Pete-Reuben Calixto's first inkling to move from the Philippines to the United States can be traced back to the simple task of reading textbooks in nursing school.

The books were written by American authors, and Calixto, RN, noticed that the technology they described was a far cry from the equipment being used in his country's hospitals. He was eager to immerse himself in the latest medical practices and was inspired by the stories of fellow Filipino nurses who'd returned to tell of their adventures in America. In 1979, he decided to pursue a job in the United States-and he's never looked back.

One of the first obstacles he remembers was trying to find reliable recruiters. He'd heard horror stories about recruiters who lured Filipino nurses to sign illegitimate contracts. With advice from fellow nurses, he connected with trustworthy recruiters and landed a job as a dialysis nurse at Florida Medical Center in Ft. Lauderdale.

It didn't take long for him to encounter his next challenge as an international nurse: learning to be direct.

"It was difficult to accept that," Calixto said. "In the Philippines, people try to beat around the bush or try to be polite by saying they understand something even if they don't because of fear of being labeled. In the United States, it's better to just say 'I don't understand.' "

He also noticed that American nurses are more autonomous than those in the Philippines, and Calixto said he thrived in an environment where he had more responsibility.

He was vacationing in San Francisco when he began tinkering with the idea of moving yet again, but this time it was within the same country. "I liked the weather in San Francisco, and I wanted to work in a teaching hospital because that environment would foster state-of-the-art nursing," he said.

In 1981, he accepted a position as a nurse in a kidney transplant unit at the University of California, San Francisco School of Medicine. Now, the challenges were rarely related to cultural transition, but focused on the dilemma of working in a unit dependent on donor organs.

"The type of people you meet is challenging," he said. "They usually approach the treatment with a lot of misconceptions that you have to correct. One is that not everybody is going to get a kidney. When you are a transplant nurse, you wish there could be more organs."

In September, Calixto was promoted to kidney transplant coordinator. He's also working to help other Filipino nurses support one another as they transition to working in the United States. Calixto is president of the Philippine Nurses Association of America.

But he has a second goal for this group as well: to educate American hospital employees about the cultural ways of the Filipino nurses they are recruiting. He and other members of the association have started giving presentations at hospitals to help American health workers understand the growing Filipino nursing population.

Although he still relates to the Filipino recruits, Calixto said that after 22 years in the United States, he feels more like an American.

"I feel glad that I'm here, and proud of America," he said. "I have gone over the fence, and now I'm one of you guys. I no longer consider myself an outsider."

Contact Heather Stringer at heathers@nurseweek.com.