Introduction

The purpose of this article is to attempt to describe how nursing is conceptualized and practiced in Japan. A review of the English language literature on nursing and health care in Japan was undertaken in addition to a two-week trip to Japan that focused on nursing education and community health. The major topics reviewed include nursing practice, licensure, education, trends in research, professional organizations, nursing workforce issues, and the demographic, social, political, and cultural context of Japan as they relate to nursing.

A major theme throughout this review is the aging of Japanese society as a driving force in nursing, nursing education, and health care reform in Japan. In the next century, one quarter of the Japanese population will be over 65 years of age. With the increase in the elderly comes a growing need for nursing care to meet the needs of this population. Indeed, nursing, health and social welfare policy in Japan have focused on enhancing the capacity of the service delivery system and providing comprehensive health and medical services, including prevention and rehabilitation in order to maximize health in the elderly, assure appropriate service utilization, and control costs. Throughout this paper, the efforts on the part of Japanese nurses and policy makers to address the aging of the Japanese population through increasing the quality of its nursing workforce are noted.

Nursing and Nursing Practice In Japan

According to reviews of Japanese nursing and medical history, modern nursing in Japan was established in 1885 when a physician who was influenced by Nightingale's concept of nursing started the first training school for nurses (Doona, 1996; Hisama, 1996; Kodama, 1984, 1994; Kusakari, 1989; Long, 1984; Nakahara, 1997; Tierney & Tierney, 1994). Although the ideal of nursing as both an art and science was introduced early on, public perception of nurses has not reflected nurses as independent practitioners with unique skills. Nurses have been perceived as being educated and caring, but also subservient to physicians. Furthermore, nursing work has been described using negative terminology such as "hard, dirty, dangerous, low salary, few holidays, minimal chance of marriage and family, and poor image" (Katsuragi, 1997; Tierney & Tierney, 1994).

As with many aspects of Japanese society, the years following World War II brought change to nursing. Specifically, efforts were made to professionalize nursing by moving education into the university setting and developing a strong professional organization to advance the profession. The Public Health Nurse, Midwife, and Nurse Law of 1948 regulates nursing practice, establishes educational requirements and job responsibilities, and sets standards for examinations and licensure for nurses, public health nurses, and midwives (Murashima, Hatano, Whyte, & Asahara, 1999). The law identified two roles of nurses: to care for the sick, disabled, and women after childbirth, and to assist physicians with examinations and treatments (Nakahara, 1997).

Today, nursing focuses on caring for patients, observing the course of illness, assessing functional status, reporting the patient's condition, health promotion and disease prevention, teaching about health and illness, care management strategies, coordinating community resources to assist families in the care of their family members, and developing community partnerships to enhance health. The role of nurses in providing community-based services through in-home support is especially important in meeting the needs of the growing elderly population (Kajita, Hattori & Murayama, 1998). Furthermore, nurses in Japan are expanding their focus by becoming increasingly involved in policy as political leaders (Hisama, 1996; Japanese Nursing Association, 1999; Mizuno, 1999). Nurses are leading advocates for improving the country's nursing education and health infrastructure to enhance care systems for the elderly.

Nursing Education and Licensure

Similar to the US, there are multiple levels of nursing present in Japan: practical nurses, registered nurses, midwives, and public health nurses. Nursing education in Japan is considered to be even more complex than the US system (Sawada, 1997). Practical, assistant, or associate nurses and educational programs are regulated and licensed at the prefectural (state) level. These programs provide at least two years of practical nurse training after high school or a three year high school nursing assistant course after junior high school (Sawada, 1997). Nurses, comparable to registered nurses in the U.S., must pass a national licensing exam following completion of one of four types of programs: a) two year nursing program after the practical nurse license; b) three years of junior nursing college; c) three year special training school for nurses (hospital or medical affiliations); or d) four years of a nursing college or university. Public health nurses and nurse midwives require an additional year of training at the university level beyond junior college or training school for licensure (Abe & Sato, 1997; Japanese Nursing Association, 2000; Nakahara, 1997). (For a full description of nursing education in Japan see Anders, 1994; Kodama, 1994; Kojima, 1987).

The Ministry of Education regulates baccalaureate and higher degree programs, licenses the schools, and determines their curriculum. The Division of Nursing of the Ministry of Health and Welfare regulates the diploma programs (Abe & Sato, 1997). The different governmental bodies that regulate the various programs present a challenge to unity in nursing. The Division of Nursing also functions as the Board of Nursing for licensure and administers the national exams for all registered nurses (Abe & Sato, 1997). However, the Japanese Nursing Association recently proposed that they perform testing, licensing, and management of the profession under commission by the national government (Japanese Nursing Association News, 1999). In Japan, licenses are issued for life and renewals are not needed (Kodama, 1994). Japan allows foreign nurses to practice if the nurse passes the licensing exam (Regulatory Network Bulletin, 1999).

Nursing education in Japan is expanding in university settings to improve the competence of the nursing workforce. The quantity of nurses seems to be adequate but there is emphasis being placed on the quality of nurses (Mitoh, 1995). In the 1992 Nursing Human Resource Law (Law for Securing Nursing Personnel), the Japanese government mandated the development of new university programs. These programs are expected to raise the educational level of nurses and meet the needs of its population, in particular the growing number of elderly whose health care is increasingly complex and community-based (Mitoh, 1997; Nakahara, 1997). Other reasons to increase the educational level of nurses were to improve the public image of nurses, establish a science of nursing, and unify training and licensure (Anders, 1994; Hisama, 1996; Long, 1984). Literature from the preceding decades documented a need to increase the educational level of nurses (Long,1984). The educational programs were considered to lack theory, focus on a pragmatic rather than a critical approach to nursing practice, be primarily taught by physicians due to the shortage of qualified nursing faculty (Anders, 1994), and be short in duration. Interestingly, as far back as the post WW II era when hospital and health care reform occurred under the direction of the United States, Japanese nurses proposed that basic nursing education be a 4 year baccalaureate program (Hisama, 1996).

Government efforts to expand university education and the number of competent and qualified nurses are addressing the need for better-educated nurses. In 1989, there were only 10 baccalaureate programs in Japan (Murashima et al., 1999). A decade later in 1999, there were 76 baccalaureate, 61 public health nursing, and 34 midwifery programs. Many four-year undergraduate programs also offer bachelor's completion programs for junior college and diploma degree graduates. The number of nursing diploma courses has also increased slightly from 832 in 1994 (Abe & Sato, 1997) to 869 in 1999 (Japanese Nursing Association, 1999). Currently, there are 57 associate degree programs (15 national universities; 15 municipal government owned universities; and 27 private schools) (personal communication, K. Makimoto, Oct. 1, 1999). In 1987, only 4 master's programs were available; in 1999, 30 master's and 8 doctoral programs existed (Japanese Nursing Association News, 1999). The government plans to continue to increase the number of baccalaureate programs by about 10 per year (Murashima et al., 1999) providing evidence that nursing education may eventually shift to the university or college level. An increase in baccalaureate nursing education should aid in the development of nursing as a discipline, enhance nursing research, and provide qualified nursing faculty.

Admission requirements for registered nursing programs are based upon entrance exams that are administered by each school and high school competency reports. Competition for admission in nursing programs has been high with some schools reporting as many as 1,000 applicants for 100 openings (Anders &Kanai-Pak, 1992). Similarly, another university reported 622 applicants for a class of 100; 115 candidates successfully passed the entrance exam (Kyoto Prefectural University of Medicine, 2000). In order to meet this demand, the development of new university programs over the next decade should help (Murashima et al., 1999). This was observed during my brief visit to Japan. Faculty at one university who had developed their nursing baccalaureate program just two years ago were beginning to plan master's programs. At another university, a doctoral program was being planned just two years after the master's programs had been launched. These dramatic increases no doubt put great demands on faculty.

Graduate Nursing Education

Specialties are increasingly being developed at the graduate level in Japan: administration, advanced clinical nursing, family, parent and child, midwifery, adult, gerontology, terminal and long-term care, psychiatry, infection control, school nursing, and community health are areas of study. Advanced practice nursing in Japan focuses primarily on the clinical specialist role. Advanced practice nurses assess clients in clinic and home settings and work with physicians to provide care, providing greater opportunities than nurses have had in the past. This type of expanded practice should help address the community-based health care needs of the elderly population. Nurse practitioners do not exist in Japan and nurses do not diagnose health conditions or prescribe medications (Sugishita, 1999). Reasons for the lack of nurse practitioner roles include the general lack of autonomy of nurses, the dominance of physicians as well as social-cultural norms of the nurse as caretaker, and social-class differences (such as physicians tending to be of a higher social class than nurses) (Long, 1984; Mizuno, 1999; Tierney & Tierney, 1994).

Challenges In Nursing Education

A challenge in nursing education has been the lack of qualified instructors and standards for nursing instructors (Kodama, 1994; Nakahara, 1997). With the growth of undergraduate, graduate and continuing education programs to prepare nurse teachers as well as nurse administrators, this challenge is being addressed (Kodama, 1994). It is anticipated that the increased numbers of nurses with higher degrees will help to facilitate the development of nursing as a discipline. At the present time, physicians continue to teach in nursing programs, and cross-disciplinary education does exist, especially in areas such as nutrition, and epidemiology. In 1997, nursing curriculum at the baccalaureate level was reorganized in order to add new topics such as home care, health promotion, policy formation, and other public health content (Murashima et al., 1999; Sugishita, 1999) as well as a focus on problem solving and critical thinking (Kobayashi, 1995; K. Makimoto, personal communication, April 25, 1999). These curricula enhancements in particular are thought to address the health and social needs of the elderly in Japan. Another challenge for nursing education and the profession is recruitment of young adults into nursing (Mitoh, 1995). As more career opportunities open for women, and as the younger population shrinks as a result of Japan's low birth rate, it is increasingly important for the nursing profession to improve working conditions and attract young people.

Similar to the U.S., an ongoing problem in nursing education is the continued existence of various types of nursing programs (Nakahara, 1997). Specifically, the practical or assistant nurse level is a source of controversy in Japan. While there are clear differences in the education of practical nurses and the higher level nurses, their practice and pay scales have not always been distinguishable (Hisama, 1996). Studies have shown that the salaries and practice of nurses with different educational levels has been quite similar (Hisama, 1996).

For decades, the Japanese Nursing Association has tried to eliminate the practical nurse training system based on their concern that medical treatment has been carried out illegally by under-prepared personnel. This movement has a goal of improving the quality of nursing personnel, enhancing educational quality, changing the complicated system of nursing education, and increasing the social status of nurses (Sawada, 1997). Although there has been long-standing opposition to abolishing the practical nurse training system from the Japanese medical community, in 1997, the Ministry of Health and Welfare moved forward to develop regulations limiting the practice of assistant nurses and intends to abolish the training system by 2001 (Mitoh,1997).

Nursing Organizations

The strongest nursing organization in Japan is the Japanese Nursing Association (JNA) which was established in 1946. With about 400,000 members, it has more members than any other professional nursing organization in the world (Abe & Sato, 1997; Katsuragi, 1997). Historically, the JNA was not considered to represent the interests of most nurses and was made up primarily of older nurses with higher educational levels (Long, 1984). Today, however, the JNA works toward the improvement in nursing practice through many activities including the development of a policy research group to influence policy development, a code of ethics for nurses, and standards of nursing practice (Japanese Nursing Association, 1999). JNA conducts surveys on nursing and nursing education, has a research center, library, and a publishing company for journals, texts, and books. It has an informative Website and publishes an English language newsletter twice a year as well as publications in Japanese. The JNA participates in policy making by providing testimony on issues related to nursing at the national level, works with prefectural (state) nursing associations to assist in lobbying efforts with organizations and governmental offices, and supports nurses as candidates through the Japan Nursing Federation (Japanese Nursing Association, 1999). As a professional organization, the JNA is not a trade union.

The JNA provides certification for Clinical Nurse Specialists in mental health, oncology nursing, and community health. Clinical specialists must be master's prepared, have five years of clinical experience, and successfully complete an exam (Research Group of Community Health Nursing in Japan, 1998). Continuing education and training by the JNA for nursing administrators includes a certificate of completion. The association also conducts six month certification programs for nurses to carry the designation of Certified Nurse for emergency care, wound, ostomy and continence care, intensive care, hospice care, cancer, chemotherapy nursing, and pain control nursing (Japanese Nursing Association, 1999). Collective bargaining, a cornerstone of the American Nurses Association and its state associations, has not been a function of the JNA or its affiliate organizations since nurses are represented by medical labor unions (Katsuragi, 1997).

In addition to the JNA, there are professional groups organized by clinical specialties such as emergency nursing, psychiatric nursing, administration, intractable illness, diabetes, community health, and disaster nursing. Most of these organizations have been started within the last 10 years (Japanese Academic Societies for Medicine and Related Fields, 2000). The JNA established the Japan Visiting Nursing Foundation in 1994 in order to support the development and advancement of home care services for the elderly population. The Japanese Family Nursing Society was formed in 1994 and began publishing a research journal in 1995 (Sugishita, 1999). Family nursing practice, education, and theory development are the focus of the organization. JANDA (Japanese Nursing Diagnosis Association) and the Japan Society of Nursing Diagnosis educate nurses and promote research about nursing diagnosis (Matsuki, 1995). Other organizations include the Japanese Society of Nursing Research, Japanese Midwives Association, Federation of Nursing Colleges and Association of Nurses, and International Nursing Foundation of Japan. At this time professional organizations are not involved in the accreditation of nursing education programs and the government continues to play this role.

Nursing Research

Nursing research and the development of nursing science in Japan are increasing as more nurses obtain graduate education within and outside of Japan. This research is contributing to nursing theory and the discipline of nursing itself (Endo, 1999). Evidence substantiating the growth of nursing research exists. Research conferences are held annually in various parts of Japan for each area of nursing: pediatrics, adult care (acute and chronic), geriatrics, maternity care, community health care, nursing management, nursing education and general nursing. Each year, approximately 17,000 nurses participate and the number of research papers presented is about 480 (Japanese Nursing Association, 1999). Also, in 1982, the Ministry of Education established a Center for Education and Research in Nursing Practice at Chiba University in order to improve the quality of nursing research (University of Chiba, School of Nursing, 1999). University nursing faculty are very much involved in research activities and it is becoming an important part of their role. However, extramural funding for faculty research is minimal (personal communication, K. Makimoto, April,1999). Research activities are undertaken by governmental agencies as well. Examples of research by the Department of Public Health Nursing at the National Institute of Public Health include the evaluation of home care, community-based, and public health services (Department of Public Health Nursing, Ministry of Health and Welfare, 1999).

A review of research published in the English language literature was conducted to identify topics, themes, and questions posed by Japanese nurses. Nursing research addresses pressing social and health needs of Japanese society and is contributing to policy development, especially in the area of community-based services for the elderly and mentally ill (Anders et al., 1997; Kajita et al., 1998; Murashima, Zerwekh, Yamada, &Tagami, 1998; Yamashita, 1996 & 1998a). Furthermore, nursing research informs the development of knowledge in a variety of disciplines. Research topics such as birth context (Sharts-Hopko, 1995), caregiver and child interactions (Wang, 1995), maternal and child health epidemiology (Makimoto & Tsukaski, 1999), sociocultural influences and the care of dying children (Sagara & Pickett, 1998) and work satisfaction (Yamashita, 1995) provide new knowledge about the social and cultural context in Japan.

As stated, the range of topic areas being addressed by nursing research is quite broad. Specific studies include the response by nurses and nurse midwives to perinatal death (Gardner, 1999), nursing therapeutics such as relaxation therapy during chemotherapy (Arakawa, 1997), nurse attitudes toward developing do not resuscitate policies (Konishi, 1998), school nursing and health education (Katoda, W-Lindgren & Mannerfeldt, 1990), and nursing education (Takahashi, 1995; Yamashita, 1998b). Another example is a study of coping, self care and glucose control in Japanese teenagers with diabetes (Nakamura & Kanematsu,1994). Endo (1998) examined the use of a theory-based nursing intervention with Japanese women who had ovarian cancer and evaluated its potential to develop therapeutics to help people find meaning in illness. Correlates of participation in adult day care and quality of life in the ambulatory frail elderly was explored by Hashizume & Kanagawa (1996). Murashima and other (1998) developed and tested a model of community-based care for the elderly that utilized a 24 hour nurse-home helper team. A study of patient-nurse collaboration in five countries shed light on attitudes about patient participation in health care decision making (Kim et al., 1993) and suggested that nurses and health care providers in Japan continue to limit full disclosure of information to patients.

Cross-cultural and comparative research is increasing as well in an effort to identify universals in theories and practice (Schmieding & Kokuyama, 1995). For example, research on nursing diagnosis provides a foundation for identifying culturally appropriate practice (Matsuki, 1995; Ogasawara et al.,1999). Nursing theories are being tested to determine cultural relevance. King's conceptual framework was translated and published in the Japanese literature in 1970, and research has been conducted that suggests the theory does have cultural relevance (Frey, Rooke, Sieloff, Messmer, & Kameoka, 1995).

Nursing Workforce Issues

In 1997, there were 928, 896 nurses and assistant (practical) nurses, 31,581 public health nurses, and 23,615 midwives (Health and Welfare Statistics Association as cited in Research Group of Community Health Nursing in Japan, 1998). Most nurses have diplomas (64.4%), and only about 1% have BSN degrees. About 2.9% are male, 63% married, and 87% who are married have children. Nurses account for about 4.4% of total female employment (Abe & Sato, 1997).

Nurses practice in a variety of settings with hospitals being the most common setting. Nurses also practice in clinics (many of which have in-patient facilities for up to 20 patients), maternity clinics, visiting nursing support centers, health care centers, municipal health promotion centers, schools, occupational health or companies, a variety of home and institutional settings for the elderly, and nursing education (Japanese Nursing Association, 1999; Research Group of Community Health Nursing in Japan, 1998).

In the past two decades, a shortage of nurses had been documented in the literature (Katsuragi, 1997; Sawada, 1997). The shortage of nurses is particularly important because of the aging of Japanese society and its declining birth rate (Sawada, 1997). The Japanese Nursing Association reported the results of a 1998 survey on hospital demand and supply for nurses suggesting that the demand for nurses was decreasing among hospitals (JNA News, 1999). Reasons for the shortage included poor working conditions (Katsuragi, 1997; Sawada,1997), an increase in the number of hospital beds (Sawada,1997), the low social status of nurses (Sawada,1997), and the cultural context of married women quitting work due to family responsibilities (Anders & Kanai-Pak, 1992; Tierney & Tierney, 1994). In a study of burnout, Hisashige (1991) reported that occupational stress for nurses was indeed high due to long working hours, overtime, shift work, low wages, lack of breaks during work, difficulty taking vacations, physical aspects of the work, and depersonalization. A 1997 Survey by the Japanese Nursing Association, reported that 4,636 nursing personnel reported working an average of 12 hours 36 minutes of overtime each month, and over 70% of hospital employees were required to work rotating night shifts (Japanese Nursing Association News, 1998).

In another study, nurses demonstrated a strong commitment toward work; however, the limited opportunity for promotion and less favorable working conditions influenced negative job satisfaction (Yamashita, 1995). Findings from these studies and others provided administrators in Japan with information on how to improve working conditions for nurses. There is hope that improving working conditions will limit the number of nurses who leave their jobs, improve the status of nurses, and encourage young adults to consider nursing as a career.

Another group that has been successful in addressing nursing shortage issues is the Japanese Federation of Medical Workers Union. This union (Nihon Iroren) was established in 1957 to organize health care workers including physicians and nurses (Katsuragi, 1997). In 1989, the union took militant action that resulted in legislation called the 1992 Nursing Human Resource Law addressing nursing shortage issues. The union's campaign included sending signatures to Parliament, media attention, and strikes. Union demands included increased staffing, the regulation of night shifts, implementation of the 5-day work week, and improved education for nurses. Public support for nurses was strong, underscoring the recognition on the part of Japanese society that nursing care is essential. Despite the efforts of the union, professional associations, and government, it remains to be seen if the demands of caring for an aging population will be met.

Traditionally, nurses' roles in Japan have been to serve physicians and institutions reflecting the history of its feudalistic medical system (Hisama, 1996; (Hoshino, 1997; Kusakari, 1989; Long, 1984). Spending most of their time assisting physicians has left less time for nurses to care for patients. These roles reflected Japanese norms where society has been male dominated society and women serve as caretakers. Japan's traditional discrimination against women has also compounded nurses' lack of autonomy (Sawada, 1997). Furthermore, Minami (1985) pointed out that while professional socialization tends to be dominated by Western thought and values such as individualism and autonomy, confusion is often created for nurses who grew up with contrasting Japanese traditions and values such as group and family loyalty. Indeed, values conflicts seem to be present for nurses today. Hospital nurses continue to wear standard uniforms and caps (Hisama, 1996). In the Japanese Nursing Association's 1997 survey, over half of respondents felt that one of the problems in their daily work was the lack of support in challenging physicians when instructions do not seem to be appropriate for patients (Japanese Nursing Association News, 1998). Furthermore, respondents felt that when information provided by the physician about diagnosis and treatment was not perceived to be satisfactory to the patient, it was impossible for nurses to provide an adequate response. Another complicating issue is that salaried physicians serve as hospital staff and admit patients rather than private physicians (Nakamura, 1997). Consequently, hospital physicians are present more than in the US, leading to less autonomy of nurses.

Public health nurses and midwives who have higher educational standards than regular nurses tend to have greater autonomy (Hisama, 1996) in their work settings. In areas of health teaching, health promotion, disease prevention, care coordination, and community development, nurses function independently. Social and demographic changes such as greater status for women and health care reform to meet care needs for an aging population are creating opportunities for nurses to work independently in community-based and other settings (Hisama, 1996). Furthermore, with more nursing seeking baccalaureate and graduate degrees and the emphasis on care management and nursing administration by the Japanese Nursing Association and schools of nursing, increasing autonomy in health care settings is anticipated.

Nurses in Japan have had to deal with competing practitioners that threaten their identity and further suggest that their autonomy is limited. Minami (1991) discussed a study conducted by the Japanese Nursing Association about the high use of nurses aides or support workers in Japanese hospitals, especially in geriatric care facilities. The growth of aides and support workers occurred in part because of the increasing need for personnel to care for the growing elderly population and the lack of response on the part of nursing to address the shortage of nurses prepared to care for them (Minami, 1991). In the past decade, the Japanese Nursing Association has become increasingly involved in social and health policy related to human resource planning in order to maintain quality of care. Also, the Japanese Federation of Medical Workers' Union has made demands to local and central government as well as hospital authorities to improve the quality of nursing education and address issues that affect work conditions such as autonomy in practice (Katsuragi, 1997).

The Value and Meaning of Health

Health and welfare are central values of the Japanese. Article 25 of the Japan's 1946 Constitution assures its citizens of social welfare and basic public health (Nakahara, 1997; Yoshikawa et al.,1996). The social security system in Japan provides pensions for people in poverty, the unemployed, the ill and injured, and the aged (Mizuno, 1999). All of Japan's citizens are covered by compulsory government or employee insurance in a nationwide, universal social health system (Nakahara, 1997). The health insurance system allows for portability so that anyone can receive care at any clinic or hospital. Reimbursement schedules for medications, procedures, hospitalization, and clinic visits are uniform. While patients generally have co-payments for services, premiums on health insurance are based upon income levels so that a redistribution of wealth occurs. In other words, the wealthy subsidize those needing assistance such as the elderly and disadvantaged.

Health is perceived by the Japanese as being very important (Mizuno, 1999). In a study completed by the Ministry of Health and Welfare about what being healthy meant, one-third reported "when one suffers from no illness at all." "When one does not have an illness that required medical attention" was the reply for 45%. And 21% reported that healthy meant "being capable of engaging in daily work and other activities without particular difficulty even though that person regularly sees a physician due to chronic illness" (Ministry of Health and Welfare of Japan, 1996 as cited in Mizuno, 1999, p. 162). Respondents in the study also believed maintaining a healthy life style, and health-promoting self-care activities were important.

While health is an important social value in Japanese society, Sawada (1997) argues that it is necessary to '˜reconstruct a caring culture." Materialism and prosperity have become increasingly important while compassion, caring and spiritual values have been lost. As the population of Japan ages, compassion for the poor, elderly, and disabled is crucial to enhance caring as a cultural value (Sawada, 1997). By focusing on spiritual values and "reconstructing a caring culture," a fundamental cause of the nursing shortage will be addressed.

Social and Political Issues and Effects on Nursing and Health Care

One of the most pressing issues in Japan is the aging of the population. In 1998, approximately 16% of Japan's population was over 65 years of age. By the year 2025, it is estimated that 27% of the Japanese population will be over 65 (Japan Information Network, 1999a). Along with the increase in the aging population comes an increase in people having dementia, chronic illnesses, and functional limitations, as well as an increase in the mortality rate. Overall, the population of Japan is expected to shrink from 126,590,000 people in 1998 to 120,913,000 in 2025 (Japan Information Network, 1999a). The decrease in the overall population reflects the country's decreasing birth rate and suggests that there will be a fewer people less than 65 years of age to care for the older population.

Along with the growing number of elderly, other changes in the social structure include the trend toward nuclear rather than extended family structures (Ministry of Health and Welfare, 1999a). Traditionally, the family unit was composed of the eldest son, his wife, and their children who lived with his parents (Mizuno, 1999). However, as job opportunities in urban areas increased, young people have moved away from their homes limiting this natural care giving structure. Mizuno (1999) reported that between 1975 and 1994, the number of young couples living with parents over 65 years of age decreased from 68% to 55.3%.

Other major changes are related to women's roles in society. Some women are choosing not to marry, others marry later and have children later (Ministry of Health and Welfare, 1999a) as employment opportunities increase for them. Women are having fewer children as reflected by the low birth rate of 1.46, thus allowing them more time free of child care responsibilities to focus on their careers (Mizuno, 1999).

The implications of Japan's aging society for nursing and health care are great. Currently, health costs are paid by medical insurance for the elderly (public, 51%), health insurance premiums (private, 32%), patient co-payments (12%), and public funding for medical services (5%) (Japan Information Network, 1999b). As the health and social needs of the elderly population increase, and care giving by family members becomes limited, the costs to society increase. Indeed, the health care expenditures in Japan have doubled in the past 15 years (Japan Information Network, 1999a). In the 1990's, the growth rate for health care expenses exceeded the growth in national income due to a slow Japanese economy (Mizuno, 1999), and it is anticipated that this will continue. Furthermore, average length of stay at hospitals (36.2 days in 1992) is significantly higher in Japan than in the US, adding to health care costs (Nakahara, 1997). Numerous policy initiatives have been developed to care for the elderly in order to prevent a national financial crisis (Murashima et al., 1999; Nakahara, 1997; Yoshikawa, Bhattacharya & Vogt, 1996). For example, increasing the options for prevention focused community-based long-term care for the elderly is crucial so that costly institutionalization can be avoided.

Health Care Policy

In addition to changes in the demographic structure of Japanese society, the leading causes of death in Japan provide valuable information to nurses and policy makers about the types of health services appropriate for the Japanese population. In 1997, neoplasms, heart disease and cardiovascular diseases were the top three causes of death (Ministry of Health and Welfare, 1999b). Mortality from these three accounts for about 60% of deaths in Japan (Mizuno, 1999). Interestingly, this percentage of total deaths is slightly less than in previous decades because advances in medical treatment allow people to survive only to die from secondary complications such as respiratory illnesses (Mizuno, 1999). Nonetheless, the death rate from cancer, heart and cardiovascular diseases has driven policy makers to address prevention for the population. The public health system is emphasizing healthy lifestyles including diet, stress reduction, and exercise. During my visit to Japan, I visited a new municipal public health service center. In addition to communicable disease control, community health promotion activities, and clinics, the center provided extensive computer-based health promotion education, massage therapy, exercise equipment, and a stress reduction center.

Japanese health care and social policy also reflects its social and cultural norms. The value placed on health, the implicit duty to care for family members, and the collective nature of Japanese society underlie the country's effort to provide comprehensive health care and welfare services. While a review of Japanese health care policy is beyond the scope of this paper, it is important to note some of the most recent policy initiatives that have been developed to address the needs of the elderly. In the 1960's, Japanese society began to build its infrastructure to care for its elderly population (Nakahara, 1997). Numerous laws were passed in the 1980's and 1990's that addressed health care including the 1989 Golden Plan, a 10-year strategy. This plan involved multiple departments of the national government and its purpose was to promote the health and welfare of the elderly by increasing the number of beds for the elderly in a variety of settings. In 1991, the home visiting nursing care system was added providing a community-based home care service system so that people with health care needs could remain as independent as possible (Nakahara, 1997). The comprehensive in-home support center system has a strong role for public health nurses as care consultants, coordinators, and home visitors. They also provide adult day care services, physical and occupational therapy, and facilities for and assistance with bathing. In 1997, a Nursing Care Insurance Law was passed which will be implemented in 2000. Community health nurses have been actively preparing to implement this law that provides a national, comprehensive home care program for people over 65.

Other aspects of health policy include an emphasis on increasing nursing personnel. As discussed, the Japanese government expanded its efforts to increase the number of nurses prepared at the baccalaureate level who can provide comprehensive care in home and community-based settings. Other efforts include trying to encourage nurses who are not currently working to get back in the work force or those who are part time to work full time. Improving working conditions for nurses (salaries, hours, and advancement opportunities) are vital to the success of these efforts. Also, home helpers who visit and provide care and nursing services for elderly and handicapped individuals are a relatively new and expanding category of worker guided by the Ministry of Health and Welfare. The number of home helpers has increased dramatically to meet the needs of community-based elderly and handicapped individuals. Home helpers grew from about 24,000 in 1984 to about 168,000 in 1998 (Japan Information Network, 1999c).

With the tremendous growth of the elderly population, the rising mortality rate, and the need for compassionate, cost effective care for the dying (Mizuno, 1999), there has been increasing emphasis on long-term care. Of the nearly 17 million people over 65 years of age in Japan in 1995, about 1 million were in institutions while 840,000 received some form of long-term care at home (Mizuno, 1999). There has been increasing interest in Hospice programs (Paton & Wicks,1996) as the implications of these demographic changes are acknowledged. However, the development of Hospice has been very slow in Japan in part due to institutional and cultural barriers. Clearly, there is a lack of policy for end-of-life decisions in Japan (Konishi, 1998).

As a culture, the Japanese tend to deny death (Paton & Wicks, 1996). The topic of death and dying is taboo and physicians do not often discuss end-of-life issues with families or patients (Konishi, 1998). Patients tend to put trust in medical authority, and studies have shown that physicians often withhold "bad news" in order to protect patients (Hoshino, 1997; Yamashita, 1996). Thus, patients are often silent recipients of prolonged treatment without their consent or knowledge (Konishi, 1998). There is evidence that change is occurring slowly in that nurses are revising their roles and responsibilities on the health care team (Paton & Wicks, 1996). Patients are beginning to desire greater collaboration in decision making and be informed of their condition and treatment options (Kim et al., 1993; Konishi, 1998). Konishi recommended that nurses teach patients about their rights, and that physicians engage in '˜truth telling' by providing patients with information about their health condition.

Summary

Japan, a highly industrialized, yet traditional county, is considered to be one of the most rapidly changing nations in the world (Nakahara, 1997). Economic and demographic trends, especially the aging of the population, have placed tremendous pressure on its universal health and social service systems. While its societal values remain traditional, family structure and women's roles are changing. The nursing profession in Japan is addressing these challenges in numerous ways. By increasing efforts to move nursing education into the university setting and by focusing curriculum on community-based care, nurses should be better prepared to meet the needs of its aging society and function in autonomous roles. Nursing research and scholarship continues to increase building a solid theoretical base for the discipline. As the profession continues its efforts to become involved in health policy at the national and local level, it is anticipated that nurses will have even greater opportunities to improve health and health care for the Japanese population.

Author

Janet Primomo, PhD, RN
Email: jprimomo@u.washington.edu

Dr. Janet Primomo is an Associate Professor at the University of Washington, Tacoma. She teaches in both the undergraduate and graduate nursing programs. Her area of expertise is community health with a focus on health policy and environmental health. She received her PhD and MN at the University of Washington, Seattle, and her BSN from Russell Sage College in Troy, New York. As part of her recent sabbatical, she spent two weeks with community health nursing faculty in Japan.

Acknowledgements

The author thanks Drs. Kiyoko Makimoto and Setsu Shimanouchi for their assistance during her trip to Japan. The University of Washington, Tacoma Nursing Founder's Endowment Fund provided partial funding.

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