“If I have seen further, it is by standing on the shoulders of giants.”–Isaac Newton

Introduction: Editor's note

In May, we celebrate Asian/Pacific American Heritage Month, recognizing the contributions and influence of Asian Americans and Pacific Islander Americans (AAPI) to the geopolitical history, culture, and achievements of the United States.

AAPI month originated with Congress in 1978. Then-President Jimmy Carter started a week-long celebration in the first week of May, which was later expanded to a month of recognition. May was chosen because it commemorates the migration of the first immigrants from Japan to the United States on May 7, 1843 and recognizes the completion of the transcontinental railroad by over 20,0000 Asian immigrants on May 10, 1869 (Library of Congress, 2022).

Those included in the designation AAPI are “all people of Asian, Asian American or Pacific Islander ancestry, who trace their origins to the countries, states, jurisdictions and/or the diasporic communities of these geographic regions” (Pew Research Center, 2021).

The U.S. Census Bureau classifies people of Asian descent as “having origins including, but not limited to China, Japan, Thailand, Malaysia, Korea, India, Cambodia, Vietnam, or the Philippines. Pacific Islanders are people who descended from the islands of Polynesia, Micronesia, and Melanesia. This includes, but is not limited to people from Native Hawaii, Samoa, Tahiti, Guam, Fiji, and Papua New Guinea” (U. S. Census Bureau, 2022).

Few of us have thought about the significant contributions and the complex history of AAPI nurses and nurse practitioners and how their efforts have moved our profession and our role forward in the United States. Many countries, peoples, and cultures are included in AAPI Heritage Month. Although all are deserving of recognition, this editorial will feature the work of Dr. Jamille Nagtalon-Ramos, a third-generation nurse, assistant professor of nursing at Rutgers University, and women's health nurse practitioner who pioneered the hospitalist role in the Department of Obstetrics and Gynecology at Penn Medicine two decades ago. Here is her story.

My family's immigration story

I was in second grade in 1986 when the People Power Revolution changed the tide of power in the Philippines from a dictatorship to a democratic government. I remember my parents listening intently to the radio as they followed the news of the ousting of then-President Ferdinand Marcos and the swearing in of the new president, Corazon Aquino. Well before this tumultuous transfer of power occurred, tensions were high in the country during the 9 years of martial law and the consequential economic collapse in 1983. The trickle-down effect of a national economic decline spurred many Filipino families to search for jobs outside of the country. Our family was one of the thousands of Filipinos who had one or both parents leave their home for the possibilities of securing a brighter future for their children abroad. The caveat in our story, mirrored in the stories of nurses who were recruited to fill the nursing shortage in the United States, was that the visas granted to the Filipino health care workers were not extended to their family members at that time.

Our Christmas celebrations were cut short when my mother left the Philippines in November 1986. She was recruited to work as a nurse in a pediatric intensive care unit in a children's hospital in one of the most populated cities in New Jersey. She would eventually work in the same unit and same hospital for 36 years until her retirement in 2022. Her first 6 years of working at St. Joe's taking care of acutely ill children was spent away from her own children and husband. My younger brothers and I lived with my father back in Manila. We saw my mother for a few weeks every year whenever she accumulated enough vacation time to make the 20-hour flight back to the motherland.

In January 1993, my mother was able to petition us and finally bring the whole family to the United States. At this point, I was 15 years old, and my brothers were 10 and 4 years of age. Making it to America seemed to be the ever-present goal since my mother left many years prior. But when the Northwest Airlines flight touched down in Newark International Airport, I looked out the plane's tiny window into the darkness of winter and felt the passing of the baton to a new unspoken goal: live a life that would make the generational sacrifices of the past, present, and future worth it. I wondered what our new life would be like reunited as a family in this country full of potential unknowns.

With only two bags of luggage in tow holding all my tangible life as a teenager, I left all my friends, grandparents, titas, titos, and cousins, to live in a country where I knew no one besides my parents and siblings. I had no choice but to start from scratch and build a new life from the ground up. Because we did not yet have the internet and social media, what I knew about America was primarily based on John Hughes' movies from the 80s and the Sweet Valley High books I read growing up. To my surprise, going to a Catholic high school (particularly as a non-Catholic) in Wayne, New Jersey, did not live up to the glorious level of angst that the Breakfast Club promised.

Finding my own way into nursing

Although my parents went to college in the Philippines, I was the first one to go to college in America. Setting foot in a university was a milestone after I found my own way through the maze of college applications and financial aid. I had to navigate college without a road map or breadcrumbs from my parents. I chose the largest, most diverse college that was not too far away from home. I started as a Biology major at Rutgers University but switched over to nursing within a year. The catalyst was not a sudden change of heart spurred on by a desire to follow the career footsteps of my grandmother and mother, but a practical, financial decision. At the end of my first semester in college, my father died of a heart attack. My family was devastated as we yearned and expected many more years together to make up for all the years apart. As with most immigrant families, we did not have the cushion of generational wealth or the luxury of extended family in America who could provide assistance. I knew I needed to find a well-paying job to support myself after college and not add to the burden that my mother faced as a young widow.

I started my career at Penn Medicine as a nurse extern during my senior year of nursing school. On graduation, I was hired as a staff nurse in the Mother-Baby unit and started graduate studies at Penn's Women's Health Nurse Practitioner program. My mother and many of her Filipino nursing colleagues shared their opinions about my pursuit of a women's health specialty. They tried to persuade me to choose med-surg or the ICU where many, if not most, of the Filipino nurses of their generation were funneled into during the height of the AIDS crisis in the 1980s.

Editor's note: In the classic book on Filipino nurse immigrants to the United States, “Empire of Care” (Choy, 2003), the author points out that at least 25,000 Filipino nurses came to the United States seeking work between 1966 and 1985.

Why so many Filipino nurses immigrated to the United States

It was not by luck or by accident that Filipino nurses were, and continue to be, prime candidates to fill the gaps in the U.S. nursing workforce. Filipinos generally spoke basic English well because English was the primary language of instruction in the educational infrastructure that Americans established in the Philippines in the early 1900s (Osborne, 2021). During this time of the United States' annexation and “benevolent assimilation” of the Philippines, missionaries and colonialists' spouses started nursing apprenticeships to train Filipinos to become nurses. Two of the pioneer traineeship hospitals established in 1907 were Philippine General Hospital (PGH) and Mary Johnston Hospital. My maternal grandmother, Lydia M. Venzon, received her nurse training at PGH in the late 1940s and decades later became the Dean of Mary Johnston.

In March 2020, when the world faced a new crisis, Filipino nurses, many of whom like my mother, at the cusp of retirement, were still working the frontlines well into their 60s and 70s in acute care units across the globe. Again and again, they have found themselves at the forefront of a calamity, but this time, the first wave of Filipino nurses worked side-by-side with the next generation of Filipino American nurses like me. Because of their proximity working with the sickest patients in ICUs during the COVID-19 pandemic and the lack of availability of protective personal equipment, compounded by their advanced age and increased risk for chronic illnesses like cardiovascular disease and diabetes, Filipino nurses made up almost 30% of all COVID-related deaths among nurses even though they only account for 4% of registered nurses in the United States (National Nurses United, 2021; Raquinio et al., 2021; Ye et al., 2009). This study from National Nurses United (2021), whose president is a Filipino American, Zenei Triunfo-Cortez, disaggregated the data on nursing and health care worker deaths during the pandemic, thus capturing the disparities not only among people of color and their White counterparts but also between Asian subgroups. This is a primary example of the importance of having Filipino American nurses in leadership roles who can advocate for communities whose voices are often underrepresented in research, policy, practice, and education.

On executive boards of national health organizations, expert panels, research conferences, higher education circles, and leadership committees, including FAANP's Executive Committee, I often find myself as one of a handful, and often the only, Filipino American nurse practitioner at the table. At my induction to the Fellows in 2019, my husband and I wore traditional Filipino outfits to represent our cultural roots. I wore a vintage filipiniana dress borrowed from one of my mother's classmates from the University of the Philippines' College of Nursing, and my husband wore a barong, an embroidered long-sleeved button-down shirt made from piña jusi. I felt a bit out of place as a neophyte and for not being able to recognize more Asian Americans in a room full of hundreds of national nursing leaders. The soiree that followed the awards ceremony was in full swing as my husband and I stood in line at the bar sandwiched between other fellows and their plus ones. I then saw a fellow dressed in her dazzling evening attire make a beeline for my husband. She proceeded to ask my husband to refill the water glasses at her table. She did not ask the fellow in front of us nor the ones behind us in line but instead asked the person of color who she instantly and implicitly decided did not belong.

Why many nurses from the Philippines who came to the United States did not have the opportunity to go to graduate school

To help develop a more robust pipeline of Filipino American nursing leaders, I decided to study the educational attainment among Filipino American nurses (Nagtalon-Ramos, 2017). I found several barriers to a graduate nursing degree, the typical expected minimum level of education to leadership pathways in health systems and administration, schools of nursing, and health policy. Cultural values, such as utang na loob (debt reciprocity), tethered nurses to their duties to their families back in the Philippines. They were determined to work extra shifts for bonus compensation, night shift for the extra differentials in pay, and a second job to simultaneously support their family in the United States and send money back to the extended family they left behind in the Philippines. The priority for coming to America was not to go back to school to obtain a graduate degree and find leadership positions but to find work to build economic stability for everyone in their family (Nagtalon-Ramos, 2020). These ties to the Philippines, cemented by ancestral obligation of utang na loob, translates to a large amount of remittances every year. In 2022, the money sent by overseas foreign workers back to the Philippines totaled $36.14 billion, which accounted for 8.9% of the Philippines' gross domestic product according to the Bangko Sentral ng Pilipinas (Arceo, 2023).

These ancestral ties continue to pull my family toward the nursing profession as we currently wait for decision letters from several undergraduate nursing schools. My son decided a few months ago that he wishes to become a nurse. His pursuit of this career will make him the fourth-generation nurse in our family. Looking through that tiny window on the plane as I landed in America on that cold, dark, winter evening 30 years ago, I never could have imagined this life and this career in nursing that has been made possible by standing on the shoulders of the giants who came before me. And now, 21 years into this profession, caring for patients and educating hundreds of undergraduate and graduate nursing students, I get the privilege to hold my own son to stand on my shoulders so he can see further.

Implications for nurse practitioners: Editor's note

This month's editorial is a moving exemplar of how nursing has affected, and been affected by, generations of individuals and families from southeast Asia. As the nursing profession and nurse practitioner role continue to make strides to diversify, it is critical to ensure that those who wish to advance their roles have the opportunity to do so. Recognizing the sacrifices that previous generations of nurses have made to help the next generation advance is key. It is important to ask nurses and nurse practitioners with many years of experience to tell their stories. An appreciation of history helps newer generations of nurses understand the gravity of their work. The advancement of nurse practitioner science is not possible without the contributions of nurse scientists from diverse backgrounds.

References Choy C. C. (2003). Empire of Care: Nursing and Migration in Filipino American History. Duke University Press. Library of Congress (2022). Asian Pacific American Heritage Month. https://asianpacificheritage.gov/ Nagtalon-Ramos J. (2020). Pakikipagkapwa and utang na loob: The infuence of family and culture in graduate degree attainment among Filipino American nurses. Journal of Nursing Practice Applications and Reviews of Research, 10(1), 56–66. https://doi.org/10.13178/jnparr.2020.10.01.1007 Nagtalon-Ramos J. K. (2017). Factors Affecting Graduate Degree Pursuit for BSN-Prepared Filipino and Filipino American Nurses Working in the United States. University of Pennsylvania. National Nurses United (2021). Sins of omission: How government failures to track COVID-19 data have led to more than 3,200 health care worker deaths and Jeopardize public health. https://www.nationalnursesunited.org/sites/default/files/nnu/documents/0321_Covid19_SinsOfOmission_Data_Report.pdf Osborne D. (2021). The promise of English: Benevolent assimilation, education, and nationalism in the Philippines. Journal of Multilingual and Multicultural Development, 42(7), 581–594. Pew Research Center (2021). Key facts about Asian Americans, a diverse and growing population. https://www.pewresearch.org/fact-tank/2021/04/29/key-facts-about-asian-americans/ Raquinio P. A. S. H., Maskarinec G., Dela Cruz R., Setiawan V. W., Kristal B. S., Wilkens L. R., Le Marchand L. (2021). Type 2 diabetes among Filipino American adults in the multiethnic cohort. Preventing chronic disease, 18, E98. https://doi.org/10.5888/pcd18.210240 Ye J., Rust G., Baltrus P., Daniels E. (2009). Cardiovascular risk factors among Asian Americans: Results from a national health survey. Annals of epidemiology, 19(10), 718–723.