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Beyond Western Expectations: Filipina Nurse Leaders Anastacia Giron-Tupas and Julita Villaruel Sotejo, 1910-1950

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Reynaldo Capucao, Jr., MSN, RN, CNL

Abstract

Since the early 20th century, Filipina/o nurses have actively shaped the global nursing profession. The United States justified its acquisition of the Philippines through benevolent modernization of the islands, particularly through the importation of nursing. Attainment of leadership positions mostly became available to Filipina/os after completing postgraduate nursing education, which until 1922, was only available abroad. This article considers American nursing as an instrument for colonization, and describes the requisite travel for nurse leaders to complete the terminal degree in Philippine nursing education. The experiences of Filipina nurse leaders Anastacia Giron-Tupas and Julita Villaruel Sotejo provide insight into the formative years of Philippine nursing at the mid-century, and the power dynamic between Filipina/o and American nurses. Together, their shared experiences add to the broader history of contributions to nursing by nurses beyond the West. The article concludes with implications for nursing today.

Citation: Capucao, R., (May 31, 2020) "Beyond Western Expectations: Filipina Nurse Leaders Anastacia Giron-Tupas and Julita Villaruel Sotejo, 1910-1950" OJIN: The Online Journal of Issues in Nursing Vol. 25, No. 2, Manuscript 7.

DOI: 10.3912/OJIN.Vol25No02Man07

Key Words: Filipino nurses, migration, race, nursing, culture, Philippines, nursing leadership, transnational, transcultural, transimperial, internationally educated nurses, nursing shortage, ethics, global nursing supply, diaspora, history, professionalization

Since the 1970s, the Philippines has been the leading exporter of nurses around the globe...By the 1970s, the Philippines became the leading exporter of nurses around the globe, with the United States serving as a prime destination for many Filipina/o nurses (Choy, 2003). The first major wave of Asian immigration during the early 19th century and the identification in the United States of the Asiatic as the paradoxical myths of the "model minority" and the "yellow peril" (Lye, 2004; Santa Ana, 2016). The influx of Filipino nurses and their ubiquitous presence within U.S. hospitals has largely reinforce the model minority stereotype of Filipinos as nurses. However, this, alongside the paucity of literature surrounding these nurses as historical agents, has furthered the state's historicization of a seamless benevolent assimilation, which has hidden Filipina/os contributions to fields of nursing and healthcare in the United States.

According to Helen Sweet and Sue Hawkins (2015), the nursing profession has continually reinvented itself in accordance to transnational relationships, race, culture, class, gender, and politics under the contexts of colonial and post-colonial rule. However, histories examining nursing have typically reflected the view of white nurses struggling for professional identity, a metric that has often cast the white nurse as the only nurse worthy of historical merit (Wall, 2019). As a result, these histories undermine the agency of Filipina/o nurses in the professionalization of nursing at the local and global levels. Through Catherine Choy’s (2003) portrayal of the complex links connecting the current migration of Filipina/o nurses to American imperialism, transnational histories of Filipina/o nurse leaders from the early 20th century provide a lens into the formative years of Philippine nursing and the power dynamic between Filipina/o and American nurses.

These policies supported the transnational exchange of people and knowledge, as well as the transfer of a social environment built upon American values.Imperialism best described the polices of the United States at the dawn of the 20th century that aimed to extend the country’s political, economic, and cultural influence beyond its borders, unexceptional from other Western countries’ colonization of indigenous peoples (Immerwahr, 2019). These policies supported the transnational exchange of people and knowledge, as well as the transfer of a social environment built upon American values. Belying the benevolent intentions of imperialism, Daniel Immerwahr (2019) explains, was a distinct division between the United States proper and its territories wrought by ideas of racism and xenophobia that excluded inhabitants of the latter from the American political identity, despite being considered “American” subjects.

The Insular Cases of 1901, with its decision characterizing the newly colonized as “savages” and “alien races,” set the precedent that territories were not part of the US, and thereby not protected under the Constitution. Proponents against incorporating the territories theorized the eventual downfall of American institutions and eventual overthrow of the United States government (Immerwahr, 2019). Paradoxically, imperialism warranted the importation of American institutions to justify benevolent US expansion. Thus, the cases supported the creation of an in-between political identity: United States nationals. This political identity enabled Filipina/os unrestricted passage to the US until the Tydings-McDuffie Act of 1934, which revoked their status to aliens in preparation for the Philippines’ independence (Cordova, 1983).

Understanding the transcultural and transnational workings of Filipina/o nurses trained in the American model of nursing illuminates the unique relationship between the nursing profession, immigration, and social construction of race across the US. Asian Americanists have argued that Asian Americans have been treated as “implied blacks” for most of the history within continental US, also noting their treatment as “honorary whites” was quite unusual (Okihiro, 1994; Ancheta, 2010, p. 25). However, the history of nursing and migration viewed through experiences of pioneering Filipina/o nurses studying and working alongside their white counterparts in the US proper during the early 20th century portrays a narrative of professional and racial privilege to address the question: How did Filipina/o nurses view their politico-cultural identities in relation to transimperial body politics?

Together, Giron-Tupas and Sotejo displayed model traits associated with present day nursing leadership...This article examines the nursing careers of Filipina nurse leaders Anastacia Giron-Tupas and Julita Villaruel Sotejo, both of whom dedicated their life work to advancing the nursing profession domestically in the Philippines and globally. The two nurses overcame barriers as imperial subjects to advance a reputable image of the Filipina/o nurse and support the development of a Philippine nursing profession that catered to the well-being of the Filipina/o people. Together, Giron-Tupas and Sotejo displayed model traits associated with present day nursing leadership; evidenced by their continued learning; advocacy for the profession; ability to think critically; and support for interdisciplinary education. These characteristics guided their leadership, which proved integral to support the production of quality Filipina/o nurses and nursing’s affixation to Philippine culture over the 20th century.

American Nursing as an Instrument for Colonization

...the acquisition of the Philippines by the United States in 1898 created a transformative space for American nurse leaders to clarify nursing knowledge and practice boundaries.At the start of the 20th century, American imperialism coincided with the burgeoning American nursing profession and nurse leaders were searching for professional status and legitimacy. According to Sarah Abrams (1997), nurse leaders of the time failed to adequately define nursing knowledge and practice boundaries amidst a growing body of healthcare professions, and instead, focused on the inherent value and usefulness of nursing. Indeed, American colonialism generated further meaning for nursing in the propagation of modern healthcare and the cultivation of womanly virtue among the indigenous inhabitants of newly acquired territories. These colonies became experimental laboratories that supported projects of professionalization that were normally hindered by red tape and institutions within the US proper (Connerton, 2016; Immerwahr, 2019). Thus, the acquisition of the Philippines by the US in 1898 created a transformative space for American nurse leaders to clarify nursing knowledge and practice boundaries. But, the development of a Philippine nursing profession also required the agency of the Filipina/o people.

As advancements in biomedical sciences represented the peak of a modernization, the US imported its institutions of medicine, nursing, and public health into the Philippines. American characterizations of Filipina/os often depicted them as an unsanitary people, whose cultural practices made them susceptible to malaria, tuberculosis, and leprosy (Heiser, 1936; Anderson, 2006). The importation of the American model of nursing enabled white women to partake in the modernization of the Philippines and reaffirm a racialized and gendered hierarchy (Choy, 2003). By 1906, the Baptist Foreign Mission Society of America founded the Iloilo Mission Hospital School of Nursing, the first nursing school in the Philippines (Giron-Tupas, 1952). A year later, the US established the Philippine Training School for Nurses as the first government-funded school. Its name later changed to the Philippine General Hospital School of Nursing in 1910 upon the Philippine legislature’s passage of Act No. 1975. This placed the school under the supervision of Director of Health Victor Heiser (Philippine General Hospital School of Nursing Alumni Association [PGHSNAA], 2018).

The Philippine General Hospital became the center of modern healthcare reform in the Philippines and was comparable to modern United States hospitals of the time The Philippine General Hospital became the center of modern healthcare reform in the Philippines and was comparable to modern United States hospitals of the time (Brush, 1997; Choy, 2003; PGHSNAA, 2018). During its construction, nurse leader Lavinia Dock claimed that basic rudimentary knowledge of hygiene and sanitation, which she deemed innate among the American people, was non-existent among the indigenous people. However, this rudimentary knowledge was a recent development in the western world upon the widespread acceptance of germ theory. While the memoirs of Heiser and Dock piece together a relatively seamless integration of healthcare institutions into the Philippines, their histories are contested when examining the experiences of both American and Filipina/o nurses (Burnam, 1998; Dock, 1920; Cameron-Smith, 2017; Choy, 2003, p. 27-28).

Filipina/o nurses engaged with all parts of Philippine society from the classroom to the hospital, and throughout the community (See Picture 1). The nurses were cultural informants of American values and nursing, and latter afforded them unexpected social mobility. Curricula of educational institutions, including nursing schools, attempted to impart American values unto its students. The first nurse training schools were located around the Philippine capital of Manila and often separated Filipina/os from their families and communities for extended periods of time to groom them under the tenets of American nursing and western civility (Giron-Tupas, 1952).

Picture 1. Filipina nurses working at Zamboanga General Hospital, Philippines, circa 1920s.

Courtesy of Albert Acena. Used with permission.

Filipino men also took up nursing, but their enrollment dwindled during the 1920s after postgraduate and employment opportunities in the profession were stifled... Filipino men also took up nursing, but their enrollment dwindled during the 1920s after postgraduate and employment opportunities in the profession were stifled by the American-run Red Cross and Public Welfare Commission (Brush, 1997). Regardless, Filipina/os who studied nursing did not simply acquiesce to American culture. Despite their racialized status as colonial subjects, some Filipino men used nursing as a stepping stone to pursue a medical degree abroad, and Filipina women, similar to their American counterparts, forged their own paths using nursing as a vehicle for social mobility (Lynaugh, 2002; Giron-Tupas, 1952). Entry into nursing placed Filipina/o nurses, specifically women, into uncharted racialized spaces between the Philippines and the US, as they advanced their nursing education in the US and demonstrated their competency as “American” nurses.

Travel to the United States: A Requisite for Nursing Leadership

Filipina/o nurses pursuing an education abroad was considered the natural progression and terminal point of nursing education.The migration of Filipina/o students to the US first began in 1903 with the passage of the Pensionados Act, which created a study abroad program for students to further their education at United States universities (Choy, 2003; Cordova, 1983). The exact number of nurses who participated in the program is unclear, but most participants were male, a reflection of traditional American gender roles formed during the Victorian period. Receiving an education in the US was associated with upward social mobility. Families from lower socioeconomic backgrounds often concentrated their resources to pay for their eldest sons to cross the Pacific Ocean and matriculate into the United States educational system (Fujita-Rony, 2003). From 1898 to 1934, Filipina/os’ status as US nationals granted them the ability to migrate freely to the United States proper despite growing anti-immigration laws restricting persons from Asia proper. Filipina/o nurses pursuing an education abroad was considered the natural progression and terminal point of Philippine nursing education.

In exchange for these scholarships, stipulations often required nurses to return home and propagate their knowledgeIn 1911, the departure of three Filipinas to continue their nursing education at Protestant Episcopal Hospital in Pennsylvania marked the first migration of Filipina/o nurses abroad (Giron-Tupas, 1952). During the first half of the 20th century, Filipina/o nurses’ primary opportunities to study abroad came from scholarships funded by either the colonial government or philanthropic institutions. In exchange for these scholarships, stipulations often required nurses to return home and propagate their knowledge (Choy, 2003). Nursing became one of the few ways for Filipina women to challenge cultural roles of domesticity and to leave the islands, enabling an unprecedented social and spatial mobility. Receiving a nursing education in the US acted as a primary measure for competency in American nursing and proved imperative for Filipina/o nurses who wished to serve as nursing leadership in the Philippines.

Nurse Leaders Anastacia Giron-Tupas and Julita Villaruel Sotejo

Anastacia Giron-Tupas (1890-1972)
...Giron used her own resources to pay for her steerage and advance her education abroad.Self-funded travel was more common among men, yet Anastacia Giron depicts an unlikely migratory and career path taken by Filipina women and nurses. A 1912 graduate nurse of the Philippine General Hospital School of Nursing’s second cohort (see Picture 2), Giron used her own resources to pay for her steerage and advance her education abroad. She believed that nursing served as a powerful tool to improve the general welfare of the Filipina/o people (Giron-Tupas, 1952). Between 1914 and 1917, she obtained a certificate in public health nursing from the University of Pennsylvania School of Social Work; received additional training at the New England Hospital for Women and Children in Boston, Massachusetts; and traveled across the country to advance her understanding of healthcare under the guidance of Jane Delano, founder of the American Red Cross (Giron-Tupas, 1952).

Picture 2. Anastacia Giron among the Philippine General Hospital School of Nursing Class of 1912.

Source: The Philippine General Hospital School of Nursing Alumni Association. Used with permission.

American nurses held early nursing leadership positions in the Philippines during the colonial regime. By 1913, the colonial government, headed by Francis Burton Harrison, began its policy for the Filipinization of the colonial bureaucracy to prepare for self-containment of the Philippines, appointing Filipina/os into leadership positions (Borromeo, 2017). However, an unspoken requisite for appointment into nursing leadership positions was the preference of those who obtained a nursing education in the US, with remarkable American experiences. Thus, Giron’s time abroad deemed her a competent leader through the lens of the colonial government.

In 1917, four years after the initiation of Filipinization, Senate President Manuel Quezon appointed Giron as the first Filipina/o to jointly hold the positions of chief nurse and superintendent at Philippine General Hospital (Giron-Tupas, 1952). These positions made her the most influential Filipina/o nurse leader at the time, garnering a salary of 3,000 pesos annually (one of the highest salaries received by a woman) which was comparable to the earnings of male senators at 4,000 pesos (Borromeo, 2017). As a nurse leader, she chaired an interdisciplinary committee comprising members from nursing, medicine, and pharmacy who were interested in the professionalization of nursing. In 1919, the committee successfully helped to enact the first law that regulated nursing practice by requiring examinations and collected associated fees for registration (Giron-Tupas, 1952).

Giron’s professional status required her to act as a cultural broker between American nurse leaders and fellow Filipina/o nurses... By the 1920s, the United States colonial government shifted to a massive internationalization effort by slowing the flow of Filipina/o nurses abroad. More American healthcare professionals were imported to teach modern healthcare sciences within the islands. In 1922, the International Health Board of the Rockefeller Foundation sent Alice Fitzgerald to act as the nurse advisor on staff to Governor-General Leonard Wood. Foremost, she formed a cooperative relationship with Giron, the authority figure of Philippine nursing. From a racial perspective, Giron’s professional nursing role required her to act as a cultural broker between American nurse leaders and fellow Filipina/o nurses, while also minimizing her social status to appease her American superiors (Brush, 1997).

In 1922, Giron and Fitzgerald jointly implemented the country’s first postgraduate public health nursing program at Philippine General Hospital and national professional organization, the Filipino Nurses Association (FNA). However, American nursing histories have often credited these accomplishments solely to Fitzgerald, which contrast with historical accounts by Filipina/o nurses who recognized her as a contributor, but not the sole driving force behind these developments (Borromeo, 2017). Ideas about a national nursing organization by Filipina/o nurse leaders began before Fitzgerald’s arrival (Choy, 2003; PGHSNAA, 2018). These histories not only diminish the impact of Giron, who presided over the first meeting of the FNA and served as the first director of the postgraduate public health nursing program, but also challenge the leadership capability of Filipina/o nurses.

Race is a factor in understanding the position of Filipina/o nurse leaders...Race is a factor in understanding the position of Filipina/o nurse leaders, as American nurses, according to Choy (2003), often found the notion of supervision under Filipina/o nurses perverse. Many American nurse leaders envisioned Filipina/o nurse leaders as puppet figures who would mimic the tenets of American nursing; they deemed any activity outside the established norm as not only contesting the moral integrity of the profession, but also their own leadership capability. The secret marriage of Giron to Albert Tupas, an instructor at the University of the Philippines College of Medicine and Surgery, prior to the arrival of Fitzgerald, created a falling out between the two nurse leaders (Borromeo, 2017; Brush, 1997; Choy, 2003). Giron’s attempt to hide her relationship provided a way to mediate the incompatibility between Philippine cultural values emphasizing family, and the American viewpoint of married women as incapable of practicing within the profession of nursing.

Fitzgerald considered Giron’s act of marriage amoral. Barbara Brush (1997) reveals Fitzgerald's anger in her letter to Victor Heiser, now the Rockefeller Foundation Director for the East of the International Health Board, addressing Giron as two separate entities: "Miss Giron and her inexcusable behavior came very near wrecking my work as I had spent most of my time strengthening her position…I believe Mrs. Tupas must be slowly eliminated by pushing Miss Macaraig forward (Fitzgerald, 1923)."

Arguably, Fitzgerald already faced extensive pressures associated with the gendered nursing profession, yet her projected frustration onto Giron cast herself as the sole individual responsible for the massive developments in Philippine nursing. The letter also provided insight about how American nurse leaders viewed Philippine nurse leaders: replaceable, if they stepped out of line. Thus, Fitzgerald’s quick about-face dismissed Giron's incompetent as a nurse leader, despite their productivity in advancing Philippine nursing. This forced the resignation of the esteemed Filipina/o nurse (Brush, 1997).

Giron had challenged the status quo of nursing, proving that marital status did not bar her dedication to advancing nursing practice. Nonetheless, Giron-Tupas, now able to use her full name, challenged the status quo of nursing, proving that marital status did not bar her dedication to advancing nursing practice. She maintained her role as director of the postgraduate public health nursing program at Philippine General Hospital. In 1929, she was instrumental in integrating the program into the University of the Philippines, changing the postgraduate certificate to a Baccalaureate of Science in Nursing (BSN), the first baccalaureate nursing program offered in the Philippines (Giron-Tupas, 1952).

To Giron-Tupas, Filipina/o nurse leaders stemmed from plucky Filipina/os who dared to travel abroad and advance their education and pursue nursing leadership positions upon their return. Leadership also included those dedicated to the welfare of the Philippines, challenging the authority of American nurses when necessary and proving their capability as nurses. She wrote, History of the Nursing in the Philippines, to encapsulate the developments made in Philippine nursing during the first half of the 20th century. In this book, she celebrated numerous Filipina/o nurses, who she considered leaders, notably describing the younger Julita Sotejo as not only an outstanding nurse leader and educator, but also a brilliant lawyer (Giron-Tupas, 1952).

Julita Villaruel Sotejo (1906-2003)
[Sotejo] is credited with the current model of nursing education widely used throughout the Philippines.Julita Sotejo remains a prominent figure in Philippine nursing. She is credited with the current model of nursing education widely used throughout the Philippines. According to Christine Peralta (2019), Sotejo is a hidden figure within American nursing because her contributions to the profession took effect after the Philippines gained independence in 1946. Her original career of choice was law, but due to the growing popularity and socioeconomic potential of nursing, her parents persuaded her to complete her nursing education first, and then later financially support herself through law school. At the time, Philippine nursing struggled to be regarded as a profession, notably facing discrimination from the upper echelon for its association with servitude, blind obedience, and minimum academic rigor. Sotejo recalled the provincial medical officer, who saw great potential in her during her adolescence, saying, “Only the not good ones go to nursing” (Buenavista-Tungpalan, 2001, p. 47).

While attending the Philippine General Hospital School of Nursing, she critically assessed flaws of education within hospital training schools. She noticed, “We were called student nurses—which to me was truly confusing. Were we not students? But why were we at the same time, nurses?” (Buenavista-Tungpalan, 2001, p. 52). For students in other professional fields, their profession served as a descriptor and identified the field of learning, emphasizing education over labor. Her thinking mirrored thoughts of American nursing leadership, as hospital training schools often prioritized the needs of hospitals over the provision of a quality education for student nurses (Buenavista-Tungpalan, 2001).

While attending the Philippine General Hospital School of Nursing, she perceived flaws of education within hospital training schools.In 1923, the Goldmark Report called for the baccalaureate education of American nurses at academic institutions, but remained largely ignored. Although Sotejo graduated as valedictorian of her class in 1929, she felt discontent with her education and told herself, "When I have the opportunity, I shall change all these [flaws]” (Buenavista-Tungpalan, 2001, p. 83).

In 1932, she enrolled at the Philippine Law School, the same year that the public health nursing baccalaureate program created by Giron graduated its first cohort. Many people, especially nurses, questioned her decision to pursue law, a field heavily dominated by men, versus public health nursing, the natural progression of nursing education. Sotejo’s answer to this question years later provided an explanation beyond her childhood dream of becoming a lawyer:

I took up Law to acquire additional knowledge in an area outside nursing; to improve my personal and professional status, not to make me a better nurse… The law course gradually gave me prestige… it taught me to argue for nursing—the physical, spiritual, emotional, cultural, intellectual, ethico-moral and legal dimensions of patient care (Buenavista-Tungpalan, 2001, p. 76).

...this type of leadership went beyond holding influential positions; it required assertiveness and creativityAfter graduating as valedictorian of her class yet again, she went on to take the position as principal of Philippine General Hospital School of Nursing. To advance the Philippine nursing profession, she determined that Filipina/o nurses required more than just superior knowledge, skills, or determination; they needed the right kind of leadership, which she thought the country lacked. According to Sotejo, this type of leadership went beyond holding influential positions; it required assertiveness and creativity (Buenavista-Tungpalan, 2001).

Picture 3. A Filipina nurse and her American nurse friend, Philadelphia, circa 1920s.

Courtesy of Albert Acena. Used with permission.

While Filipina/o nurses found themselves relatively accepted working among and studying under American nurses across the US (see Picture 3), American nurse leaders did not necessarily view their Filipina/o counterparts as equals. This thus reinforced a racialized hierarchy within the profession and contributed to the professional deskilling of Filipina/o nurses (Peralta, 2019). Sotejo left her esteemed role as an educator in 1941 for a Rockefeller Foundation fellowship, maintaining her enthusiasm to elevate the status of the nursing profession. While the foundation primarily funded nurses to pursue studies abroad in public health nursing, Sotejo and her colleague, Leonor Malay, received funding for studies in nursing administration in Canada and the US between 1941 and 1943.

...the two nurses found discrimination while conducting independent studies at some of their host institutions.Although working among American nurses became commonplace, the two nurses found discrimination while conducting independent studies at some of their host institutions. At the Yale University School of Nursing, instructors criticized Sotejo and Malay for their unwillingness to do ward duty. However, working ward duty had little to do with advancing the fellowship purpose of attaining knowledge in nursing administration, and seemed keener on exploiting the two as free labor. Dean Effie J. Taylor interpreted their behavior as an ineptitude of skill and knowledge and mandated that they take remedial coursework and perform ward duty for three hours a week. These two nurses, who previously held nurse faculty positions, found these requirements debasing (Buenavista-Tungpalan, 2001; Peralta, 2019).

Because Sotejo sought to find her own path as a nurse leader and challenged American nurse leaders’ prescribed norm for Filipina/o nurses to study public health nursing, she seemed to face increased professional and racial barriers. Yet her resolve to professionalize Philippine nursing also found supporters. Sotejo enrolled at the University of Chicago for a master’s degree in nursing administration. She wrote a thesis that recommended the establishment of a direct entry baccalaureate nursing program at the University of the Philippines, influenced by the ongoing Second World War:

Yet her resolve to professionalize Philippine nursing also found supporters.The end of this war will undoubtedly find in war-torn countries conditions of great destruction and poverty. The ravages of disease, communicable or otherwise, will continue to claim [a] mounting toll of human lives. Problems affecting public health and sanitation will be greater than they were before the war…There will be a pressing need for large-scale health and social planning and for the execution of these plans expediently and effectively… Only through the medium of nursing service can one important aspect of the health needs of the people of the Philippines be met. It is through nursing education, by means of which nurses prepared to render service after graduation that nursing needs can be realized (Buenavista-Tungpalan, 2001, p. 104).

Sotejo’s thesis did not simply attempt to transfer another American model of nursing, it carefully examined the health needs of the Philippines...Sotejo’s thesis did not simply attempt to transfer another American model of nursing, it carefully examined the health needs of the Philippines and various nursing school models found in Canada, the US, and Europe, to determine the appropriate education to support training of quality nurses who would be well versed in the sciences and humanities (Peralta, 2019). Miss Hawkins, her advisor, said, “When you go home, this will be your contribution to the rehabilitation of your country through nursing service of a superior quality as a result of a superior kind of nursing education” (Buenavista-Tungpalan, 2001, p. 103).

While Sotejo graduated in 1943, the war extended her stay in the US and exacerbated the need for nurses on the American home front. She remained in Chicago, working as a nurse at the Albert N. Billings Hospital. Upon her return to a war-torn country in 1945, a heightened need for nursing services helped garner support to train higher quality nurses. University of the Philippines President Bienvenido Gonzalez was a steadfast supporter of Sotejo’s project to create a college of nursing, and the university officially offered a direct-entry BSN degree in 1948. Although the country's first direct-entry baccalaureate nursing entry program at the University of Santo Thomas graduated its first cohort in 1950, Luz Buenavista-Tungpalan (2001) argues that it was baccalaureate only in name, lacking academic rigor. Sotejo then went on to become the first dean of the University of the Philippines College of Nursing, and the implementation of her thesis provided the structural framework for future baccalaureate entry nursing programs in the Philippines.

Upon her return to a war-torn country in 1945, a heightened need for nursing services helped garner support to train higher quality nurses.In 1947, Sotejo, acting as president of the FNA, was among several Filipina/o nurse delegates invited to the Grand Council of the International Council of Nurses and (ICN) meeting in Washington, D.C. The Philippines had previously become a country member of the ICN in 1929. Aside from the Philippines, China was the only other country from Asia that sent delegates, having gained membership in 1922 (Buenavista-Tungpalan, 2001; ICN, 1947). Other notable ICN members from Asia not in attendance included Japan and India. The Korean Nurses Association (KNA) had applied for ICN membership in 1925 but was denied for being “deficient as an association (Kim, 2019, p. 94).” The same year the Philippines became a member, the ICN rejected the KNA again on the grounds that it was a Japanese colony, as it would not recognize both Japan and Korea. Yet several ICN members were colonies, including the Philippines. The only difference was that Korea fell under Japan, the only non-Western imperial power. This hypocrisy portrays efforts by the ICN to maintain a white space and restrict its delegation from the East.

Patricia D’Antonio (2010) posited that values of place triumphed over professional representation at this meeting, as the host, the District of Columbia’s Graduate Nurses Association (GNA), refused to extend an invitation to Black nurses. Prior to the Grand Council Meeting, Josephine Pitman Prescott, one of the conference organizers and director of the federal Bureau of Public Health Nursing, appealed to GNA president Ashby Taylor to invite Black nurses, stating, “the ICN stands for democracy, tolerance, and freedom of opportunity for all nurses (D’Antonio, 2010, p. 136).” This statement reflects the hypocrisy of the ICN that was also found within the “American Creed” of liberty, justice, and fair treatment. Taylor responded that GNA functions were private affairs specifically limited to ICN delegates, “special guests,” and its white members (D’Antonio, 2010, p. 137). As such, nurses of Asian descent were in attendance, but not Black nurses.

...Filipina/os found an elevated social status through nursing that complicated the established racial hierarchy. While not necessarily treated equally to Whites, Filipina/os found an elevated social status through nursing that complicated the established United States racial hierarchy. The 9th ICN Congress in Atlantic City, New Jersey, shortly followed the Grand Council meeting. Sotejo served as an invited speaker whose charisma helped her stand out and befriend delegates from around the world, regardless of color lines. After hearing Sotejo speak, the president of the Brazilian Nurses Association approached Sotejo and asked, “Are you going to be a candidate for any office? I will vote for you. And there will be others voting for you as well” (Buenavista-Tungpalan, 2001, p. 131). With no intent to run for a position, she received enough votes to become one of the ten members on the Education Committee, holding office from 1947 to 1957.

The work of Sotejo and Giron-Tupas on the international stage portrays the growing development of a global network of Filipina/o nurses (See Picture 4). Efforts of Filipina/o nurses led to the establishment of local nursing bodies across the globe that extended the mission and values of the original FNA, which later renamed itself to the Philippine Nurses Association in 1966. Resulting from colonial ties to the US, the FNA of New York became the first professional Filipina/o nursing organization formed outside the Philippines in 1928 to support the professional and social needs of Filipina/o nurses abroad.

Picture 4. Julita Sotejo receiving the International Committee of the Red Cross Florence Nightingale Medal and being congratulated by the wife of the Vice-President of the Philippines, 1961.

Source: The International Committee of the Red Cross. Used with permission.

The work of Sotejo and Giron-Tupas on the international stage mirrors the development of a global network of Filipina/o nurses.The need for a national voice of Filipina/o nurses in the US became apparent during the Vietnam War, which exacerbated racial inequalities faced by Filipina/o nurses. In 1977, the court case US v. Narciso and Perez indicted two Filipina nurses for the murder of multiple patients at the Ann Arbor Veterans Administration Hospital under circumstantial evidence (Choy, 2003). In 1979, local chapters of Filipina/o nurses associations unified under one umbrella organization, the Federation of Philippine Nurses Association, now named the Philippine Nurses Association of America, to challenge their treatment as alleged racial scapegoats (Maharjan, 2014).

In 2018, Filipina/o nurse leaders across the globe created the first international professional organization of Filipina/o nurses...In 2018, Filipina/o nurse leaders across the globe created the first international professional organization of Filipina/o nurses, the Filipino Nursing Diaspora Network, with membership spanning the US, Canada, Australia, Singapore, Saudi Arabia, Germany, Ireland, Philippines, Kuwait, and the United Kingdom. The legacy of Giron-Tupas and Sotejo finds prominence in the post-colonial age of Filipina/o nurse migration, as their exemplary work on the global stage supported the integration of nursing as a cultural tenet of the Philippines.

Philippine Nursing at the Mid-Century

With the result of Filipinization, many Filipina/o nurses who studied abroad became nurse leaders upon return, taking on executive and administrative positions previously held by American nurses. In 1951, World Health Organization Nurse Consultant Lorena Murray reported on the status of nursing in the Philippines, and indicated that the country had the right kind of nursing leadership, the ability to help prepare nurses from other countries, and a system of education not behind those of progressive countries (Giron-Tupas, 1952). Indeed, this deemed Philippine nursing on par with American nursing and also proved the capability of nurses had nothing to do with race.

Yet, even after the establishment of domestic postgraduate opportunities, Filipina/o nurses continued to travel to the US after the country’s independence to escape the depressing and devastating effects left by World War II and the lack of employment opportunities in nursing. The social environment of the Philippines supported the professionalization of nursing. However, the migration of Filipina/o nurses to the US continued, due to the country’s economic inability to employ a surplus of nurses within all of its health sectors, which only worsened from the aftermath of war.

Implications for Nursing Today

The globalization of the profession of nursing has significantly increased since the mid-century, skewing the flow of nurse migration from low-income to high-income countries. The Philippines ranks as the top exporter of nurses (Choy, 2003; Ortiga, 2018). To address the inequitable distribution of nurses around the globe, nurse leaders of today must critically examine the historical roots of nursing within their own countries and remain cognizant of transnational and transimperial relations.

To address the inequitable distribution of nurses around the globe, nurse leaders of today must critically examine the historical roots of nursing within their own countries...Sharing heightened social awareness, Giron-Tupas and Sotejo understood that American nurse leaders largely viewed their leadership abilities as inferior, but instead of acquiescing to the culture of Western nursing, they explored the boundaries of the nursing profession. The two nurses spanned the globe to exchange nursing knowledge across cultures; they viewed nursing within the larger context of global healthcare. Targeting the global nursing shortage requires more nurse leaders who are experienced with this type of cultural humility and systems-level thinking. Nursing education, regardless of country, should promote interdisciplinary and interprofessional collaboration; create opportunities for critical thinking at a multi-system level; and require coursework in nursing history to instill a cohesive and inclusive professional identity among undergraduate and graduate students.

Presently, the intersection of race and immigration within the profession of nursing often includes the use of outdated terms, such as “foreign nurse graduate” and “foreign-trained nurse,” to describe internationally educated nurses. These terms should be removed from the profession’s lexicon. The introduction of modern models of nursing into countries outside Europe and North America stems from western interventions in the form of missionary work and colonization. This begs the question whether “foreign” truly denotes nursing education or the physical appearance of the nurse.

...the intersection of race and immigration within the profession of nursing often includes the use of outdated terms, such as “foreign nurse graduate” and “foreign-trained nurse,” to describe internationally educated nursesThis article explored the many similarities that Filipina/o nurses shared with their American counterparts, and they proved their status as anything but “foreign.” As a political term, “foreign” can serve as another way to ostracize internationally educated nurses and it continues to racially identify Asian Americans as such. The COVID-19 pandemic has brought to light increased xenophobia and racism toward Asian American physicians and nurses, belying the status of Asian Americans as “foreign” and casting them as racial scapegoats for feelings of fear, suffering, and anger (Jan, 2020). Yet large networks of Filipino nurses are on the frontlines fighting the pandemic across the world and also dying. They remain caring in spite of any prejudice towards them (PBS Newshour, 2020). In the case of these two Filipina nurses, the word “foreign” suggested an imagined color line that diminishes the longstanding shared history of Philippine and American nursing and the contributions of nurses of color.

Conclusion

The importation of nursing under American colonialism shaped Filipina/os in the image and values of the American nurse. Despite the racial hierarchy, a career in nursing provided social mobility and opportunities abroad, primarily for Filipina women (Choy, 2003). Originally, the terminal degree of Philippine nursing education required travel to the US, thereby supporting the migration of Filipina/o women abroad. For Filipina/o nurses, acquiring a United States nursing education served as a merit for competency through the eyes of American nurses and opened leadership positions for them back in the Philippines (Giron-Tupas, 1952).

Giron-Tupas and Sotejo, both dedicated to advancement of nursing, had their own perceptions about nursing leadership. Giron-Tupas, with a more concrete perspective, believed that nurse leaders were those emboldened to improve the general welfare of the Filipina/o people. In her eyes, returning Filipina/o nurses who braved the journey to the US and assumed nursing leadership positions in the Philippines proved themselves as capable leaders (Giron-Tupas, 1952). Sotejo’s perception was more abstract, as she deemed that Filipina/o nurses in leadership positions lacked assertiveness and creativity. To cultivate these traits, she established the University of the Philippines College of Nursing (Buenavista-Tungpalan, 2001). Both nurses challenged the established values of American nursing and a racial hierarchy prescribed by some American nurse leaders onto Filipina/o nurses. Together, their narratives support a better understanding on the professionalization of nursing between the US and the Philippines, underscoring the contributions of nurse leaders beyond the West.

Authors

Reynaldo Capucao, Jr., MSN, RN, CNL
Email: rcc9vq@virginia.edu

Reynaldo Capucao, Jr. is a nurse historian affiliated with the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry and a PhD student in nursing, American studies, and digital humanities at the University of Virginia. Contextualized through the Filipina/o nurse diaspora, his research examines migration as a space for meaning-making and the social construction of race in the United States to answer larger questions about the nursing labor supply, transnational exchange of people and knowledge, and social history of nursing and immigration. Using an historical framework, he addresses issues in healthcare by practicing both academic and public aspects of history to inform policy making and to advocate for past, present, and future patients and nurses. He is the Virginia Humanities project director and curator of the traveling exhibition, A Culture to Care: The History of Filipino Nurses in Virginia, and the 2020 Alice Fisher Fellow at the University of Pennsylvania Barbara Bates Center.

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© 2020 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2020


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