Many US states passed reforms in licensure for nurses. Decreased training mandates were created, as well as stricter adequacies for getting into a nursing institution. For instance, one prerequisite was at least one year of high school education. The idea of having students work in a more active role prior to seeing patients was a new idea that was beginning to pay off. In the Philippines, it was also the early 1900s when the first school for nursing was established. The program of study was still shattered and unclear. Only a few students were enrolled informally in this kind of education. A legislation or law was needed at the time, contributing to the establishment of the "First True Nursing Law" in 1919. The Philippine Nurses Association was founded on September 2, 1922. The Philippines is the leader in exporting nurses to meet the demands of the United States and other developed nations. It has been argued, however, that the Philippines' persistent production of nurses for the global market is a state strategy to develop an export industry for economic development. Things such as immigration services and nursing licensing authorities encourage the production of nurses for export. Of all registered health practitioners, nurses are among the largest group, even though there are very few nursing positions or jobs available to them. Only 15-25% of jobs in the Philippines are provided for the nursing population. The remainder of the work force go on to seek out other professional career opportunities outside the country. Per year, the national government has approximately 18,000 nursing positions with an eventual turnover of 1,000 careers. The increase of Filipino nurses overseas has attracted the curiosity of other countries to better understand nursing in the Philippines and what makes Filipino nurses accommodating. The first two years of general education is grounded on liberal arts that strengthen the values and character of the person as a caregiver. The language of instruction in all local institutions is English. This prepares the student for licensure both locally and internationally. This also gives the nurses access to ever-growing literature in the health sciences. The community skills, competence and confidence in the use of English certainly contribute to healthcare in any setting. The curriculum also strengthens the students' capabilities to participate in research in nursing and other health sciences, provides flexibility in the openness to the use of new teaching approaches, and encourages active involvement in extension work that reaches out to the other sectors. All registered nurses in the Philippines are required to have a bachelor's degree in nursing. The first pursuit to constitute the nursing practice was made by the Director of Health in 1913, but was not officially enacted upon by the Filipino legislature.