F. Efendi, C. M. Chen, N. Nursalam, R. Indarwati, and E. Ulfiana, “Lived experience of Indonesian nurses in Japan: A phenomenological study,” Japan J. Nurs. Sci., vol. 13, no. 2, pp. 284–293, 2016.
Abstract
Aim: The movement of Indonesian nurses via a bilateral agreement with Japan has led to a substantial number of migrants to work as nurses in that nation’s healthcare system. The purpose of this research was to develop a deeper understanding of the meaningful experiences of Indonesian nurses while working in Japanese hospitals.
Methods: In this phenomenological study, sampling was purposive and was based on information shared by ?ve Indonesian nurses. The data were collected in interviews; the analysis was thematic.
Results: Six key themes were identi?ed: (i) seeking better than before; (ii) communication
challenges; (iii) the nursing examination as a culmination; (iv) differences in nursing practice;
(v) cultural differences; and (vi) the bene?ts of living in the developed country. Among these challenges, communication as the basis of shared meaning and understanding was viewed as a complex issue, by both patients and coworkers.
Conclusion: The results of this study call for further intervention in supporting Indonesian nurses living in Japan in their struggle with the issue of communication. The emphasis on language acquisition for personal and professional objectives, and the bridging of cultural differences as well, should be considered in an international context.
Discussion:
This study yielded six themes that captured Indonesian nurse migrants’ successful experiences while working in Japan. The ?rst theme was communication. Indonesian nurses were better prepared for facing communication encounters in daily living or in their personal lives. In fact, they were required to work with patients around the clock to gather patient information and ascertain their needs, develop a plan of care, implement the chosen care plan, and evaluate the effects of this implementation. Those activities require an advanced level of communication skills. Communication is a critical point in nursing care. According to Thorsteinsson (2002), communication is more than transmitting the information from nurse to patients, it also involves feeling, trust, and empathy. All of the respondents perceived communication as a complex process between the sender and receiver. Even if they are well prepared, somehow nursing communication requires skill, technique, and processes that are familiar. They must have not only haveabilitiesrelatedtospeaking,reading,andwritingin kanji (Chinese characters used in Japanese writing), but they also need a thorough understanding of these processes. The success rate on the Japanese national examination was only 9.6% of the total number of foreign nurses who applied in 2013 (Kobayashi, 2013). In line with other research, the communication barrier is somewhat of a problem for migrant nurses when talking to both patients and peers (Alexis & Vydelingum, 2004, 2005). Dif?culties also arose from differences between what they had learned formally and what was required in daily nursing care. For example, their coworkers talk or write in speci?c terminology that they may not have heard before. The communication dif?culties were also a result of unfamiliar dialects, and problems related to talking with the elderly and reading and writing in kanji were also reportedinanotherstudy(Alam&Wulansari, 2010). The second theme was cultural differences. Japanese people are well known as being disciplined and punctual. Because of this, Indonesian nurses were challenged to understand the host culture and adjust to a new environment. For Indonesians, showing up late by 1 or 2minuteswouldbeconsideredunremarkable.However, the Japanese are particularly punctual, and they may be irritatedwithnurseswhoshowuplatetowork(Condon & Masumoto, 2011). Another issue related to cultural differences was family bedside attendance. In Indonesia, it is assumed that the family members will have a great deal of involvement in facilitating a secure and safe environment. Throughout the period of hospitalization, at least one relative will stay by the patient’s side and help provide basic personal care and mental support around the clock. The third theme was seeking a better life than before. The reasons behind migration were complex. It was not only for career and economic reasons, as reported by other researchers (Dywili, Bonner, & O’Brien, 2013; Kingma, 2008), but also because of their interest in living in Japan. It is a very interesting phenomenon because Japan is famous for its high technology and for being a strong economic power. Numerous Japanese products ?ood the Indonesian market, and also there is history between Japan and Indonesia that occurred during the colonization era. This image and bonding has attracted a great deal of curiosity among Indonesians that has led them to enter the Japanese labor market. The fourth theme was differences in nursing practice. Amongthedifferencesdiscoveredwasthatnursingpractice was accorded major regulatory protection. Under the Japanese law, Japanese nurses are much more independent and accorded more protection. Article 5 of the Act on Public Health Nurses, Midwives, and Nurses de?nes a nurse as a person under licensure from the Minister of Health, Labor, and Welfare to provide medical treatment or assist in medical care for injured and ill persons or puerperal women, as a profession (MHLW, 1984). Unlike the situation in Indonesia, the nursing profession is on the way forward to being recognized as a professional profession from what once wasviewedasaso-calleddoctor’s“servant”(Nursalam, Efendi,Dang,&Arief,2009).Atthetimeofwritingthis article, a draft Nursing Act has been approved by the
F. Efendi et al. Japan Journal of Nursing Science (2016)
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Japan Journal of Nursing Science (2016) 13, 284–293 Indonesian nurses in Japan
House of Representatives on 25 September 2014, after 10 years undergoing tough scrutiny (DPRRI, 2014). In addition, many Indonesian nurses are not well informed of the role of the family in caring for the sick in Japanese society. It was surprising for them that family members did not assist with ADL at all. In Indonesia, the patients’ families help them with ADL. Indonesian family members provide intimate care for those whom they love and view it as a privilege. The ?fth theme was the nursing examination as a culmination. The hardest part of the process for foreigners to get a nursing license in Japan is the national examination. Despite extra help from the Japanese government, time extensions, and translation of kanji into hiragana (phonetic characters which are easier to read), the passing rate has been stuck around 9.6% (Japantimes, 2013). Apart from the language barrier, other issues related to the content and questions on the national examination may need further study. The role of Japanese institutions in facilitating their learning, either in the Japanese language or nursing knowledge should be encouraged as an added value of this program. While the participants are proud of who they are and of being a nurse and working in Japan, their wish is that they can support their family and their nation as a whole. The last theme was the positive impact of migration on the nurses’ lives. Indonesian nurses found value and satisfaction in their working experience in the Japanese health system. They perceive enjoyment from living in an advanced country. While working in Indonesia, nurses’ salaries are categorized at a low level in hospitals, particularly in the case of those not accorded civil servant status. Their earnings range $US 150–300/ month, depending on the location and ?nancial capacity of the hospital; some recent news has even reported that nurses’ salaries are below $US 150/month (Berita Jatim, 2013; Gajimu, 2012). This situation may drive nurses out of the country when they ?nd that the same work they are doing in Indonesia is rewarded abroad at a higher salary. The economic bene?ts can become the driving factor that attracts them to work in Japan. Substandard nurse salaries all over Indonesia has become a serious issue that has led to higher levels of migration. Living in Japan would be a dream for some Indonesians, and an initial study conducted by Hirano and Wulansari (2009) showed that Indonesian applicants have high expectations related to living and working in Japan. Indonesians with a limited knowledge of Japanese culture may think that working in Japan is prestigious. The living costs and taxes are
high, but Japanese hospitals will pay nurses as assistant nurses in the range of $US 1100–1800/month, a number that may allow some nurses who are living in a big city the ability to save on expenses. It was normal for them to think about the ?nancial bene?ts since they may be able to send money back home while contributing to Japan’s health system. The aspect of communication and different nursing practices should not be interpreted as a universal problem faced by Indonesian nurses in every receiving country. Hence, it must be viewed as a need for good preparation related to training and education, either in the sending or the receiving country, in order to create a goldstandard.Thespiritofinternationalizationwhichis re?ected in the curriculum by several nursing education institutions in Indonesia may be adjusted to the need of each receiving country. The ?ndings of the current study are consistent with those of Alexis and Shillingford (2014) as well as those found by Jose (2011), who described role restrictions, a dif?cult journey, and cultural shock experienced by international nurses in the UK and the USA. Language barriers, communication, and different work cultures have been reported by other studies as challenges faced by foreign nurses (Brunero, Smith, & Bates, 2008; Higginbottom, 2011; Sochan & Singh, 2007; Xu, 2007; Xu,Gutierrez,&Kim,2008).Otherthannegativeexperiences, this study corroborates the ideas of Liou and Cheng (2011), who noted some bene?ts of working in developed countries. In addition, the present authors’ ?ndings imply that relevant stakeholders should provide privileges or speci?c interventions for nursing candidates who are transitioning or facing the Japanese nursing examination. This study may help decisionmakers who are involved in government-to-government migration policies to develop support for international migrants, speci?cally nurses. The above discussions of Indonesian nurse immigrants to Japan reveals the connectedness and dependency that occurs between Japan and Indonesia. The degree of connection and dependency varies; therefore, the impact may also vary for both countries. International nurse recruitment is a quick ?x to meet the need of a country that is suffering from shortages (Aluttis, Bishaw, & Frank, 2014). However, it may create complex situations and dilemmas in the sending country (Efendi, Mackey, Huang, & Chen, 2015). Indonesia, as a developing country that is suffering a health worker crisis, and as such could negotiate with the Japanese authorities to take into account the needs of Indonesia. Examples of needed strategies for Indonesian nurses are support for domestic health personnel retention, technology and skill transfers, facilitating return migration, and even ?nancial support.
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