Understanding International Immobility through Internal Migration: “Left behind” Nurses in the Philippines

Abstract

Migration scholars have tended to portray internal mobility as a step toward broader cross-border movement, reinforcing the notion of ongoing progress toward international migration. This article argues for a need to recognize how internal mobility can also explain international immobility, or why people do not move across national borders. Using the case of Filipino nurses, we argue that while internal migration does allow aspiring migrants to build the potential ability to emigrate, individual trajectories are much more diverse and multi-directional, often prolonging or reinforcing their international immobility. As a result, and in our case study, the costs and burdens of constant internal movement can also alter nurses’ migration aspirations, prompting them to either alter their original goals or acquiesce to their inability to leave their origin countries. This article calls for migration scholarship to address not only a “mobility bias” within the field but also the over-focus on international migration, rather than internal mobility, as a subject of study.

Keywords

immobility internal migration nursing

Introduction

In a 2020 article published in this journal, Kerilyn Schewel discusses what she terms the “mobility bias” in migration studies. Schewel’s article amplified the long-held critique that migration scholars have placed too much attention on the factors that cause migration and have ignored the question of why more people actually do not move (see Glick Schiller and Salazar 2013; Hjälm 2014; Kalir 2013). In particular, migration scholars have treated immobility as a “default situation,” in which it is the act of moving that is worthy of academic study (Mata-Codesal 2017). Such is the case, despite a growing number of studies on the structures that constrain people’s movement and the emergence of theories challenging the notion that immobility is merely a passive state of being (see Hannam et al. 2006).¹

This article echoes Schewel’s (2020, 2) call for more research on immobility or the condition of remaining in a geographic space over a period of time. In doing so, we argue that migration scholars must address not only a “mobility bias” but also an over-focus on international migration. In a seminal review article, King and Skeldon (2010) discuss how internal and international migrations actually flow into each other — a popular example being migrants’ movement from rural areas to urban centers to gain social and economic capital before seeking opportunities internationally. Yet, the label of “migration studies” continues to be mostly associated with movement across international borders, not within them (see De Jong and Garner 1981; Hickey and Yeoh 2016). Studies on international migration rarely cite the vast literature on internal movement (Nestorowicz and Anacka 2019), despite a growing number of scholars calling for a theory of movement beyond border-crossing activities (Hannam et al. 2006; Xiang 2016). This overemphasis on international migration reinforces the idea of discrete categories of people: those who move and those who are “left behind”; those who move beyond national borders and those who move within them. While there are important differences among these categories, the labels of “migrant” and nonmigrant” have become inflexible when used in scholarly research, glossing over the many ways that mobility and immobility are intertwined (see Conlon 2011; Mata-Codesal 2015).

This article demonstrates how tracing movements within national borders can provide a deeper understanding as to why people alter their plans to move beyond national borders (i.e., international migration). We show how international immobility can be rooted not only in structural constraints within the receiving nation but also in people’s migration pathways within their own origin countries. In particular, we integrate internal movement into Carling’s (2002) aspiration-capability model of international migration — a two-step approach that explains why people do or do not emigrate. In doing so, we address the following questions: How does internal migration impact individuals’ ability to migrate internationally? How does the experience of moving within one’s country shape individual aspirations for international migration?

We address these two questions, using the case of aspiring nurse migrants from the Philippines who, at the time of our study, were unable to realize their overseas aspirations due to the narrowing of opportunities in destination countries like the United States and the oversupply of nursing graduates within the Philippines (Acacio 2011; Ortiga 2018b). In the following sections, we discuss how existing studies relate internal migration to people’s aspirations and capabilities for emigration. We then outline the development of the nursing profession in the Philippines as a career associated with global opportunity, despite fluctuations in the demand for foreign nurses overseas. The findings section of this article elucidates how, contrary to being “stuck” in place, Filipino nurses’ inability to move internationally compelled them to remain constantly mobile within the Philippines, leaving crowded urban centers to find clinical work experience that would keep them employable to foreign hospitals. We also discuss how this process of moving within the country shaped individual migration aspirations, as the costs of moving internally pushed many nurses to either develop adaptive preferences that subdued their original aspirations or acquiesce to their inability to leave the country. We end the article with a section on how the direction and diversity of nurses’ current internal movements and possible international destinations are connected to the development of the nursing profession in the Philippines, as the same structures and institutional changes that enable some nurses’ successful international mobility also create the conditions that impede the emigration of many more.

Internal Movement within the Two-step Model of Emigration

Since Carling first introduced the aspiration-ability model of international migration in 2002, a growing number of scholars have used it as a means of explaining immobility and mobility (see Carling and Schewel 2018 for review). This model defines migration in two steps: (a) how people evaluate emigration as “a potential course of action,” and (b) whether they are able to realize this decision at a particular time period (Carling and Schewel 2018, 947). In this way, the model highlights the need to understand people’s desires, intentions, and plans to emigrate, alongside their capabilities and actual movement. Carling (2002) argued that rather than simply explain the factors that drive migration, his two-step model provides an opportunity to also make sense of individuals’ non-migration, or how people come to stay in place.

In this article, we argue that bringing internal migration into Carling’s two-step model provides an important opportunity to understand how movement within borders impacts both people’s migration aspirations and their ability to act on their desire to move internationally (Sherr et al. 2012). To date, scholars have mostly focused on how internal mobility allows individuals to build their capacity to eventually leave the country, with the aspiration for international experience prompting a stepwise movement from rural areas to urban centers, from the provinces to the capital city, and so on (e.g., Czaika 2012; Iredale et al. 2015). A common theme in these studies is how people’s aspirations change as they move from the countryside to the city, and they develop both a stronger desire and an increasing ability to move internationally. Such trends have long been evident in the migration of health workers, whose movement to urban centers also brings access to bigger healthcare institutions and a higher concentration of migration brokers who facilitate the process of seeking potential employers in other countries (Tabatabai et al. 2013; Marcus et al. 2014). In this sense, internal movement mainly serves as a steppingstone to international migration.

However, a number of migration scholars have also raised doubts as to whether aspiring migrants necessarily follow a linear trajectory from rural to urban areas before leaving the country. For example, studies on migration intermediaries show how brokers can provide the resources and international contacts that allow aspiring migrants to move directly from rural villages to international destinations (Wee et al. 2019; Walton-Roberts 2020). At the same time, geographers have argued that even within “developing” nations, there is a massive gap between rich capital cities and rural areas (Sidaway 2012; Horner 2019), making it sometimes harder for internal migrants to move within the country rather than beyond it. Thus, aspiring migrants can follow a variety of pathways in leaving their origin countries, sometimes skipping urban centers altogether in building their capacity for emigration.

In recognizing the complexity of aspiring migrants’ trajectories within national borders, there is also a need to investigate how internal migration shapes not only international mobility but also international immobility. Scholars have used the aspiration-ability model to argue that different forms of immobility arise, depending on individual aspirations and the broader structures that influence people’s capability to move. First, Carling (2002, 6) introduced the concept of “involuntary immobility,” where individuals have aspirations to migrate but are unable to do so. This form of immobility is especially evident in cases where aspiring migrants struggle to go on the initial journey from their home nations due to structural constraints such as state restrictions and changing labor markets.² Later, Schewel (2015) argued that while people might be unable to migrate, they may also no longer have any desire to do so — a condition she called “acquiescent immobility.” Hein de Haas (2003) proposed replacing the term “ability” with “capability,” arguing that enacting one’s freedom to migrate also depends on whether one’s surrounding environments provide opportunities to pursue endeavors that they value and desire. The aspiration-ability model defines all these forms of immobility in terms of whether people accept their inability to move internationally and what resources they have to act on their preference to either move or not move. However, missing from this model is how movement within borders can create such different forms of immobility.

If internal mobility can enhance people’s aspiration and ability to leave their origin countries, can it also have the opposite effect and lead to an eventual letting go of one’s emigration plans? To date, few scholars have sought to address this question (Langevang and Gough 2009; Kalir 2013; Schapendok and Steel 2014). In the following sections, we use the case of Filipino nurse migrants to elucidate how diverse internal movements shape their aspirations and abilities to emigrate.

Immobility in International Nurse Migration: the Case of the Philippines

Migration scholars often portray nurses as highly mobile professionals for whom a “nursing cap” is as good as a passport in a world with rising healthcare needs (Choy 2003; Pyle 2006). There is a wide literature, for example, on the experiences of nurse migrants in the countries that receive them, the impact of their departures on the places they leave behind, and the factors that shape individual decisions to work internationally (Kingma 2006; Guevarra 2010; Walton-Roberts 2012; Showers 2015; Zhou et al. 2016). In all these studies, nurses’ capacity to move across borders is largely treated as a given, and the ability that nursing credentials grant individuals hoping to leave their origin countries is taken for granted.

Yet, in reality, global “demands” for nurse labor are erratic, oscillating between peaks and dips in response to changing immigration policies, domestic labor markets, and state regimes (Ortiga 2018b). Despite such instability, the nursing profession continues to be associated with international opportunity within large source countries like India and the Philippines, which encourage young people to pursue nurse education as a means to emigration (Guevarra 2010; Timmons et al. 2016). The discrepancy between nurses’ migration aspirations and the availability of desired jobs underlines the importance of understanding aspiring nurse migrants’ mobility and immobility. While the international mobility of nurses — mostly from poorer to wealthier nations — raises important questions for migration scholars, so, too, do the experiences of those who have not moved internationally (see El-Jardali et al., 2013).

As one of the top sources for migrant nurse labor in the world (Guevarra 2010), the Philippines has experienced periods of both high and low demand for Filipino nurses among foreign employers. The country’s long history of nurse migration began in the American colonial period in the early 1900s, when American officials established the Philippines’ first nursing school and granted nurses special visas that encouraged travel to the United States (Choy 2003). The institutionalization of the Philippine state’s labor-exporting strategies in 1975 turned nurse labor into a lucrative commodity, as government agencies actively marketed Filipino nurses to international employers, with the intention of maximizing the remittances these migrants would eventually send home (Guevarra 2010).

However, the same structures and institutional changes that facilitated the successful international migration of some Filipino nurses created the conditions that eventually made it difficult for many others to leave the country (Ortiga 2020). First, the Philippine state’s active brokering of Filipino nurse labor and its celebration of successful migrants reinforced the image of nursing as an ideal steppingstone to overseas opportunity (Guevarra 2010). Aspiring migrants turned to nursing education as a means of realizing their migration dreams, and private nursing schools were quick to capitalize on the opportunity to attract more tuition-paying students (Ortiga 2014). Due to lax government regulation, Philippine nursing schools proliferated in the early 2000s, and school owners expanded student enrollment to maximize their profits (Ortiga 2018a). All these factors created a “migration trap,” where aspiring nurse migrants invested in training credentials for international work yet graduated at a time when those international jobs were no longer available (Ortiga 2018b).

This article focuses on the most recent cycle of “demand” for nurses in the Philippines. Beginning in the early 2000s, US hospitals embarked on an aggressive recruitment drive for foreign nurses, working with recruitment agencies in large source countries like the Philippines (Acacio 2011). While the Philippine state deploys nurses to more than 50 countries worldwide, the United States remains the most popular destination and also one of the largest recruiters of foreign nurse labor (Keuhn 2007).³ As a result, the early 2000s marked a massive demand for nursing degrees in the Philippines, with almost half a million students enrolled in nursing programs in 2006 alone (Ortiga 2018a).

By 2008, however, available nursing jobs in popular destination countries began to decline (Acacio 2011). Some barriers to nurses’ mobility were beyond the Philippine state’s control: a global financial crisis that slowed foreign nurse recruitment in North America and Europe (Buchan et al. 2013), and retrogression⁴ at the US embassy that limited the number of visas available for Filipino nurse applicants to the United States (Acacio 2011; Crisostomo 2012). However, the largest obstacle to Filipino nurses’ international mobility was a product of institutions within the Philippines. In particular, local health institutions lacked the funding to open positions for the massive number of nurses entering the Filipino labor market, leaving aspiring nurse migrants unable to complete the two years of work experience that most foreign hospitals required (Ortiga 2018b). This problem was made worse by Philippine state officials’ reticence to raise nurses’ salaries or devote public funds to creating more permanent positions for staff nurses in public hospitals, given the dominant image of Filipino nurses as rich immigrants overseas (Cabanda 2017). As a result, nurses’ international immobility constituted a new reality for the Philippines: an oversupply of employable aspiring migrants.

While forced to remain within their own country, Filipino nurses who maintained their migration aspirations could not simply “stay put” while waiting for international opportunities to return. Rather, as this article shows, their inability to move overseas spurred a need to be internally mobile in order to keep their nursing skills viable for foreign employers in the context of a domestic job market oversaturated with aspiring nurse migrants.

Data and Methods

This article draws from in-depth interviews with 48 Filipino nursing graduates (33 women and 15 men) based in the Philippines at the time of our study (2015–18). We conducted these interviews in a mix of Tagalog and English, and translated the transcripts ourselves. Interviews focused mainly on the period between when participants obtained their nursing license in the Philippines and when the interview was conducted. Participants’ ages ranged from 22 years to 35 years old. All but six participants shared that they chose to major in nursing as a steppingstone to overseas work. Parents and relatives were heavily involved in making this decision - all interviewees stated that they knew very little about what nurses’ work entailed before they began their studies but had relatives or friends who worked as nurses overseas. As a result, the initial decision to pursue nursing was mainly driven by a desire to invest in a profession that promised better opportunity, rather than a passion for healthcare.

At the time of this study, no participant had been able to realize his/her initial goals of working overseas as a professional nurse.⁵ Two interviewees had worked overseas, but not as registered nurses. One had gone to Japan as a caregiver before pursuing a nursing degree, while another had spent two years in Singapore as a nursing aide at a home for elderly patients. When we spoke with them, less than half (20 out of 48) of respondents were still actively working toward pursuing their aspirations of leaving the country. The remaining 26 no longer had plans to pursue professional nursing jobs overseas.

We recruited participants through personal networks and the contacts we made in previous research projects. Ortiga had conducted research in nursing schools from 2011 to 2015 and had asked clinical instructors to recommend friends or former students who had already graduated. Macabasag recruited nurses he met while conducting research in rural health centers in the Philippines. In many ways, our contrasting experiences as co-authors informed our approach to these interviews. As a sociologist studying skilled migration, Ortiga was interested in how aspiring nurse migrants thought about their overseas employability and how they sought to present themselves to future employers. Meanwhile, Macabasag, a registered nurse himself, had given up on initial plans of working overseas and wondered how other nurses made the decision to stay in the Philippines. We realized that these two themes were related and very much intertwined with nurses’ movement within the country. As two Filipino scholars conducting migration research, we were keenly aware that Filipino nurses often face enormous pressure from family and peers to migrate to desired destinations like the United States. Ortiga’s previous work on nursing students made us cognizant of how interviewees might hide their decision to let go of migration plans to avoid having to explain the less popular decision of remaining in the Philippines. Here, the fact that Macabasag was a registered nurse who had tried and “failed” to go overseas was important in building rapport with interviewees and in having them talk candidly about their struggles to realize their migration aspirations. In the analysis that follows, we focus on how nurses’ efforts to enhance their employability for overseas work helps us develop a deeper understanding of aspiring nurse migrants’ international immobility.

When International Immobility Creates Internal Migration: Building Potential Ability

Nurses in our study regarded internal migration as a necessary part of accumulating the work experience needed to qualify for international jobs.⁶ Interviewees charted their post-graduation job search in line with the requirements set by desired destinations like the United States and the United Kingdom, where most hospitals required foreign nurse applicants to have at least two years of work experience in a “tertiary” hospital with a 200-bed capacity. In the Philippines, such health institutions were mostly concentrated in big cities like Manila and Cebu City, making it important for aspiring nurse migrants to move toward these metropolitan areas. This effort of moving to find relevant work experience reflected a conscious strategy to build what Carling and Schewel (2018) call potential ability, or “a person’s prospects of realizing migration aspirations” (p. 955).⁷

Yet, the peak and decline of overseas opportunities for Filipino nurses created a more complex pattern of how internal migration impacted their potential ability to migrate internationally. Given the massive number of aspiring nurse migrants in the national labor market, Philippine hospitals were inundated with applicants for nursing jobs, all desperate to accrue the hospital experience needed to apply for overseas work (Ortiga 2020). Both private and public health institutions capitalized on this demand, requiring job applicants to work as volunteers before they could be considered for a permanent position. Other institutions charged nursing graduates a “training fee” in exchange for their supposed “exposure” to the hospital floor (Ortiga 2018b).

As a result, Filipino nurses’ international immobility spurred a different form of internal mobility. Rather than moving toward large metropolitan areas where the job market was crowded, many interviewees returned to their parents’ hometowns in provinces far from the country’s urban centers. There, they relied on family networks to seek opportunities in local health institutions. One interviewee, Jessa, was a self-described “Manila girl,” having lived in the capital city all her life. Yet, shortly after passing the nursing board examinations in 2015, she moved to her mother’s home province on the island of Mindoro because her uncle promised her a nursing job funded by the Department of Health. Similarly, Rizza, a registered nurse since 2012, first moved from her parents’ home in Eastern Samar to pursue a nursing degree in Cebu City, where there was a larger number of nursing schools. Yet upon graduating, she found it easier to find work back in Eastern Samar because of her family’s contacts in the local provincial hospital.

Aside from family networks, nurses looking for work experience also relied on small-scale, local government programs that provided temporary work for unemployed nursing graduates. Nurses submitted their names to a tambiolo (lottery or raffle drum), where government officials picked a selected number of individuals to be offered short-term contracts at a local public hospital. Only residents of the town or municipality could join this lottery system, thus encouraging nursing graduates to stay “at home” or, if they had left to pursue their nursing degrees elsewhere, to move back to their provincial towns and villages. While provincial hospitals were smaller and less well equipped compared to tertiary hospitals in urban centers, interviewees insisted that they would still qualify for particular employers within their targeted destination countries. For example, Peter, a registered nurse since 2013, chose to remain in his home province after he “won” a three-month contract with the provincial hospital. Having done his own internet research, he shared that the province’s 150-bed hospital was enough to fulfill employer requirements in the US state of Maryland. In this sense, internal migration away from the Philippines’ crowded urban centers allowed aspiring nurse migrants to continue building their potential ability for emigration, amid a context of limited overseas opportunities and an oversupply of nursing graduates.

Moving to Sustain Everyday Life

In the process of accumulating hospital work experience, internal migration also served as a means of surviving the lack of stable nursing positions that offered a living wage. Interviewees found that while hospitals outside urban centers provided more nursing jobs, many of these positions remained contractual, temporary, and poorly paid. As such, aspiring nurse migrants also moved from place to place to earn an income that could cover their daily needs. For example, Felipe, a registered nurse since 2009, initially moved from his hometown in Ilocos to the capital city of Manila to look for work in a tertiary hospital. After a few months, he moved to another province, La Union, where his daily expenses would be more manageable. He explained, “Everything in Manila was expensive. The cost of living was so high, and the hospitals were charging me for volunteering. At least in La Union, I could volunteer in the hospital without having to pay a fee.” To support himself, Felipe took on other non-nursing jobs that paid higher salaries. Once, he moved from La Union to the next province of Benguet because he could save on rent by staying with relatives. Eager to “just earn money,” he worked at the ticket counter of a local mall’s cinema. After six months, he returned to Manila to find hospital work, filling his time between job searches with work as a research assistant for a local university.

Felipe’s case shows how nurses who wanted to continue building their potential ability to emigrate also had to balance a combination of contractual jobs to sustain their everyday lives. Thus, aspiring nurse migrants did not follow a typical trajectory of moving from rural to urban areas to build their capacity for future emigration. Instead, they moved from one smaller city to another, maintaining multiple jobs while trying to gain relevant nursing experience, even as opportunities dried up. In line with the observations of geographers such as Horner (2019), interviewees felt that large metropolitan areas like Manila had become inaccessible due to the high cost of city living, leading them to avoid such urban centers and embark on alternative pathways of internal migration.

Unfortunately, the decision to move toward jobs that paid a living wage sometimes worked against nurses’ efforts to build their potential ability for emigration. Such was the case for interviewees who had chosen to enter a rural nurse deployment program administered by the Department of Health (DOH), where nursing graduates were hired to provide services to village health centers in rural communities. This program paid nursing graduates almost double the wages that regular staff nurses earned at public hospitals and offered full-time contracts of up to two years.⁸ For this reason, many interviewees sought refuge in these programs after going through a period of precarious hospital jobs. For example Michelle, a registered nurse since 2014, juggled two part-time positions at a public and private provincial hospital before deciding to enter a nurse deployment program that assigned her to a rural community outside her hometown. She explained,

The private hospital paid me 8,000 to 10,000 pesos per month. You can earn more through overtime, but you end up paying more taxes. In the public hospital, they paid you per day, so basically it’s no work, no pay…. I admit it: I transferred to the community because I needed the money. Everything adds up, you need money to get to work, and at the end of the day, you don’t have enough to support yourself. Kulang na kulang talaga (It really wasn’t enough).

Like Michelle, many interviewees regarded the move to community nursing as a much-needed “break” from the stress of managing a grueling hospital schedule while trying to earn enough for everyday expenses. However, this “break” from precarious hospital work also generated much anxiety among nurses hoping to move on to jobs overseas. As noted by Walton-Roberts (2020), nursing credentials are “time sensitive,” and aspiring nurse migrants must actively practice their profession in a clinical setting to remain up to date in the profession. Consequently, interviewees who took on jobs outside the hospital worried that they were at risk of losing the skills they needed to prove their overseas employability. Yeng, a registered nurse since 2015, was particularly worried that her two-year stint in a rural health center would be detrimental to her plan of eventually moving to Canada. While she practiced her profession as a “community nurse,” Yeng admitted that much of her work involved implementing public health programs and conducting “basic” health check-ups. When her contract with the community ended, she returned to searching for hospital work because she felt she needed to build her skills from scratch.

I have classmates from college who worked in the hospital. All of them are so good at nursing! They all got experience at special areas like the ER [emergency room]. I ended up just working in the community, doing basic things. Ang laki nga ng sahod ko pero…wala akong masyado alam [I do have a bigger salary, but I actually don’t know very much]. This makes me feel low — like I don’t have the confidence to help in a medical emergency.

Despite community work’s supposedly detrimental effect on one’s prospects of leaving the country, nurses eventually came to depend on these jobs as an income source for their families. A majority of interviewees were single women, and many espoused the common expectation that Filipino daughters supported aging parents, especially if they did not have their own children (Concepcion and Perez 2006). Rizza, a registered nurse since 2012, explained,

I really wanted to work in a hospital, but there was no way that they would pay me as much as the DOH (Department of Health) was paying me. That’s why I decided to just stay in the community. At that time, my parents were already retired, and their company was only going to give them their pension after five years. I had to find a way to sustain them. They have no income, and all my brothers have their own families to take care of.

Rizza only considered working toward emigration once again after three years of working as a community nurse, when her parents’ finances were more secure. She moved to Manila to pursue a master’s degree in nursing while holding a part-time job as a researcher in a local university. Rizza was hopeful that obtaining a graduate degree would give her an advantage in her application to Australia, where her cousin worked as a nurse. However, she was also well aware that in deciding to prioritize higher wages over hospital experience, she would need to make up for lost time. Nikka, who became a registered nurse in 2012, had a similar experience. She initially moved to a rural health center to earn more money and hoped to return to the city and gain more hospital experience after accumulating enough savings. Yet, when her father became very ill, she decided to renew her contract with the DOH and have herself assigned to a community near her parents’ hometown:

Actually, I want to try to find work in a hospital, even if it means paying the fee. But I don’t think I will go to Manila yet. I need to stay here because my father is sick and there needs to be someone nearby. Syempre, family first (Of course, the family comes first).

Nikka admitted that while she was technically a practicing nurse, community work did not offer the kind of skills that recruitment agencies wanted to see:

Hospital experience really matters for places like the US. Like here, in our community, the health center only has ten beds. Recruitment agents are telling us that if you want to go abroad, bed capacity is something they really look at. If you don’t have experience in a big hospital, you’re not appealing to them.

Nikka’s experience reflected the contradictory impact of internal mobility on interviewees’ capacity to realize their international migration aspirations. On the one hand, internal migration allowed nurses to move toward places where they could build their work experience for foreign hospitals. Yet, as these aspiring nurse migrants moved beyond hospitals to access jobs that paid a living wage, they also compromised their potential ability to emigrate in the future. In other words, not all internal moves enhanced nurses’ ability to leave the Philippines. Instead, movement to non-nursing work or jobs outside the clinical setting made it more likely for nurses to remain in the Philippines for a longer time period.

When Internal Migration Affects Migration Aspirations: Acquiescent Immobility and Adaptive Preferences

In many ways, aspiring nurse migrants in the Philippines could be considered involuntarily immobile. Most interviewees had entered the profession with a desire to work as professional nurses overseas, yet at the time of our interviews, all were still in the Philippines. In the following sections, we discuss how internal migration shifted interviewees’ aspirations for overseas work by either changing how they viewed their inability to find nursing jobs overseas or transforming their planned trajectories for the future.

Acquiescent Immobility

As some interviewees moved from place to place in the Philippines, they eventually let go of their original migration aspirations. In line with Schewel’s (2015) definition of acquiescent immobility, these nurses came to accept that they would not be able to migrate overseas as professional nurses and eventually developed a preference for staying in the Philippines. For some, this shift occurred as they became exposed to a wider range of work that nurses could pursue within the country. Weena, a registered nurse since 2015, moved from her home province in Mindoro to pursue her nursing degree in Manila. She had spent a year volunteering at a public hospital in Manila when her parents informed her that there was an open position for a community nurse in a rural health unit near their home. Before then, Weena was not aware that nurses could pursue careers in the public health sector. After a year as a community nurse, Weena claimed that she no longer had definite plans of leaving the country and would rather find a permanent position in the DOH.

I wouldn’t mind staying in the community if they gave me a regular job. I feel really fulfilled as a community nurse. People know you, they say hello, they get to know you even if you’re not related to each other. It’s not like how it was in the hospital, you don’t get to check how patients are doing because once they leave, you don’t see them anymore. Here, you live with people, so you can see how they are doing. And you feel nice when you see they are getting better.

One might argue that Weena had jeopardized her ability to move overseas by leaving a hospital job for a position as a community nurse. Yet Weena’s experiences in the community had also diminished her aspirations to move away from the Philippines. In line with the concept of acquiescent immobility, Weena expressed a preference not to emigrate and to practice her profession as a community nurse within the country.

For other interviewees, the process of constantly moving eventually wore them down, leading them to question whether it was still worth pursuing their dreams of working abroad. Tired and burnt out, a few interviewees chose to settle in their respective communities when permanent positions opened in local health units, even if it meant giving up the possibility of finding work abroad. Kimberly, a registered nurse since 2012, initially moved from her hometown to the main city of her province to volunteer at a public hospital. When she heard that the local government in her municipality opened a permanent position for a community health nurse, she immediately applied for the job and returned home. While the pay was much lower than what she would earn overseas, Kimberly said she no longer had aspirations to leave in the future.

Our town is very poor, and that’s the reality. Of course, some people feel that I wasted the opportunity to go abroad. But if you think about it, I have a lot of comfort and convenience. When I was at the city, I had to pay for my board and lodging, my food, my electricity bill, my water bill. Here, I own my house. I live near my parents. The only thing I worry about is my transportation getting to work.

Meanwhile, interviewees who could not find permanent nursing positions (whether in rural or urban venues) simply left the profession altogether for better-paying jobs in other industries. Out of 48 interviewees, 15 nursing graduates were no longer working in health-related occupations at the time of the interview.⁹ One interviewee, Darlene, a registered nurse since 2007, moved through two volunteer jobs in two different cities, before deciding that she wanted a more settled way of life with her husband. She eventually opted to work as a cashier at a factory canteen near her home and no longer desired to become a nurse in the United States. In all these cases, interviewees grew weary of the process of building potential ability and the internal mobility that often came with the search for hospital work experience. Of course, these periods of immobility may not last forever, and interviewees could always restart their migration aspirations in the future (Schewel 2020). However, what is important to note is how internal movement was a key part of how interviewees made sense of these periods of immobility and how their previous migrations within the Philippines shaped their current aspirations of leaving — or staying in — the country.

Adaptive Preferences

A few nursing graduates in our study developed what Carling and Schewel (2018) describe as “adaptive preferences,” or subdued migration aspirations in line with limited abilities to emigrate. Interviewees expressed these preferences in different ways. For many of those who still aspired to leave the country, adaptive preferences meant considering other destinations that may not have been their “first choice” for work. As interviewees grew tired of moving for hospital work, for example, they shifted their goals toward receiving countries where employer requirements for clinical experience were less stringent. Raymond, a registered nurse since 2007, decided to work as a clinical instructor in a local nursing school when he could not find a job in the city hospital. While recruitment agencies for hospitals in the United States did not recognize his teaching work as valid clinical experience, he claimed that employers in Saudi Arabia and the UAE would accept his application. Unwilling to move away from his hometown in Manila, Raymond decided to shift his energy toward getting a job in the Middle East instead.

Meanwhile, some interviewees formulated adaptive preferences by seeking other avenues to emigration, even if it meant being unable to practice as a professional nurse. For example, Michelle maintained her aspiration to migrate to Canada because most of her relatives were based there. Yet after struggling with short-term contracts in multiple public hospitals in the Philippines, she shifted her goal from being a registered nurse to migrating as a live-in caregiver instead. Relatives assured Michelle that she would have an easier time emigrating to Canada as a caregiver first and then “working her way up” to a nursing job later on. This change in Michelle’s aspirations altered her own internal migration trajectory within the Philippines. Less concerned about gaining hospital experience, Michelle became content to join the DOH’s rural deployment program because the higher salary allowed her to save more money to pay for English proficiency exams and visa fees.

Yet, for others, formulating adaptive preferences meant changing both their career aspirations and desired destinations. This was the case for Karlene, who first moved from her home in Mindoro to the neighboring province of Batangas to pursue her nursing degree. She immediately started volunteering at a local district hospital after passing the board examinations in 2012 but left after seven months because she felt ashamed that she was still receiving support from her parents. She joined the DOH nurse deployment program and was assigned to a community near her home for two and a half years. In 2014, her mother encouraged her to pursue her plans of finding a nursing job overseas. Yet, with little hospital experience, she did not qualify for the United States or Canada, her two ideal destinations. Determined to fulfill her mother’s expectations, she found work as a nursing aide in a Singapore nursing home instead:

I could have stayed in the community longer, but this [working overseas] was what my mom always wanted. When my dad died in 2010, she worked hard so I could finish my nursing education. So whatever she wanted, I said I would give it to her. The job [in Singapore] was like being a nurse. We changed their diapers; we bathed them and fed them during mealtimes. But we weren’t in the hospital.

However, settling with one’s adaptive preferences did not always bring a sense of fulfillment. In Karlene’s case, she eventually became unsatisfied in Singapore (“I was doing the same things again and again”) and returned to the Philippines after completing her two-year contract with the nursing home. She re-entered the nurse deployment program and was assigned to Lubang, an island municipality, two hours away from her home. At the time of our interview, she was no longer willing to move away from her province to find work at a city hospital or a bigger healthcare facility in Manila. She explained,

I would love to work in a hospital. I really got to practice my skills, I really learned so much. But as a volunteer, it just wasn’t worth it. Pagod na pagod ka (Your body is so tired) — I pushed myself to learn as much as I can, and I learned a lot! But I can’t do that anymore…. It is also too expensive to move to the city. I would rather just go abroad again.

Karlene was well aware that her unwillingness to move for hospital work curtailed her chances of ever qualifying for jobs in the United States. However, her experience in Singapore made her realize that she did not want to let go of her professional career as a nurse. She developed new adaptive preferences and narrowed her possible destinations to countries that did not require hospital experience from foreign nurses. At the time of the interview, she was preparing documents to apply to either Saudi Arabia or the Cook Islands, a small nation near New Zealand.

Karlene’s case raises interesting questions as to how the disparities between urban centers and peripheral towns in the Philippines influence how aspiring nurse migrants formulate adaptive preferences. In the previous section, we discussed how the high cost of living and the crowded job market within the Philippines’ urban centers could push nurses to move among smaller peripheral cities instead. While these smaller cities did not provide aspiring migrants with the work experience necessary to qualify for hospital jobs in their desired destinations, interviewees were able to accumulate enough credentials to pursue nursing positions in other countries. Many interviewees also developed these adaptive preferences because they allowed them to avoid having to move to expensive cities like Manila. As this section has shown, the costs of some forms of internal migration can encourage aspiring migrants to plan different paths out of the country, beyond the usual step from rural to urban areas, further highlighting the complex relationship between internal and international (im)mobility.

Conclusion

This article has argued that to fully understand how people experience international immobility, scholars must also recognize and investigate aspiring migrants’ movements within national borders. Contradicting the common assumption that internal mobility builds people’s capacities for international migration, we found that in the case of Filipino nurse migrants, the need to keep moving within the country undermined their potential ability to emigrate from the country. Embarking on multiple internal migrations drained interviewees’ time and resources as they chased opportunities to practice clinical skills while seeking gainful employment to support their everyday needs. Therefore, while choosing not to embark on internal migration could also be detrimental to one’s future ability to leave the country, we found that constantly moving from one place to another within the Philippines did not necessarily lead to higher chances for emigration.

As the stresses and costs of internal migration prolonged aspiring migrants’ experiences of international immobility, they also altered these nurses’ own migration aspirations. Some interviewees eventually let go of their aspirations to leave the Philippines altogether, while others adjusted their initial goals, either choosing to take non-nursing jobs overseas or modifying their original desired destinations for alternative countries like Saudi Arabia or the UAE. Although all nurses in our study still lacked the potential ability to leave the Philippines, their internal migration led to a spectrum of immobility, on which would-be migrants could be either involuntarily immobile or acquiescent to their inability to move (Schewel 2015; Ortiga and Macabasag 2020). We have argued here that closer attention to the role of internal migration can reveal how individuals shift from one form of immobility to another, as they also move (literally) within their origin countries.

More broadly, this article demonstrates how tracing aspiring migrants’ internal migration trajectories can reveal the problems that keep people internationally immobile. On the one hand, Filipino nurses’ movement through provincial towns and small cities highlights issues that have long plagued the Philippines’ health care system: the lack of funding for full-time positions within public hospitals, inequalities among rural and urban health institutions, and a for-profit education system that generated an oversupply of nursing graduates. Yet, as noted by Thompson and Walton-Roberts (2019), seemingly local problems are also constituted by issues that go beyond national borders. In the case of the Philippines, the nursing profession’s status as a prime “export product” (Choy 2003; Guevarra 2010) led government officials to invest more on Filipino nurses’ overseas employability than on health services in Philippine hospitals and clinics (Cabanda 2017). In many ways, such problems have been understudied within the migration field, where scholars have largely centered on the loss of care labor as nurse migrants leave to fill jobs in wealthier countries (Lorenzo et al. 2007; Connell and Buchan 2011). This article demonstrates how understanding the impact of nurse migration entails an attention to internal movements that occur before they even leave their origin countries.

Even as we write this article, the need for in-depth research on international immobility has become even more prescient, given the emergence of the COVID-19 pandemic that continues to overrun health systems across the world. While media attention has focused on how efforts to control the virus shut down international borders (Brumfiel and Wilburn 2020; Burke 2020), many countries have also seen the hardening of internal boundaries between cities, towns, and provinces (Baker 2020; Rao 2020). In the case of Filipino nurses, the shortage of health workers due to the COVID-19 pandemic has actually opened up overseas opportunities in places like the United Kingdom and Germany (Santos, 2020). Yet the rising cases of COVID-19 patients within the Philippines also shut down domestic transportation and prompted local government officials to impose a confusing bureaucracy of permits that restricts internal movement (Manila Times, 2020). These restrictions have stranded aspiring nurse migrants in their home provinces and cities, making them unable to travel to the larger urban centers where recruitment agencies and international airports are located. Such changes emphasize the need for more research on how new constraints on internal mobility will affect international migration as a whole. This article provides one example of how migration studies can recognize the co-existing pathways that define aspiring migrants’ trajectories, both within and beyond national borders.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received financial support for the research, authorship, and/or publication of this article: This work was supported by Japan Society for the Promotion of Science: [Grant Number JSPS KAKENHI Grant Number 15H05171].

ORCID iD

Yasmin Ortiga

Romeo Luis Macabasag

Notes

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