AMAT Educational Series

1. AMAT Educational Series Cultural Conversations – Understanding Filipino Nurse History and Working with Filipino Families Hosted by the AMAT Asian Pacific Islander Committee Chair: Sabrina Ho

2. Objectives • Develop an understanding of Filipino nurse history from the Philippines to United States • Explore Filipino nursing culture • Overview of Filipino culture surrounding death/dying • Best practices when working with Filipino families

3. A History of Filipino Nurses in the United States Professor Catherine Ceniza Choy University of California, Berkeley Department of Ethnic Studies

4. Presentation Objectives • Give an historical overview of Filipino nurse migrations to the U.S. • Identify some of the current developments of this phenomenon • Reflect on Filipino nurse cultural beliefs surrounding medicine

5. Empire of Care: Nursing and Migration in Filipino American History • Co-published by Duke University Press and Ateneo de Manila University Press in 2003 • Documents the creation and development of a Philippine professional nurse labor force for international export • Places a “human face” on the phenomenon of Filipino nurse migration

6. Why focus on Filipino nurses? • Since the late 1960s, the Philippines has been the leading exporter of nurses to the United States • By the late 1970s, the Philippines became the world’s leading exporter of nurses • A 2005 study noted that Filipino nurses make up almost 40% of the internationally trained nurses in the US, with about 100,000 nurses or 3.7% of the total US nursing force.

7. Historical Overview of Filipino Nurse Migration to the United States • Filipino nurse migration to the United States is not a 21st century phenomenon • originated during the early U.S. colonial period in the Philippines • U.S. colonial government created an Americanized training hospital system

8. “1915 Class and the Superintendent of the School of Nursing, Philippine General Hospital School of Nursing,” 1915-1916

9. “Senior Class Receiving Instruction in Operating-Room Techniques,” from Philippine General Hospital, 1915-1916

10. Maria Abastilla Beltran (left) prior to her departure to America in 1929

11. Historical Overview of Filipino Nurse Mass Migrations • Recruitment of Filipino nurses to alleviate U.S. nursing shortages began in the 1950s and continued throughout the second half of the 20th century • 1950s-1960s Exchange Visitor Program • 1960s-1970s Occupational Immigrant Visas • 1970s-present Temporary Work Visas (H-1) • 1990s-present EB-3 immigrant visas

12. 1965 Advertisement in Philippine Journal of Nursing: “Travel as a simple route to happiness”

13. 1969 Advertisement in PJN Targets Exchange Nurses for Permanent U.S. Employment

14. Changing Attitudes About the Significance of Filipino Nurse Migration • In the early 1900s, Philippine nursing was conceptualized as a form of nation-building • In the 1960s, Philippine government criticizes exchange nurses who remain in the U.S. as national traitors • Beginning in the 1970s, Filipino overseas nurses are conceptualized as national heroes

15. Past and Present Challenges Faced by Filipino Nurse Migrants • Fraudulent recruitment practices • Exploitive work conditions • Resentment between“foreign” and “home-grown” nurses • Language issues (testing; English-only)

16. Current Developments and Resources • International export continues • Reports of Philippine doctors enrolling in nursing degree programs to work overseas • Ethical dilemmas continue • Multiple generations of Filipino nurse migrants exist • Philippine nursing organizations abroad are important resources (Philippine Nurses Associaton of America or PNAA)

17. Cultural Beliefs Surrounding Medicine Filipino nurse training in and incorporation of Western medical practices is dynamic • Persistence of traditional beliefs; for example, the significance of keeping the body intact for viewing and burial • Fear of the unfamiliar and unknown • The need for new narratives, educational resources, and community support

18. Catherine Ceniza ChoyContact information Please feel free to contact me by email at ceniza@berkeley.edu The link to my faculty webpage can be found at http://ethnicstudies.berkeley.edu/faculty/

19. End of Life discussions with a Filipino Family Michael Munoz-Romero RN CCRN CPTC Procurement Transplant Coordinator 05/16/2013

20. How does Philippine law define “death”? Republic Act 7170 or the “Organ Donation Act of 1991” in Section 2, paragraph J • j) “Death” - the irreversible cessation of circulatory and respiratory functions or the irreversible cessation of all functions of the entire brain, including the brain stem. A person shall be medically and legally dead if either:(1) In the opinion of the attending physician, based on the acceptable standards of medical practice, there is an absence of national respiratory and cardiac functions and, attempts at resuscitation would not be successful in restoring those functions. In this case, death shall be deemed to have occurred at the time those functions ceased; or (2) In the opinion of the consulting physician, concurred in by the attending physician, that on the basis of acceptable standards of medical practice, there is an irreversible cessation of all brain functions, and considering the absence of such functions, further attempts at resuscitation or continued supportive maintenance would not be successful in restoring such natural functions. In this case, death shall be deemed to have occurred at the time when these conditions first appeared.The death of the person shall be determined in accordance with the acceptable medical practice and shall be diagnosed separately by the attending physician and another consulting physician, both of whom must be appropriately qualified and suitable experienced in the care of such patients. The death shall be recorded in the patient’s medical record.

21. Superstitious Beliefs • Have grown in number throughout the various regions and provinces in the country. • These beliefs have come from the different saying and superstitions of our ancestors that aim to prevent danger from happening or to make a person refrain from doing something in particular. • These beliefs are part of our culture, for one derives their beliefs from the influences of what their customs, traditions and culture have dictated to explain certain phenomena or to put a scare in people. • Some are practiced primarily because Filipinos believe that there is nothing to lose if they will comply with these beliefs.

22. Superstitious Beliefs about death

23. Superstitious beliefs • When a member of the family has persistent fever, the spirit of a deceased relative is presumed to remind the family of an unfulfilled obligation to the departed soul. • To scare the spirits away and to cure those afflicted by the evil spirits, the curative practices are: to flog the patient, put signs of the cross on his forehead or at every post of his house, and make all kinds of noises; sacrifice some live animals or offer some food, buyo and oil to appease the offended spirit; and wear amulets (anting.anting) to neutralize the machinations of the devil. • When a sick person is seriously ill or is pronounced by reputable physicians as hopeless or incurable, he and his family have that instinctive urge to resort to the cure of the magicians, wizards, sorcerers, voodoos, mystics, conjurers, manghihilot (sprain curer), herbokirios, or faith-healer, be it of dubious value. Remorse comes if they do not resort to such a practice because as a result of breaking away from old beliefs and practices, someone in the family might keep saying ever afterward, If only we had done this, the patient might have pulled through.

24. Some more: • After a person dies, his soul wanders around, for a time at least, before it goes to its final assignment. To keep this soul from molesting the bereaved family, relatives, and friends, and to coax it to go to its resting place, a novena should be recited for nine consecutive days. • Friday the 13th is an unlucky day-doubly unlucky-for anyone who does any business, work, or operation.

25. ASSESS THE FAMILY Things to consider • Is family gathered at bedside? Who is present? Any idea on religious preference? • Are there Filipino nurses in the unit? What is their view on Donation? • Has anyone met with the family MD or RN? • Are there any additional family members on their way? Chances are, there is one or more family members in the Healthcare industry • Does the MD plan to meet with the family again? Or is the RN relaying MD’s information to the family? MAKE SURE THERE IS ENOUGH TIME TO GATHER THESE INFORMATION!

26. EXPLORE • Are there other family who aren’t present? • Ask if they would like to call any other family the discuss decision. • Have you mentioned directed donation? • Families don’t always remember they know people in need. Mention that if they know someone on a transplant waiting list that they would be tested first. • Has the priest been by to give “last rites”?

27. Further explore • Does the family know what to expect after declaration? • Are there more family expected from out of state or from the Philippines? • Does the family have any questions about Medical Examiner or Funeral home?

28. Organ Donation in the Philippines

29. Organ Donation • Because of the Philippines' deep family ties, religious devotion and superstitious/traditional beliefs, the number of cadaver harvests is dismally low. To help relatives make the decision to donate, the Organ Donor Card project was started. Although not the equivalent of a legal consent document at the present time, it can help the relatives realize that the donor has consented beforehand and that his wishes be respected. • Cadaver Organ Donation in the Philippines is still in its infancy even though it was started way back in 1983 because of budgetary constraints. However this does not daunt the people of HOPE to do the best they can. *LIVING RELATED ORGAN DONATION IS STILL PREFERRED

30. The Stolen-Kidney Myth • The original story comes from a "friend of a friend/cousin/neighbor" who is supposed to have walked into a bar and met an extremely beautiful girl who allows herself to be seduced by the friend.  After a few drinks they go to a nearby hotel/motel.   The next thing he remembers is waking up in a bathtub, filled with ice and a fresh incision scar on his back.  Consulting his doctor he finds out that one of his kidneys had been removed and is warned that there is a syndicate specializing in stealing kidneys from healthy looking people, drugging them and performing the surgery in a hotel/motel room.  The kidneys are then sold to wealthy people who need the organ

31. Organ Donor Card • In the Philippines, this is only INTENT to donate.

32. The Donation Conversation • Transition to donation – this will differ based on designation vs. not designated • Designated – Make sure you discuss legalities of the “Donor Dot” • “I wanted to share with your family that Jane had made the decision, when she was able, to designate herself on her driver’s license as an organ and tissue donor.” • That is a big deal! Make sure to tell the family so! • “My role is to support your family through honoring Jane’s wishes to help others. There are over 120,000 people waiting for organ transplants, and Jane is in a very unique position to be able to save the lives of some of these individuals. . .” • Assume family is going to support patient’s wishes.

33. The Donation Conversation • Before going to conference room, ask if a translator is needed • “There are some other opportunities and resources we provide to every family when they are making end of life decisions. I just wanted to make sure if your family would be okay waiting to speak with her, and see if there is anything you need in the meantime (call a chaplain, water, etc).” • Ask the family to go to conference room to speak with you (Preferred).

34. The Donation Conversation • Not Designated • Introduce the opportunity for donation; stress how important it is while apologizing if it is an imminent situation. Do NOT apologize for what you are offering! • “I apologize for interrupting your family during this impossible time, and I only do so because after talking to [RN,SW] we realized there was some important information we hadn’t been able to share with your family. Jane is in a position to save someone else’s life through organ and tissue donation . . .” • Discuss the “standards” – the great need, unique position, etc. • Normalize that they likely have not discussed it. • Stress that they knew Jane best, and would know if she would want to help others if given the opportunity.

36. Questions?

37. Next AMAT Educational Series Webinar June 6, 2013, 2pm ET Increasing Donor Designations through Partnerships in the African American Collegiate Community 2013 AMAT Annual Conference