overseas and
sending money home. She identified that the knowledge that she may be able to receive
a better salary and repay her parents through migrating had come from her friends. She
noted that, “My colleagues, the nurses outside, and my cousin… that’s why I am also
motivated because they said they have a lot of money [and they could send money
back to their parents and family]…”.
The experience was also internally compelling. Participants planned to carry out
reciprocities that were influenced by their experiences, individual beliefs, and personal
values. Brenda felt more inclined to reciprocate to her parents, not only through
financial provision, but through sending them on an overseas holiday. She believed
that being able to help her parents to experience travelling overseas was appropriate as
a reciprocal act, and it fit into her parents’ life experiences. Brenda’s expression
matched her own experience, as well as their family’s economical condition, since
travelling or holidaying overseas was outside their norm. By doing this, her parents
would then experience travelling overseas, something that they had not yet
experienced. Brenda believed that this was an appropriate reciprocity to her parents
because this was a more suitable reciprocity for them. She planned to, “… take my
parents abroad… it’s my payback time… I plan to take them to at least an Asian or
European tour…[and] it’s my decision [to send my parents for an overseas holiday
trip]…”.
Brenda was informed by her own perception of what she thought was appropriate
payback for her parents and for their lives. Although reciprocity does have individual
distinctness that is influenced by an individual’s view of life, and the values they hold
74 Chapter 5: Results
to be true (such as Brenda’s desire to send parents for an overseas holiday), what
mattered most for the participants was the internal desire to payback and this was all
about achieving an appropriateness of the kagandahang loob received from their
parents.
However, conforming to society and following their own perceptions was not a
one-time act, but a series of ongoing reciprocal activities; the values of society and
individual beliefs about reciprocity were inter-related, inseparable, and extended
across a life time. In living an indebted life, participants opened themselves up to
commonplace societal values and chose reciprocal acts relevant and appropriate, not
only for themselves, but that would be greatly appreciated by the favour provider. For
instance, financial preparation for a parents’ death was one expression of reciprocity
for Brenda, and was appropriate for her parents because of their medical conditions.
She chose to be prepared for a good funeral as an appropriate act of reciprocity for her
parents. She explained that, “… my mom is already 65 and my dad is 62 so basically,
sooner or later they will say hello to God. So, I want to be prepared [financially]”.
Anna was struggling to financially provide for her parents because she was
studying her Master of Nursing. Her salary in the Philippines was insufficient to fulfil
an obligation of giving money to her parents, although she desired to fully fulfil this
upon migration. She shared that, “Actually I cannot give money to my parents….
Because I am taking my Masterals. I’m the one paying for that one”.
Life circumstances allowed participants to pursue different expressions of
reciprocating. The reciprocities participants pursued expressed an obligation to
reciprocate and were influenced by two values: societal standards and expectations, as
well as an individual’s internal perception or understanding of what it was to
reciprocate kagandahang loob. These two values had relevance to each participant and
their favour-providers’ life circumstances, and had perceived appropriateness to the
value of utang na loob. This lived experience of taking action to payback parents and
significant others was a strong motivator for participants in deciding to seek
employment overseas through migration.
5.2.5 Summary
Living an indebted life was important for participants and was a result of deeply
engrained socio-cultural traditions of gratitude known as utang na loob. This cultural
Chapter 5: Results 75
value was expressed as both emotional responses, as well as reciprocal actions. Sense
of indebtedness as an emotional response was expressed as either a perceived
obligation to reciprocate as an expectation, and/or an internal desire to reciprocate as
a result of assimilating utang na loob. Indebtedness carried a sense of flow, where
reciprocating was a natural and spontaneous emotional response for each individual.
Consequently, in carrying out actions of reciprocity, the expressions of indebtedness
were acted out based on the expectations and standards of society, as well as
participant’s internal perceptions of reciprocating favours. However, what was being
reciprocated was not the actual material or the act of kindness received, but rather the
internal goodness or kagandahang loob enclosed within each favour. Choosing an
appropriate reciprocal act (by societal standards or the individual’s beliefs) had to suit
the participants’ life circumstances and be relevant to the favour-provider and their
life.
5.3 ANTICIPATING LIBERATION: THE HOPE TO BE RELEASED FROM SOCIO-CULTURAL CONSTRAINTS
Decisions to migrate overseas were expressed in terms of the hope of becoming
self-determined individuals. Participants described wanting to be able to pursue
personal goals, dreams, hopes, and life aspirations, whilst at the same time continuing
to live out their Filipino values, particularly associated with utang na loob. They
anticipated a future where they could achieve their personal dreams. Living this
aspiration for a liberated life was perceived to be unattainable in their home country
because participants described constraints that were both personally constructed, and
influenced by living in the Philippines. Constraints included having to live in
accordance with their upbringing and life in the Philippines, and migration offered an
opportunity to eliminate constraining effects associated with social expectation and an
environment that was restrictive and often financially deprived. There were limited
opportunities to fulfil personal dreams and aspirations in the Philippines. For each
participant, anticipating liberation did not mean relinquishing a Filipino socio-cultural
heritage, but rather adopting new ideas, opportunities, and freedom. Living out being
Filipino was part of who they were as individuals, but it also impacted and influenced
their lives to such an extent that it constrained their ability to be self-determined
individuals. For each participant, their experiences were limited and this prevented
their ability to pursue personal hopes and dreams; especially in terms of their financial,
76 Chapter 5: Results
emotional, and professional lives. Anticipation of being liberated from these effects
was a motivator for participants.
5.3.1 Anticipating liberation through release from socio-cultural constraint
Liberation was characterised as anticipated personal release from constraints that
inhibited their potential to pursue a self-determined life in the Philippines. Constraints
were experienced either internally or externally and were given meaning as a result of
the socio-cultural values held by each participant. Internal constraints were particularly
evident when participants expressed a sense of guilt associated with wishing more for
themselves. Living an indebted life tended to constrain finances, restrict their social
life, constrain professional status, and ultimately influenced how they felt about
themselves. External constraints included obligations such as financial expectations of
parents and families. Reminders of their obligations were also interpreted as a
constraint, and this resulted in judgment about themselves and their ability to be a
‘good’ Filipino person.
5.3.1.1 Living with internal constraints
Financially providing for family fulfilled cultural needs but ultimately
constrained the person’s ability to live their own life. Individual desires to help their
family limited their ability to financially support their own goals and dreams. For
instance, when Brenda was explaining how she spent her salary, she explained that she
divided a portion of her wages to give to her parents, rationalising that, “Because I am
single and I just have my parents with me…”. However, her desire to support her
parents was a problem, and this became evident when Brenda further explained that,
“What I am earning now is just enough for our daily expenses”.
Brenda’s desires to financially support her parents hindered her ability to pursue
her own personal goals. In fact, participants experienced constraint to their financial
status as a result of meeting the needs of others while working as an RN in their
country. There was often ‘just enough’ funds for their own daily and familial needs,
which meant that there was little to nothing left to pursue personal goals. For example,
Brenda had a desire to change her career from nursing to become a business owner;
however, financially supporting her parents constrained her ability to chase that dream.
She explained that, “I’m just tired working as a nurse… [after migrating overseas] I
[also] plan to invest to (sic) business”.
Chapter 5: Results 77
She saw an opportunity to be released from her situation through the promise of
a higher salary working overseas, and anticipated saving money so she could come
back home with enough savings to leave nursing and venture into her own business.
For her, anticipating liberation was about being able to fulfil both desires; financially
supporting herself and others and changing her career.
Ellen also experienced feelings of constraint, and she explained that because of
her desire to help her family, her ability to meet her personal needs were financially
constrained. She was dissatisfied about not being able to shop for things she wanted to
buy. Although financially sharing bills with her family was not a parental request, she
still felt the need to do it. This internalised desire to give financial assistance to her
parents hindered her ability to purchase the things she wanted for herself. She
explained her experience, noting that, “… of course as a young adult we tend to desire
some things that we want to buy or something and we’re deprived of it...”.
Ellen was hoping that through migration she would be able to have the things
she wanted for herself while giving back financially. Ellen believed that through
migration she would achieve liberation. She would be able to continue giving back
whilst have the ability to pursue the things she truly wanted. She described her
expectations, noting that:
Well, I expect it [migrating] to be [a] much more promising salary than what
we have here… because if I have this much salary, then I will be able to buy
the things that I want [and] buy the things I want for my family….
Participants voiced frustration about their inability to fulfil personal dreams as a
result of a priority to give financially. Deborah felt boxed in and unable to be self-
determined in any part of her life. She felt socially isolated as a result of her life in the
Philippines. She stated, “I don’t have [a] social life anymore… like travelling [to
different places], like [what] other people do…”.
Participants not only felt constraint in terms of social success, they also
expressed concerns about their financial future. Participants forecast their financial
future as limited if they continued working as an RN in the Philippines. They feared a
lack of financial freedom. None of the participants were able to save money working
in the Philippines, often expressing concerns about financial stability. Charice
78 Chapter 5: Results
intended to save money when she went overseas because, “If ever I have my own
family, I don't want to be dependent on him [future husband]…”.
There was a strong sense of limitation and fear because financial rewards and
opportunities in the Philippines were extremely limited. Limitations to the individual
ability to pursue personal desires in their social life, an inability to change career, and
worry about their financial future were all examples of concerns that participants had
experienced. Constraints to life were associated with giving back to family and parents
and more generally reflected an inability for a registered nurse to financially advance
within a socio-cultural system geared toward supporting the family. Social values and
expectations around giving dominated and eroded personal wealth, while the
employment sector for nursing was limited and not associated with high wages.
Participants hoped that through migration they would be released from limitations, yet
continue to give back to parents whilst pursuing personal dreams for the future.
5.3.1.2 Living with external constraint
External constraints were derived from other people within their communities.
Reminders about financial obligations and social pressure related to how live an
appropriate Filipino life were limitations for each person. Participants tended to
express feelings of emotional constraint to the point of feeling shame or guilt,
especially when parents hinted at their obligations to pay back. Deborah struggled to
provide financial assistance for her mother because of her priority to meet the basic
needs of her son. Her mother’s view was that she was failing to fulfil expectations and
this affected their relationship. She regularly sought approval from her mother, but the
only way she could achieve this was through providing monetary assistance. She
explained that, “I [want] to give her money because… that makes her appreciate me”.
Deborah felt un-appreciated by her mother despite her sacrifices. She
experienced emotional turmoil and conflict when reflecting on her own self-image.
Because of her mother’s lack of appreciation, she felt a sense of guilt for failing to
meet the standards demanded by her mother, which compounded her feelings of shame
and sense of inadequacy. She revealed that she felt that, “…I am not appreciated at
home… I’m really seeking for (sic) appreciation…”.
Chapter 5: Results 79
In trying to re-gain appreciation from her mother and redeem herself, she took
the strategy of trying to create a good professional name for herself in order to secure
better employment. She said:
Since then, I struggled, I really struggled well (sic). I want to prove myself to
her, but you see… it’s really rare that a student becomes absorbed in the
university to teach and I was given the chance. I’ve been a level coordinator,
I’ve earned positioned (sic) in my, like, 22 years old (sic)… After three years,
I was promoted as a charge nurse. After a week, I was promoted as head nurse.
For me, it’s an accomplishment, but for her, it’s nothing….
These experiences typified the inclination of participants to feel a sense of guilt,
shame, and inadequacy. Anticipating liberation offered the possibility to express a
genuine self without these challenges. Anticipating liberation for Deborah was about
her ability to fulfil the requirements of her mother and meet socio-cultural needs
without the associated feelings of shame and disappointment. Fear of public shame
influenced the way the participants viewed themselves. Deborah understood that
migrating overseas was a big decision, which could result in failure, but she was being
very careful and strategic about her migration plans. She had a contingency plan
(creation of a ‘good name’ at work), which she explained would assist her if she failed
in her migration plans and had to return home. She explained that:
…I am creating a name… that’s why I’m really ok-ok [obsessive compulsive
or perfectionist] with the things that I do. I make sure that everything is ok
because in the end, it will fall back to my name, and going abroad is just a
temporary thing... And then you have to go back, and what if [there is] nothing
to go back for? That is my contingency plan B…
External constraint was expressed as a limitation to self-determination.
Participants felt directed and driven by parents as a result of pressure to meet family
obligations and feared public shame. Many participants sacrificed careers and personal
life goals to gain acceptance. Migration was an alternative plan to achieve more and
live up to expectations. Public shame was explained as social failure to live up to the
expectations set by society. It is customary for Filipinos working overseas to send
money back to their family and parents. In doing so, the Filipino meets societal
expectations and it is commonplace for parents to laud them as a good daughter or
good family member. For instance, Anna described that she expected to have the same
80 Chapter 5: Results
experience, “They [friends] were able to save for themselves and then give part of
them [salary] to [their] family… [I am motivated to migrate] to save enough money”.
Anna hoped to save more money, so that she could send back money to her parents
when she migrated because this was what most Filipino migrants do. It would be her
way to return the favour to her parents, obtain social acceptance, and be free to live
out her own life aspirations.
5.3.2 The hope to becoming self-determined
Anticipating liberation was ultimately about finding a way to achieve self-
determination whilst living their Filipino-ness. Migration was about making and
pursuing life decisions based on personal preferences and interests. Self-determination
in the Philippines is constrained by socio-cultural conditions and values, especially the
value of utang na loob. In living out socio-cultural values, its affects weigh heavily on
daily experience and influence each person’s chances to achieve a financially liberated
life. Many people never achieve goals related to themselves. The Filipino system of
sharing and paying back, whilst good in terms of equally sharing wealth and resources,
significantly constrains each person in terms of their ability to rise above the average.
Migrating overseas offers the opportunity for achievement and personal choice. For
participants of this study, self-determination was about release from internal and
external constraint, which served to regulate and manage their actions and decisions.
Participants were goal-oriented and wanted a greater chance to be self-directed. For
example, Deborah anticipated being able to pursue her own life decisions and
described her vision for the future in terms of running through an infinite, endless
prairie. She expressed an image of seeing herself running a prairie in any direction she
wanted without restriction. She further embellished the vision by claiming she would
not feel exhausted when running, as if the activity was limitless. She dreamt of being
able to fulfil her life’s passion and aspirations effortlessly and without constraint; not
defined by society or the ideas of others. She was physically and mentally exhausted
by living in the Philippines and explained that, “… like in New Zealand there’s a
prairie where people could run a (sic) fresh air… I feel like when you’re abroad it’s
not easy but… you will not feel that exhausted”.
For her, running in a prairie had become a metaphor for becoming self-
determined and free. She described migration in terms of anticipating a new kind of
life. She would travel and visit places she had never seen before. For her, this was her
Chapter 5: Results 81
current dream; a dream she would not afford as an RN in the Philippines. She explained
that:
You see, that is one thing that I feel I was (sic) able to do when I am abroad…
I can go a lot of places, I can go around, go into places where I’ve never been.
That’s one thing that, hopefully, would happen after I go abroad.
In fact, migrating overseas was itself an act of self-determination for each
person. Deborah anticipated an ability to spend more quality time with her son and she
hoped for less financial problems. She hoped that migration would lead to greater
financial opportunity beyond what she could achieve in her country. Deborah wanted
to, “…buy my own house…”. Life goals of continually supporting family, having a
business, and spending quality time with her son reflected her own preferences and
interests, and were characterised by a desire for liberation from some of the constraints
she had experienced in the Philippines.
Similarly, Anna wanted to migrate overseas to gain financial and family stability.
She declared that, “…If I want to have [a] family I need to have more [financial
capacity]…”. Anna believed that having a financially stable family would give her
satisfaction as a good mother, and at the same time, the ability to be self-directed in
her life was attractive to her. She had contemplated that through migration the fears
she had about gaining financial stability would be resolved, she also hoped that she
would also fulfil her dreams of becoming a lecturer or professor in the Philippines,
because a better salary overseas would enable her to afford and achieve the
postgraduate studies necessary to qualify as a lecturer. She described her ultimate
dream to be a, “… clinical instructor… [or] be a professor in my school where I
graduated…”.
The ability to pursue a dream was best achieved through migrating overseas. A
decision to do so was about gaining the ability to achieve the unobtainable in their
country. Brenda noted that:
I’m just tired working as a nurse… I don’t really see myself doing this for
another, like, 20 years or so. I’ll be coming home and hopefully stay here for
good. And maybe venture into business.
82 Chapter 5: Results
Brenda did not want to feel limited anymore. Migration was an opportunity to
achieve a self-determined life and have continuity in fulfilling obligations towards her
family; doing so would be living a liberated life.
5.3.3 Summary
Fundamental to each participant’s desire to migrate was the anticipation of
liberation. Participants would be able to choose and make decisions about their life
whilst continuing to live their life of indebtedness. Anticipating liberation is a lived
experience in which participants hoped for self-determination, a capacity to pursue
personal life goals and dreams, meet socio-cultural obligations, and relinquish internal
and external constraints. Participants hoped to become the person they wanted to be.
To be able to pursue their own dreams and to be able to get what they desired for their
own lives. They realised that their dreams and goals were unlikely to be achieved living
and working in the Philippines. In preparing to migrate they were examining
themselves and their socio-cultural obligations, and anticipated liberation through a
new life. They believed their decisions offered new opportunities for resolving
tensions between societal expectations, family demands, societal restrictions on
wealth, and a desire for individual self-determination and success. Participants
identified that migrating overseas was a strategy that offered them the opportunity for
a new liberated self in which personal life goals would be met in their lives.
5.4 MAINTAINING CLOSE FAMILY TIES: LIVING AN INTER-CONNECTED LIFE
Living an inter-connected life was about maintaining a relationship with family
and significant others, being one, and closely inter-linked with them. Inter-
connectedness is an expression of Filipino identity and being, where self is found
within the context of family and vice versa. This experience is locally known as close
family ties, and is a deeply engrained and widely accepted Filipino practice.
Close family ties is a Filipino value that places great importance on family
connections and relationships characterised with loyalty, love, respect, maintaining a
sense of fellowship, and prioritising family over self. Participant accounts relayed the
intention to migrate overseas, which was strongly inter-linked with how they expressed
close family ties as family being their support system in deciding to migrate, consulting
family’s opinion and advice, and having them agree with their decisions, the
Chapter 5: Results 83
experience of becoming selfless and embracing sacrifices required in migrating, as
well as putting their family’s interests at the top of their life priorities. Moreover, close
family ties extended from the idea of physical proximity towards the potential to better
the lives of family members. These experiences of maintaining close family ties or
living a life of inter-connectedness with family were expressed as a motivator for
participants’ experience to seek overseas migration.
5.4.1 Family as a support system
Close family ties or inter-connectedness is about family as a support system.
Having a good relationship with family is about providing each other with a source of
strength and confidence. Having good family relationships provided a source of
courage for participants to take the risks associated with migrating, and come to terms
with their decisions and plans to migrate, because they knew that their intention to
migrate was being supported by their family.
Each participant understood that there was no absolute guarantee of achieving
success in their goals to migrate, and that their plans had associated risks. However,
because they knew their family would always be there and be their support system
whatever happened in their migration journey, participants were more than willing to
take the step. Ellen believed that family support was important to her and was an
important factor in having the courage to make the decision to migrate overseas. She
shared that:
…it just sinked (sic) in to me that whatever you experience, whatever
difficulties you have, the family will always be with you [as your support
system]… they’re still your family no matter what.
Ellen’s family were central to who she was as a Filipino and her being, without
her family there would be incompleteness and emptiness in her life. Ellen believed that
maintaining a good family relationship through family approval and support was
essential. This experience was common for all participants.
5.4.2 Family as part of life decision making
Participants sought family consensus on big life decisions. Participants not only
solicited support and approval of parents for their intention to migrate, but also from
other family members. There was often family consultation and discussions prior to
proceeding with plans. Brenda believed family was her foundation for decision-
84 Chapter 5: Results
making. She felt at ease sharing and discussing her life plans with her family, and there
was no constraint in telling her family her life decisions and the things she wanted to
do, particularly her intention to leave the country for overseas work. She solicited her
family’s opinion and support about decisions and desired to maintain good
relationships with her family and felt inter-connected with them. When she was
making plans to migrate overseas, she shared that, “… I am very much open to my
reason [of seeking overseas migration with her family]”.
Anna’s decision to migrate was also influenced greatly by her family. She felt
that having her family agree meant being at peace with her decision, and as a result,
this would maintain a good relationship with them. She considered their opinions and
feelings in her plans because her intention to migrate, “… is affected by my family
because, I also want them to agree with all my decisions…”.
Anna’s desire to solicit family approval and their opinions was expressed as
essential. She talked with them about the intention to seek overseas employment, when
she should apply, how long the contract would be, and what role the job contract should
entail. She believed it would be very difficult for her to migrate without the approval
of her family. There was desire to avoid conflict and disagreement. There was also a
sense of respect and consideration for family members, and in some capacity, a sense
of fellowship, rather than a purely individualistic intention. Opening herself and her
life decisions to family opinion demonstrated the value of family connectedness as a
component of living a Filipino life.
5.4.3 Family as a top priority
Lasting relationships required participants to be selfless in how they lived their
own lives and accept that family members were participants in their life decisions.
Participants were less focused on their own wellbeing, and more on the concerns and
welfare of their family and significant others. Making family interests a life priority
meant embracing the sacrifices involved in this pursuit, particularly sacrifices
associated with leaving family for overseas work. Brenda valued inter-connectedness
with her family and admitted that her intention to migrate was not for her own benefit,
but for the benefit of her parents. If she had to think about her own life, she would not
apply for overseas nursing jobs as she was already satisfied working as an RN in her
Chapter 5: Results 85
country. She stated, “Because if I’ll be thinking about myself only, I’m satisfied with
what I’m doing here…”.
Brenda was focused on fulfilling the needs of her family. She did not care much
about the satisfaction she was already experiencing working as RN in the Philippines,
and the things that mattered to herself alone. She was more focused on the things she
could provide for family when she migrated. She was willing to take risks and embrace
the sacrifices associated with her intention to leave. She expressed the difficulty she
was feeling, noting that migrating overseas is, “…very, very hard. The thought of
leaving my parents… is very hard for me, but I have to do it, because it’s for them…”.
Deborah was also selfless in her intention to migrate because she was thinking
mainly about the future life of her son. Being a single mother, she wanted to achieve
all the good things she could to provide for her child and make his life better and as
comfortable as possible. Her desire as a single mother to achieve more for her son
made this a priority more than things for herself. She explained that she wanted to
migrate because it was, “… all for him [son]… not for me….”.
Participants’ desire to make the lives of family and significant others better by
providing for their daily needs revealed selflessness that in part originated from living
and valuing close family ties or inter-connectedness. Motivation to migrate was driven
in large part by plans to maintain close family ties with family and/or significant others
as a life priority.
5.4.4 Maintaining close family ties beyond the physical
Maintaining close family ties or inter-connectedness went beyond physical
closeness and proximity. The idea of embracing sacrifice and being selfless for family
and significant others meant participants were willing to exchange physical contact for
opportunities to fulfil needs for their family. Close family ties were not all about
physical closeness, rather a fellowship that extended the idea of “with the other”. Many
of the participants did not discount feelings that being physically distant from their
family would be emotionally difficult. However, close family ties or inter-
connectedness was not about physical boundaries, but extended to other things. For
instance, Brenda was worried that she would be physically distant from her family. It
would be difficult, but she embraced the migration plan in order to achieve more for
86 Chapter 5: Results
her family, since fulfilling the needs of her family and significant others outweighed
her desire to be physically close to them.
Likewise, Deborah admitted that being a single mother meant leaving her son
was not, in any capacity, an option, but she believed the gains of moving overseas
outweighed her desire to stay with her son in the Philippines. She shared that:
[moving overseas would be a big] …sacrifice. It should not be. It should not
be because I should be there for him because his dad is not there… ideally [a]
mother should be with her kid, but right now in my situation it cannot be…
but you see the world will not go ‘round if there is no money. I would not want
to see my child uneducated because I can’t provide him a good education.
For Deborah, anticipating the potential of being able to educate her son
outweighed her belief that no mother should leave their son, even when the son would
grow up without a father (Deborah is a single mother). She believed that her sacrifice
to leave her son was less important to the potential benefit of being able to provide a
good education for him. She thought that the long-term benefits of migrating were
more important in her life.
The potential to make the lives of family and/or significant others better was an
important factor in decisions about overseas migration. Participants anticipated
making the lives of their families better through overseas financial gain, and were more
than willing to embrace sacrifices of moving, and being physically separated from
them. Their experiences were expressions of living out close family ties or inter-
connectedness beyond the physical.
Brenda knew how difficult it would be to achieve the “best things” for her
parents with no extra financial savings in her country. For her, the best pathway she
had was through migration because it offered a better salary. She had high hopes that
she could, “provide a lot more for them [parents] if I leave…”.
A higher salary was a common expectation of participants, but this did not mean
that participants wanted to be wealthy. Intention to migrate was to take advantage of
financial opportunities after migration in fulfilment of family needs, not specifically
to become wealthy. This was clarified by Anna when she mentioned that, “I need not
more [just a].. well compensating job”.
Chapter 5: Results 87
5.4.4.1 Better life for family, better life for self
Participants were willing to sacrifice being away from loved ones if it meant
helping their family to live better lives. For Filipinos, their “being”, “life”, “self”, is
expressed in terms of their relational commitment and alignment of purpose and
presence with family. Their inter-connectedness with other people, primarily their
family and significant others, is a central component of how they make sense of who
they are and their being in the world. Their identity is always shared. Their family is
like their “self”, since each is a reflection of the other. Life, dreams, and aspirations
centre around family and their actions are often about making sure that families
wellbeing is pursued first; family is valued more highly than their own wellbeing. This
deep and lasting connection with family was an expression of the identity of
participants. Self became a central component of the lived experience of each person
in terms of their place in the family, and seeking overseas migration was an extension
of that relationship.
Deborah’s close family ties were expressed through wanting to fulfil the needs
of her son. She wanted to work overseas because of a higher salary, which would
enable her to meet her son’s educational needs. She stated “It will make me satisfied
because I will see my son [have a good education]… for him. It’s [all] for him”.
Similarly, Charice’s close ties with her family were expressed as trying to meet
the needs of her sick brother. Being able to provide financially for her brother’s
medical treatment was a reason for her to seek overseas migration. She shared that, “I
was thinking about my brother’s condition also who has a kidney disease, so he has to
undergo dialysis twice a week plus his medicines. Cause his dialysis actually costs
$2000 per session”.
For her, close family ties were also expressed through fulfilling the educational
needs of her three nieces. She noted that, “… I have three nieces, which I [financially]
help them to study”.
Charice was more concerned about the needs of her relatives than herself.
Participants purposefully committed themselves to migrate to improve the lives of
their families. There was an intangible connection lived out in fulfilling family needs,
and they pursued migration for this reason. Each participant expressed their own
reasons, but all described how they would feel satisfied and fulfilled once plans to
88 Chapter 5: Results
improve their families lives were achieved; family was how they defined self and
identity.
Anna and Charice also wanted to have financial savings and stability for their
future family. Anna explained that, “… if I want to have [a] family [in the future] I
need to have more... I think even [the] stable financial aspect. I think that's the only
problem, that's why I will resign [from] here [to migrate]”.
Likewise, Charice wanted to have enough financial savings and stability in life
to support her future husband and not merely be, “dependent on him”.
5.4.4.2 Life mirrors success and shame
When participants had failed the family, the whole family would lament their
failure, whilst each achievement of triumph would make the whole family proud.
Whatever or whoever they became in life would directly affect other members of the
family. For Deborah, becoming a single mother placed a sense of dishonour and failure
onto her mother. She carried the stigma of ‘failure’ onto the whole family. Shared
celebration within families in life was associated with emotional turmoil, and
behaviours and successes had a mirroring effect onto close family. Self was therefore
not expressed within an individualised construct, as it extended beyond to the
collective life of every member of the family and significant other.
5.4.5 Summary
Living out close family ties was one of the motivators for participants to decide
to choose overseas migration. Participants anticipated an inter-connected life and good
relationships with their families. Better remuneration would assist participants to help
family members with physical ailments, their education, and provide support for
parents and family. Identity, life goals, and aspirations were all centred and focused
on family. Experiences were often described in terms of selflessness and participants
believed that this was how they would achieve life satisfaction and contentment. A
better life for family was a better life for each participant. They would risk failure and
endure physical distance from their family, as difficult as it would be, in anticipation
of achieving a better life for everyone. Close family ties were not defined in terms of
physical closeness, but as family connectedness despite distance and separation. The
opportunity to achieve more through migration outweighed the common boundary of
close physical family relations. The lived experience was about the potential and
Chapter 5: Results 89
possibility. Their goals created meaning and arose from their relationship with family
and significant others and each participant would do everything they could for their
family. Giving everything for the family was what they perceived would help them to
individually achieve an authentic Filipino life of being closely aligned with family.
5.5 CHAPTER SUMMARY
Three experiences emerged through this the study of Filipino RNs prior to
migration. Participants were strongly motivated by Philippine socio-cultural values
that concentrated on family, connectedness, sharing, and paying back. The desire of
participants to seek overseas migration was about better remuneration, but was also
deeply rooted within linkage to family and significant others. The experience of
reciprocating for sacrifices made by parents and a life of indebtedness had
consequence, framed their ability to pursue personal wishes, yet influenced decisions
about big life choices. Each individual in this study believed that migration offered the
opportunity to fulfil the values important to themselves, their society, and their family.
Participants would live a life, not only for themselves, but more importantly, for family
and significant others. Migration as a lived experience was deeply influenced by
notions of what it is to be Filipino, and a strategy for fulfilling life goals for family,
significant others, and self.
The next chapter discusses the significance of the three themes presented in this
thesis as compared with current literature. It situates the implications of the findings
of this study and the importance of the knowledge gap it fills in understanding
Philippine nurse migration.
Chapter 6: Discussion and Conclusion 91
Chapter 6: Discussion and Conclusion
6.1 INTRODUCTION
This chapter presents the significance and implications of the study. It highlights
the relevance of understanding the lived experiences of Filipino nurses wanting to
migrate and challenges nurse migration literature and the relevance of current
knowledge. This discussion can inform global nurse migration policy, and importantly,
the findings of this study provide a more holistic insight into the reasons why Filipino
nurses work overseas and their intentions to migrate.
Analysis of data from the group of Filipino nurses who desired to migrate
overseas produced three themes in this study: (1) living an indebted life, (2)
anticipating liberation, and (3) living an inter-connected life. Participants desired to
live out their utang na loob (sense of indebtedness) to their family and the opportunity
to best achieve this was through migration. Each person was influenced to a large
degree by dominant socio-cultural values emphasising support of family and the
broader community, and they experienced a consequential desire to live out their utang
na loob. Filipino socio-cultural values were strong motivators for seeking overseas
employment. Even though participants in this study sought to leave their country and
family, they were doing so to meet perceived obligations. Migration was not about
relinquishing Filipino values, rather it was viewed as a pathway to fulfillment of these
obligations, and offered more potential for them, including pursuing personal
aspirations.
6.2 FAMILY AS CENTRAL TO FILIPINO INTER-CONNECTEDNESS AND BEING
There can be difficulties understanding Filipino culture; however, two important
concepts originating from Enriquez’s work predominate: family orientation as a result
of kapwa and the Philippine value of utang na loob ( as cited in Pe-Pua & Protacio-
Marcelino, 2000, p.56).
First, kapwa (the self in the other or togetherness) is considered one of the core
values of being Filipino (Pe-Pua & Protacio-Marcelino, 2000, p.56). Kapwa is about
being in a community and fully immersed with the people and doing things together
92 Chapter 6: Discussion and Conclusion
rather than being alone (Domigpe & Domingo, 2012, p.9). Many important Filipino
values are products of kapwa, and one of them is close family ties. The Philippine
family is considered to be “the wellspring of a meaningful existence, of obligation and
fulfillment” (Mulder,1991, p.73). Filipinos cannot think of themselves without
thinking of the concerns of other people, especially significant others. Close family
ties are manifested in many ways, but importantly, Filipino nurses in this study put a
high significance on their family members, placing the concerns of family above any
other thing, even some aspects of themselves. Close family ties influence how
Filipinos make life decisions and set goals. Living in the Philippines means living a
life that revolves around family, including parents and siblings, grandparents, uncles
and aunties, cousins, and other relatives (Mulder, 1991). The significance of close
family ties is even expressed in one of the State Policies of the Philippine Constitution
in which “the State recognises the sanctity of family life and shall protect and
strengthen the family as a basic autonomous social institution” (Republic of the
Philippines, Official Gazette, n.d.), placing additional importance on Filipinos’ way of
valuing their families.
Close family ties not only includes physical association, but also acknowledging
family to be the primary, social, and psychological component of a person’s life and
life priorities. Close family ties has been expressed as “we will move mountains to
provide our family with only the best” (Mulder, 1991, p.73). Valuing family is the
foundation of one’s self: the meaning of being a Filipino. Filipinos perceive their own
self through the lives of their families (Domigpe & Domingo, 2012, p.9), and this
shapes each individual’s moral and psychological world.
On the other hand, utang na loob, which Enriquez defined as the Filipino way of
“gratitude or solidarity” (as cited in Pe-Pua & Protacio-Marcelino, 2000, p.56), is the
returning or repayment of favours received from someone (Domigpe, & Domingo,
2012). Although translated as debt of gratitude, or debt of one’s inner self by Western
philosophers, this explanation does not capture the holistic nature of the Filipino value
(Pe-Pua & Protacio-Marcelino, 2000). Utang na loob is not a burden for the person
who has received a favour, as the word “debt” connotes (Pe-Pua & Protacio-Marcelino,
2000). It is a way of being in which living a life informed by the value creates meaning
and both contextual and social alignment. This Filipino value does not require the
favour-provider to obligate the receiver to return the favour(s), rather they are innately
Chapter 6: Discussion and Conclusion 93
compelled to do so because this is the right thing to do (Pe-Pua & Protacio-Marcelino,
2000). For example, discussions surrounding repayment details become unnecessary
because there is a sense of shared experience and the favour-receiver will appropriately
define how to repay the goodness of the other person. This value is very prominent
within familial relationships (Alampay & Jocson, 2011). Parents instil the value of
paying back in their children at a young age. This way of life and social affiliation is
how Filipinos express love and gratitude, and is lived out within traditional familial
relationships; living a life focused on paying back parents and significant others
(Alampay & Jocson, 2011). The value of indebtedness is believed by scholars to be “a
beautiful element of Filipino interpersonal relationships that binds a person to his or
her home community or home country” (Pe-Pua & Protacio-Marcelino, 2000, p.56),
particularly for those who live overseas or away from their significant others.
Filipino family is central to life experience and a strong driver for migration,
individual dreams, personal goals, and future aspirations. In terms of life journey,
family is inseparable to each persons’ experience and understanding of being Filipino.
To migrate is not about leaving the family. It’s about being with the family but locating
yourself at distance, so in a strong sense, as a lived experience, migrating nurses do
not see themselves as leaving the family, and possibly don’t even see themselves as
leaving the Philippines.
To live out a life of Filipino-ness is to embrace a lived experience defined by
Philippine family values and putting the social and family interests at the centre of all
life’s decisions and goals. Brenda understood her potential to provide more for her
family through migration and that was why she was keen to leave her family despite
the considerable sacrifices associated with the decision. Family were central to her
migration story and her commitment was expressed as selflessness and putting the
family’s interests before her life priorities.
Salami, Nelson, Hawthorne, Muntaner, and McGillis Hall (2014) studied the
motivation of Filipino nurses who migrated to Canada as domestic workers between
years 2001-2011 under the Live in Care Program. They found that Filipino nurses
were attracted to move to Canada to “have a better life for their family. They used the
phrase ‘all for their family’ frequently when describing their reasons for migrating to
Canada to work as live-in caregiver…” (Salami et al., 2014, p. 483). Motivation to
94 Chapter 6: Discussion and Conclusion
migrate centred on family because this is who they were as Filipinos. Lived experience
is associated with sacrificing personal desires as a way to fulfil the needs of family.
An intentionality to put family first is about hope and anticipation. After
completing a nursing degree, participants sought to migrate overseas and provide more
for their family. Smith, Allan, Henry, Larsen, and Mackintosh (2006) noted similar
behaviour in overseas trained healthcare professionals’ in the United Kingdom, which
revealed that “for many Filipinos, being able to support the parental family through
migration was a primary motivation for entering nursing profession” (p.27).
In fact, as a life journey, decisions that affect future life are made much earlier
in consultation with family; clearly, each family has a social investment in how each
Filipino family member expresses their inter-connectedness. Every person’s chosen
life endeavour is not conceived or lived as an individualistic choice, but rather as a
familial one. Inter-connectedness is about being with each other and sharing the
responsibility of life choices.
It has previously been argued that family are central to migration and can be the
driver for change (Long, 2014). Alora and Lumitao (2001) explained that family is
central to each individual Filipino’s life. They “make decisions and perform actions
based not only on their own personal and individual benefit but on the family’s welfare
as well. The family encroaches into every aspect of individual life” (Alora & Lumitao,
2001, p.82). This current research shows how the role of family in decision making
and choice is far more than a driver of decisions. Family are with each participant as a
life journey, and life decisions such as intention to migrate and future life goals and
aspirations, are everyone’s business.
Social behaviour and choice that aim at improving family success is the norm in
Philippine community(ies), and was a primary reason for why participants undertook
nursing as their professional career; it was a family decision. Ronquillo, Boschma,
Wong, and Quiney, (2011) explained that:
…it was common for… [Filipinos] 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
Chapter 6: Discussion and Conclusion 95
remembered as being an uncomplicated event and without mention of conflict
(p.270).
Ronquillo et al. (2011) explained that through inclusion of family in life
decisions and plans, “there was a shared sense of contentment” (p.271). Filipino values
are expressed through a collective awareness of family success, which Wolf (1997)
affirmed as the greatest role in each person’s life journey, including their experience
and motivation to migrate overseas.
The lived experience of wanting to migrate overseas has a tendency toward being
non-dualistic, as there appears to be limited separation between the act of migration
and what it means to be Filipino (the values are intertwined as part of being).
Participants did not aim to relinquish family ties as a consequence of their migration
decision. Desire to migrate overseas is an embedded experience dictated and driven
strongly by living out Filipino-ness (valuing family and interconnectedness). The lived
experience is part of living a life defined by Philippine culture, which is identified as
part of Philippine norms and values.
Interestingly, research examining the Tongan community has identified similar
experiences related to the central role of family. In an essay about migration of Tongan
people to Australia, Cowling (1990) highlighted the inter-connectedness and a
mirroring effect across members of each Tongan family. The accumulation of either
success or shame is shared and reflected back to the entire family. Tongans’ view
family as, “the provider of everything for the individual…members of a family are
said to ‘belong to each other’. They… operate in a spirit of mutual love, caring for
each other” (Cowling,1990, p.104).
Concepts of family and self are inter-connected with “belong[ing] to each other”
as central to their lived experiences, motivated by desire to “help the family” (Cowling,
1990, p.106), as formed and influenced by Tongan socio-cultural values. From a group
of people that moved from Tonga to Australia in 1987, “almost eighty-six percent of
a sample of seventy respondents interviewed in Tonga stated that family
members…had emigrated in order ‘to help family’” (Cowling, 1990, p.106). Like a
Filipino family, strong motivators for behaviour arise from a desire to live a life in
which helping family is embedded within their values, and fed by sense of inter-
connectedness.
96 Chapter 6: Discussion and Conclusion
The significance of the experiences presented for the group of Filipino nurses in
this study is important, as there remains a general lack of literature and research
expressing a deeper and more complex explanation of dasein as an extension of family.
Migration studies often classify helping family under the category of financial
motivation. Smith et al. (2006) claimed that Filipinos are driven to migrate overseas
so they can financially help their family, and they categorised the behaviour as
“material advancement” motivation. There is certainly a financial component to
Filipino nurse migration, but this explanation significantly underplays family, which
is rooted deeply within each person’s expression of Filipino-ness. To classify helping
family as a motivation for material advancement is to fail to see the lived experiences
embedded within the broader social and cultural context(s). This study presents a
holistic examination of experience that is grounded in the context of being. Migration
fulfils a sense of family linkage and expresses contextual and familial association
through the enactment of migration.
This limitation is common to nurse migration literature, as knowledge gaps lie
within a cultural misinterpretation of Filipino family and individual inter-
connectedness. In fact, participants in this study explained that their family relations
were significantly different to Western culture. For Filipinos, family is part of ‘self’
identification because self is found within the context of family. Jackson (2006)
explained that, “the concept of self for the Filipino is strongly identified with the
individual’s… family… [and] family remains central throughout [their] life” (p.217).
In Western culture, the meaning of “self” is often interpreted in terms of personal
boundaries, linked but potentially separated from social context, and more aligned to
an emphasis on autonomy and independence (Markus & Kitayama, 1991). These
cultural differences are often expressed as a misinterpretation of the value of providing
for family, and sacrifices embedded in lived experiences of Filipinos. The new
knowledge arising from this study challenges research arguing Filipino nurse
migration as singularly financially or economically driven: all for the money. Future
migration studies require researchers to understand the socio-cultural contexts so often
neglected in prior studies, interpretation, and discussion.
6.2.1 Sacrificing for family is part of being Filipino
Providing more for family means embracing the sacrifices of working overseas,
which seemingly entails the paradoxical situation of leaving, not only home, but
Chapter 6: Discussion and Conclusion 97
country. Yet, inter-connectedness transcends “physicality” and is lived out, even at a
distance. Each participant’s intention was to seek out symbols of inter-connectedness,
and they aspired to send money back to the Philippines, and make the life of every
family member better as a result of their sacrifice. These bridges to inter-
connectedness had no geographic limitation. Each participant expected that they would
maintain inter-connectedness with their family as part of migrating; after all, that’s
what Philippine family members do.
Each participant in this research had no desire to be separated from family, and
in fact, saw themselves as still with them. Similar experiences were found by Lamvik
(2002), who examined Filipino seafarers and their motivations and experiences in
gaining overseas employment. Seafarer accounts of their experience often focused on
the notion of sacrifice for their family. It was explained that Filipino seafarers are:
…willing to live a professional life - which has its overall aim to improve the
wellbeing of the family - away from the family. In other words, they sacrifice
themselves, in the name of their families. Despite a strong family orientation,
the seaman is willing to face solitude and hardship on board, just to ensure
that his family is better off as a consequence of this arrangement (Lamvik,
2002, p.24).
The ability and willingness to sacrifice for family was consistent among
participants in this study. Being Filipino is about embracing sacrifices and the
phenomenon is not only part of the Filipino cultural experience, but “functions as a
highly appreciated value and ideal…” (Lamvik, 2002, p.29). Through working
overseas, participants would be “able to consummate one of the fundamental values in
the Philippine society” (Lamvik, 2002, p.30), placing family as a central part of being
Filipino by embracing sacrifice. Filipinos revere every Filipino working overseas as a
“modern hero” or bagong bayani (Pajaron, 2011), because despite the many obstacles
it takes to leave loved ones, they often do so very successfully. There is an attitude that
emphasises that “one always gives oneself up to certain ideas in the name of
someone…” (Lamvik, 2002, p. 25), and for Filipinos it is often one’s family.
6.2.2 Providing more for family is more than being altruistic
To provide more for family, participants hoped to remit money home upon
migration. Numerous studies have concluded that Filipino migrants (including nurses)
remit money as part of altruistic behaviour (Fullenkamp et al., 2008; Sigurðsson,
98 Chapter 6: Discussion and Conclusion
2015). It is common to read articles discussing the behaviour of remitting money
highlighting altruism as the reason and an ideal that emphasises the “willingness of a
migrant worker to provide assistance to their household” (Samson, 2011, p8). For
example, Lucas and Stark (1985) argued that:
…certainly, the most obvious motive for remitting is pure altruism - the care
of a migrant for those left behind. Indeed, this appears to be the single notion
underlying much of the remittance literature (p.902).
A study by McDonald and Valenzuela (2012) into the motivation of Filipino
migrants to remit money concluded that “our results show that the decision to remit is
strongly affected by both home and host country factors with altruism motive as a
ubiquitous underlying element” (p.1). Although altruism is an obvious explanation for
the phenomenon of Filipino migrants and their willingness to send remittances, it does
not fully capture the social and cultural intentions embedded in the experience.
The limitations of the current literature relate to persistent misinterpretation of
behaviour, fed especially by a failure or inability to consider the significant social and
cultural beliefs embedded within the remitting behaviour. Unsurprisingly, it would
appear that most researchers in the area would benefit from greater acquaintance with
Philippine culture and values, which differ significantly to Western culture. Severino
and Salazar (2007) explained that:
…in the Asian context [like the Philippines], and probably also in the other
developing countries with strong familial ties, caring and giving [including
remittances] among family members are typically not considered ‘altruism’
but a natural gesture of concern. ‘Altruism’ is essentially an individualistic
concept that probably more to Western Societies (p.240).
Concern is about Filipinos expressing care toward their family. Concern for
Filipino family is described in terms of, “sense of support, care, warmth, and intimacy,
and shared values and beliefs. These were elements that make a Filipino family amidst
all the issues like global and urban migration…” (Tarroja, 2010, p. 187-188).
This concern for family, when interpreted through the lens of Philippine life
experience, presents a richer explanation of dasein in terms of living a life inter-
connected with family members. It provides greater meaning for the behaviour of
remitting money, which is fundamentally not only about altruism. For example, when
discussing Philippine traditions and ways of life, American criminologist/researcher
Chapter 6: Discussion and Conclusion 99
Timothy Austin (1995) observed that the way Filipinos value their family “pertains to
a mood of altruism that gives rise to self-help activities aimed at protecting the
immediate family” p.12). In response, Paredes (1996) argued that valuing family and
other Filipino traditions is not simplistically altruistic. It is a deep part of Filipino-ness
and social identity. Paredes (1996) summarised her argument that the American
researcher “appears to be seriously misinformed about the contexts in which such
traditions and organisation may operate” (p.244).
Similar problems are encountered in nursing literature, which has often resulted
in a culturally misinformed understanding of Filipino nurses and their migration
(Aguilar, 2013). Aguilar (2013) noted:
…many studies on family and migration… in the Philippines - are guided
ultimately by a Westernized understanding of Philippine culture which resulted
into the exclusion of the…complex web of social relationships in which
individual migrants and family members are embedded (p.348).
This is considered one reason why many studies about the experiences of
Filipino nurse migrants are often socially and culturally misinformed. This current
study demonstrated that future studies must consider the importance of social and
cultural constructs when studying Filipino nurses. Using appropriate lenses to
understand the experiences of Filipino nurse migrants, for example, is very essential
in:
…decolon[izing] non-western epistomological space, and valorize native
knowledges about Asian [including Filipinos] mobilities…Rather than
continuing to rehearse those tired, hegemonic viewpoints that (subtly)
naturalize and perpetuate very particular racialized subjectivities about
migrants, academics out to strive to question their own tacit assumptions about
‘Asian’ and other ethnic transmobilities, and work to provincialize an overly-
dominant western imagination of/in the field (Lin & Yeoh, 2010, p. 130).
6.3 FILIPINO NURSE MIGRATION: IT’S MORE THAN JUST ECONOMICS
This study demonstrates that for Filipino nurses, motivation to seek migration is
more than just a matter of economics. The experience emphasises giving back to
family and maintaining family ties. Whilst participants expressed their hopes for better
100 Chapter 6: Discussion and Conclusion
remuneration, their desire to maintain family and social affiliation remained the
primary focus of their intention.
Desire for better salary for the benefit of the entire family was a large part of the
pre-migration experience and presents a deeper interpretation of the phenomenon than
has been demonstrated in previous studies (Alonso-Garbayo, & Maben, 2009; Kline,
2003; Lorenzo et al., 2007; Nicholas & Campbell, 2010). This current study provides
the richness and depth of meaning that has so often been missing in interpretation and
provides knowledge as to why Filipino nurses are attracted to higher remuneration.
Prior socio-cultural experiences seem to produce a willingness to incorporate Filipino
values into individual life journeys and play a significantly role in decision making
and reasons to migrate. There’s an essence or meaning within their life experiences
that is deeper than mere desire for higher remuneration. Importantly, the findings from
this study also demonstrate that labels such as ‘economic migrant’, which denotes
someone who has chosen to move to another region or country to advance their
economic prospects (Semmelroggen, 2015; United Nations High Commissioner for
Refugees, 2016), can be inaccurate, or at minimum misleading. Terms such as
economic migrant are sometimes applied to immigrants by people from host countries,
including internationally educated nurses (IENs), and this leads to misperceptions and
is prejudicial. The lived experiences of the nurses involved in this study show that it is
not a suitable descriptor and it fails to capture and portray the depth of causality for
migration and even the reality of many people’s lives. For example, the label
incorrectly implies that the driver for Filipino nurse migration is simply wanting a
better salary. This is due to failure to understand Filipino cultural and social factors
that influence lived experience and reasons why many people may in fact seek
overseas migration. Every cent Filipino nurses remit back to their families signifies
the love they have for their family. Migration is not all about economics and the
financial value it holds for the individual, it is much more to do with being Filipino,
which concentrates on loving family and significant others.
6.3.1 Challenging current nurse migration literature
Research studies have attempted to explore nurse migration (Alonso-Garbayo &
Maben, 2009; Kline, 2003; Lorenzo et al., 2007; Nicholas & Campbell, 2010) and a
common theme across studies has been economics as a major driver for nurses to leave
their country of origin. Although researchers such as Kline (2003) and Dywili et al.
Chapter 6: Discussion and Conclusion 101
(2013) emphasised a number of reasons for migration, including professional
advancement, employment, adventure, or a better work environment, economic gain
is considered the major reason for nurses to seek overseas migration. It is the most
common explanation posited by authors and has been articulated in terms of a push
and pull model or theory of nurse migration (Alonso-Garbayo & Maben, 2009; Kline,
2003; Mejiaet al., 1979; Nichols & Campbell, 2010). For example, Lee (1996) argued
that people migrate due to various factors that push them to leave their place of origin,
including unemployment, natural disasters, slavery, and war. They are pulled towards
their destination due to factors such as job opportunity, living conditions, and freedom.
The push and pull theory is a common framework for researchers examining
nurse migration (Alonso-Garbayo & Maben, 2009), but its dominance has created a
gap in the holistic interpretation of the phenomenon. Ronquillo et al. (2011) noted that:
Push and pull factors are important aspects of migration and a common theme
in the migration literature. A careful analysis of the interviewees’ stories [of
their study], however, seemed to suggest that it is important to move beyond
these traditionally discussed themes of migration (p. 266).
Whilst identifying many of the influential factors affecting a person’s desire to
migrate has been an outcome of the theory, it insufficiently assists in providing an
understanding of the familial, social, and cultural factors behind the migration
experience. As a result, nurse migration studies tend to highlight economic gain as the
major driver for movement and fail to engage with issues associated with cultural and
social expectations that lie behind the activity (Dywili et al., 2013; Nicholas &
Campbell, 2009). For instance, an analysis of nurse migration literature published from
1995 to 2007 in the UK concluded that the major reason for Filipino nurses to migrate
overseas was economic gain: desire for better remuneration (Nichols & Campbell,
2009). Winklemann-Gleed (2005) surveyed 358 internationally recruited nurses, some
of whom were Philippine trained, working in London and the study concluded that 40
percent of the sample revealed economic factors to be a major motivator for their
migration. However, the literature failed to investigate the meaning behind their
economic aspirations, especially with regards to nurses from the Philippines. Studies
have also tended to be descriptive and often centre on individual desires for better
salary as the motivator for migration, completely missing the significance of social
values, individual life experience, and links to family. There is often a lack of inclusion
102 Chapter 6: Discussion and Conclusion
of various horizons in the creation of meanings that remains at a descriptive level of
analysis, in that analysis focuses on financial gain, and posits it as the main motivator
for behaviour. Analysis of this nature is clearly at odds with the lived experiences
revealed in this study and the literature arguably serves to further provide an
incomplete explanation of the realities for many overseas nurses and migrants more
broadly, and likely feeds prejudicial interpretation.
A review of literature of a similar nature conducted by Dywili et al. (2013)
analysed articles published between January 2004 and May 2010 in an effort to
examine the reasons why nurses migrate. Although the authors found that there were
complex sets of reasons for migration, such as financial, professional, political, social,
and personal, most of the reviewed literature identified economic gain as the major
driver for nurse migration. In fact, out of the seventeen papers reviewed, sixteen
identified economic factors to be the major motivator for nurse migration. The authors
concluded that although a significant volume of work had examined nurse migration,
none of the seventeen articles specifically explored the actual economic motivations
responsible for the migration of nurses to another country (Dywili et al., 2013). Their
study provides one of the few more in-depth analyses of the motivations for groups
such as Filipino nurses leaving their country, yet failed to identify any explanation in
the literature informing readers of the reasons behind the desire for better
remuneration. Other studies that argue economic motives as the major driver for nurse
migration include Mejia et al. (1979), Kline (2003), Lorenzo et al. (2007), and Alonso-
Garbayo and Maben (2009); however, all share the same inadequacy and a tendency
toward ill-informed assumptions dominated by an ignorance of social and cultural
precursors or drivers. Current literature does not fully reflect the realities of Filipino
nurse migration, their intentions to migrate, the lived experience of nurses, or the ways
that living out Filipino-ness and family values creates inter-connectedness and bonds.
One study outside of nursing that did strive to identify the meaning behind
economic motivation, with results similar to this study, was an earlier work by Trager
(1984), who explained that familial reasons were strong motivators for Filipino women
moving to a secondary city in the Northern Philippines. Trager (1984) concluded that
utang na loob played a huge role in Filipino women leaving their provinces to go to a
city. She explained that:
Chapter 6: Discussion and Conclusion 103
…such decisions [to move to a city] are made in a cultural context where there
are strong expectations regarding the obligations of family members to one
another. Relationships of mutual obligation and reciprocity [utang na loob]
are particularly important within the nuclear family… (Trager, 1984, p. 1274).
The only other study of a similar nature was undertaken by Limpangog (2013),
who interviewed 20 professional Filipino women who migrated to Melbourne,
Australia and wrote that “the family was motivator and facilitator in the informants’
migration” (p. 313-314). The studies completed by Trager (1984) and Limpangong
(2013) affirm the lived experiences of the participants in this study and further
emphasise the need for future researchers to be culturally informed when researching
and explaining influences behind Filipino experiences of migration.
6.3.2 The ‘economic migrant’ label: a deeply rooted prejudice
An economic migrant is someone who chooses to move to another country or
region, to improve their standard of living through better paid employment (United
Nations High Commissioner for Refugees, 2016). The label commonly implies that
the workers are “unskilled and semi-skilled individuals from impoverished countries
in the global south [including the Philippines]…” (Semmelroggen, 2015, para. 9). A
study conducted by Larsen et al. (2005) of internationally educated nurses (IENs) in
the United Kingdom (UK) revealed that people living in the UK have different life
perspectives and foci and perceive IENs as “‘economic migrants’ who are ‘here [in the
UK] just for the money’” (Larsen, 2007; Larsen et al., 2005; Lipley, 2004). Local
people in the UK often claim that their migration is more closely linked to the status
of refugee, since they come from poor and underdeveloped countries (Larsen, 2007;
Larsen et al., 2005). In fact, IENs are often linked to low income backgrounds and
developing countries and are labelled economic migrants (Lorenzo et al., 2007).
Scholars have previously argued that the economic migrant label reflects a deeply
rooted prejudice which:
…frequently implies that the migrant has freely decided to move with the only
aim of improving their financial situation, in other words for ‘personal
convenience’. At worst, it is suggested, with a xenophobic twist, that
‘economic migrants’ move to ‘steal’ the jobs and social benefits of their
destination’s population (Althaus, 2016, para.5).
104 Chapter 6: Discussion and Conclusion
As a consequence, the label has a negative impact on overseas nurses, as they
can often feel devalued and discriminated against (Larsen et al., 2005; Lipley, 2004).
Importantly, Professor Alexander Betts, Director of the Refugee Studies Centre at
Oxford University, recently warned that inappropriate labels such as economic migrant
“convey[s] an exaggerated sense of threat [and] can fuel anti-immigration sentiment
and a climate of intolerance and xenophobia” (Taylor, 2015, para.2). Alarmingly, and
in support of the prejudicial nature of the label, Lee (2004) pointed out that if a UK
trained nurse migrates to another country for a better salary, they are labelled expats,
but if an RN from a poorer country, such as the Philippines, migrates for the same
reason, they are labelled economic migrants. Migrants consequently often have to live
with all of the negative perceptions associated with the term, such as “you are here
only for the money” (Lee, 2004). These differences in language highlight a clear
paradox in which interpretation of working status is based on racial and economic
backgrounds, seemingly superficial interpretations, and understanding of the
motivations for migration, and ultimately a probable furthering of discriminatory
opinion fed by deep seated suspicion and prejudice.
The findings from this study demonstrate that inconsistency in perception is
probably due to a lack of understanding and awareness of socio-cultural differences,
quite apart from a tendency toward discrimination in many countries. What is created
are unnecessary descriptive labels and prejudices that do not lead to holistic knowledge
of the phenomenon. To really understand what it means to be, or what motivates one
to make a decision to leave family and country, is to also understand the meaning of
such experiences as they relate to the person’s cultural and social context(s). For
participants in this study, family inter-connectedness is a Filipino value that dictates
decisions to migrate and leave family; the intention behind the decision to apply for
overseas migration did relate to a desire for better salary, but was also fundamentally
driven by the products of living out familial values; it was less about individual gain
than about communal betterment. To simply label such actions and behaviours as
economic negates the real and present motives behind such experiences. Studies that
focus solely on economic gain negatively influence public perception about migration,
and have the potential to cultivate prejudicial reaction. This study clearly shows that
desire to migrate was not purely economic, although participants expressed a desire
for better remuneration. The study demonstrates that the economic migrant label is an
Chapter 6: Discussion and Conclusion 105
inappropriate and inadequate explanation applied to migrants from the Philippines and
should not be used in arguments and discussions about Filipino nurse migration.
6.3.3 Remitting money as a lived experience
Intertwined with the desire to help family after migration is the intention to send
money home. For each nurse in this study, remittances, which are “transfers of money
from residents of one country to residents of another country” (Vargas-Silva, 2013,
para.1), were expressions of helping family and giving back. The act of remitting not
only had an economic influence but also significant socio-cultural value. Remittances
from overseas Filipino migrants, including those working as nurses, is an economic
lifesaver for the Philippines (Salvosa, 2015a). In 2014, remittances from Filipino
migrants was $24.3 billion US dollars, which accounted for one tenth of the gross
domestic product of the Philippine economy (Salvosa, 2015a). Discussion and debate
about remittances have identified it as one of the major benefits of migration (Piracha
& Saraogi, 2011), and has attracted attention from academics, policy makers, and
financial industries (Trager, 2005, p. 22). Various studies have concentrated on the
effects of remittances from an economic perspective, including reports issued by the
Asian Development Bank (2009) and scholarly studies such as Quisumbing and
McNiven (2013). Research has explored the economic impact of remittances on
reduction of poverty, housing, and consumer power within remittance-receiving
households.
Trager (2005) studied the motivation of migrants from different parts of the
world and their act of remitting money, and argued that:
…in the Philippines…[remittances] need to be considered in a cultural context
that places high value on reciprocal obligations [utang na loob] that are
expressed through both symbolic gifts and giving of necessities, including
money (p.26).
The Filipino migrant who is sending money is expressing “a manifestation of
utang na loob…” (Mansalay, 2014, para.4). The motivation to remit money to their
families is part of “family obligation [that] begins early on when children are
conditioned to be grateful to their parents for their birth” (Wright, 2013); and
importantly, they do not feel obligated to repay parents, but rather they feel bound to
illustrate feelings of gratitude through remitting (Mansalay, 2014).
106 Chapter 6: Discussion and Conclusion
As part of living out utang na loob as a lived experience, and establishing an
inter-connectedness with family, participants believed they were intending to live out
an expression of an inherent moral value, enacted through their willingness to send
money to their family in their home country upon migration. They anticipated the
remitted money would act as a strong symbol of linkage and affiliation that would be
capable of building a geographic bridge and maintenance of feelings and connection
to family and significant others. Experiences appeared to originate from simply “being
Filipino” and a shared desire to live out values essential to the maintenance of Filipino-
ness. Desire and willingness to remit was a symbol of inter-relationship with family
that would be unbroken despite geographic distance. Indeed, remittances “are the most
tangible evidence that migrants do not break ties with their countries or communities
of origin even as they migrate” (Katigbak, 2015, p 521). and the phenomenon not only
constitutes an economic intention, but has largely a socio-cultural distinctiveness. For
Filipinos, remitting money is an overall expression of their dasein, and meanings
associated with such behaviours are driven largely by notions of living a Filipino life.
It should be noted that recent discussions in some countries (US and Saudi
Arabia) that focus solely on the economic nature of the practice have been occurring,
and relate to proposals to tax remittances of any person sending money to another
country. In fact, there have recently been proposals in Gulf Cooperation Council
(GCC) countries to legalise remittance taxes. The reason for this is that policy makers
in these countries believe that:
…remittance outflows are seen as leakages of money that could be otherwise
circulated and invested in the domestic economy. Therefore, large remittance
outflows prompted the GCC governments to seriously consider introducing
taxes on money transfers (Malit, Jr. & Naufal, 2016, p.4).
Saudi Arabia is one of the top destinations for Filipino nurses wanting to work
overseas (Lorenzo et al., 2007), and if these policies are implemented in the GCC,
many Filipino nurses in Saudi Arabia would be affected. Article 27 of the Universal
Declaration of Human Rights (Claiming Human Rights, 2016) acknowledges the right
of individual to freely “participate in the cultural life of the community”, whilst Article
27 of International Covenant on Civil and Political Rights (1966) states that
“persons…should not be denied the right…to enjoy their own culture…”, and the right
to express and practice cultural beliefs. As demonstrated in this research, remittances
Chapter 6: Discussion and Conclusion 107
are expressions of Filipino cultural identity and lived experience, and one of the core
values associated with the practice is maintaining family ties and relationships; it’s
about living a full expression of one’s Filipino-ness. If helping family by sending
remittances was limited by the laws of destination countries, such as imposing
remittance taxes or restrictions on amounts of money, this in itself would be a
restriction on cultural identity. Net financial resources are generally considered “take
home pay”, and are generally free to be used as seen fit by a worker. This study
challenges such future actions and suggests discussions should concentrate less on the
economic advantage of taxing remittances, than the importance of individual freedom
and the importance of such behaviour for socio-cultural identity. The human rights of
Filipino nurse migrants are important and exist through financial expressions of
affiliation, cultural values, and living a life defined as being Filipino.
6.4 MIGRATION AS LIVING A LIFE THAT IS AUTHENTICALLY FILIPINO
For each participant in this study, migrating overseas was about living an
authentic Filipino life. Being “authentically Filipino” was about being able to live a
life expressed in terms of their Filipino-ness; expressing their socio-cultural heritage,
living out shared values, remaining linked to family, and being able to achieve a degree
of self-determination. Anticipating working overseas as a nurse was experienced in
terms of hoping for a life of freedom and liberation informed by a life defined by
Philippine socio-cultural values but amended by what they hoped migration would
bring. Their lived experience was one of anticipating some degree of liberation in
which they would become more able to be self-determined in their life choices, whilst
continuing to live out their Filipino-ness. Experiencing these outcomes was expressed
as being an ‘authentic Filipino’. It is an expression of dasein that traverses
geographical boundaries and is part of identity. Migration was, for this group of
people, neither a changing nor relinquishing of being Filipino, but an expression of a
continuing way of being despite relocation to another country. They would take their
affiliations with them, continue to further strong association in their home country, but
take the opportunity to decide for themselves what their life in their new country would
become. Their past and present, as expressed in social values and commitment to
significant others, would inform their lived experience, and be part of their future.
108 Chapter 6: Discussion and Conclusion
For participants, living an authentic Filipino life was about the ability to pursue
what they personally wished for themselves (self-determination) but still remain
culturally linked to their family and past. Participants did not intend to forget the
cultural values they embraced growing up in the Philippines. They envisioned a
continuum in which their lived experience would be dictated strongly by their Filipino-
ness. Moses (2000) explained that:
…authenticity… is defined…as a state of being within which one has the
ability to act in keeping with one’s true self, that is, to make uncoerced choices
and to feel public affirmation of one’s personal identity, of which one’s
cultural identity is a central part (p.297).
Moses (2000) argued that authentic living is a product of two identities: personal
and cultural. Personal identity is a result of “inner reflection” of who you truly are, the
values you treasure and beliefs that matter to you personally, whilst cultural identity is
a result of one’s personal relationship with others. She explained that in authentic
living an individual should “need to feel a sense of authenticity in making choices that
allows them to be true to themselves, to both their personal and cultural identities”
(Moses, 2000, p. 297).
Self for participants was defined by their family or community despite physical
distance. Participants intended to maintain relationships with family and/or their
community upon migration, and had no intention of breaking ties despite the distance
between them. Participants would carry their Filipino cultural identity with them,
because their being-in-the-world cannot be detached from ‘self’ to its ‘world’. For
participants, ‘being-in-the-world’ was envisioned as self as part of family and their
community and this had to remain if they were to live a life defined as being authentic.
Authenticity for people living in Western cultures concentrates on both personal
identity and self-fidelity. The former is about “being or remaining oneself”, whilst the
latter is “being true to oneself” (Kristinsson, 2007). These two concepts are believed
to be inter-connected; when someone remains true to what he or she really is, and the
things he or she wants to achieve and pursue in life without the opinion or influence
of others, he or she is being authentic to him or herself. C. Taylor (1992) defined
authentic living in a Western context as:
Chapter 6: Discussion and Conclusion 109
… being true to my own originality, which is something only I can articulate
and discover. In articulating it, I am also defining myself. I am realising a
potentiality that is properly my own (p.7).
Being authentic in Western societies is often about avoiding social conformism
(Kristinsson, 2007, p.2). For someone to be original and to be living an authentic life,
one has to avoid public opinion of oneself and not live only by the expectations of
others. Many modern philosophers (such as Andre Gide, Velleman, and romantic
thinkers like Herder and Humboldt) regard this definition to be what is meant by living
authentically in Western society (as cited in Kristinsson, 2007). These philosophers
insist that central to living an authentic life is the:
…value of individuals’ conducting themselves based on their own substantive
beliefs, desires, emotions, and ideas, rather than dismissing or repressing them
in favour of what they think is acceptable to others (Kristinsson, 2007, p.4).
This way of thinking is reflected in Western cultures, which focus on
individualistic pursuits, such as values of autonomy and independence, and is very
different to the authentic Filipino experience.
6.4.1 The authentic Filipino life
Living an authentic Filipino life has been a focus of many studies, especially
those that have looked at the integration of Filipino migrants into a new country. A
study by Tibe-Bonifacio (2003) examining the meaning of Australian citizenship for
migrant Filipino women revealed that women were able to live a dual identity: Filipino
and Australian. Filipino women tended to retain their Filipino-ness, yet were
committed to being Australian. According to Tibe-Bonifacio’s (2003) study, being
Filipino was expressed in terms of maintaining linkage and ties with family in the
Philippines. Participants were able to maintain family ties through sending
remittances, maintaining communication through telephone contact, and periodic
visits. The author further clarified that for her participants, “…the continued financial
support is not designed to achieve national objectives but to help their families left
behind” (Tibe-Bonifacio, 2003, p. 223).
One of her participants explained that “I help many people in the Philippines. I
am supporting two people in my family [to] finish their college education”, whilst
another clarified that helping family was deeply rooted in her sense of being Filipino,
110 Chapter 6: Discussion and Conclusion
noting that “I am still a Filipino. My roots” (Tibe-Bonifacio, 2003, p.224). For
Filipinos, family is their primary identification; hence, anticipation of living in a
different location does not reduce the idea that one can still live out their Filipino-ness.
On the other hand, being Australian was described as an affirmation of their loyalty to
Australia, but not fully to the Australian culture. One participant described this identity
as, “Knowing my rights as a[n Australian] citizen and doing my obligations… It’s not
just accessing your rights but what are your rights, as well, as a citizen. What can you
contribute to the community?” (Tibe-Bonifacio, 2003, p. 229).
For Filipino women, Australian citizenship and identity “operates in terms of
identification with the Australian state while their Filipino identity is oriented towards
an ‘imagined’ belonging to the Philippine nation” (Tibe-Bonifacio, 2003, p. 229). The
author concluded that these two identities are not conflicting and can co-exist, as
shown by the experiences of Filipino women who had migrated to Australia (Tibe-
Bonifacio, 2003). There is an acknowledgment of someone’s past acquired values and
the carrying out of these values to the country of destination. The fusion of time
horizons did not force giving up of one’s cultural identity, but rather the creation of a
new space for continuation of Filipino-ness in a different context; it was about
allowing their potential to integrate with values of their country of destination (e.g.,
Australian values, particularly those incorporated by laws).
The Tibe-Bonifacio (2003) study aligned with the expectations of the
participants in this study, in that they believed they would be able to maintain their
cultural identity, express their socio-cultural values as Filipinos, and maintain family
inter-connectedness whilst residing overseas. What is especially interesting about
Tibe-Bonifacio’s (2003) study is that the process was occurring in Australia, a
democratic, Western, and largely individualistic society. The co-existence of both
identities (Filipino and Australian), is grounded in two very different social and
cultural contexts, yet was comparable to living authentic Filipino-ness.
The expectations of participants were also consistent with the findings of a study
by Molina (2012), who explored the transition process and the acculturation of recently
arrived Filipino immigrants in the United States. She found that “Immigrants’ cultural
values and beliefs were not replaced by those of the mainstream…” (p.iii). Core values
distinct to Filipinos also do not disappear and Molina (2002) concluded that:
Chapter 6: Discussion and Conclusion 111
…the core cultural values that interviewees described like the importance of
family and respect did not appear to diminish with increasing time since
migration. Yet retaining these values also did not tend to hinder people’s
ability to acclimate to life in the U.S. (p.iii).
Values distinct to being Filipino, such as utang na loob and close family ties,
need not be compromised, even as a result of migration (Molina, 2002. p. 82).
Similarly, Bhugra (2004) noted that “when participants migrate, they don’t leave their
beliefs… no matter what the circumstances of their migration” and argued that when
people migrate, they carry their identity with them (p. 134). After all, as Tibe-
Bonifacio (2003) confirmed, “becoming an Australian citizen does not negate one’s
identity as a Filipino”, and that both can co-exist without the need to relinquish
someone’s natural culture (p. 221). Evidence affirms, and as expected by participants
in this study, that the integration of themselves as Filipino nurses in another country
need not strip away their Filipino identity. Living a Filipino life as central to their life
journeys and individuality is likely to be expressed as planned as it is the core of who
they are as people.
In a study of the experiences of Filipino seafarers, Lamvik (2002) went even
further and argued that it was evident within the life journey of seafarers that:
…at a more fundamental level, [they] never actually leave their families. They
constantly see themselves as delegates from their kin back home, and during
their contract period on board, they put a lot of effort into upholding this
orientation (p. 3).
Lamvik (2002) described the Filipino seafarers as constantly trying to re-connect
with their family back home through letters, telephone calls, and purchasing gifts
(pasalubong). Filipino seafarers re-connected through finding foreign items that were
reminders of their loved ones and seafarers carried these items with them on board
until they finally arrived home. Moreover, gifts were reminders of the reasons why
they have left their family in the first place. Filipinos make sense of “being” through
the context of who they are within their family. Therefore, for Filipinos to authentically
live life as who they are requires the ability to maintain the practices of their Filipino-
ness, whilst not neglecting to embrace the laws and values of their destination country.
In Western countries, such as Australia and the USA, this goal is possible. A
democracy such as Australia or USA gives hope to Filipino nurses who look forward
112 Chapter 6: Discussion and Conclusion
to a self-determining life upon migration, while at the same time not stripping away
the essence of who they are as Filipinos.
6.4.2 Misperceptions towards immigrants’ identity: A cultural blind spot
The experiences of participants in this study challenge commonplace arguments
and misperceptions about immigrants, their identity, and their integration into new
societies. In an American national survey conducted by CNN/Opinion Research
Corporation (2010), “two thirds of whites say that immigrants should give up some
important aspects of their culture to blend in; only about 4 in then Hispanics, and an
equal number of blacks, agree with that view” (para. 5). The result is similar to the
survey of the Saulwick poll conducted in Australia in 1994, which revealed that, “61
percent of respondents [Australians] felt that migrants ‘should live like the majority’”
(Holton, 1997). Additionally, Markus (2011) analysed various surveys that
investigated the perceptions and expectations of the Australian public toward migrant
integration into Australia (such as 2003 International Social Science Program, national
polls in 1994, 1996 and 1997, as well as surveys in Melbourne in 1993, 1998 and 2006)
and revealed that:
… [there was] majority support for the view that immigrants should assimilate
to Australian norms of behaviour at the cost of their own customs – depending
on the wording of the question, around 60-80 per cent are in agreement, with
a few poll findings above 85 per cent (p.96).
These views could mean that for Filipino nurses wanting to work in the US or
Australia, they would have to give up important aspects of their social and cultural
identity, including their values in relation to family inter-connectedness, which would
ultimately be inauthentic to the Filipino’s sense of being. Bhugra and Becker (2005)
noted that:
…if the individual feels isolated from his or her culture, unaccepted by the
‘majority culture’ and has a lack of social support, a consequent sense of
rejection, alienation and poor self-esteem may occur. During the stages of
migration, there may be factors that predispose participants to mental
disorders (p.19).
There are many psychological consequences for nurse migrants as they stake
their own personal values and views against another society. Requiring someone to
give up important aspects of their cultural identity in order to fit in or join the majority
Chapter 6: Discussion and Conclusion 113
culture relies on a significant depth of ignorance, and a failure to understand the
importance of self-identity.
Furthermore, the identity of being Filipino after migration, as demonstrated by
the lived experiences of participants, is to desire the continuation of a life inter-
connected with family. For Filipinos migrating overseas, attraction to communities
that value inter-connectedness and family linkage (e.g., church) eases the way for them
to actuate their goals, and is likely essential to more easily living out their Filipino-
ness. However, people of host countries can view community formation to be socially
and culturally threatening, likely constraining the formation of new national
identity(ies), and communities are often labelled as “ghettos” (Holton, 1997).
Perceptions challenge notions that being a migrant includes carrying values acquired
by past and present experiences that obviously make up someone’s identity. To expect
someone to fully or partially give up important aspects of acquired values is antithesis
to the ideas associated with the fusion of horizons and the relationship of “being” to
its “world” that influences someone’s intention and motivation to migrate.
This study presents the life experiences of Filipino nurses wanting to migrate
overseas who look forward to continuing a life of inter-connectedness with family and
the Filipino community in their destination country, because this is genuinely who they
are as people. Their identity includes the desire to be connected and part of a family
and community that shares the same history. Fear of people within host countries likely
originates from misperceptions about what it means to be Filipino and a lack of
understanding about their culture. People within host countries have expressed views
that Filipino nurses form ‘ghettos’ that are socially exclusive. For example, in
Australia, many believed that:
Asians [including Filipinos] are socially exclusive and culturally alien. Such
sentiments are typified in Pauline Hanson's first Parliamentary speech in
which she argued that Asians 'have their own culture and religion, form
ghettoes, and do not assimilate’ (Holton, 1997).
This is not the experience nor evidence presented through completion of this
research study. It has been demonstrated that inter-connectedness is central to being
Filipino and their identity. This finding is supported by other studies conducted in
Australia, such as Limpangog (2013), concludes that individuals go beyond identity
and do not seek to hinder integration of their Filipino-ness into Australian society. For
114 Chapter 6: Discussion and Conclusion
Filipino nurses, wanting to feel connected within a community that values family and
social linkages is not a prohibition to social cohesiveness and integration. One can be
Australian but still maintain Filipino values.
Misperceptions about identity persist across literature and represent a probable
failure of awareness and a cultural blind spot. ‘Cultural blind spot’ is the way we
interpret someone’s behaviour, actions, or beliefs using only our own personal
experiences and culture, without understanding the socio-cultural aspects of the other.
Potgieter (2011) explained that “our cultures, upbringing, environments,
circumstances and life experience all impact on our perceptions, prejudices and
attitudes…” (p.38), including how scholars and people view immigrants. These
migrant misperceptions based on their cultural unawareness or lack of acquaintance
with other people’s culture(s), are consistent with Heidegger’s view about being and
the fundamental elements of dasein (being) which “is grounded in the aspect of time
(past, present, future)…” (Blattner, 2005, p. 312). A person’s identity is influenced by
his or her past experiences. People who have rarely lived or worked with Filipinos, or
are not acquainted with Filipino culture and their values, often interpret Filipino nurse
experiences using their own personal beliefs, which leads to distorted meaning. It is
essential that scholarly studies on global nurse migration, particularly in regards to
Filipinos, are informed by understanding and awareness of the participant’s socio-
cultural conditions. This will help to reduce personal cultural blind spots that create
misinformed conclusions about the experiences of others and the broader migration
experience.
6.5 REFLECTIONS ON THE RESEARCH
6.5.1 Limitations of the research
Heideggerian phenomenological research is an in-depth investigation of the
individual experience of a particular phenomenon and the methods afford smaller
sample sizes than empirical studies. A common argument put forth by empirical
researchers is that the sample size adopted is too small, making it difficult for
phenomenological findings to be generalisable to other sub-populations or variances
of groups. Whilst this is a sound argument, it is never the intent of the approach, as
phenomenology aims not to exhaust all variances within population, but rather to
Chapter 6: Discussion and Conclusion 115
investigate, in a deep sense, the meanings of groups of people experiencing a
phenomenon in order to produce a coherent understanding.
Additionally, all participants in this study were female. Including Filipino male
nurses may have provided more enriching meanings of experiences about intentions
to migrate overseas. Researcher had attempted to locate male nurses during
recruitment, but failed to do so. Although there are male nurses in the Philippines,
nursing is still dominated by women. Despite this, participants were able to provide
sufficient experiential accounts necessary in answering the research question.
6.5.2 Potential researcher bias
Although the acknowledgement of the researcher’s bias in interpreting
participants’ experiences is considered vital in Heideggerian phenomenology, the
nature of this qualitative study posed a risk that the researcher would embed his pre-
conceived ideas about the phenomenon. This risk was minimised by personal
reflection, supervisory input, and supporting explanations with participant data (as
outlined in Chapter 4, section 4.10). By presenting the outcomes in this manner, the
readers can assess the integrity and validity of the arguments/ideas/themes presented
based on what participants expressed in their interviews, and as presented in this thesis.
6.5.3 Recommendations for future research
Further studies, particularly in relation to Filipino nurses, are required to inform
knowledge about the migration of nurses. Nurse migration policies, both in the
Philippines and receiving countries, need to be revisited and incorporate the findings
of this study, particularly informed by understanding the motivations of emigrating
nurses and how best to assist them. The implementation of pre-migration seminars for
each Filipino nurse emigrant should be re-evaluated to incorporate the values of family
orientation, as well as support for people with their identity when overseas.
6.5.4 Contribution of this research
This study presents a new perspective on Filipino nurse migration that has been
neglected in the literature. It provides meaning about the experience of potential
Filipino nurse migrants and is oriented and explicated from a Filipino socio-cultural
perspective. It focuses on the life experiences of a group of nurses and the findings
challenge current nurse migration literature and demonstrate that Filipino nurse
emigrants are human beings driven by a strong orientation toward family and
116 Chapter 6: Discussion and Conclusion
community that involves more than just economics. This study shows the human side
of the phenomenon and deservingly warrants attention.
References 117
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Appendices 139
Appendices
Appendix A: QUT Human Ethics Approval Certificate
University Human Research Ethics CommitteeHUMAN ETHICS APPROVAL CERTIFICATENHMRC Registered Committee Number EC00171
Date of Issue: 26/4/12 (supersedes all previously issued certificates)
Mr Zenn UrbiDear
A UHREC should clearly communicate its decisions about a research proposal to the researcher and the final decision to approve or reject a proposal should be communicated to the researcher in writing. This Approval Certificate serves as your written notice that the proposal has met the requirements of the National Statement on Research involving Human Participation and has been approved on that basis. You are therefore authorised to commence activities as outlined in your proposal application, subject to any specific and standard conditions detailed in this document.
Within this Approval Certificate are:
* Project Details * Participant Details * Conditions of Approval (Specific and Standard)
Researchers should report to the UHREC, via the Research Ethics Coordinator, events that might affect continued ethical acceptability of the project, including, but not limited to:
(a) serious or unexpected adverse effects on participants; and(b) proposed significant changes in the conduct, the participant profile or the risks of the
proposed research.
Further information regarding your ongoing obligations regarding human based research can be found via the Research Ethics website http://www.research.qut.edu.au/ethics/ or by contacting the Research Ethics Coordinator on 07 3138 2091 or [email protected]
If any details within this Approval Certificate are incorrect please advise the Research Ethics Unit within 10 days of receipt of this certificate.
Project Details
Category of Approval:
Approved From: 24/04/2015
Approval Number: 1200000127
Human non-HREC
Project Title:
Approved Until:24/04/2012 (subject to annual reports)
The lived experience of Filipino registered nurses working in Manila, Philippines seeking to emigrate overseas
Experiment Summary: Understand the lived experience of Filipino Registered Nurses who are seeking overseas employment.
Chief Investigator: Mr Zenn Urbi
Investigator Details
Other Staff/Students:Investigator Name Type RoleDr Alan Barnard Internal Supervisor
Dr Yvonne Osborne Internal Supervisor
Participant Details
Participants:Approximately 4-6
Location/s of the Work:Makati Medical Center, Makati, Philippines
RM Report No. E801 Version 4 Page 1 of 2
140 Appendices
Appendices 141
Appendix B: Approval Letter from Makati Medical Center
142 Appendices
Appendix C: Recruitment Flyer
Appendices 143
Appendix D: Participant Information and Consent Form