When Dr Teresita Barcelo’s nursing classmates have their reunions they choose Las Vegas or New York. With 90 per cent of the former Philippine Nursing Association president’s class living in the States, they argue it just makes sense.

The Philippines is a country whose economy has long been bolstered by an estimated 10 million of the 100-million-plus Filipinos living and working abroad sending money home to their loved ones – around US$2.5 billion a month.

Filipino nurses began arriving in New Zealand in increasing numbers towards the end of the last decade, helped by a major glut of Filipino nursing degree graduates unable to find work in the traditional mecca, the US. At the same time, interest from New Zealand’s traditional source of migrant nurses, the UK, dwindled (see Table 3).

Philippine-trained nurses have very quickly become a quarter of New Zealand’s IQN workforce and in 2015 made up six per cent of the total nursing workforce.

In addition, an unknown number of Filipino nurses, without New Zealand registration, are bolstering the caregiver workforce in the residential aged care and home care sectors.

Call centres staffed by unemployed nurses

That person politely answering your query about a phone account or mobile plan may well be a nurse.

Call centres in the Philippines are one of the biggest employers of nursing graduates unable to get nursing jobs either in the Philippines or abroad.

The exact number of unemployed nurses in the Philippines is unknown but the Alliance of Health Workers union and others have estimated that a glut of up to a staggering 200,000 nursing graduates have been unable to find nursing work in recent years.

Most of these underemployed nurses graduated in the midst of a nursing school boom that started last decade when they enrolled with the dream of well-paid nursing jobs in the US – like their cousins or aunts – but ended up instead working in call centres, health spas and department stores.

Dr Cora Anonuevo, a retired nursing professor and a current member of the Philippine Board of Nursing (the equivalent of the Nursing Council of New Zealand) says that nursing education in the Philippines is unfortunately market driven. The upsurge in demand for places in the first decade of the new millennium saw nursing schools mushrooming from around 300 turning out 20,000–30,000 graduates a year to about 500 schools in 2010 producing around 80,000-plus graduates a year.

To put this in proportion, Anonuevo says the Board of Nursing estimates that currently there are about 186,000 actively practising registered nurses in the Philippines; a further 280,000 Philippine-trained nurses are believed to be working abroad. Getting a clear picture of how many licensed, i.e. registered, nurses are actually nursing in the Philippines is difficult. Until this year – in a similar manner to New Zealand before the Health Practitioner Competence Assurance Act came into force in 2004 – nurses could renew their professional identification card without actively practising as a nurse at the time. (The PIC is the equivalent of New Zealand’s annual practicing certificate and nurses can’t practice with out it).

Dr Teresita Barcelo, a nursing professor as well as former president (from 2009 to 2011) of the 60,000-strong Philippine Nurse Association (PNA), says such a rapid expansion in nursing schools could not be matched by an equal increase in hospital training places and nursing academics so, obviously, some students were at schools that were not of a high standard.

Most of those schools are probably closed now. Demand tumbled when it became clear overseas job opportunities couldn’t absorb the number of inexperienced graduates swamping the market – due partly to the global recession and the tightened US immigration rules – and the glut could not be absorbed locally.

Anonuevo says that stricter monitoring has also seen the number of approved nursing schools drop to just 305 in 2016.

The number of graduates sitting the board’s twice-yearly Nurse Licensure Examination also shrank from more than 40,000 candidates each exam session a few years ago to just 14,600 sitting in November 2016. And around 40 per cent of these are repeat candidates.

“Silent’ policy to export nurses

University of the Philippines nursing students.

In the past, sitting the nursing licensure exam was often just a stepping stone towards the ultimate goal of passing NCLEX (the National Council Licensing Examination) and becoming licensed to nurse in the US or Canada.

The nursing curriculum of the former American colony has long been influenced by the NCLEX goal and, Barcelo says, the government has a ‘silent policy’ of encouraging nurses to migrate.

With well-paid overseas jobs not forthcoming for the inexperienced ‘boom’ graduates the government in 2011 responded by working with the Board of Nursing and PNA to give some nursing experience by sending them out to work in poor and remote communities around the country.

In the first year about 10,000 unemployed nurses were hired under the RN Heals (Registered Nurses for Health Enhancement and Local Service) programme. This year the programme, now known as the Nurse Deployment Project, is employing around 15,000 nurses on limited one- to two-year community contracts.

Having two years’ nursing experience is one of the minimum requirements for IQNs wanting to register in New Zealand. Desperate to find work, some graduates come anyway, often as students, and end up working as caregivers or healthcare assistants in our residential aged care and home care sector (see related article in online version). Experienced Filipino nurses are also boosting our HCA and caregiver numbers.

In return, New Zealand gains a low-paid, highly qualified workforce caring for its elderly. Positive stereotypes usually abound when you ask Kiwis about Filipino nurses and caregivers.

But working in residential aged care is not what these nurses with four-year university degrees trained for.

Love of God, people and country

Rest homes are very rare in a family-centred culture such as the Philippines.

“In the Philippines you are looked down on if you don’t care for your parents,” says Barcelo. This strong belief in family values, she believes, is one of the reasons that Filipino nurses are so appreciated in aged care.

The national education standards for the four-year nursing degree also state clearly that caring is the ‘core of nursing’ and should be emphasised in the curriculum, along with the other core values of “love of God, love of people and love of country”.

Anonuevo believes putting such values at the core of Philippine nursing education is part of what has made Filipino nurses – apart from their being English-speaking – so attractive to the world market.

“We are into details – our hospitality, our cultural sensitivity and our caring – these are the characteristics of the Filipino nurses as described by others.”

Dr Lourdes Marie Tejero, Dean of the University of the Philippines (UP) College of Nursing points out that there is an atheist society at her university, but agrees that a love of God is a core value that influences the caring culture in a country that is 80 per cent Catholic (and most of the remaining 20 per cent are other Christian denominations or Muslim).

But all the nursing leaders spoken to also stress that the Filipino nursing workforce is about more than just being good at the soft skills of caring. Since the 1980s all Philippine-trained registered nurses from the long-established schools have undergone a four-year degree programme to ground them in the ‘hard’ skills required to be clinically competent nurses (in the long-established schools anyway – Nursing Review is not sure that these nursing academics are quite so ready to vouch for graduates of fly-by-night schools that have since closed). 

That degree has largely supplied graduates for the US market. Tejero shares an anecdote of meeting a nurse manager of a big New York hospital at an international forum, who told her that half her nurses were Filipinos and they “really like they way they are trained”.

Anonuevo says the Board of Nursing is conscious that a high percentage of graduates will always head abroad but now wants the curriculum to be more relevant to the Philippine health care system and the social determinants of the country. It is also excited about a new Nursing Bill (being re-submitted to senate after being vetoed last year by the former president) that looks to expand the scope of practice and includes definitions for advanced practice nursing as currently there is no framework for accrediting or recognising nurse specialties.

From this year nurses will also be legally required to undergo continuing professional development to be able to renew and maintain their professional identification card.

“Our vision is really to produce nurses who are the best for the Filipino first and (secondly) nurses who are the choice of the world,” says Anonuevo.

Both Barcelo, who has nursed in the US and Germany, and Tejero, who did her post-doctoral study in Sydney, express sadness and some frustration that New Zealand sets so many hoops for Filipino nurses to jump through for registration and that so many end up in the low-paid aged care sector.

Deskilling a skilled workforce?

If Filipino nurses meet the Nursing Council’s English language, educational equivalency and work experience requirements, the final hoop they must jump through is coming to New Zealand to complete and pass a competence assessment programme (CAP).

There are limited places on the six- to eight-week, work-based CAP courses, so most people go on waiting lists for the extra hoop not required by most other countries in which Filipino nurses seek work. The courses are also expensive – with providers charging $6,000 to $8,000 and, in addition, nurses face the cost of airfares, accommodation and food. This is no small amount to a New Zealand nurse, let alone a Filipino nurse, with some earning as little as 12,000 peso (about NZ$350) a month.

“I am saddened by the fact you require us to take a bridging (CAP) course,” says Tejero, who wonders how many years nurses have to work to be able to pay for the course.

She is also unhappy that so many Filipino nurses in New Zealand end up in the lower-paid aged care sector, despite having been experienced theatre or ICU nurses back home. “Let’s give justice to their education,” says Tejero.

This is echoed by Barcelo, who is concerned that experienced Filipino nurses risk being deskilled by being pigeonholed in the aged care sector.

She met with Nursing Council of New Zealand chief executive Carolyn Reed during Reed’s information-gathering visit to the Philippines back in 2009 at the height of the nursing school boom. “My position then, and the position I continue to hold, is that our nurses have the necessary competencies,” says Barcelo.

Barcelo does reluctantly accept the Nursing Council’s right to require a CAP course as an acculturation process for Filipino nurses entering the New Zealand health system, but asks why nurses can’t at least come on a temporary working visa. “If you don’t pass [the CAP] you don’t get a working visa and you have to come home – but you’ve spent so much money.” The other option is to seek a job as a caregiver or HCA.

Barcelo is a little cynical that the economic spin-off for New Zealand of Filipino nurses failing to meet New Zealand’s stringent registration requirements is access to a ‘nursing’ workforce to whom you don’t need to pay a nurse’s salary.

Reed told Nursing Review that with a lot of Filipino nurses working here as registered nurses “obviously they are a very important part of our workforce”. She says the CAP course is asked for as “no one would suggest the practice setting in the Philippines is similar to the practice setting in New Zealand and we have a commitment to the New Zealand public to test those people in our practice setting to see whether they are competent to practice”.

One practice area that some New Zealand nursing leaders in the past have suggested is an issue is Filipino nurses being too respectful of hierarchy.

Barcelo says this is not the fault of the curriculum, which trains nurses to be decision-makers and advocates for their patients. “The disconnect comes in the hospitals – particularly in private hospitals owned by doctors – it’s very difficult to be assertive otherwise you lose your job.” She adds as an aside that that is why nurses like herself had worked in the community, as community health was really the turf of nurses, in which they could take charge.

Tejero says it would also be fair to say that Filipinos are not confrontational as a people. “So we try not to hurt the feelings of others. And if we don’t feel good about something, we don’t shout about it.”

“That is cultural and yes that is a negative trait. But it is not as negative as some cultures where they are so arrogant. I’d rather have a Filipino who cares about how people feel than someone who doesn’t care about how I feel.

And one feeling commonly shared by the Filipino nursing leaders spoken to was that the US – which so many Filipinos already call home – remains a mecca for nurses who are currently looking to the UK, Canada, New Zealand and Australia for work.

So when, inevitably, a global nursing shortage returns and the US opens it doors wider again to Filipino nurses (although probably not under the current president), little old New Zealand may well fall off the map.

Because if the choice for Filipino nurses is between a nursing job in a Californian hospital in a state that is already home to 1.5 million Filipinos, or working as a caregiver or nurse in New Zealand’s residential aged care sector, it’s obvious which choice the majority will make.

And with New Zealand still reliant on overseas nurses for a quarter of its workforce – the majority of these coming from the Philippines – the impact could be major.

Table 4: Student visa applications* approved 2015-16

 Source: Statistics supplied by Immigration New Zealand.

N.B.: Immigration NZ says information does not include visas/residency granted on relationship grounds or other residence policies

* Work and student visa application statistics are for applications approved not individual people. People can have more than one application approved in a year.