Filipino Nurses' Health Beliefs, Behaviors, and Practices - CiteSeerX

HOME HEALTH CARE MANAGEMENT & PRACTICE / December 2004

Integrating Traditional Beliefs and Modern Medicine: Filipino Nurses’ Health Beliefs, Behaviors, and Practices Rosalia V. Ordonez, MEd, RN Noemi Gandeza, MSN, RN

national language. This country of 70 million inhabitants is located just above the equator. It was colonized by Spain for more than 300 years and was under the American rule for almost half a century (Limson et al., 1992). This explains the heavy Spanish influence and why the major religion is Catholic. This also explains the American influence on the educational system. The Philippines has also been involved in international commerce over the years and, as a consequence, has been influenced by European political thoughts. All of these events and exposure to different peoples led to the diversified Filipino culture. The majority of Filipinos in the United States work in health-related fields, and most of them are nurses. The cultural background of Filipino nurses may have a strong influence on their selection of nursing as a profession, because caring for others is emphasized and valued, especially among females. The migration of Filipino nurses to the United States has been in progress for 50 years. Filipino nurses comprise the majority immigrant nurses in this country in response to the cyclic nursing shortage. The Philippines is also one of Asia’s main exporters of nurses for foreign employment causing brain drain to the country. Brain drain is the immigration of professionals to other countries leading to their shortage in the home country. Filipino nurses are targeted because of the relative surplus of nursing graduates who are eager to gain foreign employment. Also, the nursing curriculum is patterned after American nursing education. Tuazon (2002) explained,

As the diversity in the patient population is growing, there is also an increasing number of diverse caregivers. Among them are the Filipino health care providers, most of whom are nurses. Understanding the culture, health care beliefs, and practices of Filipino nurses is important, as it affects the way they assess the needs and provide care for their clients. This article provides a general profile of the health care beliefs, behaviors, and practices of Filipino nurses in the United States within the context of the general Filipino culture. Like any other ethnic group, Filipinos have become acculturated at various levels after coming to work and live in this country over the years. It is the integration of their cultural beliefs, values, and behaviors that affects their caregiving attitudes and practices.

M

uch can be said about “you are a product of your past.” One’s past is, of course, a conglomeration of factors or influences ranging from family, community, school, religion, government, society, environment, political events, and experiences. This article examines the health care beliefs, behaviors, and practices of Filipino nurses in the United States within the context of the general Filipino culture and how the integration of their cultural beliefs, values, and behaviors affects their caregiving attitudes and practices. The Philippines is a small country consisting of 7,000 islands and several dialects; Tagalog is the

Key Words: Filipino; values; culture; women

Home Health Care Management & Practice / December 2004 / Volume 17, Number 1, 22-27 DOI: 10.1177/1084822304268152 ©2004 Sage Publications

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Ordonez, Gandeza / FILIPINO NURSES’ HEALTH BELIEFS

The curriculum revision in 1977 resulted in one entry level for nursing—a four year bachelor science in nursing program. The curriculum is comparable to the U.S. and includes both didactic courses and clinical rotations. Almost all of the textbooks used in colleges of nursing are authored and published by Americans. (p. 2).

According to Amy de la Paz (2001), executive director of the Filipino Nurses Association in America, “The Philippine Overseas Employment Agency approximates that there are about 50,000 Filipino nurses working in America’s health care system” (p. 1). However, there are no exact statistics on Filipino nurses from either the Philippines government or the U.S. Immigration and Naturalization Services (Joyce & Hunt, 1982). The United States is experiencing yet another cycle of a nursing shortage. According to Mary Foley (2001), president of the American Nurses Association, The increasing demand for nursing services, coupled with the imminent retirement of today’s aging nurse, will soon create a systemic nursing shortage. A recent study published in the Journal of the American Medical Association estimates that the overall number of nurses per capita will begin to decline in 2007, and that by 2020 the number of nurses will fall nearly 20 percent below requirements. (p. 8)

It is not unusual for the United States to again recruit nurses from abroad, including Filipino nurses. On the other hand, employment in the United States is attractive to Filipino nurses primarily for economic reasons. Once employed in the United States, Filipino nurses can earn as much as 20 times what they were making back home (Chang, 2001; Prystay, 2002).

GENERAL VALUES OF FILIPINO NURSES Work Ethic

As a group, Filipino nurses are well liked because they are hardworking. They place high value on responsibility and seldom complain. Joyce and Hunt (1982) commented, “Many [Filipino nurses] work nights, holidays and/or overtime. So, during this time of nursing shortage, one can rely on a Filipino nurse to volunteer to cover the shift” (p. 1226). It is not unusual to find Filipino nurses who work two jobs. The financial rewards, job security, and personal advancement that U.S. jobs provide to Filipino nurses are valued.

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This leads to an attitude of perseverance, tolerance to poor working conditions, and accepting less pay for jobs offered to them. At work, sick call is a rarity for Filipino nurses. A joke among some Filipino nurses is to call in sick when one is dying, not before. In other words, they do not call in sick for casual reasons. They feel guilty if they call in sick, especially when the workplace is busy. Although management may favor such a work ethic, such practice may expose coworkers to communicable diseases such as the flu and upper respiratory tract infections when they prefer to work rather than nurture their bodies.

Spirituality Filipino nurses are very religious people. There is a deep faith in God that is reflected in the expression of bahala na—“it is up to God” or “leave it to God.” This tends to be incorrectly equated with an expression of fatalism and a passive acceptance of or resignation to fate. Bahala na may also apply to acceptance of illness or malady. Although it is an indication of acceptance of the nature of things including one’s own inherent limitations, bahala na operates psychologically to elevate one’s courage and conviction to persist in the face of adversity and improve one’s situation (Okamura & Agbayani, 1991).

Sensitivity Unmarried Filipino nurses recoil at the question, “Are you pregnant?” when they go for a medical checkup. Because the Philippine society considers sexual relationships not to occur outside of marriage, it seems odd to them that they would be questioned, although they are aware that this is part of a routine health assessment. Filipinos are generally sensitive and equally sensitive to the feelings of others, so they try to find a way to say things diplomatically. On one trip by one of the authors, she noted a Filipino nurse say to her Caucasian husband, “Would you like to turn on the next road sign?” as if giving him the choice instead of a declarative command. The husband appreciated it very much. This approach, coming from an individual who holds a position of authority, may be misinterpreted as being soft, especially at work. On the other hand, this is one way of valuing feelings and the temperament of another human being. If such an approach is ineffective, an alternative is called for. Being sensitive to the feelings of others is also reflected in the way Filipino


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nurses conduct patient teaching, especially with the elderly, immigrants, and the less fortunate.

Interpersonal Relationships

Filipinos are generally quiet. Very conservative families do not allow their younger members to join the conversation of adults without an invitation. Once they are here in the United States, Filipinos are often misunderstood when they do not give feedback. They are sometimes hesitant to articulate their views, especially if it is different from the majority, as it might indicate discordance with the team or group. Engaging in arguments, especially with someone who is older or holds an authority position, is considered uncivilized. Filipinos also have difficulty turning down requests from supervisors to whom they feel obligated (Joyce & Hunt, 1982). By their culturally determined nature, Filipinos are shy and appear timid, especially women. They are reluctant to express their opinions for fear of offending others. They are used to a culture of maintaining cordial relationships and group harmony. Raising questions may be considered offensive. In class, most Filipinos would rather ask the classmate sitting next to her or him to clarify ideas or instructions rather than asking the teacher. In this situation, the shyness predominates more than the concern of asking the teacher. The concern arises from the fact that the student is troubled by letting the teacher know that he or she is not following the class discussion. However, acculturated Filipinos in the United States are likely to be less shy. Also, as Filipinos are exposed to the culture of assertiveness, they can adopt the same openness as their American counterparts. In terms of health assessments of Filipinos in general, health care providers are encouraged to probe more to ensure accuracy and completeness of health information and validate if the Filipino patient can actually demonstrate understanding of provided instructions regarding their care. Most Filipinos would answer, “Yes,“ to most questions without giving serious thought. “Yes” does not necessarily mean that she or he understands the discussion, nor is it intended to agree with the decision or opinion of the health care provider. In most cases, “yes” merely means, “I heard you.” Because Filipinos in general tend to respond with “yes” or “no” without explaining or amplifying their condition, health care providers need to be more careful when inquiring about health and personal information to ensure its validity.

Respect and Reverence

One’s position in society, professional achievements, and age carry a lot of weight in the Philippine society. Physicians, lawyers, priests, engineers, teachers, and nurses are among the well-respected professionals in the Philippines. Hence, their opinion is generally accepted without question. Filipino values and traditions provide a framework for conduct and mode of communication. Because of a high regard for the elderly and authority, Filipinos tend not to oppose or contradict other views for fear of embarrassing the other party. “Filipinos generally are neither assertive nor aggressive and may often appear guarded or reticent. Nurses often misunderstand this need for passivity and do not appreciate the culturally induced motivation to maintain harmonious balance between man and nature” (Vance & Davidhizar, 1999, p. 16). This nonconfrontational behavioral pattern accounts for the perception of Filipinos as being passive or timid. Few are cognizant that this conflict-management style stems from a culture of agreement and a virtue of pleasing others. When a female Filipino nurse goes for a medical appointment, she is more likely to accept what her physician says. A second opinion is seldom sought, because that would mean questioning the wisdom of her physician. On the other hand, if there is a lingering doubt, it is discussed with friends and relatives who are likely to influence the decision on whether to seek a second opinion. This is an area where a Filipino nurse may readily advise her patient but rarely practice what she preaches. Filipino nurses who have recently come to the United States would never call a supervisor by his or her first name. It is always Ms. ____ or Mr. ____. Someone older is spoken to in the third person, which is perceived as a sign of respect. This is not even enough. The word po is a suffix added to practically every sentence when speaking with an older or elderly person. This kind of cultural value and corresponding behaviors may hinder some Filipino nurses from performing their patient advocacy role. For this reason, assertiveness training is very beneficial for Filipino nurses so that they can exercise patient advocacy in a more effective way. In a study of Filipinos working in health care fields in the United States, Castillo (n.d.) explained, All informants seemed to agree that their cultural background gave them the framework to be proficient



nurses or health care workers. Of those who were nurses, one stated: “I see my patients as my relatives and this influences the way I care for them. I feel that my upbringing helps me see people and care for them.” Another nurse indicated that Filipinos are very compassionate and this helps when working with people. (p. 69)

Filipino nurses highly value their elderly clients. This may be influenced by the way they feel toward elderly parents and relatives. There is a sense of obligation and personal fulfillment in caring for one’s parents. Elderly individuals are given high respect and revered. Family commitment fosters a sense of pride, and therefore, caring for others is embedded in the culture. “Concern for the welfare of the family is expressed in the honor and respect bestowed on parents and older relatives, the care provided to children, and the individual sacrifices that are made on behalf of family members” (Okamura & Agbayani, 1991, p. 1).

Modesty

Filipino nurses find it uncomfortable to accept even a well-deserved compliment. For example, if someone gives a complement like, “Your dress is beautiful!” the answer might be, “Not really. I bought it cheap.” Or if someone says, “You are so knowledgeable,” the answer might be, “Not really, I just happen to know it.” Yet they are proud of their accomplishments in a sort of quiet way. As a result, many have culture-based barriers to marketing themselves. Filipino nurses are less likely to use I to express what they have achieved. More than likely, they will use we to acknowledge others’ contributions no matter how insignificant the contributions might be. This may explain why they work well with others. This may come from the practice of Bayanihan. In the Philippines, if you want something done, it is easy to get a group together to work on a project so that it will get done faster and better.

Language

Respect is integrated in the Filipino language. Reference to the elderly is the use of the third person. Hence, when spoken to assertively in a direct way, Filipinos feel offended. There is no gender differentiation in the Filipino language. Although they are fully aware of the male and female genders, their native language is what hinders them from precisely using he or she in spoken English. Frequently, this leads to confusion. The Fili-

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pino accent is recognizable by the inflection on the second syllable of a polysyllabic word. For example, penicillin is pronounced as peNIcilin. It is also interesting to know that there is a common pronoun for the singular third person regardless of gender. Filipinos use siya (pronounced as /sha/ in shadow) in referring to another person. As a result, Filipinos may inadvertently interchange he and she (Tuazon, 2002).

Close Family Ties Filipino nurses have strong family ties. While in the United States, their close friends become their family members. As a result, they perpetuate the cultural burden (as a downside) thus making it more difficult and taking them longer to assimilate into the mainstream culture of their adopted country. Joyce and Hunt (1982) found that “in the first year in the U.S., social contact with Americans outside of work setting is infrequent and most of their social interaction is with other Filipinos” (p. 1224). They tend to eat the same food and mingle with individuals of the same ethnic background. Hence, the old health beliefs and practices continue.

HEALTH BELIEFS, BEHAVIORS, AND PRACTICES Preventive Health Because most of their time is devoted to work, going for preventive health checkups takes a backseat. Yet, one may hear a Filipino extolling the importance of preventive health to her patients or clients. Filipino nurses have a tendency to self-diagnose, self-medicate, and seek alternative therapies. In rural areas in the Philippines, people go for Hilot for relief of pain and aches instead of seeking medical attention. In an alternative context, Hilot may refer to a practitioner or the practice of chiropractic manipulation and massage for the diagnosis and treatment of musculoligamentous and musculoskeletal ailments (Stuart, 1977). Home remedies in the form of medicinal plants are also popular for Filipino nurses who believe that plants can heal common ailments. The practice of self-healing and self-treatment prevents them from getting early formal medical access and interventions. This poses a great concern to most health care providers, as Filipino nurses only seek medical care when their medical condition is already very serious or in an advanced stage.


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Home Remedies

Three concepts underlie Filipino American health beliefs and practices: flushing, heating, and protection. Each identifies a basic process used to promote good health. Flushing keeps the body free from debris, heating maintains a balanced internal temperature, and protection guards the body from outside influences. Although Western and scientific concepts are similar, Filipino theories are founded on different premises. Flushing is based on the notion that the body is a container that collects impurities, heating means that hot and cold qualities must be balanced in the body, and protection involves safeguarding the body’s boundaries from supernatural as well as natural forces (McKenzie & Chrisman, 1977). Although this belief is practiced in the Philippines, first-generation Filipino immigrants still carry with them the understanding that the above theories can help alleviate any medical illness, and they thus seek home remedies rather than getting professional health services from a medical doctor. Another reason is that home remedies are readily available and cheap. An example is the consumption of tea for stomachaches, boiling ginger and drinking water for a sore throat, and boiling corn hair and drinking water to promote urination. Although the approach might be benign, it is the delay of medical attention that may worsen the medical ailment and miss the optimal treatment opportunity. For health care providers, it is important to establish rapport with the Filipino patient to gain trust to elicit information on the use of home remedies. Having a working knowledge of the culture can improve health assessment and interventions from health care providers as well as promote understanding of a culture that, although Westernized, still believes in the power of home remedies to correct ailments.

Pain Tolerance

Generally speaking, Filipino nurses have a high tolerance to pain. For example, one of the author’s sisters has severe arthritis, yet she continues to do housework regardless of her pain. Filipino nurses normally use home remedies such as liniments and topical ointments and manage pain before seeking medical care or while under medical treatment. Health care providers need to probe more into the cause and degree of pain from Filipino patients to elicit more information. The elderly group, in particular, is unlikely to complain about their pain because they do not want to have extra burdens being imposed on caregivers.

The belief in the bahala na attitude predominates pain management, especially for first-generation Filipino immigrants. They value the opinion of elder family members regarding their condition or the opinion of a trusted friend before seeking medical attention. The elderly are also secretive of their ailments and the types of home remedies used to control their conditions. Such secrecy poses greater risks of herbal or medicinal interactions. Again, careful probing with increased sensitivity facilitates rapport and trust between caregivers and Filipino patients and the attainment of accurate health information.

Privacy

Filipinos are mostly reserved and private people. As patients, they may not readily reveal their personal and health information. Women in particular are sensitive to touching another individual as well as being touched. “Young female service providers should practice discretion with regard to touching older Filipino male patients such as laying one’s hand on the patient’s hand or shoulder to reassure comfort in moments of distress” (McBride, n.d., p. 13). So, in gathering information for a more comprehensive health assessment, Filipino nurses would know how to probe without being aggressive. They would know how to express compassion without the perceived unnecessary physical intrusion. Filipino women, especially the first generation of immigrants, are usually very reserved in terms of subjecting themselves to medical testing related to female body parts. Some deeply religious women may consider touching their breasts to be a sin. Other traditional women may consider self-examination a violation of respect for their body. For these types of examinations, a female provider is usually preferred, although a male physician who communicates sensitivity, respect, and gentleness would be acceptable (McBride, n.d.). In recognition of the heightened sense of modesty on the part of Filipinos, health care providers should ask permission before examinations and avoid rushing through. Explanation should be offered before, during, and after procedures.

CONCLUSION Although Filipino nurses are being acculturated in the U.S. health care system, traditional values and the Filipino culture continue to influence their health beliefs, behaviors, and practices. Instead of being a disadvantage, this enhances their cultural competence,



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because understanding one’s own culture facilitates understanding that of others. Together with their flexibility and adaptability, their open attitude to learn and understand others can only lead to increasing confidence and satisfaction of the patient. As hardworking health care professionals, Filipino nurses have made a name for themselves and have achieved professional success as supervisors, managers, hospital administrators, and entrepreneurs. Many Filipino nurses are seeking higher education; others hold executive-level positions in hospitals and academia. As a result, Filipino nurses are being recognized for their contributions in various arenas.

McBride, M. (n.d.). Health and health care of Filipino American elders. Retrieved July 12, 2003, from www.stanford.edu/group/ethnoger/fililpino. html

REFERENCES

Vance, A., & Davidhizar, R. (1999). Developing cultural sensitivity when your client is Filipino American. The Journal of Practical Nursing, 49, 16-24.

Castillo, M. (n.d.). Caring in the diaspora Filipino immigrants, health care, healing and religion. Retrieved July 11, 2003, from www.pna-america.org Chang, G. (2001, September 1). Importing nurses: A moneymaking venture. Dollars and Sense, pp. 1-2. de la Paz, A. (2001). Calling all Filipino nurses. Retrieved July 3, 2003, from www.geocities.com/reggiedoc/PNA50statesvision.htm Foley, M. (2001). Statement of the American Nurses Association before the Committee on Education and Workforce in the Nursing Shortage: Causes, impact and innovative remedies. Retrieved July 29, 2003, from http:// nursingwrold.org/gova/federal/legis/testimon/2002/edwork.htm Joyce, R., & Hunt, C. (1982). Philippine nurses and the brain drain. Social Science Medicine, 16, 1223-1233. Limson, A., Danguillan, L. J., Gutierrez, R. R., de Jesus, R. S., Crisostom, A. C., Roxas, A. M., et al. (1992). Surgery in the Philippines. Archive of Surgery, 134, 323-327.

McKenzie, J., & Chrisman, N. (1977). Healing herbs, gods and magic. Nursing Outlook, 25, 326-329. Okamura, J., & Agbayani, A. (1991). Philippines culture, Filipinos, values, Philippine beliefs. Retrieved July 12, 2003, from www. livinginthephilippines. com/values.html Prystay, C. (2002, July 18). U.S. solution is Philippine dilemma. Wall Street Journal, p. B17. Stuart, G. (1977). Philippine alternative medicine. Manual of some Philippine medicinal plants. Retrieved July 12, 2003, from www. stuartxchange.org/OtherHerbals.html Tuazon, N. (2002). Blending care and culture. Nursing Spectrum [online]. Retrieved July 29, 2003, from http://community.nursingspectrum.com/ MagazineArticles/article.cfm

Rosalia V. Ordonez, MEd, RN, is the chief of patient services education in the Department of Veterans Affairs—New York Harbor Healthcare System and a member of the Philippine Nurses Association, the Global Society for Nursing and Health, the National Nursing Staff Development Organization, the American Association of Critical Nurses, and the Preventive Cardiovascular Nurses Association. She can be reached via e-mail at rosalia.ordonez@ med.va.gov. Noemi Gandeza, MSN, RN, is a nurse educator in the Department of Veterans Affairs—New York Harbor Healthcare System and a member of the Philippine Nurses Association, the American Association of Critical Care Nurses, and the Emergency Nurses Association. She can be reached via e-mail at [email protected].


Filipino Nurses' Health Beliefs, Behaviors, and Practices - CiteSeerX

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