Journal of Transcultural Nursing

Transition Into Practice: Experiences 21(3) 257­–264

© The Author(s) 2010
Reprints and permission:
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DOI: 10.1177/1043659609358787

Practitioners http://tcn.sagepub.com

Alan B. Jauregui, MD, MSN, APN1 and Yu Xu, PhD, RN, CTN, CNE1

Abstract
An increasing number of Filipino physician-turned nurse practitioners (MD-NPs) are working in the United States.  This
phenomenological study examined the transition-into-practice experiences of eight self-identified Filipino MD-NPs in Las V   egas,
Nevada. Four themes emerged from the data. First, unfamiliarity with the U.S. health insurance policies and guidelines was
identified as the most frequent and challenging barrier to transition and successful work performance. Second, limited scope
of practice and the legal requirement to have a physician collaborator posed problems to some Filipino MD-NPs who were
once independent, full-fledged physicians.  Third, working in a litigious U.S. health care environment changed their attitudes and
practices. Fourth, having the education and experience as a physician facilitated their transition and role as NPs and led to a
higher job satisfaction than working as staff nurses. T
  argeted measures are needed to facilitate the transition of Filipino MD-NPs,
especially in the context of patient safety, quality of care, and the retention of these new advanced practice nurses. Further
research is needed on their transitional issues, including development and testing of an evidence-based transitional program.

Keywords
physician-turned nurse practitioners, the Philippines, transition, phenomenology

Nursing shortage and migration of nurses constitute a global
phenomenon (Buchan & Calman, 2004; Kingma, 2006). The
Philippines has been the major supplier of nurses for the global
market (Brush & Berger, 2002; Kingma, 2006). According to
the latest national survey, Filipino nurses constituted 50.2%
of the internationally educated nurses in the U.S. health care
system in 2004 (Health Resources and Services Administra-
tion, 2005). Although the migration of Filipino nurses and
their presence in U.S. health care facilities, especially in inner-
city hospitals, is common, a recent phenomenon is the exodus
of Filipino physicians from the Philippines who are retrained
as nurses to work in the United States.
The practice of medicine in the Philippines can be consid-
ered humanitarian to some extent because the majority of
physicians render health services to their patients despite low
compensation. Oftentimes, the physicians are not paid because
of the existing Philippine law that exonerates patients from
nonpayment of physician services. Patients can be discharged
from the hospital without paying the physicians for services
rendered. This leads to piling up of promissory notes given
by patients that were never paid. Payment through health insur-
ance has just started in the Philippines, and no data exist as
to whether this reimbursement method has reduced the burden
of nonpayment for Filipino physicians. In their clinical prac-
tice, Filipino physicians usually arrive at diagnoses using
minimal ancillary procedures and laboratory diagnostic tests,
thus reducing total health care costs. Filipino physicians are
known to have excellent clinical skills and can easily establish
rapport with their patients. Therefore, malpractice law suits
against Filipino physicians are rare. Patients are generally
satisfied with the treatment prescribed by their doctors. Physi-
cians are held in high regard in the Filipino society.
However, there are multiple reasons for the increasing
number of Filipino physician-turned nurses (MD-RNs) migrat-
ing to the United States. First, nurses in the United States make
more money than physicians in the Philippines. Filipino
doctors earn between $300 and $1,000 a month (Gatbonton,
2004). Second, it is much easier to emigrate to the United States
as a nurse than as a physician because of the preference for
nurses by the U.S. immigration laws to address the worsening
nurse shortage crisis. The difficulty and drawn-out process of
passing both written and clinical exams, matching for resi-
dency program, and the limited “quota” for foreign-trained
physicians make the medical career path unachievable for
many former Filipino physicians. Low pay for medical resi-
dents, grueling residency training schedule, and aging
1
University of Nevada-Las Vegas, Las Vegas, Nevada, USA
Corresponding Author:
Yu Xu, PhD, RN, CTN, CNE, University of Nevada-Las Vegas, 4505
Maryland Parkway, Las Vegas, NV 89154-3018, USA
Email: yu.xu@unlv.edu

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258 Journal of Transcultural Nursing 21(3)
of Filipino physicians are additional barriers to pursuing a
medical career in the United States. Third, “push” factors in
the Philippines include political instability, rising living costs,
high taxes, and disenchantment with the medical profession
(i.e., the paltry HMO-driven consultation fees, looming threat
of compulsory malpractice insurance, pressure from the gov-
ernment taxation agency, and persecution by the Bureau of
Internal Revenue). These factors have contributed to the exo-
dus of physicians, who find working as nurses in the United
States as an easier “ticket out” from the Philippines. Two to
3,000 Filipino physicians were enrolled in nursing schools,
and 100 physicians took the nursing board exam in June 2002
alone in the Philippines (Gatbonton, 2004).
Migration is never an easy decision (Kingma, 2006) and
its effects on nurses and their families are enormous. These
challenges are multifaceted, including economic, political,
psychosocial, and cultural (Allan & Larsen, 2003; Allan,
Larsen, Bryan, & Smith, 2004; Baumann, Blythe, Rheaume,
& McIntosh, 2006; Buchan, 2003; Daniel, Chamberlain, &
Gordon, 2001; Davison, 1993; Konno, 2006; Lopez, 1990;
Withers & Snowball, 2003; Xu, 2007). For MD-RNs who
comprise a “new breed” of international nurses, they experience
a “double whammy” of stressful adjustment to a new cultural
and work environment common to all international nurses and
the adaptation from the discipline of medicine to nursing (Vapor
& Xu, 2010). Vapor and Xu (2010) found that Filipino MD-RNs
working as staff nurses in the United States did not have job
satisfaction because of the challenge of changing professional
roles from physician to nurse, unmet socioeconomic expecta-
tions of practicing nursing in the United States, and the physi-
cal and mental challenge of nursing. Consequently, becoming
a nurse practitioner was the logical and realistic career option
for many Filipino MD-RNs.
This phenomenological study examined the transition-into-
practice experiences of a group of Filipino MD-NPs working
in Las Vegas, Nevada, after graduating from a formal training
program designed for MD-RNs. As of this writing, there are no
published studies on the work experiences of foreign MD-NPs
or MD-RNs. It is hoped that knowledge gained from this study
will help understand the transition of MD-NPs and issues in
their new role as NPs, thus providing a scientific foundation
for interventions to facilitate their transition.
Method
Research Design
Phenomenology is both a research method and philosophical
movement with the main objective of describing and examining
phenomena as they are consciously experienced (Spiegelberg,
1975). The purpose of phenomenological research is to capture
the lived experiences of study participants and their meaning.
Discovery of the meaning of human lived experiences is
considered an important goal of phenomenology. A basic
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philosophical assumption of phenomenology is that a person
can know what one experiences only by attending to percep-
tions and meanings that awaken conscious awareness (Husserl,
1962). For this study, the investigators were interested in the
transition-into-practice experiences of Filipino MD-NPs and
their meanings.
Sample
A purposive sample of eight Filipino MD-NPs participated in
this study. The inclusion criteria were (a) Filipino nurse practi-
tioners working in the United States who were formerly licensed
physicians in the Philippines and (b) aged 18 years or older.
Procedures
After the study received approval from the researchers’ insti-
tutional review board, participants were selected by referral
from colleagues and/or acquaintances in the health sector.
Participants were then contacted via telephone or in person
to arrange a face-to-face interview at a time and place chosen
by the participants. A written informed consent form explain-
ing the study was given to participants prior to each interview.
Once the informed consent was obtained, including permission
for audio-taping the interview, each participant was asked to
respond verbally to the following open-ended questions:
•• As a former physician from the Philippines, what are
your transitional experiences of working as a new
Nurse Practitioner in the United States?
•• What are the issues you have encountered while working
as a new Nurse Practitioner in the United States?
Each audio-taped interview lasted 30 to 90 minutes. Following
Collaizzi’s (1978) method, the data obtained were transcribed
verbatim and independently analyzed by two researchers to
identify emerging themes.
Data  Analysis
In context of this study, Collaizzi’s (1978) seven-step proce-
dure for phenomenological method was followed:
1. Reading all the interview transcriptions of partici-
pants to acquire a feel of their emotions
2. Extracting significant statements pertaining to the
investigated phenomenon
3. Formulating meanings based on these significant
statements
4. Organizing the formulated meanings into clusters
of themes
5. Integrating results of the data analysis
6. Constructing an exhaustive description of transition-
into-practice experiences of Filipino MD-NPs
Jauregui and Xu 259
7. Returning to the participants to validate findings via
member check and incorporating new relevant data
into the final research report
Measures to Ensure T  rustworthiness of Study
Bracketing is a measure used by researchers to consciously
separate their own life experiences or preconceived notions
from the phenomenon under study to avoid real or potential
interference. To achieve bracketing, researchers must reawaken
their own presuppositions and abstain from them for a moment
(Merleau-Ponty, 1956). As the layers of meaning that give
persons interpreted experiences are laid aside, what is left is
the perceived world prior to interpretation and explanation
(Oiler, 1986). Essentially, bracketing brings the participants’
experiences into clearer focus. Prior to each interview, the
researcher (AJ) attempted to “lay aside” his experiential
knowledge of the phenomenon under study to capture the
empirical reality outside himself and attune attentively to the
experiences described by the participants in the study (Swanson-
Kauffman & Schonwald, 1988).
Investigator triangulation was another measure taken. The
two research team members conducted independent data analy-
sis. Consensus was sought through discussion to resolve inevi-
table differences during data analysis. Intuiting was the third
measure wherein the researchers made conscious efforts to
remain open-minded to let the interviewee and data to “take
the lead” during both interviews and data analysis. Member
check, the fourth measure, was carried out whereby research
findings were sent back to the participants for validation. Finally,
an audit trail was maintained, including, among others, records
of decisions, field notes, and research team discussions.
Results
Demographic Profile of Participants
It turned out that all eight participants were graduates of
the first cohort of one Family Nurse Practitioner program
in Las Vegas. The age of the eight MD-NPs ranged from 40
to 58 years. There were seven females and one male. In addi-
tion to a Doctor of Medicine and Bachelor of Science in Nursing
from the Philippines, they all pursued additional training to
become specialists in their own medical fields. The specialty
certifications earned by the participants were in the follow-
ing areas: internal medicine (3), family medicine (2), anes-
thesia (1), pediatrics (1), and radiology (1). The length of time
worked as physicians in the Philippines spanned from 4 to
20 years.
Furthermore, all participants were retrained as nurses and
received a Bachelor of Science in Nursing from the Philippines.
All of them immigrated to the United States and used their
nursing degree to work legally as bedside nurses prior to pur-
suing their advanced nursing education. The length of time of
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working as staff nurses prior to becoming a NP ranged from
2 to 8 years. At the time of this study, all participants worked
in outpatient clinic settings for less than 1 year as a NP. Four
of the eight participants became clinic coordinators within
months of their hire.
Emerging T  hemes
Theme 1: Unfamiliarity with the U.S. insurance system policies
and guidelines was identified as the most frequent and challenging
barrier to transition and successful work performance. The majority
of the informants expressed frustration over insurance policies
and guidelines because of their unfamiliarity with the system
and the role as gatekeeper of health services. The MD-NPs
were uncomfortable in asking patients for their insurance cov-
erage, if their insurance is accepted by the MD-NP’s company,
and whether the patient had the money for his/her co-pay.
Such issues never existed when they practiced as physicians
in the Philippines because their patients usually had no insur-
ance and payment was almost always in cash. During the
initial patient encounter, problems with delivery of health care
services could arise if the patient’s insurance was not accepted
by the MD-NP’s company.
One MD-NP mentioned,
We cannot see the patient unless the insurance is okay.
If their insurance is not accredited, we refer them to
another primary care provider. In some instances,
patients were persistent and wanted to be seen right
away by the NP.
In this particular situation, the MD-NP explained to the patient
that his insurance would not cover the services to be rendered,
and the patient was given the following options: (a) pay in
cash for needed services, (b) given a list of other providers,
or (c) payment for services rendered by the MD-NP is waived.
In the third scenario, approval by the clinic coordinator was
required, which can delay the delivery of the service. Some
patients were turned away; others were referred to physician
collaborators of the MD-NPs. Consequently, the MD-NPs had
to apologize and explain to the patients that their company
did not accept their insurance policy. It was not uncommon
for patients to become upset if their insurance was not on the
accepted list of insurance providers and paying cash was the
only remaining choice to obtain the services.
One area of concern was the choice of treatment options or
medications. Decisions were no longer determined by what
was best for the patient but rather dictated by what the insur-
ance covered. If an MD-NP wanted to prescribe a particular
antibiotic that was not on the drug formulary of a patient’s
insurance, he/she must inform the patient. Although the MD-NP
believed that a particular drug was best for the patient, the
added cost in getting a nonformulary drug became a financial
burden to the patient. The MD-NP needed to ask the patient
260 Journal of Transcultural Nursing 21(3)
whether to buy the prescribed drug or choose a different drug
covered by the insurance. One MD-NP stated, “Instead of prac-
ticing evidence-based medicine, sometimes you have to bend
a little bit.” There were various ways of overcoming these
difficulties. One solution was to follow the insurance protocols:
“I have to go with what the insurance requires; otherwise, the
patient will have a hard time paying off.” Another solution was
to seek the help of medical assistants who were more knowl-
edgeable about insurance policies and guidelines.
Theme 2: T  he limited scope of practice of NPs and the legal
requirement to have a physician collaborator posed difficulty for
MD-NPs who were once independent, full-fledged physicians. Prac-
ticing under the supervision of a physician collaborator was
perceived as limiting their autonomy and scope of practice as
well as lack of trust in their ability. All the informants once
practiced independently as physicians in the Philippines. Now,
for them to practice in the United States as NPs, they were
required to have a U.S.-trained physician as a collaborator.
Having practiced medicine for years, the MD-NPs felt confi-
dent about their ability to diagnose and treat patients. Yet their
hands were “tied” because they had to adhere to established
treatment guidelines and had to inform their collaborating
physicians when confronted with cases beyond their scope of
practice as NPs. The MD-NPs usually ended up referring
patients to other providers and specialists even though they
knew they had the expertise to manage these conditions. In
addition, they must follow existing protocols in their daily
practice established by their employers or insurance compa-
nies. The following statements validated their difficulty:
Now we are tied up to different protocols and SOAP
(subjective, objective, assessment, plan).
I cannot be independent anymore and I have to rely on
my collaborator.
Yes, there are limitations here, based on the protocol; we
can only treat common illnesses and not emergent cases.
We have to refer them to other primary providers. . . .
There is also a range of ages that you can see, only
12 year olds to 65 year olds.
For the MD-NPs to adapt, they had to restructure their thinking
and accept their new role as NPs. One MD-NP who used to
own her practice stated:
It really affects my practice because I’m now working
as an employee, not as an employer. I think it’s difficult
to work with them. In order for me to succeed, I make
sure that I have a good working relationship with them.
The limited scope of practice was difficult for the MD-NPs
initially because they were used to treating patients
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independently in the Philippines. There were no protocols to
follow. They had their own guidelines based on standard prac-
tices and the recommendation of the Board of Medicine. Now,
working as NPs in the United States, the majority of them had
to strictly follow certain rules and protocols. One informant
expressed her frustration, “As a physician in the Philippines,
I get to do Internal Medicine with sub-specialty in Nephrol-
ogy; but now, I’ll be getting a limited scope of practice.”
Another MD-NP who was working in an outpatient clinic
stated the following:
We just treat patients with uncomplicated respiratory
illnesses. Once they have wheezing, we have to refer
them to the emergency room or to their primary care
physicians. We are not supposed to treat patients with
chronic diseases. The only patients we are supposed to
treat are hypertensive and non-chronically ill patients.
Even toothache, we’re not supposed to treat. It’s very
limited. We have protocols to follow and we call them
practice guidelines or algorithm.
On the other hand, a limited scope of practice was perceived
advantageous by other MD-NPs as established protocols and
practice guidelines offered them security with the collaborating
physician assisting them when necessary.
Regarding relationship with my collaborator, [there is]
no problem because we usually have meetings every
month. This is a good set up as this will assist me in my
transition.
I think it’s less stressful. You just have to follow what’s
in the protocol and you won’t get into trouble or end up
with a malpractice suit.
The protocol was clear-cut and straightforward; I don’t
think anyone can commit a mistake from following it.
As long as the physician gives me the autonomy, I won’t
have problems.
In reality, autonomy was only possible after the MD-NPs
gained the trust of their collaborating physicians. They
should expect that their collaborating physicians could audit
or check on them anytime. Auditing by a collaborating
physician was perceived as lack of confidence and trust in
their ability, which lead to feelings of shame and humilia-
tion. Moreover, having to rely on someone else was per-
ceived as having a “big brother” looking over one’s
shoulders, which made them uneasy and even resentful at
times. In contrast, one MD-NP commented, “You can’t
come here as a NP and still act like a doctor. You have to
forget about that career.”
Jauregui and Xu 261
Theme 3: W  orking in a litigious U.S. health care environment
changed their attitudes and practices. In the Philippines, medical
practice was more clinically oriented. Physicians usually
arrived at a diagnosis using very minimal technology and
relying heavily on health history and physical assessment. It
was an environment wherein patients were generally satisfied
and grateful for the services rendered by doctors. Malpractice
suits are almost nonexistent and patients rarely complain about
doctors. One informant mentioned that “the patients are very
compassionate and so are the doctors.” When the Filipino
MD-NPs started practicing in their new role as NPs in the
United States, all of them became keenly aware of the litigious
health care environment. The following views were shared by
majority of the informants:
Patients here are very arrogant; you need to be very
careful with what you say to your patient. At the same
time, they are trying to find fault on you, though not a
lot, but they just want to sue the doctors so they can get
money out from the doctor.
Because of liability suits against doctors, practicing
medicine is very defensive. We are very defensive against
lawsuits.
Because of this “litigious environment” in the United States,
the MD-NPs had to adjust their attitude and practices accord-
ingly to protect themselves from malpractice:
With these malpractice suits, it affected my decision-
making skills and I have to be extra careful.
I think the reason why people use a lot of laboratory
work-ups is to protect yourself from malpractice. I would
be doing the same too, just to follow the guidelines. I
know, but I have to cover myself from malpractice even
if it would mean an increase in health care cost.
To prevent potential problems, the MD-NPs recommended
the following strategies that seemed to work for them:
We should be very careful, especially in taking the
history and physical exam to arrive at a diagnosis.
Every diagnosis should be supported by laboratory
work-ups and ancillary procedures. If there’s any doubt
in my mind, I can always call my collaborating
physician.
Make sure everything has been done the right way. Track
the patient’s documents to see if they have the right
documentation.
That’s why you have to be very careful for every patient’s
symptom. You shouldn’t be negligent in preparing him
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for any ancillary procedure that will rule out the symptom/
disease.
Theme 4: Having a medical education and experience as a
physician facilitated their transition to the NP role and led to a
higher job satisfaction than working as staff nurses. Informants
affirmed that the transition from physician to nurse practitioner
was easier than from physician to staff nurse.
I don’t think it will take weeks or months before I will
be able to adapt to my new role as a NP because with
my medical and nursing background, I think it will be
easy for me compared to my work as a [staff] nurse.
It [medical education and experience] will be an advan-
tage. It’s like going back to curing and healing patients
like a doctor with the NP title.
I think the practice of nurse practitioner is just like an
extension of my medical career.
In addition, the perceived similarity between the work of
physicians and that of NPs made their transition into prac-
tice easier.
As far as the practice of a physician and a nurse practi-
tioner [is concerned], it was practically the same—we
deal with history taking and physical examinations
which were all the same for both physicians and NPs.
My medical background had lots of advantages in terms
of assessing the patient, giving the diagnosis, and prin-
ciples of therapy.
Because of their relative ease of transition to the NP role,
majority of the MD-NPs became confident in taking care of
patients within weeks on the job. In fact, they viewed the
combination of their medical and nursing background as ben-
eficial to their patients.
Now, I’m more knowledgeable; I can educate my
patients more thoroughly.
You see them [patients] in the context of the family,
context of the environment. You don’t only see the per-
son as a person per se, but you see them in the context
of so many things.
We used good critical thinking skills and already have
the clinical eye which helped us decide when to and
when not to refer our patients.
They affirmed that their combined medical and nursing back-
ground was more advantageous for patients cared for by an
262 Journal of Transcultural Nursing 21(3)
NP who is also a professional physician. For the participating
MD-NPs, such a combination was best of the two worlds for
the patient: benefiting from the expertise of a physician while
paying lower costs for services and having more quality time
with an NP without waiting for an appointment. An informant
stated, “It [NP practice] is a summation of the attitude of a
doctor and the attitude of a nurse practitioner. So it’s a sum-
mation of those approaches that makes the quality of care.”
Another MD-NP commented,
I am a NP and a healer; I’m the curer and I care for the
patient too. It’s all in one, it’s like nursing and doctor
in one as a Nurse Practitioner. . . . My experiences as a
nurse and doctor made me a well-rounded NP.
Another informant explained that being an MD-NP was “a
big advantage because no one would [need to] baby us or
cuddle us anymore because they [employers] can be very well
assured about our capacity.” Essentially, the Filipino MD-NPs
felt greater congruence between their medical background
and their current role as NPs, especially within the paradigm
of holism because they can treat and educate their patients at
the same time. Consequently, the majority of the informants
felt happier and more fulfilled in their newly found career as
NPs when compared with their previous careers as staff nurses
at the bedside. One NP commented that
it [being a NP] was the next best thing from being a
doctor. I don’t want to go back to residency and intern-
ship again because that takes a long time. I’ve been there
already. I just wanted to work. I will be happy because
I’m fulfilling what I was educated for. I may not earn
as much as a doctor, but I’m happy.
Another source of job satisfaction was the quality relationships
between providers and clients. These former physicians were
educated and practiced in the holistic paradigm in the Philippines.
In the NP role, they found applying the holistic care approach
possible once again.
NPs spend more time with their patients. Besides giving
treatment, you were there to educate your patient regard-
ing their disease process, and I found that . . . very
satisfying, because when you educate your patients, you
empower them. They’ll know what to do with their
illness.
There were also practical advantages of working as NPs.
Their work schedules were more flexible compared with that
of physicians, with no extended work hours and on-call
responsibilities. “Before we cannot take time off, we cannot
have vacations because you always have patients waiting.
But now you can go on a vacation any time you want because
you are entitled.”
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Discussion
Successful transition into practice is an important practice and
research issue for novice NPs in the United States. There is
an adjustment period that all new graduates undergo as they start
their role as advanced practice nurses (Brown & Olhansky,
1997). During this transition period, the beginning practitio-
ners frequently felt uncertain, anxious, and stressed out to
make sense of their new role. The most common concerns
during the first 6 months of NP practice were uncertainty
regarding diagnosis and treatment, fear of missing something,
and consulting more often than necessary (Lukacs, 1982).
Additionally, new NPs felt like they were impostors or just
faking it during their initial period after entering advanced
practice and stated that they had considerable difficulty feeling
real (Brown & Olhansky, 1997). Studies suggested that many
of the skills and knowledge gained during advanced practice
education in nursing were reinforced during the first year of
practice after graduation (Brown & Olhansky, 1997; Lukacs,
1982). Usually by the end of the first year, the new NPs felt
they had established a clear sense of themselves and functioned
relatively smoothly as advanced practice nurses ever after
(Brown & Olhansky, 1997).
Findings of this study indicated that Filipino MD-NPs had
a different transitional experience. They did not experience
the same clinical difficulties experienced by their American
peers. In fact, the most common concerns experienced by
novice NPs during their first 6 months of practice, as docu-
mented by Lukacs (1982), were virtually nonexistent for this
group of MD-NPs. For the majority of them, it only took a
few weeks before they became fully adjusted to their new role
as NPs. The Filipino MD-NPs indicated that they had acquired
the clinical skills and knowledge for their new roles long before
they were NPs; and “it was like coming back again” when they
started practicing as NPs. It was evident that their background
as physicians enabled them to bypass the transitional issues
commonly experienced by new NPs.
In contrast, nonclinical issues such as unfamiliarity with
the U.S. insurance policies and guidelines, limited scope of
practice, the need to have a physician collaborator, and the
litigious environment of practice presented more challenges.
In addition, finding from this study appeared to support Rich,
Jorden, and Taylor’s (2002) conclusion that educational back-
ground and prior experience as a registered nurse were two
factors that significantly facilitate entry into NP practice. Based
on Benner’s (1984) stages of clinical competence, it is reasonable
to expect that the Filipino MD-NPs could smoothly and safely
achieve Stage IV (proficient) of clinical competence based on
the following criteria: learning from experience what typical
events to expect in a given situation and how to modify plans
in response to these events; and holistic understanding of a
given situation that improves the proficient nurse’s decision-
making skills (Benner, 1984). Building on this trajectory, the
Filipino MD-NPs as a group could be expected to achieve
Jauregui and Xu 263
Stage V of clinical competence (expert) within a relatively
short period.
Implications for Practice
In light of the study findings, measures tailored to the spe-
cific needs of the Filipino MD-NPs should be taken in order
to facilitate their smooth transition into the U.S. health care
environment. The issue of transition takes on an added
importance because it could affect patient safety, quality of
care, and retention of these new advanced practice nurses.
Possible measures include enhancing existing orientation
programs to address concerns related to health insurance;
strengthening relationships with physician collaborators,
educating peers, and patients alike to respect these new NPs;
and building a supportive work environment. Also, continu-
ing education workshops such as those on U.S. health care
financing and reimbursement, legal aspects of clinical prac-
tice, consumer relationships, and so on should be included
in their pre- and postemployment training. In addition,
enhancements of these content areas in the current NP cur-
riculum are recommended.
Implications for Future Research
This study has triggered more research questions concerning
the new phenomenon of Filipino MD-NPs that are of impor-
tance and scholarly value. What are the major differences
between the transition from physician to staff nurse and transi-
tion from physician to nurse practitioner? Is there any differ-
ence in quality of care provided by Filipino MD-NPs versus
care by U.S.-trained MDs and nonphysician NPs? Is there any
difference in job satisfaction among the three groups? What
are the elements of an effective transitional program for
Filipino MD-NPs based on available evidence? What is the
impact of Filipino MD-NPs on the current primary care pro-
vider shortage in the United States?
Conclusion
With the worsening nursing shortage, the number of Filipino
MD-NPs working in the United States and other countries
is likely to increase in the foreseeable future as a result of
the interplay between the “push” and “pull” factors for migra-
tion. They will be employed not only in outpatient clinics
as clinicians but also in many other roles beyond the primary
care provider such as clinical director, gatekeeper of health
insurance, and so on. The successful transition of Filipino
MD-NPs is not only in the interest of this new breed of NPs
and their employers but also in the interest of patients. It is
hoped that the insight gained from this study will be helpful
in designing an effective program to facilitate the transition
and retention of these internationally educated advanced
practice nurses.
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Acknowledgments
The authors wish to extend their gratitude to all participants of this
study who graciously agreed to let the authors into their world and
shared their experiences with the public.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the author-
ship and/or publication of this article.
Funding
The authors received no financial support for the research and/or
authorship of this article.
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