THE LIVED EXPERIENCE OF ILIPINO REGISTERED NURSES … · THE LIVED EXPERIENCE OF FILIPINO REGISTERED NURSES SEEKING TO MIGRATE OVERSEAS Berzenn Urbi RN BSN, MAdvPrac A thesis submitted

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

3.2.1 Husserlian phenomenology ................................................................................ 38 3.2.2 Heideggerrian phenomenology .......................................................................... 41

3.3 Reasons for using Heideggerian phenomenology ........................................................ 46 3.4 Summary ....................................................................................................................... 47

Chapter 4: Methods ........................................................................................... 49 4.1 Introduction ................................................................................................................... 49 4.2 Research Method .......................................................................................................... 49 4.3 Recruitment Procedure ................................................................................................. 49 4.4 Participants.................................................................................................................... 50 4.5 Sample Size................................................................................................................... 51 4.6 Data Collection ............................................................................................................. 52 4.7 Transcribing Interviews ................................................................................................ 53 4.8 Data Analysis ................................................................................................................ 53

4.8.1 Hermeneutic circle.............................................................................................. 53 4.8.2 Seven-stage data analysis ................................................................................... 56

4.9 Ethical Considerations .................................................................................................. 58 4.10 Credibility of the Researcher ........................................................................................ 58 4.11 Methodological Rigour ................................................................................................. 60 4.12 Summary ....................................................................................................................... 64

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

5.5 Chapter Summary ......................................................................................................... 89

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

References ............................................................................................................... 117

Appendices .............................................................................................................. 139

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,

Vydelingum, & Robbins, 2006; Gerish & Griffith, 2004; Gonagle, Halloran, &

O’Reilly, 2004; Jose, 2011; Nichols & Campbell, 2010; Tiongco-Cruda, 2008; Smith,

2004, Withers & Snowball, 2003). Studies have often focused on Filipino RNs because

the Philippines is considered the world’s major exporter of nurses (Masselink & Lee,

2013; Ruiz, 2008; Tiongco-Cruda, 2008; WHO, 2007; Yumol, 2009). Recent data

shows that almost one million Filipino RNs are working in over 116 countries

(Castillo, 2015). In fact, in 2003 it was estimated that almost 85 percent of employed

Filipino RNs were working in countries outside the Philippines (Aiken et.al, 2004;

Masselink & Lee, 2013; Prescott, 2016).

2 Chapter 1: Introduction

It is also interesting that despite the overwhelming numbers of Filipino RNs

migrating and working in other countries, very little is known about the experiences

of nurses who were working in the Philippines and prior to their migration (Buchan,

Duffield, & Jordan, 2015). Literature has tended to focus on the experiences and

expectations of Filipino RNs after they have migrated (Nichols & Campbell, 2010;

Tiongco-Cruda, 2008; Yumol, 2009). Likewise, a number of studies have explored the

causes and patterns of migration (Alonso-Garbayo & Maben, 2009), studies have

examined historical factors leading to nurse migration (Brush & Sochalski, 2007), and

the implications of migration for the health care system, including migration patterns

(Lorenzo, Galvez-Tan, Icamina, & Javier, 2007; Perrin, Hagopian, & Huang, 2007).

However, little is understood about the experiences of Filipino RNs prior to their

migration journey and an investigation of this group has not been extensively

undertaken.

Based on these facts, a research study with a focus on pre-migration is an

important contribution to the area, and affords needed development to a well-informed

understanding of Filipino nurse migration. It fills a knowledge gap in the literature and

advances a deeper understanding of the phenomenon in order to more broadly guide

decision makers and those involved in both receiving countries and the Philippines to

better assist nurses. It provides needed insight into the migration journey of Filipino

nurses.

Many academics and scholars who have explored Filipino nurses’ experiences

post migration have concluded that the migration of Filipino nurses is primarily driven

by economics (Alonso-Garbayo & Maben, 2009; International Organization for

Migration [IOM], 2013; Li, Nie, & Li, 2014; Lorenzo et. al, 2007; Tiongco-Cruda,

2008). Studies have tended to explain Filipino nurse migration in terms of economic

benefit; however, the arguments are often limited and ignore the range of intricate

drivers that originate from the socio-cultural background(s) of Filipino RNs.

Examining the experiences of Filipino RNs pre-migration introduces essential

knowledge that situates the experiences of their migration journey within a more

adequate and informed discourse and account of the phenomenon.

This thesis aims to provide greater understanding of the meaning of Filipino

nurses’ intention to seek migration and describes the associated implications of

Filipino nurse movement to their own country’s health care system, particularly its


health workforce. The Philippines continues to suffer greatly from health worker

maldistribution, and there are many health disparities amongst its people that need to

be accommodated by a robust and stronger health care system (Romualdez et al.,

2011). However, despite known challenges of maldistribution and under-resourcing of

Filipino health workers, the Philippines continues to be an active participant in global

nurse migration, sending over 24,000 nurses worldwide on an annual basis (Dabu,

2012; Department of Labor and Employment, 2015). In fact, the Philippines is the only

country in the world to have a nurse export policy, making it known as the leading

donor of nurses worldwide (Brush & Sochalski, 2007; Mendoza, 2015). Reports by

the World Bank (2009) and Blake (2010) demonstrate that for countries such as the

Philippines that send their nurses overseas, nurse migration results in aggravating an

inadequate healthcare workforce, often below the WHO’s recommended minimum

threshold density of 2.5 professional healthcare workers for every 1000 population

(Delucas, 2014). At one level, the active Philippine nurse exportation policy versus

maintaining an adequate healthcare workforce for Filipino citizens remains a

significant dilemma for the Philippine government. However, nurses may not only

migrate due to a government policy. In fact, little is known about the experiences of

Filipino nurses pre-migration, apart from the aforementioned claim that they migrate

for economic gain. Thus, this study seeks evidence to guide this debate.

1.3 PHILIPPINES: A COUNTRY OF EMIGRANTS

The Philippines is one of the leading countries in the world in relation to

population emigration. In 2013, it was estimated that the total number of Filipino

emigrants was around 5.5 million (as shown in Figure 1.1) (Migration Policy Institute,

2016). The Philippines is the eighth highest emigrant country in the world (Migration

Policy Institute, 2016). More disturbing is the fact that in 2012 the Philippine

government estimated their emigrant population (that is the number of people residing

and also working overseas) to be more than 10.5 million (Thomas-Brown & Campos,

2016). The reality is that more and more Filipinos are leaving their country for various

reasons and it is now a country defined by its emigrants.


Adopted from Migration Policy Institute (2016)

Figure 1.1 Total emigrant populations by country, mid-2013 estimates

1.3.1 The rise of an industrialised country

The Philippines is an island country in Southeast Asia and an archipelago

consisting of at least 7,100 islands (Hernandez, 2016). In 2015 it had a population of

over 100 million people (Philippine Statistic Authority, 2016), and in 2012 the

Philippine government estimated that around 10 percent of its population were

emigrants, living and working overseas (Thomas-Brown & Campos, 2016). In 2015

the Philippines was considered the world’s second fastest growing economy after

China (Robinson, 2015), and the country’s gross domestic product (GDP) had reached

$284.8 billion in 2014. This trend has led world economists to consider the Philippines

to be a newly industrialised country (Maung et al., 2014). Agriculture plays the biggest

role in sustaining the economy through rice production and fisheries, which remain the

leading products for Filipino consumption. Mining also contributes to the country’s

export earnings, as does the sector of information technology-business process

outsourcing (Dominguez, 2015). However, it must be noted that the continued


affordance of remittances sent by Filipinos workers living and working overseas takes

a leading and important role in sustaining the Philippine economy and GDP. Recent

reports demonstrate that remittances account for more than 10 percent of the country’s

GDP (WHO, 2011; World Bank, 2016).

Yet, despite this economic improvement, the Philippines continues to have the

highest unemployment rate of all countries in the Southeast Asian region (IOM, 2013;

Salvosa, 2015b). One identified reason for this phenomenon is that job creation is

outpaced by expanding population numbers. The number of people who enter the job

market is greater than the number of jobs created by the government or private

enterprise. Reports have estimated that every year more than one million Filipinos

enter the workforce, which creates an enormously competitive employment market

(IOM, 2013). Other factors that contribute to problems include fewer people actively

looking for employment and a predominance of low quality jobs being created (IOM,

2013; Salvosa, 2015b). People drop out of the employment sector and many fall into

poverty and under-employment in menial positions. These are major problems for the

country and no doubt lead to the reasonable assumption that Filipinos leave their

country to work overseas for economic reasons (Witt & Redding, 2014).

Additionally, health conditions in the Philippines lag behind those of its

neighbouring countries (WHO, 2011). For instance, the Philippines’ infant mortality

rate during 2005-2010 was 23%, whilst Brunei, Malaysia, Singapore, Thailand, and

Vietnam’s mortality rates were 5%, 5%, 2%, 12%, and 16%, respectively (Jones,

2013). Additionally, the maternal mortality ratio per 100,000 live births in the

Philippines was 99, whilst in Vietnam, Thailand, Malaysia, Brunei, and Singapore it

was 59, 48, 29, 24, and 3, respectively (Jones, 2013; WHO, 2012). Although the

country has managed to improve health care delivery to its people for the last four

decades (WHO, 2011), health inequities still mar the Philippine health system. There

are major problems associated with variable health access, particularly for the poor.

There are high costs and ongoing inefficiencies in health service delivery and a chronic

inadequate supply of health workers in rural areas (WHO, 2011). As a result, the total

health status of Filipinos has not changed dramatically over recent years, and key

health status indicators, such as infant mortality rate and life expectancy, continue to

lag behind those of other Southeast Asian countries (Ronquillo, Elegado-Lorenzo, &

Nodora, 2005).


The migration of health workers, including nurses, has likely contributed to the

health status of the country (Battistella & Liao, 2013). Inexperienced and novice nurses

take specialised roles due to nurse migration, which results in reducing the quality of

the Philippine health care workforce and service delivery (Lorenzo et al., 2007). Senior

and specialised nurses tend to leave the country for overseas work, as they are what

overseas employers are looking for (Lorenzo et al., 2007). Although this trend has not

been extensively and concretely validated, scholars are convinced that Filipino nurse

migration is negatively affecting the Philippine health system (Battistella & Liao,

2013).

The Philippines has now moved from being the ‘sick man of Asia’ to a

developing country (Dominguez, 2015), and yet along the journey there is no doubt

that although it is a rising industrialised country, it has a long way to go to solve

problems of unemployment and quality health care for its people.

1.3.2 Philippine culture of migration

Due to a recent history of colonialism under both Spanish and then USA rule,

the Philippines’ historical richness is strongly tied to these two countries. The origins

of an increasing flow of migrant workers to overseas destinations can be traced back

to the Spanish era around the 16th century when many Filipino men worked in the

galleon ships of the Manila-Acapulco trade (IOM, 2013; Orbeta & Abrigo, 2009;

Samonte & Centre for Indian Development Studies, 1995). More recently, during the

American regime, there were notable movements of Filipinos to America, especially

farmers who left the country to work on Hawaii’s sugar plantations (IOM, 2013;

Orbeta & Abrigo, 2009). However, numbers really increased rapidly when overseas

employment was formally facilitated through the 1974 Philippine Labor Code due to

the country’s declining economy in the 1970s (IOM, 2013; O’Neil, 2004; Sills &

Chowthi, 2008). The code framed the beginning of an even larger emigration of

Filipinos (IOM, 2013) and labour migration was initially encouraged to temporarily

help ease the increasing unemployment in the country during President Marcos’

regime. However, despite changes to governance and colonialism, succeeding

administrations in the Philippines have viewed migration as economically strategic;

and thus, have continued its promotion and facilitation up to this time (IOM, 2013).

History has demonstrated a ‘culture of migration’ among Filipinos, which

remains strongly present today. Scholars of Philippine migration often discuss


Filipinos’ culture of migration as a social fact (Aguilar, 2009), or more importantly, as

a way of life (Sills & Chowthi, 2008). It has often been viewed as the main vehicle to

achieve a good or a better life (IOM, 2013). A 2015 survey conducted by universities

in the Philippines revealed that 74.3% of first year university students aspired to gain

a job overseas after completion of their college degree (Rappler, 2015). Filipinos

accept the premise that moving overseas will improve the conditions of their lives and

that of their families.

This culture of migration is widespread in the country. Filipino parent(s) migrate

to improve the lives of their family, as do their children. Parents migrate in a desire to

improve the future of their children, whilst children migrate to provide a comfortable

life for their parents. Migration often increases when one family member or relative

has migrated and has successfully achieved their goals. An aspirational linkage is

created and aspirants try migrating in the hope of achieving similar outcomes.

Successful migrants therefore tend to influence people from their communities who

also then tend to embrace migration as a pathway to improving the conditions of their

family. Clearly, there is a resultant spillover effect that arises from such success (IOM,

2013).

Aside from familial networks, institutions in the country also entice Filipinos to

migrate overseas. Educational institutions, particularly privately-owned colleges, have

increasingly adapted curriculum and educational programs to meet in-demand

overseas jobs, and advertise overseas employment to their graduates. For instance,

during the mid-2000s, nurses were in demand overseas, and a large number of colleges

offered nursing degrees, peaking at 491 by 2004 (Lorenzo et. al, 2007; WHO, 2013a).

Educational providers attracted a lot of enrolments, many of whom sadly ended up

unemployed after the global economic crisis in 2008 (IOM, 2013).

Undeniably, there is societal acceptance and encouragement for Filipinos to

leave their country. Social acceptance and migration policies combined with bilateral

migration agreements with Japan, Germany, and the UK are evidence of the Philippine

government’s complicity in its citizens seeking overseas migration (Galam, 2015).

Filipino nurses embody the Philippine culture of migration, which is arguably now in

the DNA of Filipinos (IOM, 2013).


1.4 PHILIPPINE NURSING EMPLOYMENT

The Philippines has an over-saturation of trained nurses (Department of Health,

2005; Lorenzo et al., 2007). Although reports sometimes conflict (Clark, Stewart, &

Clark, 2006), the fact is, many Filipino RNs are unemployed, and as a result, there is

a nursing pool that is defined as nurses who have graduated and are registered to

practice but are not formally employed (Mateo, 2011). Gaining nursing employment

takes from six to twelve months, is often described as difficult, and is made more

challenging because recruitment of nurses is in line with their affiliation to the local

government. Employment is highly political, and the selection, retention, and

promotion of staff nurses in public hospitals are influenced by political patronage and

affiliation (Choy, 2003; Perrin et al., 2007; Sia et al., 1999). Political interference by

government officials is a part of the culture (Tiongco-Cruda, 2008) and it is well

known that it is “who you know” and your “political relationships” that will help you

secure a job. Further to this challenging environment is that a criterion of international

employers for overseas nurse applicants is that the person must have at least two years

clinical experience (Nubla, 2008). Since there are limited employment opportunities

in the Philippines, only a few get employed. Even if employed, nurses are further

impeded by under-employment, poor pay, and working below their professional

potential (Lorenzo et al., 2007). They accept most employment offers because there

are limited nursing employment opportunities in the country. If they cannot obtain a

nursing job, new RNs are forced to endure further exploitation as a hospital volunteer

(often paying for the privilege), hoping that they can cite their volunteer experience as

sufficient to go overseas and secure employment (Mateo, 2011). Although the

Philippines’ Department of Health (DOH) issued Memorandum No. 2011-0238 on

August 2011 directing all DOH hospitals to discontinue all existing volunteer training

and similar programs (Vera, 2011), there are still reports of hospitals continuing

volunteerism training to Filipino nurses wanting to gain experience as a requirement

for overseas employment (Rudin, 2013). Those who cannot enter a hospital, either as

a nurse or a nurse volunteer, change their career by becoming call centre agents,

medical transcriptionists, or at worst, end up completely unemployed (Nubla, 2008).

Many nursing graduates aim to work overseas (Collen, 2010), and the road to success

is not easy. There is limited knowledge about the associated experiences in regards to

the meaning nurses attribute to their journey towards migration.


1.5 RESEARCH QUESTION AND AIMS

This study focuses on the lived experience of Filipino RNs working in Metro

Manila, Philippines with the intention of leaving their country for overseas

employment. Heideggarian phenomenology informed the research approach and the

research question addressed in the study was: What is the lived experience of Filipino

registered nurses seeking to migrate and work overseas?

The aims of the study were to:

• Identify the experiences of Filipino RNs working in the Philippine health

care system seeking to migrate overseas.

• Analyse and make meaning of the lived experience of Filipino RNs seeking

to migrate overseas.

• Examine the implications of the Filipino nurse migration experience.

1.6 SIGNIFICANCE OF THE STUDY

Despite ongoing migration of Filipino nurses, very little is known about their

experiences prior to migration. This phenomenological study examines pre-migration

experiences and seeks insights and knowledge for a deeper and broader understanding

of overseas worker aspirations to migrate. The study describes meanings associated

with a group of Filipino nurses in their intention to migrate and the perceived benefits

that migrating overseas has towards improving their lives. Moreover, it contributes

new knowledge about the phenomenon of Filipino nurse migration.

1.7 THE RESEARCHER AS A REFLECTIVE PRACTITIONER

This study adopted a Heideggerian phenomenology to inform the research

process, and as such the researcher was an essential element embedded within the

whole study process (Geanellos, 2000; Koch, 1995). Self-reflection and realisation of

personal bias and values were important for the quality of the research process, and

the researcher engaged in self-reflection about the research topic and his involvement.

I was born and grew up in the northern part of the Philippines. After finishing

high school, my parents asked me what college degree I wanted to undertake. I said I

wanted to take accountancy because I am good at math. I remember having

conversations with my father over the phone who told me to consider nursing, as it


would help me to get a job overseas. Although my parents were not forcing me to

choose nursing, I decided to study nursing as I dreamt of traveling and experience

living in another country. Although I initially had an alternative and preferred

university course, I have never regretted exchanging accountancy for nursing, because

I eventually realised that I did enjoy and love nursing.

In 2006, I was accepted to study nursing and initially didn’t like the course.

Although science was one of the subjects I really liked, the lessons and study were

very challenging. I didn’t have any idea what happens in a hospital, as none of my

family nor I had ever experienced being in a hospital environment. Studying nursing

concepts and clinical practice was very new to me and generated a degree of disinterest

at the beginning. However, in the final two years of my degree during hospital

practicums I developed a love and passion for my registered nurse role, enough to also

later dream of pursuing medical training after completion.

I graduated with my degree in early 2009 and passed the Philippine national

licensure examination to qualify myself as an RN. Later that year I remember my

classmates and friends preparing themselves for the National Council Licensure

Examination (NCLEX), which is the examination I needed to pass to be qualified to

work in the USA. I vividly remember most of our lecturers were doing the same thing.

They often shared their experiences about preparing for the examination and used the

same assessment strategies in our exams. Everyone thought it was a really good idea

to learn how to pass the NCLEX exam, but as I think on it now, it seems to me that it

was part of a grooming process to move me toward migration as a nurse.

After gaining nursing registration, I initiated an NCLEX application even though

a US visa was more difficult to gain at the time due to an economic recession. I was

able to enter a training programme in a tertiary hospital in my province so as to gain

hospital experience whilst taking the time to prepare for the NCLEX and US work

applications. However, my father offered me an opportunity to migrate to Australia

rather than the USA. After long consideration, I applied for an Australian visa and was

eventually granted Australian residency in 2010.

Upon migration to Australia I wanted to work as an RN. I applied for my nursing

accreditation via Australian Health Practitioner Regulation Agency (AHPRA), which

took 8 months. I remember my painful journey of going back and forth to council

offices to check updates on my assessment and awaiting letters from assessors. I almost


gave up the possibility of working as an RN in Australia due to the experience, but the

experience did inspire my curiosity about issues related to emigration from the

Philippines. Why do overseas trained nurses seek the experience in such large numbers

and why do they do it? Why did I participate so willingly in the process? I also became

interested in international nurse migration when encountering Filipino trained nurses

working as wait staff or assistants in nursing (AIN) in age care facilities in Australia.

I listened to their stories about sacrifices, plans, and journeys to become RNs in

Australia (many had plans that did not end how they had envisaged them), and I

became passionate about understanding more about the phenomenon.

I believe I embody much that is typical of Philippine culture, as I grew up in the

Philippines. I put a lot of value on family and I would do anything to protect and care

for them. I value education and have excelled in my academic study. Understanding

these experiences has become something that I see now as very important and is part

of a journey towards something that I had not understood when I was living in the

Philippines. The experiences and personal prejudices I have developed have been

carefully explored and critically considered in the process of the data collection, data

analysis, and interpretation of this thesis. Prejudices were acknowledged and did not

directly lead data interpretation and meanings of participants lived experiences, but

rather aided in explaining in more depth and greater detail the lived experiences of

study participants, which in the Heidegerrian phenomenological approach, is vital and

essential.

1.8 SCOPE OF THE RESEARCH

This study is informed by a Heidegerrian phenomenology to understand the lived

experiences of Filipino RNs seeking to migrate overseas. The participants of this study

consisted of five Filipino RNs working at a tertiary hospital in Metro Manila,

Philippines who were seeking to migrate overseas. They were either engaging in the

process of preparing for an overseas job application, awaiting job interviews, awaiting

final decisions related to their applications, or awaiting completion of their local

employment contracts so as to leave, as they had already received an overseas

employment offer. This research engages with their stories, and in a process of

examination undertaken through an interpretive lens, assists with understanding the

lived experience of this group of nurses seeking to migrate overseas.


1.9 STRUCTURE OF THE THESIS

This thesis consists of six chapters. This introductory chapter has provided an

introduction and background to the study.

Chapter 2 presents a critical analysis of literature related to Philippine nurse

migration. The chapter examines conditions of global nurse migration, the reasons for

nurse migration, the impacts of the phenomenon, global policies to mitigate it, and its

consequences. Furthermore, it engages in discussion regarding Philippine nurse

migration, and published research studies on experiences of internationally educated

nurses (IENs), including Filipinos, post migration. The final section then presents the

limited evidence currently available that informs understanding of the experience of

Filipino nurses prior to their actual migration.

Chapter 3 justifies the application of Heideggarian phenomenology as a

theoretical framework for the research. The chapter presents the major concepts related

to Heideggerian phenomenology used in this study and their significance.

Chapter 4 presents an overview of the participants, explains the research

methods, including how data was collected and the process of its interpretation and

analysis.

Chapter 5 presents the three themes that emerged from participants’ experience

of the phenomenon. They are as follows: living a life of indebtedness as a socio-

cultural lived experience in the Philippines; the anticipation of liberation from the

constraints of living out Filipino-ness; and lastly, living a life of inter-connectedness,

mainly through family and significant others. The first section presents that

participants were motivated to migrate overseas because they desired to pay back their

parents and family as part of living out their socio-cultural value of indebtedness or

paying back. The result of this lived experience is presented in the following section

explaining how the experience of paying back parents and/or family constrained

participants’ ability to become self-determined participants, because it meant that most

of their resources (mainly their finances) were shared with their families and their own

interests were a lesser priority. Migrating overseas offered hope to be liberated from

the constraints of their lived experience of being indebted and being Filipino.

However, the last section of the chapter explains that liberation did not mean

relinquishing Filipino values, including the desire to help family. In fact, because of


the inter-connectedness they have towards family and significant others, migrating

overseas did not only offer an opportunity to be free, but also to continue being Filipino

via helping family members despite migration. These inter-related and inter-connected

lived experiences were motivators for participants to seek overseas migration, and are

discussed in detail in this chapter.

Chapter 6 discusses the significance and relevance of the Filipino nurse lived

experience presented in the previous chapter. The first significance is that family is

central to Filipino inter-connectedness and being. The epicentre in participants’

decisions to migrate overseas was all about being Filipino: family. The second

significance is that the lived experience of being indebted to family and family inter-

connectedness suggests that Filipino nurse migration was not only driven by

economics, but has a strong relationship with living out Filipino-ness. Migrating

overseas was an expression of who participants really were. Lastly, although migration

also offered hope to become self-determined and being liberated from the constraints

of living out Filipino values, this did not indicate an individualistic pursuit. Rather, it

signified living out authentic Filipino-ness: the need to maintain the ability to pursue

things they truly desired and dreamt of, whilst at the same time, maintaining their

Filipino values, particularly helping family. This chapter concludes with a discussion

of the limitations of the study, the researcher’s reflections of the study findings, and

its contributions to the literature.

Chapter 2: Literature Review 15

Chapter 2: Literature Review

2.1 INTRODUCTION

This literature review provides a historical background to global nurse

migration, an overview of the current context to situate this study within the

phenomenon of global nurse migration, and summarises the findings of current

research regarding the experiences of Filipino nurses in their migration journey.

2.2 HUMAN MIGRATION: A NATURAL PHENOMENON

Migration is defined as “the movement of a person or a group of persons, either

across an international border, or within a State. It is a population movement,

encompassing any kind of movement of people, whatever its length, composition and

causes; it includes migration of refugees, displaced persons, economic migrants, and

persons moving for other purposes, including family reunification” (IOM, 2011, para.

20). Migration has been indispensable to human history, cultures, and civilisations

(International Federation of Red Cross & Red Crescent Societies, 2012), never more

so than in recent history.

Human migration has affected every corner of the world, yet discourses on the

phenomenon are often negative (Martin, 2016). Although it is now a commonplace

phenomenon due to the increasing access to countries globally, migrants are often

neglected and excluded from parts of society(ies), and often not properly accounted

for in discussions of local, national, and international developmental policies (IOM,

2016). William Lacy Swing, Director General of International Organisation for

Migration (IOM, 2016), an organisation that has been assisting migrants worldwide

for the past 65 years, strongly believes that the world should view human mobility as

a necessary and natural component for our economies and societies -- and not as a

“‘problem’ or ‘failure of development’” (IOM, 2016, para. 3). He further argued that

“increased migration is inevitable… necessary… and desirable, if well-governed”

(IOM, 2016, para. 8). If human migration is to be viewed as a natural phenomenon and

an essential part of how people live their lives, country and international community

policies should reflect it. Sadly, the reality is that human migration is “contradicted by

16 Chapter 2: Literature Review

a patchwork of rules and regulations designed to reverse such a process” (Swing, 2016,

para. 7).

2.3 GLOBAL NURSE MIGRATION: A REALITY

The movement of people, and more specifically health professionals, from one

place to another is epitomised by registered nurses, who are now one of the most

mobile professions in the world (Kingma, 2007). Recruitment of internationally

educated nurses (IENs) is a common practice in industrialised nations such as the USA

and the UK, and is seen as one solution to nursing staff shortages (Brush, 2008;

Delucas, 2014). Recruiting countries are commonly developed nations, whilst sending

countries are those that struggle economically. The migration of nurses in response to

nurse shortages has intensified in both scope and magnitude (Brush, 2008). The

phenomenon is now described as a ‘carousel’ of international nurse mobility (Brush,

2008; Kingma, 2006). Movement of nurses is considered circular, as groups move

between countries. The recruitment of IENs is also considered a big business, with

increasing competition and health delivery consequences (Brush, 2008).

A nursing shortage is defined as the “gap between current or projected supply of

[nursing] staff, and the current or projected demand for [nursing] staff” (Buchan et al.,

2015, p. 543). The WHO (2013b) reported that the world would be in need of 12.9

million health care workers, including nurses, by 2035. Ten million of the projected

12.9 million health worker staff shortage will occur in African countries, which at

present suffer severely from health care worker supply and retention (WHO, 2013b).

Despite ongoing attempts to resolve health worker inadequacy in Africa and other parts

of the world (Buchan et al., 2015), the active recruitment of nurses from these nations

is still ongoing. The ongoing recruitment from developing countries is considered

unethical and a barrier to the WHO’s (2013b) goal of global universal health coverage.

As a result, the WHO was tasked to develop the Global Code of Practice on the

International Recruitment of Health Personnel to influence and mitigate the ethical

impacts of international nurses leaving vulnerable countries (Buchan et al., 2015).

There is a clear need to address international migration, as it is an identified barrier to

the achievement of sustainable developmental goals. More recently, the Global

Strategy on Human Resources for Health: Workforce 2030 (WHO, 2016) was formed

to help address shortages of health workers, including nurses, through the gathering of

latest research and evidence to support the creation of evidence-based policies and the


mitigation of negative impacts of health worker shortages and their recruitment

(Matthews & Campbell, 2015). Policies are needed to properly manage negative

consequences, as well as to address ethical issues surrounding nurse migration. There

is global recognition of the fact that nurse migration will be an ongoing reality, and

implementing policies addressing negative impacts of migration, such as brain drain,

has been one of the foci of WHO and the UN (WHO, 2013b).

Nurse migration will continue to be an ongoing global phenomenon. Nurses

make up the largest group of health workers in the world (International Council of

Nurses, 2007), and as an increasing nursing shortage emerges globally, particularly in

developed nations where significant proportions of the population are ageing, the

recruitment of overseas nurses is predicted to continue. Australia is predicted to have

a shortage of 109,000 nurses by 2025 (Anderson 2013; Fedele, 2016), whilst the

Canadian Nurses Association estimates Canada’s nursing shortfall will be around

60,000 nurses by 2022 (Chachula, Myrick, & Yonge, 2015). In a USA report published

in 2014 by the US Department of Health and Human Services, it was projected that if

the USA continues to train nurses at its current rate, by 2025 the supply for nurses will

outweigh the demand (nursing growth rate of 33 percent versus 21 percent demand

resulting in a 340,000 nurse excess by 2025). These shortage claims have been

challenged (NewsRx Health & Science, 2015; USR Healthcare, 2015;), with authors

interestingly arguing that US Department of Health and Human Services reports do

not address assumptions related to a steady projection of nursing graduates, the

geographic mobility of nurses, as well as gaps in specialist nursing areas (USR

Healthcare, 2015, p.14). Despite debates about accuracy and projections, in contrast to

the US Department of Health and Human Services findings, researchers anticipate that

the USA will have a shortage of 130,000 nurses by 2025 (NewsRx Health & Science,

2015; USR Healthcare, 2015).

The European Commission expects also that the EU’s nursing shortfall will be

around 600,000 nurses by 2025, while the Caribbean will be short around 10,000

nurses (Royal College of Nursing, 2015). Japan is also not excluded from the trend, as

studies show that the country may be in need of an additional one million nurses to

meet its healthcare demand by 2025 (Royal College of Nursing, 2015).

Identified causes of nursing shortage in industrialised countries include, but are

not limited to, an ageing nursing workforce and an ageing population (Buchan et al.,


2015), nurses exiting the profession, and a lack of job vacancies (Delucas, 2014). By

2020 there will be more than one billion people aged 60 years and above in the world

(International Council of Nurses, 2007). This has significance for increased health care

demand and the health care workforce. However, with this ongoing trend, the nursing

staff workforce is also ageing. By the time the demand for more nurses peaks globally

in 2020-2025, most currently employed nurses will be retired. Scholars believe that if

the trend is not corrected, the situation will further worsen the predicted nursing crisis

(International Council of Nurses, 2007).

Although predicted shortfalls are massive for developed nations, the other side

of the equation shows a more severe situation emerging. Developing countries suffer

worst when it comes to nursing staff shortages. For instance, India had a nursing

shortage of 2.4 million in 2014 and the situation is getting worse every year (Royal

College of Nursing, 2015; WHO, 2010b). There is little political and global

intervention to reverse the ongoing and alarming trend (WHO, 2010b). Africa is now

considered to be in a “nursing crisis” characterised by nursing inadequacy, and is

plagued by issues of nurse migration from that continent (International Council of

Nurses, 2007). For example, in 2002, South Africa had an estimated 30 percent

hospital staff vacancy rate due to nursing staff shortages and as a result of nurse

migration (Li, Nie, & Li, 2014). In 2010, African countries had one nursing or

midwifery personnel per 1,000 population compared to five nursing or midwifery

personnel per 1,000 population in America and eight nursing or midwifery personnel

per 1,000 in Europe (Naicker, Eastwood, Plange-Rhule, & Tutt, 2010). The situation

is also distressing when it is recorded that African countries have only 1.3 percent of

the global health workforce but are faced with 25 percent of the global burden of

disease (Nkomazana, Mash, Shaibu, & Phaladze, 2015).

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.


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).


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


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


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


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).


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


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).


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


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


(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


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,


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


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

migration (Daniel, Chamberlain, & Gordon, 2001; Hughes, 2008; McGonangle,

Halloran, & O’Reilley, 2004; Withers & Snowball, 2013). Adapting to a new

environment and migration itself is a stressful journey. Roy’s adaptation model

highlights that a successful adaptation to a new environment is when someone feels

secure within the boundaries of other groups, such as workmates and colleagues,

patients, organisations, communities, the society, and their own family and self, which

in itself can be intricate and stressful journey (as cited in Alkrisat & Dee, 2014). Nurses

experience high levels of stress at work (Abualrub & Al-Zaru, 2008; Edwards &

Bumard, 2003), and stress responses such as feeling anxious and fearful lead to

physical and psychological burn out (Alkrisat & Dee, 2014). There is no doubt that the

experiences of Filipino migrant nurses and IENs demonstrate widespread struggles

integrating into new environments and cultures, which are compounded by the stresses

they face in their nursing employment. The experience of these nurses often centres

around life struggles and difficulties in the process of adapting to new environments

as a result of immigration.

2.10 THE EXPERIENCE OF FILIPINO RNS PRE-MIGRATION

Literature examining nurse experiences in the Philippines is limited. Tiongco-

Cruda (2008) described the experiences of Filipino nurses working in the Philippines

without a specific focus on pre-migratory expectations, the working experiences of

Filipino RNs, or their motivation for migration. However, a more recent study

completed by Vartiainen, Pitkänen, Asis, Raunio,

and Koskela (2016) explored the

expectations of potential Filipino migrants to Finland. The two studies found Filipino

RNs to be dissatisfied with their salary in the Philippines, believing they are not

properly compensated for their heavy workloads, the myriad of duties they perform,

and the significant responsibilities they carry and their role as RNs (Tiongco-Cruda,

2008; Vartiainen et al., 2016).

Publicly employed Filipino RNs are generally dissatisfied with their monthly

salary, which ranges from PhP14,500-15,000 ($426-469 AUD as at the June 2016


exchange rate of $1 AUD= 34 PhP) (Tiongco-Cruda, 2008). The situation is in fact

worse for privately employed nurses, who receive much lower monthly pay than those

working in government hospitals. In a study by Perrin et al. (2007), staff nurses in

private hospitals received monthly salaries as low as $69 USD (2007), an amount

below the government’s recommended minimum monthly income of $86 USD. In a

recent Philippine report, it was noted that approximately 600,000 registered Filipino

nurses were working for below minimum wage (Voluntary Service Overseas

Bahaginan, 2010). Poor pay is believed by many scholars to lead many Filipino RNs

to seek overseas migration (Aiken et al., 2007; Lorenzo et al., 2007; Perrin et al., 2007;

Tiongco-Cruda, 2008). They not only experience dissatisfaction with their salary, but

many believe that their remuneration causes low morale as it is not enough to cover

their own and their family’s daily needs (Perrin et al., 2007). Likewise, many Filipino

RNs believe their nursing wages do not equate with their training or the amount of

work and responsibilities they perform day to day (Tiongco-Cruda, 2008). Filipino

RNs are educated in nursing schools for four years and have to pass a national licensure

examination in order to be qualified and registered to work (Brush, 2010). Many

wonder if their salary is worth the sacrifices made to become an RN in the Philippines

(Tiongco-Cruda, 2008). A comparison with other professions in the country easily

justifies concerns raised by nurses. In 2014, a Philippine teacher received around

PhP18,500 ($544 AUD) a month, a Philippine Military Academy (PMA) cadet around

PhP22,000 ($647 AUD), whilst a call centre agent received a monthly salary of

PhP15,000 to Php25,000 ($441-$735 AUD) (Geronimo, 2014). A Filipino RN,

however, only receives an average of PhP15,000.00 per month ($441 AUD).

Interestingly, the Philippine government passed a policy called the Magna Carta

for Public Health Workers in 1992, which aimed to standardise pay scales and benefits

for all public health workers (Perrin et al., 2007) and the policy still remains, but is

ineffective. The implementation of the policy has always been hindered by local

government sectors, because the decentralisations of public health care services is

determined by local government officials and not the state (Perez, 1998). This has led

to poor implementation of public policy and creation of significant discrepancies

where below minimum wage remuneration and inadequate benefits for groups like

nurses has continued in the Philippines (Perrin et al., 2007).


In 2016, the Philippine Senate and House of Representative passed a bill to

increase minimum salary of nurses to PhP25,000 per month (Brosas, 2016; Infonurse,

2016). Even though Filipino nurses nationally and across the globe hailed the success

of this provision, their dream of appropriate remuneration was quashed by Philippine

President Aquino who vetoed the bill signed by both the Congress and Senate

(Corrales, 2016). The Philippine President supported a letter he received from the

Philippine Hospital Association (PHA) appealing to veto the bill (Brosas, 2016;

Infonurse, 2016). The main reason for the veto was that both local and national

hospitals had insufficient resources to support salary increases (Brosas, 2016). The

PHA also suggested that any increases in nurse wages might lead to a necessary

reduction in the number of nurses employed in the system (Infonurses, 2016). In the

letter, PHA explained to the President that:

While we have no objection to most provisions of the said proposed law, we

would like to inform your Excellency that Sec. 47 thereof, which provides for

a base pay upon entry into service, of not less than Salary Grade 15, which at

Step 1 amounts to P26,192.00, will have adverse effects to many sectors…

(Infonurses, 2016).

Although nurses continue to lobby for better and higher compensation (Brosas,

2016), the Philippine government is not willing to provide proper compensation for its

nursing workforce as set by law. Despite the emergence of comprehensive laws

mandating a minimum monthly wage of P26,000 for every Filipino nurse, the recent

situation only accentuates ongoing issues and makes overseas migration more

attractive. The reality for Filipino RNs has not changed for many years, as they are

still inappropriately compensated for their labour. It is therefore no surprise that

ongoing dissatisfaction with Filipino RNs salary is strongly believed by researchers to

be pushing Filipino nurses to emigrate (Aiken et. al., 2004; Lorenzo et al., 2007; Perrin

et al., 2007).

Low nursing remuneration is a push factor for migration in other Asian and

South East Asian countries, including Malaysia, India, Cambodia, Vietnam, and China

(Birks, Chapman, & Francis, 2009; Dieleman, Cuong, Anh, & Martineau, 2003;

Falaknaaz, 2004; Munjanja, Kibuka, & Dovlo, 2005; Sovoluntaryeters & Griffiths,

2003; WHO, 2010b;). Nurses in countries such as Fiji, Somao, Tonga, Vanuatu, Papua

New Guinea, Vietnam, Cambodia, and Thailand highlight a link between low salary


and job dissatisfaction (Bolger, Hauck, Mandie-Filer, & European Centre for

Development Policy Management, 2005; Dieleman et al., 2003; Oum, Keat, Saphonn,

& Oum, 2005; Wibulpolprasert & Pengpaiboon, 2003), which is a motivation for

many to pursue migration due to a desire for higher and better remuneration.

Filipino RNs working in the Philippines have heavy and excessive workloads,

and a wide range of functions associated with carrying out medical staff orders,

coordinating other health care teams, administering medications to patients, and doing

practical tasks that fall within the purview of preventive, curative, and rehabilitative

care of patients (Tiongco-Cruda, 2008). Workload equates to “the amount of care that

a patient requires” (Tiongco-Cruda, 2008, p.97), and is basis for nurse to patient ratios.

In the study by Tiongco-Cruda (2008) it was revealed that nurse to patient ratios in the

Philippines range between 1:30-40 patients per nurse, which is grossly above DOH

standards of 1:12 (as cited in Tiongco-Cruda, 2008). This situation negatively affects

quality of care. Reports describe even worse conditions in different parts of the

country, especially in rural areas of Mindanao. A nurse to patient ratio can reach 1:50

(Umil, 2015) in some places, and at worst, can reach 1:150 (Ebesate, 2008). Writing

in a local newspaper, Umil (2015) described stories of Filipino RNs she interviewed

as demonstrating that they were overworked and overloaded, especially in public

hospitals. It is a common scenario for Filipino RNs in the Philippines, and is further

aggravated by extended working hours of up to 16 or 24 hours if an incoming nurse is

sick or an area is understaffed. Umil (2015) described the experiences of a nurse called

Jose, who early in his nursing career did not realise that when he “started to work in a

public hospital in Manila, he didn’t think that he would be on-duty for 16 straight

hours. It went on for a week and he thought of quitting his job. But for the sake of

gaining experience, he stayed” (para. 1).

Dabu (2012) argued that Filipino nurses are the most overworked professionals

in the Philippines, yet receive remuneration that is insufficient for a decent and humane

daily living. They are often deprived of economic benefits, incentives, overtime

payments, night-shift differentials, and even holiday pay. The author further argued

that there is a cultural practice in the Philippines in which many people would rather

choose to be passive than have any confrontation to discuss a complaint about their

job (Dabu, 2012). Thus, if a Filipino nurse complains, they believe this will not resolve

their concerns and, at worst, it might lead to an end of their employment contract (and


no chance to emigrate). There is a revolving door of exploitation and a preference for

avoidance of confrontation. As a result, many nurses end up having no choice but to

obey their managers and work beyond their legal obligations (Umil, 2015). Many

Filipino nurses believe that developed countries, such as the USA or UK, offer better

working conditions than working in their own country.

Many Filipino nurses feel helpless due to unchangeable employment conditions

in their country. Yumol (2009) argued that many Filipino nurses choose to work as

nurse volunteers without getting paid. Worse still, many nurses choose to pay

institutions so that they can volunteer, hoping to gain nursing experience that they can

use to apply to work overseas (Rudin, 2013). This phenomenon is a testament to a

Philippine nursing crisis, where levels of desperation are strongly driven by the needs

of one’s self and family for future survival (Mateo, 2011; Yumol, 2009). With

unchanging working conditions and dissatisfying remuneration, the movement of

Filipino nurses toward better avenues for a good life for their family and themselves

will continue and the country will remain a global exporter of nurses.

Despite some research studies on Filipino nurse migration, there is still a lack of

understanding regarding the motivations for Filipino nurses to migrate overseas,

particularly understanding that extends a broader insight than a simply economic

perspective. Understanding the motivations or drivers for Filipino nurses to seek

overseas nursing jobs is essential in properly understanding global nurse migration.

Shifting the lens of understanding to a more human centred view as informed by

‘potential migrants’ broadens knowledge. It is needed in the creation and maintenance

of bilateral labour agreements (such as with the UK, Germany, and Japan) and for

adequate evaluation of policies primarily driven by arguments around economic

advantage. Moreover, the lives of potential nurse migrants give voice to the reasons

and implications for recruiting Filipino nurses, and aid in understanding the

implications of recruitment.

2.11 SUMMARY

Nurse migration has become part of the global human migration story. It is an

ongoing phenomenon with associated ethical issues and negative impacts. Global

nursing shortages have primarily attracted nurses from developing nations such as the

Philippines, where over 24,000 nurses every year are being recruited to migrate (Dabu,


2012; Department of Labor and Employment, 2015). Literature emphasises the pull

factors from developed countries, such as better salary, better working conditions, and

career opportunities that are attractive to Filipino nurses. Filipino nurses do migrate

for economic reasons and this is supported by studies highlighting the poor working

conditions of Filipino nurses in the Philippines. Filipino nurses from both public and

private sectors continue to battle for proper implementation of the Magna Carta for

Public Health Workers and the standardisation of pay scales. There is limited evidence

regarding the migration of Filipino nurses amongst the known employment challenges

in the Philippines. This study aims to assist with clarifying the knowledge gaps related

to the pre-migration experience and provide a more robust examination of the

experience of Filipino nurses who seek to migrate overseas.

Chapter 3: Methodology 37

Chapter 3: Methodology

3.1 INTRODUCTION

This chapter examines phenomenology as methodology with emphasis on

Husserlian and Heideggerian phenomenology. It discusses the basic tenets of each

methodology and provides justifications for adopting Heideggerian phenomenology

and its appropriateness for this study.

3.2 PHENOMENOLOGY AS A METHODOLOGY

Phenomenology, or the study of being, is often used as a philosophy in studying

lived experience (Johnson, 2000; Koch, 1995; Priest, 2003). Phenomenology argues

human consciousness has structures or essences (Dahlberg, 2006) and through

illuminating structures others are able to understand how participants experience a

certain phenomenon (Liamputtong, 2014). Human consciousness is always directed to

structures, whether this is a direct structure (for example, a real football in your hand)

or an ideal structure (such as a scene in an individual’s dream) (Siewert, 2016).

Illuminating the structures of consciousness as perceived by participants first-hand

provides understanding and insight into phenomenon. The process of unveiling

structures or essences of human consciousness is what phenomenology seeks to

achieve. It is both a philosophy (science) and a research methodology that guides

exploration and description of the appearance of things in people’s minds (Matua

&Van Der Wal, 2015). It provides a gateway for understanding someone’s experience

of a range of phenomena (Creswell, 2007; Daly, 2007; Liamputtong, 2009).

Phenomenological research always begins by questioning “What is the meaning,

structure, and essence of the lived experience of this phenomenon for this person or

group of people? (Patton, 2002, p. 104), or “What is the essence of this phenomenon

as experienced by these people and what does it mean?” (Liamputtong, 2014, p. 270).

Essences are “structures of essential meanings that explicate a phenomenon of

interest” (Dahlberg, 2006, p.11). Essences belong to the everyday world and we all

experience and encounter these essences as we operate with them in our thinking. For

example, when I sit on a chair and stare through my window, I can see a mango tree

with a hammock on one of its branches. In order for me to see the phenomenon (mango

38 Chapter 3: Methodology

tree with a hammock), I would have to grasp the essences of the phenomenon, that is,

I understand what a mango tree and a hammock are. Without my understanding of

these objects, I would not be able to explain or describe that I was staring at a mango

tree with a hammock. I could not separate the essences or meanings of a mango tree

or hammock, for what makes the mango tree a mango tree (or a hammock a hammock)

is the essence or meaning my consciousness has grasped about what a mango tree (or

hammock) is. In understanding a phenomenon, one has to understand its essences as

this is how it presents itself (Dahlberg, 2006). The presence of essences is what makes

that phenomenon be that very phenomenon (Dahlberg, 2006; Liamputtong, 2014).

Without these, the phenomenon would not exist (Dahlberg, 2006; Liamputtong, 2014).

When a person intentionality attends to a certain phenomenon, that is the way a person

understands a phenomenon as it presents itself; (s)he sees the essence of a

phenomenon. However, this process of understanding essence(s) is often not a direct

human concern, rather, it is lived out and becomes part of human existence and

people’s everyday life. This is for this basic reason that Heidegger, a philosopher

whose ideas gave rise to Heideggerian phenomenology, explained that the way to

understand human existence is not how many of us understand our being and existence,

but rather through meticulously studying essence. Through this, we can make

meanings of someone’s lived experience. This is the aim of phenomenology;

disclosing the essences or meanings from participants who have first-hand experience

of the phenomenon under study (Moustakas, 1994).

3.2.1 Husserlian phenomenology

Edmund Husserl is considered the founder of phenomenology (Benoist, 2003;

Draucker, 1999; LeVassueur, 2003; Maggs-Rapport, 2000; Wojnar & Swanson,

2007). His philosophical idea of conducting science gave rise to the descriptive

phenomenological approach to inquiry. Husserl challenged others who believed that

“objects in the external world exist independently and that the information about

objects is reliable” (as cited Groenewald, 2004, p.4). He hoped to free philosophy from

the notion that human beings are only physical entities (Groenewald, 2004; Husserl,

1970). Husserl believed that researchers who only view humans as subjects who attend

or respond to physical stimuli are missing very important variables of their existence

leading to “a highly artificial situation” of phenomenon (as cited in Laverty, 2003,

p.4).


Husserl (2008) claimed that human consciousness has a value, thus, it is an

object for study. His philosophy centres on descriptions of human experience as it is

consciously experienced in everyday life (Liamputtong, 2014, p. 270). He believed

consciousness is a constant dialogue between a person and the world and he saw this

as the avenue through which one can grasp an understanding of a phenomena (Laverty,

2003). This grasping is through an intentional process, where “the mind is directed

towards objects of study”, not through “mechanistic causation” (Laverty, 2003, p. 5).

Consciousness is the starting point to build one’s knowledge of reality and make

meanings of someone’s experience of a phenomenon. Husserl further proposed that

one can develop descriptions of particular phenomena by coming face to face with the

essence of one’s consciousness about an object of study or phenomenon (as cited in

Laverty, 2003).

Husserl developed transcendental phenomenology in response to his

dissatisfaction with the natural science’s incomplete understanding of human

experience. He argued that human consciousness or mind is always directed to

something, hence his examination and enquiry into the concept of ‘intentionality’- the

consciousness or awareness of our experiences (McIntrye & Smith, 1989). What gives

human beings characteristics of a particular event is due to our acquired understanding

of what makes a particular object or a phenomenon that itself. For example, we have

in our consciousness the intentionality or characteristics of what it feels like to

experience pain. In understanding a painful experience, our consciousness is directed

to characteristics of how we interpret pain. For some, a particular embarrassing event

is not too painful, but for others it can be devastating. This intentionality of our

consciousness is one of the central tenets of Husserlian phenomenology (McIntrye &

Smith, 1989).

In order to achieve understanding of human consciousness and gain knowledge,

particularly of one’s lived experience, one’s preconceptions of a phenomenon need to

constantly be assessed and evaluated. For example, bias needs to be identified and

neutralised to achieve and maintain objectivity. To attain this, Husserl introduced

bracketing, a concept whereby it is argued that one’s prejudices and preconceptions

are suspended and are set aside in studying one’s consciousness in order to reveal its

‘true essence’ (as cited in Laverty, 2003). As an outcome, data are epistemological in

nature and analysis has a focus on the descriptive, rather than attempting to finding


meaning from one’s own experiences. For this reason, Husserl used the phrase “back

to things themselves”, which means describing how things or essences of a particular

phenomenon present themselves to the experiences and not how a person understands

things as they are (as cited in McConnell-Henry, Chapman, & Francis, 2009).

Bracketing is a feature of Husserlian phenomenology and has to be justified and

observed during data collection, interpretation, and analysis in order to establish and

claim objectivity in any research study designed based on a transcendental approach

to phenomenology (Husserl, 2008).

The focus of Husserlian phenomenology is to describe and identify the structures

of a phenomenon from a traditional, normative, and scientific sense (Finlay, 2011).

This approach tends to focus on a retrospective collection of people’s experiences,

which are often obtained through in-depth interview. Researchers aim to gather

descriptions of participants’ experiences (Finlay, 2011). For example, a researcher

might begin by asking participants to describe their experiences of a certain

phenomenon in a general sense, then afterwards engage to probe in a more detailed,

concrete, and greater depth those descriptors, such as asking the participants their

thoughts, feelings, or behaviour during the experience.

In Husserlian phenomenology, the researcher can recruit at least three

participants in order to come up with variations and descriptions of the structures of

the phenomenon (Finlay, 2011; Matua & Van Der Wal, 2015). During the data

collection and analysis, the researcher is expected to conduct bracketing or

phenomenological reduction and consider the participants’ experiences in their pure

form by allowing the texts or data to describe itself and not based on what the

researcher understood of the meanings of texts (Finlay, 2011; Matua & Van Der Wal,

2015). The researcher who adopts Husserlian phenomenology starts data analysis by

re-reading the whole text to obtain a sense of it as a whole before dissecting each

phrase or word into groups or ‘meaning units’ (Finlay, 2011). Grouping allows the

data to be manageable and be reflected by the researcher. Following this rigorous

process, the meaning of each data group is described and elaborated by the researcher,

and later synthesised by grasping the essential elements or essences of the

phenomenon. This is then presented as the structures or meanings of one’s lived

experience. The process in arriving at this analysis phase requires the ongoing

bracketing and reflection of the researcher at any stage of data analysis. Husserlian


phenomenology permits the primitive and direct descriptions of one’s lived experience

that emerge from “presupposition-less description of a phenomenon” (Matua & Van

Der Wal, 2015, p.23).

There are critics of the concept of bracketing (Koch, 1995) and achieving “true

essence” of one’s experience. A principal critic of the concept was Heidegger, who

was a student of Husserl. Heidegger (1962) disputed the idea of bracketing, as he

considered the person studying a phenomenon to be part of the process of

understanding human experience. He argued that someone’s ability to make meaning

from lived experiences was reliant on that person’s preconceptions and knowledge to

the study phenomenon (Geanellos, 2000; Koch, 1995). Heidegger explained that, “We

do not, and cannot, understand anything from a purely objective position. We always

understand from within the context of our disposition and involvement in the world”

(as cited in Johnson, 2000). This is one of the reasons that the researcher of this study

did not consider Husserlian phenomenology to be an appropriate methodology. The

researcher acknowledges that his previous experience of migrating overseas was a

precursor to beginning this inquiry and his preconceptions about migration have

ultimately influenced the analysis.

3.2.2 Heideggerrian phenomenology

Martin Heidegger (1962) challenged some of Husserl’s assumptions. He

believed that all descriptions are already in their form an interpretation and that human

understanding is an essential element of being-in-the-world, and humans can not

completely separate themselves from the pre-conceived understanding or prejudices

of a certain phenomenon (Dreyfus, 1991). Husserl claimed that “mental content gives

intelligibility to everything people encounter”, whilst Heidegger argued that

phenomenology is a “mindless everyday coping skills [being] the basis of all

intelligibility” (as cited in Dreyfus, 1991, p. 3). Human beings acquire relationships to

the world as a consequence of being in the world. Because humans are already

immersed in the world, they eventually learn coping skills, such as learning to walk

and understanding human activities in the world, which in turn, creates meaning for

human experience, phenomena, or life events. Understanding the relationship between

human existence and the world, and vice versa, is the focus of a phenomenological

approach (Dreyfus, 1991).


3.2.2.1 Flow

Heidegger introduced the idea of “flow”, an essential concept in understanding

the relationship of being to the world. He explained that when daily life is going well,

one is experiencing what athletes called “flow” or playing out of their heads. In these

circumstances, one is not consciously able to distinguish one’s experiences, and hence,

“has no experience of oneself as a subject causing that activity” (Dreyfus, 2004).

An individual will only be consciously aware when one’s action is

accomplished; for example, arriving safely at work after driving from home. When an

individual drives to work and does this many times, the activity of driving becomes

part of daily living. Most of the time that person becomes unconsciously aware of the

small things that happen whilst driving to work. One embraces the flow where the

mind automatically knows when to turn for an exit, where to go and park, and such.

This flow of driving becomes “mindless everyday coping skills”, and for Heidegger,

this is where we can start to understand someone’s experiences and existence (Dreyfus,

1991). The flow is one of the main concepts of Heidegger’s (1962) philosophy

discussed in his book Being and Time, where he explained his ideas on the meaning of

human existence.

3.2.2.2 Dasein (Being-in-the-world)

Heidegger (1962) presented the concept of dasein or being-in-the-world; the

meaning of existence or being is dependent to the contexts of that being. Dasein,

literally translated as ‘being-there’, is what Heidegger (1977) believed to be “the place

of the understanding of being” (p. 8). It is the idea that the existence of a human being

is inseparable to the world (Warnock, 1970). Heidegger (1962) argued that for a dasein

to have meaning, human beings must be immersed and embedded in the tangible, day

to day world (Steiner, 1978); hence, the idea of being-in-the-world. Heidegger (1962)

considered being-in-the world to be “a priori, it is not pieced together, but is

primordially and constantly a whole” (p. 65).

Additionally, Heidegger (1962) believed that a focus on studying being should

be about finding meaning that presents itself to the phenomenon, rather than describing

essences of phenomenon. Understanding dasein gives relationship to the idea of

human “flows”, where in order to understand what it means to be, one has to find

meaning in human’s relationship of “being” to the “world”, and vice-versa. This means


that a person cannot understand what it means to be about a particular phenomenon

without understanding the world or the contexts of that particular being. This is

because ‘being’ is already known or has relationship to the world. By excluding being

from the world, being would be meaningless (Dreyfus, 2004). The method of

interpreting human existence and experiences is not to segregate dasein away from the

world. Without the other, there will be no means of understanding dasein and the

meaning or essence of human existence (Mackey, 2004; Spiegelberg, 1965). Human

beings cannot exist without the context of their world, although the latter does not

determine or constitute human being (Heidegger, 1962).

The focus of Heideggerian phenomenology is to make meaning of lived

experiences in relation to the world. What is valuable in Heideggerrian

phenomenology is the focus on what an individual’s narratives imply of his or her

experiences in relation to their context (Heidegger, 2010; Solomon, 1987; Wojnar &

Swanson, 2007). This perspective means that one’s experience is embedded in the

context of family traditions, community values, and the broader socio-cultural context.

Understanding these contexts is necessary in interpreting the lived experience of

participants (Benner, 1994; Draucker, 1999; Heidegger, 2010).

Given the chosen methodology, flow and dasein were essential to this study.

Desire to migrate is embedded within the Philippine culture and has widespread

acceptance amongst Filipinos. These views helped the researcher of this study to make

meaning of participants’ experiences about intention to migrate, as did insight into the

context of Philippine culture. Understanding of participants’ dasein or being immersed

in their world as a part of being Filipino was essential to examining meaning and

participants’ lived experiences.

3.2.2.3 What is being?

Heidegger (1977) often discussed that being is not easily definable because of

how we normally understand our existence. This means that although being has a

universal nature, it is not generally accepted as a universal notion of being, which is

commonly external and substantial, and defines human existence. For Heidegger

(1977), being is a self-evident concept used in all “knowing and predicting, in every

relation to beings and in every relation to oneself, and the expression is

understandable” (p. 44). He explained that:


Everybody understands, “The sky is blue”, “I am happy”, and similar

statements. But this average comprehensibility only demonstrates the

incomprehensibility. It shows that an enigma lies a priori in every relation and

being toward beings as beings. The fact that we live already in an

understanding of being and that the meaning of being is at the same time

shrouded in darkness proves the fundamental necessity of recovering the

question of the meaning of “Being” (Heidegger, 1977, p. 44).

Heidegger believed that the way we should understand human existence is

through the way of our being or the way we are (as cited in Polkinghorne, 1983), and

this can be achieved through examining our a priori or pre-understanding. A priori

was described by Koch (1995, p.831) as historicality, which is a person’s history or

background and the framework which we use in understanding things in advance.

Historicality includes the culture where the person was born and grew up, and the

values and belief acquired that then become lenses through which one’s understanding

of the world and existence is moulded from and formed. Munhall (1989) explained

that historicality or pre-understanding is not only contained within one’s background

but also even the cultural, social, and historical contexts that are factors that influence

one’s understanding of being. Heidegger (1962) explained that disclosing a priori is

where we begin understanding of who we really are. He discussed that:

If the question of being is to have its own history made transparent, then this

hardened tradition must be loosened up, and the concealments which it has

brought about dissolved. We understand this task as one in which by taking

the question of being as our clue we are to destroy the traditional content of

ancient ontology until we arrive at those primordial experiences in which we

achieved our first ways of determining the nature of being-the ways which

have guided us ever since (Heidegger, 1962, p. 44).

Heidegger (1962) argued that one of the ways we can understand someone’s

experience of a phenomenon is to rigorously consider the meanings associated with

their experiences with their past. This means that a researcher has to consider the socio-

cultural context and historical upbringing of participants because their past experiences

or pre-understanding gives way to how they understand their being-in-the-world. For

example, an individual knows what a hammer is for and its characteristics (meanings

of a phenomenon), because this person has used a hammer in his or her past and

understood its characteristics. Past experiences give way to how this individual


understands a hammer, its usage, and characteristics. To understand what participants

mean by what they say, the researcher has to understand the proper context of the texts

or data through explicating what the texts imply in that particular situation or specific

circumstance (Matua & Van Der Mal, 2015).

Heidegger’s idea of examining essences of phenomenon with the recognition of

one’s preliminary conceptions or a priori is the opposite of Husserl’s notion of

bracketing. He argued that we cannot understand essences of a phenomenon without

relating these essences to our a priori, or to participants’ backgrounds. In fact, he went

on to say that there is no such thing as bracketing because human beings are already

immersed in this world, and the meaning of one’s experience is only made possible by

acknowledging participants’ a priori (Laverty, 2003). Pre-understanding is not

“something a person can step outside of or put aside, as it is understood as already

being with us in the world” (Laverty, 2003).

Examining a priori or pre-understanding of participants using various contexts

such as the social, cultural, or historical factors helped the researcher of this thesis to

make meaning of participants’ experiences of migrating overseas. Understanding

“being a Filipino RN wanting to migrate” was made possible through a process of

examining and exploring participants’ a priori, what it really means to be and to want

to migrate overseas. Through immersion and shifting data analysis meanings arose

from these experiences as understood by participants. This process of bringing forth a

priori produced meanings that are unique, and furthermore, challenge current Filipino

nurse migration literature.

3.2.2.4 Fusion of horizons

The goal of Heidegger’s phenomenology is to identify the participant’s

meanings from a blending of the researcher’s understanding of the phenomenon,

participant-generated information, cultural and social context, and data obtained from

other relevant sources (Wojnar & Swanson, 2007). This blending pertains to the

concept of “fusion of horizons”. Heideggerian phenomenology is most useful as an

approach in examining the contextual features of a lived experience as generated from

a blend of meanings and understandings articulated by both researchers and

participants (Draucker, 1999; Koch, 1995; Parse, 1999).


Horizons for Heidegger (1962) pertained to time, as examined in his book Being

and Time. Time is dasein’s past, present, and future. There is no such thing as

“objective time”, only dasein’s time (past, present, and future). Our understanding of

the world and our being is made possible by networks of things that come to us with

our past, present, and future experiences, and this network of things has always been

there in the world (Blattner, 2005). We can have many and different possibilities of

meaning to our experiences because of these horizons, of someone’s past, present, and

future experiences. Horizons are very important, as interpretation of participant

experiences entailed the researcher considering his past experiences as a Filipino

nurse, the desire to study nursing, present context conditions, and what factors

motivated participants to migrate in response to future hopes and aspirations. Studying

horizons combined with the researcher’s own horizons generated significant meaning

from participant experiences. Fusion of horizons entailed not only the researcher’s pre-

conceptions of the phenomenon, and participant socio-cultural contexts, but also what

the horizons of the participants were in relation to their stated experiences at the time

of data collection.

3.3 REASONS FOR USING HEIDEGGERIAN PHENOMENOLOGY

Whilst these two phenomenological approaches (Husserl and Heidegger) have

similar history and are common methodological approaches used in studying one’s

lived experience, the two phenomenological approaches have differences in terms of

their research focus and outcomes. First, Husserlian phenomenology focuses on

describing phenomena without assumption of obtaining interference of the

researcher’s pre-suppositions or prejudices. The focus concentrates on descriptive

knowledge of how someone experiences the study phenomenon without considering

the contexts of social, cultural, or even historical function of understanding throughout

data collection, analysis, and interpretation. On the other hand, a Heideggerian

approach focuses on obtaining broader and deeper understanding of the phenomenon

by unveiling hidden meanings of experience taking into account various contexts

during data collection, analysis, and interpretation, such as the socio-cultural and

historical drivers for participants’ descriptions of their experiences (Matua & van Der

mal, 2015). Second, the two approaches differ in terms of their research outcomes. In

Husserlian phenomenology, the outcome is to arrive at describing ‘universal essences’,

which are pure descriptions of the phenomenon unduly influenced by the researcher.


It does not aim to generate theories or explanations about the phenomenon, but rather

to describe the essences or elements of the experience. On the other hand, a

Heideggerian approach aims to bring readers into a different world (i.e., the study

phenomenon), and to discover the possibilities and understanding therein. The

outcome is achieved through the so-called fusion of horizons, that is, data collection,

analysis, and interpretation as results of understanding meanings from different factors

such as participants texts or descriptions, the researcher’s knowledge of the

phenomenon, the socio-cultural drivers and contexts of participants experiences, and

other relevant information, such as literature or previous study(ies) (Matua & van Der

mal, 2015).

Heidegger’s interpretation of phenomenology was used in this study because the

aim was to appreciate a holistic context of participants’ experiences and discover

meanings in what participants expressed. The researcher acknowledges his

predetermined knowledge and prejudices about the phenomenon, because he was a

Filipino registered nurse who worked in a public hospital in the Philippines, and

subsequently immigrated to another country. These horizons influenced the analysis

and interpretation of data. The researcher, having had these experiences, was

consequently led to conduct this research and this awareness of biases was necessary

so that the text can be presented in all its otherness; thus, declaring its own truth against

one’s own assumptions (Wojnar & Swanson, 2007). Having these experiences and

knowledge of the phenomenon, the researcher believed that Heideggerian

phenomenology would better assist and guide this study, which led him to adopt the

said approach.

3.4 SUMMARY

Two common approaches used in phenomenology are Husserlian and

Heideggerian. Although these two approaches have similarities with regards to their

basic tenets of consciousness and studying human experiences, they differ

significantly with regards to the role of researcher(s) in data analysis, the treatment of

bias and pre-conceived ideas of study phenomenon, and the process of data analysis.

This study adopted Heideggerian phenomenology because the aim was to explore

participants’ experiences interpretively. Additionally, the researcher acknowledges his

influence on the data analysis, as he had experienced migrating overseas. This is


considered vital in Heideggerian phenomenology, and supports the inclusion of pre-

conceived ideas about a phenomenon as necessary in interpretations.

The following chapter discusses the research method, recruitment procedure,

participants’ backgrounds, and process of data analysis.

Chapter 4: Methods 49

Chapter 4: Methods

4.1 INTRODUCTION

This chapter explains how participants were recruited, the sample size, the

rationale, how data were collected and analysed, the ethical considerations, and how

the researcher enhanced the methodological rigour for this study.

4.2 RESEARCH METHOD

This study investigated the experiences of Filipino RNs prior to emigration by

conducting in-depth interviews, for at least an hour, which concentrated on exploring

feelings and thoughts about the participants’ upcoming immigration and motivations

surrounding their desire to work overseas. Participants who joined the study were

working in a tertiary health institution located in Manila, Philippines. Interviews were

transcribed by a professional Filipino transcriptionist, and were analysed using

hermeneutic circle.

4.3 RECRUITMENT PROCEDURE

After gaining approval from the QUT Ethics Committee (see Appendix A),

participants were recruited from a tertiary hospital in Manila, Philippines. The

researcher also sought approval from the Makati Medical Center (MMC) chief nurse

(see Appendix B) who helped him recruit potential participants for the study. The

MMC chief nurse sent the QUT approved recruitment flyer (see Appendix C) to RNs

in their institution. The five participants were chosen based on their eligibility for the

study, as well as their availability to attend the interview. The MMC chief nurse

scheduled interview dates with the participants prior to the researcher’s arrival at the

hospital.

Prior to the interview, participants were given time to read the consent form and

think about the study and its aims before giving their final decision to participate. The

researcher then read and explained the contents of the participant information and

consent form. It was emphasised that joining the study was voluntary, the possible

benefits and risks of joining the research were stated, and the participants were told

they could withdraw at any time without penalty. In addition, it was stressed that all

50 Chapter 4: Methods

collected information would be treated with confidentiality and anonymity, and that

the interview would be audio recorded. Details were given about how and when the

participants would be provided with a copy of the final research and a summary of the

research findings. Participants were given the opportunity to ask clarifying questions

prior to signing the consent form to ensure that they were fully informed. The informed

consent was recorded as a written agreement and was signed by both the researcher

(as the interviewer) and the participant. A signed copy of the participant information

and consent form was given to participants for their own records. The strategy was

successful and a total of five participants consented to participate.

4.4 PARTICIPANTS

Participants in this study consisted of Filipino registered nurses working at

Makati Medical Center (MMC), Metro Manila, Philippines. Criterion based sampling

was used to select information rich cases for the study (Liamputtong, 2009; Patton,

2002; Trochim & Donnely, 2007). Selected participants were taken from a pre-defined

group of registered nurses who had completed their nursing degree in the Philippines.

They had all engaged in regular, full-time equivalent employment as an RN within the

last two years, and intended to apply for overseas nursing employment. An intention

to migrate overseas was defined as either a participant planning to or having submitted

an application for overseas employment, or who had verbally expressed desire to work

overseas.

Five female participants met the study criteria and were individually interviewed

in a private room at MMC. The participants were given pseudonyms (Anna, Brenda,

Charice, Deborah, and Ellen). Participants were between the ages of 20 and 30 years

old; four were single and had never been married, and one was a single mother. Anna

was living with her family and had been working for the past two years. She received

a study grant from her employer, which was financial assistance given to her to

complete her nursing degree. After graduation and passing the national licensure

examination, she was automatically employed at MMC as a condition of her study

grant agreement. She was working full time as a charge nurse (equivalent to a Clinical

Nurse in Australia) in a medical unit. Brenda was also single and living with her family

during the interview. She had been working as an RN for more than two years. She

had also received a study grant from her employer during her nursing studies. She was

also working full time as a charge nurse in a medical unit. Charice had been practicing


as an RN for the past two years. She was working fulltime in a medical unit and was

also living with her family. Deborah was a single mother, but was also living with her

family. She had been practicing as an RN for more than three years and was working

as a head nurse (equivalent to a Nurse Unit Manager in Australia) in a medical unit at

the time of interview. Lastly, Ellen had been an RN for more than two years, and was

working as a nurse educator. Like all of the participants, she too was living with her

family. All of the participants were living in Manila, Philippines and categorised

themselves as middle-class workers. Common destinations for all of the participants

were the Middle East and Northern America. All had submitted applications for

migration, with Anna, Brenda, and Charice having already been allocated to an

overseas employer at the time of interview, whilst the other two were still awaiting the

outcome of their applications.

4.5 SAMPLE SIZE

Choosing the participant sample size in phenomenological research is about the

quality of data and not the quantity of people (Todres, 2005, pp. 109-10). The aim of

phenomenology is “not to count how many people have had a particular experience”

but rather the aim is “to understand a phenomenon more deeply through the adequate

exposure to the qualities of the phenomena that are given by the living of the

phenomenon” (Liamputtong, 2009).

In Heideggerian phenomenology, the aim of the inquiry is to explore in detail

how participants make sense of their life world in relation to a particular event or

phenomenon by studying the meaning of their experiences. The methodology is more

concerned with detailed examination of the participants’ personal and social world, as

well as what it means for participants to experience the study phenomenon. Sample

size is about the participants’ ability to express experiences about a study phenomenon

using thick and rich descriptions. Experiences are described during interviews with a

focus on how each person views their life world, their feelings, and intentionality.

Interviews during this study relied on each person’s ability to express their experiences

as a detailed account of what it felt like to be them and to experience the study

phenomenon. All participants communicated rich descriptions of their experience

citing their personal and specific experiences of the study phenomenon; and all were

included in the data analysis. Participants were able to express themselves freely using

the English language and there were no identified communication barriers, such as


accents, slang, or known contextual misunderstandings of what participants were

expressing to the researcher (interviewer).

4.6 DATA COLLECTION

Data were collected through in-depth semi-structured interviews (Bryman, 2008;

Esterberg, 2002). The interview is “a specific form of conversation where knowledge

is produced through the interaction between an interviewer and an interviewee”

(Kvale, 2007, p. xvii). The interview is the main method of data collection for

phenomenology because it provides opportunities for participant descriptions to be

explored, illuminated, and gently probed (Kvale, 1996). The aim is to gain perspectives

and insights from participants (Johnson, 2002), and for participants to reconstruct their

experiences of the phenomenon under study (Seidman, 1998). The in-depth semi-

structured interviews in this study allowed the researcher to weigh up participant

responses and explore some of their motives and experiences. Semi-structured

interviews allowed participants a degree of freedom to examine and explain their

thoughts, highlighting areas of particular interest. The strategy also provided the

opportunity to question and explore their responses in greater depth. The aim of the

interviews was to bring out and resolve apparent contradictions and explanations that

were unclear (Horton, Macve, & Struyven, 2004) in order to bring about rich

description and a defendable interpretation of the data.

Interviews were conducted in English in a private interview room and each lasted

for at least an hour, and were audio-recorded. Recording the interview created a more

relaxed atmosphere because the interviewer was freed from the distraction of note-

taking and able to concentrate on interacting with the participants (Whiting, 2008).

During the interview, participants were asked open-ended questions and encouraged

to express themselves freely and without reservation. Open-ended questions

established the territory to be explored while allowing participants to take any direction

they wanted (Seidman, 1988). However, the researcher did have some established

general areas of focus for investigation to ensure that he had some control over the

conversation (Liamputtong, 2009). Interview questions pertained to the working

experience of each participant at MMC, their intentions to migrate overseas, their

expectations of working overseas, and their thoughts on Filipino nurse migration. The

following are the semi-structured questions used during each interview:


1. Can you tell me about a usual day working at MMC as an RN?

2. Can you please explain to me what made you decide to seek overseas

migration?

3. Why do you want to migrate overseas? Can you explain your reasons for

migration?

4. What are your expectations of migrating to (country of destination)?

5. What are your thoughts about Filipino nurses leaving to work overseas?

4.7 TRANSCRIBING INTERVIEWS

Transcription is the transformation of an oral text to a written form and is the

initial stage of data analysis (Gibbs, 2007). Each interview was transcribed verbatim,

keeping the informal conversation style and emotional expressions such as pauses,

emphases, laughter, etc. Pseudonyms were used to protect the personal information of

participants. A Filipino professional transcriber was hired to transcribe each interview

after signing a confidentiality agreement. Both questions and answers were

transcribed. After transcribing, the researcher listened to the tape to review the

transcribed texts to check for any error(s). All data were electronically saved in the

QUT drive system and saved in a password protected folder. All scanned consent

forms were also stored in the same electronic storage file.

4.8 DATA ANALYSIS

4.8.1 Hermeneutic circle

Hermeneutics is about understanding dasein. The goal of hermeneutics is for

dasein to understand itself on the basis of pre-established understanding of the person.

By grasping an understanding of the world and relationship of being the world, and

vice versa, dasein positions itself more properly towards its proper existence. This

means better understanding of a person based on individual characteristics and their

existence. The process of understanding dasein is achievable through the hermeneutic

circle of analysis. Hermeneutic circle of analysis involves interpretation of texts in a

repeating manner. When a text is interpreted using a hermeneutic circle, it is claimed

to assist in understanding our existence - our being (Martinkova & Parry, 2016).

Hermeneutic circle guided the process of data analysis in this thesis. It refers to the

methodological process of analysing texts through continual movement of


interpretation between parts of the text (data) and the whole (evolving understanding

of the phenomenon) (Ajjawi & Higgs, 2007). These two parts (text and whole) give

meaning to each other and are ways of understanding the participant experience.

Additionally, the data analysis process is circular. Interpretation includes and embeds

the researcher himself in the process of understanding texts, using his own

preconceptions, but keeping aware of these, the texts and its contextual meanings, and

other relevant information related to the study phenomenon (Polit & Beck, 2013), such

as information from the literature review. The process is what Heidegger called

“original repetition” (as cited in Martinkova & Parry, 2016). How I interpret texts and

the meaning originating from them is the result of how my life world and experiences

relate to the texts and the story itself, and the contextual meanings of the texts

(historical, cultural, social, political implications of texts read). Hence, it is given

meaning by how I interpret the story. Interpreting texts in hermeneutics through

disclosing what the texts are related to is very necessary (Martinkova & Parry, 2016).

The analysis process involves the acquisition of history for the present, which serves

to determine the context of what the text implies from historical, cultural, and social

perspectives. A hermeneutic circle requires both the texts and the whole story to be

exploited and counter-checked in the analysis, but also to disclose how the interpreter

arrived at such a conclusion or meaning.

A hermeneutic circle as a means of analysing data also means that contexts

between texts is understood where the person or participant, his or her family, and his

or her community are considered in analysis and interpretation (Cohen, Khan, &

Steeves, 2000). Data interpretation arises from the meanings developed by the

researcher from texts, yet importantly, it is still directed by the texts themselves and

not merely by the researcher’s own personal interpretation (Ajjawi & Higgs, 2007).

Additionally, interpretation of data in this thesis became more rigorous as the

researcher became open to questioning his interpretation of the study phenomenon,

and through allowing participants’ excerpts as texts to inform answers to arising

questions.

A hermeneutic circle of analysis is an important concept explained by Heidegger

and was used in this study. To understand the meaning of what being a Filipino nurse

seeking to migrate overseas means, was to let participants think and reflect about the

meaning of their intentions and the lived experiences that informed the decision to


migrate overseas. This process can be described in an analogy where someone tries to

learn how to play basketball. A great basketball player does not question his being and

the reason for playing basketball during the game. He is immersed in the game, and

his goal is to shoot the ball to the ring in order to win. However, if that player suddenly

loses the ability to play the sport, he realises the value and meaning of playing

basketball. There’s a problem that emerges for that person who faces the existence of

being a basketball player and it suddenly becomes a “concern”. Questions such as how

he should re-organise life and his ability to get back to playing basketball become

issues. This process of understanding being can also be achieved by removing one’s

self from the busy-ness, or outside the sport engagement. This can happen through

quiet moments, pondering about passion for the sport, or the implications of an injury

from playing the sport. Interviewing participants in quiet rooms, asking questions that

helped them to reflect on the meaning of their desire to migrate overseas, and to openly

talk about what they felt within the protection of research privacy and confidentiality

helped disclose participants’ experiences of what it really meant to intend to migrate

overseas. The things that were of concern and issues for them were investigated during

the interviews, and were probed deeply so that the interpretation of experiences was

as objective as possible.

Interpretation of the texts was taken from the whole story and the context of

where it was from. For example, Brenda initially shared that she wanted to support her

ailing parents. Upon questioning, she was able to express that this act of medically

supporting her parents was seen as an expression of her utang na loob, or reciprocity

to her parents. Brenda’s concern at the time of the interview was in regards to the

things she could do for her parents; she even defined this as “life success”. With this

interpretation, helping parents was a descriptive explanation of the “concern” of

Brenda wanting to migrate overseas. Through the hermeneutic circle of analysis this

type of explanation was able to be linked to a contextual meaning. There is a cultural

value enclosed within the explanation, and without help through interpreting phrases

originating from the context of the texts and Brenda’s entire story, the cultural

implications could easily be ignored.


4.8.2 Seven-stage data analysis

In order to best achieve a hermeneutic circle as a way of data interpretation for

this study, Diekelmann, Allen, and Tanner (1989) described a seven-stage process of

data analysis, and this framework was adopted by the researcher (see Figure 4.1).

Figure 4.1. Seven-stage process of data analysis

The following describes the Diekelmann, Allen, and Tanner (1989) processes in

depth:

• Stage 1: The researcher examined each transcript after transcription of the

participant interviews. During this stage, the researcher listened several

times to each audio recorded interview whilst checking the accuracy of the

transcribed texts. This was the stage where the researcher immersed himself

in participant stories whilst examining each text and phrase. Minor editing

was done wherein participants personal identifications were removed, as

well as the inclusion of researcher’s notations within the transcripts during

the actual interview, such as, if a participant emphasised a particular story,

they may have used hand gestures, facial expressions, and body language.

All of this was included in the transcripts to assist with a more objective

analysis.

• Stage 2: During this stage, the researcher divided the transcripts into

interpretive sections by looking for natural breaks within texts or identifying

transitions between stories. Each interpretive section was given a summary

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 Stage 7

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).


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


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


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


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.


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


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.


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.


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


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


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


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.


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…”.


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).


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


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


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


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,


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”.


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


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…”.


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


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


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.


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


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-


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


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


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”.


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


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


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


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


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


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.


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


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,


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


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


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.


(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


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:


…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).


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


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).


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


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.


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:


… 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,


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:


…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


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


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


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


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


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

144 Appendices