Research centre REACH

A deskilling and challenging journey: the lived experience of Indonesian nurse returnees

A deskilling and challenging journey: the lived experience of Indonesian nurse returnees


  • Funding

    This research received a grant from Sumitomo Foundation, Japan. The funder had no involvement in research design, data collection, analysis and publication process.

  • Conflicts of interest

    The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.



To illuminate the lived experiences of Indonesian nurses who previously worked as caregivers in Japanese residential care facilities, by exploring the journey of becoming returnees.


The creation of bilateral agreements between Indonesia and Japan has facilitated the movement of Indonesian nurses to work as caregivers in Japan since 2008. While this decision raised concerns with regard to the degradation of nursing skills, little is known about this issue from the perspective of nurse returnees and how the experience affects their life.


A hermeneutic phenomenological method was employed for this study. A purposive sample of 15 Indonesian nurse returnees participated in this study. Semi-structured interviews were conducted in four of Indonesia’s provinces between August and October 2015. Data were analysed thematically, supported by QSR NVIVO 10 software.


Four key themes emerged from the data analysis: (i) returning home; (ii) going back to zero; (iii) walking through a difficult journey; and (iv) overcoming barriers. These findings described the lived experiences of nurse returnees when they got back to the country of origin.


Indonesian nurse returnees experienced deskilling and struggled to re-enter the nursing profession or to find other non-nursing jobs. The significant impact of this migration on individual nurses with regard to maximizing the benefits of return migration deserves further investigation.

Implication for nursing and health policy

The Indonesian government, jointly with other stakeholders, should develop a brain gain strategy to align returnees’ expertise with the needs of the national labour market. The public-private partnership should be strengthened to utilize returnees in healthcare services.

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Citation for this article:
Nugraha S, Tanaka M, Efendi F. A Comparative Study of Nursing Educational System in Indonesia and Japan. Vol. 3 No.2 October 2008-March 2009, Jurnal Ners
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According to Economic Partnership Agreement (EPA) between Indonesia and Japanese governments, Japanese government plans to recruit Indonesian nurses and caregivers to fulfill the demand of those positions at the hospital and health centers. However, to be a qualified worker in Japan, one has to pass a national examination that is conducted by the Minister of Health, Labor and Welfare for a license of a registered nurse within 3 or 4 years of working as a nurse or caregivers, respectively. Having considered that matter, a comparative study of the background of educational systems in Indonesia and Japan is discussed in this paper, with particular reference to the Diploma 3 nursing program.
There is no specific difference between Indonesian and Japanese nursing educational systems. However, current health condition of the countries remains as the focus of the curriculums where Indonesian nursing education is focusing on communicable disease and surgery nursing, whereas Japanese is focusing on gerontology and chronic disease nursing. In case of qualification method, Japanese nurses should undertake national board examination to be a qualified nurse. On the other hand, there is no national board examination for Indonesian nurses.
Keywords: nursing educational system, Indonesia, Japan

    Japan and Indonesia have been working toward Economic Partnership Agreement (EPA), a comprehensive bilateral economic agreement that will include liberalization of trade in goods and services, as well as cooperation in the fields of investment, competition policies and people movement (Antara, 2008). As a part of the implementation of Article 7 of EPA regarding with the “people movement”, Japanese government plans to recruit approximately 400 nurses and 600 caregivers within a 2-year-period.
    On 5th August 2008, the first group of Indonesian nurses arrived in Japan. Having been trained for Japanese language and introduced with Japanese nursing systems for the first 6 months since the arrival, they have to face a nursing national board examination. The examination will be conducted in Japanese, using Japanese characters and Chinese characters (Kanji). Furthermore, the nurses and caregivers have to pass a national test within 3 and 4 years working period, respectively, as a requirement to continue the works in Japan.
    The agreement has opened an opportunity for Indonesian nurses to find a new labor market. Indonesian nursing educational institutions graduate approximately 15,000 nurses annually. However, due to inappropriate health care and worker distribution systems, Indonesian labor market can only accept 25% of total nurses (MOHRI, 2006). This agreement also brings some benefits to Indonesian nurses and caregivers i.e. gain new experiences and learn different systems in nursing profession. Therefore, these experiences can be applied in Indonesia or internationally, and the quality of Indonesian nurses will be considered consequently.
    According to Okamoto (1992), improvement in living standards among Japanese people and increasing of medical care usage caused aging population rapidly, decreased the number of death rate for all age groups caused by Tuberculosis and other infectious disease, and falls in mortality among infants, adolescent, and young adult. Increasing the number of aging population means the increasing of demand in medical care. The demand of nursing worker has outpaced the supplies, due to the development of medicines, increasing the number of bed and aging patients. Additionally, a number of nursing workers is required in various areas. Implementation of long?term care insurance encourages to shift the place for treating and rehabilitating patients in chronic illness from hospital to facilities for long term care, in home medical care and visiting nursing. Having considered those conditions, through the EPA agreement, Japanese government has opened the labor market for foreign nurse to meet the demand of nursing staff and caregiver.
    Success of EPA implementation will bring a lot of benefit for both countries, and to achieve that objective, both of Indonesian nurses and Japanese nurses need to understand each other. Indonesia and Japan have different background on language and culture. It will be a big challenge for both nurses while working in the same hospital, although they have the same background on nursing. In case of nursing skill, there is no wonder about the nurse’s skill. It’s because the nurse has the same background on nursing education. And each country has their caring character.
    This paper describes about Indonesian and Japanese nursing educational backgrounds in order to figure out general description of their educational systems. Having comprehended the educational systems, the capability of nurses in knowledge and skill of nursing would be known. The other advantage is to complementing their liability and majority while caring the patients. Comparison of educational background would be the first step to know their competence and potential in the working field. In advance, this comparison will figured their majority and shortage in nursing knowledge. By understanding this condition, Japan and Indonesian nurse will be able to have mutual charge on knowledge and experience in the working field. Besides that, during the EPA agreement on nurse’s recruitment, Indonesian and Japanese nurses will have better preparation in the future recruitment.
    A comparative descriptive study was performed based on databases of published materials and electronic journals. This comparison focused on curriculum that was stipulated by government law for Diploma 3 (D-3) degree of nursing education.
    2.1 Present nursing condition based on educational path
    2.1.1 Educational institution

Figure 1. Indonesian nursing educational path

In general, nursing educational institution in Indonesia consists of two kinds of educational path, i.e. undergraduate program (S-1) and diploma program (D-3), after completing basic educational program at Senior High School (Figure 1). These nursing educational institutions provide the curriculums as stipulated by National Education Systems No. 20/2003 of Ministry of Education, which adopted the recommendation from Indonesian Nurses National Association. 
The numbers of nursing educational institutions in Indonesia are 427 and 173 for D-3 and S-1 levels, respectively, while the average numbers of graduates are 12,810 and 3,460 for D-3 and S-1 levels, respectively (MOHRI, 2006). 

2.1.2 Curriculums
The curriculum of S-1 program consists of academic and professional phases. Having completed academic phase in 8 semesters, students are required to conduct a research that will be examined at the end of the academic phase for a bachelor degree. Furthermore, they have to continue to the professional phase for 2 semesters in order to get a Ners degree. In this phase, students have to conduct nursing practices in a hospital under supervision at 9 division of nursing science, i.e. Nursing Management, Emergency Nursing, Maternity Nursing, Medical Surgical Nursing, Mental Health Nursing, Pediatric Nursing, Family Nursing, Community Nursing, and Geriatric Nursing.
On the other hand, the curriculum of D-3 also consists of the academic phase and the professional phase which can be fulfilled in 6 semesters, but in contrast to the S-1 program, both of the phases are integrated. At the end of each semester of academic activities, students are required to continue directly to the nursing practices in hospitals under a close supervision. The nursing practices from semester 1 to 4 are fulfilled by simple nursing practices, such as taking temperature or measuring blood pressure of patients. Afterwards, for the whole semester 5 and 6, the students are required to conduct comprehensive practices.
These educational institutions provide curriculums for the applicable qualifications as stipulated by law. According to Decree of Ministry of National Education No. 139/U/1999, D-3 program has 96 credits and consist of class lectures, laboratory practices, and clinical trainings with the duration over 4,800 hours (Table 1).

Table 1. Indonesian national curriculum for D-3 program

The nursing school curriculum guideline stipulates the range of class hours per credit i.e.  18 hours for lectures, 36 hours for experiment and skill practices, and 72 hours for clinical trainings. Instead of the above curriculum, each institution has to apply some local curriculums which are decided by each institution for 14 - 24 credits. Each institution determines class hour equivalent to a credit. 

2.2 Professional nurse
2.2.1 Qualification of the nurses
Having graduated from nursing school, one will be qualified to work as a nurse in a hospital as a professional nurse.
Nurses who graduate from Bachelor of nursing called professional nurse and nurse who graduate from Diploma III in nursing called the beginner of professional nurse. Professional nurse is a person who passes the high level of accredited education. The beginner of professional nurse is a nurse who has good knowledge on intellectual, technical, interpersonal and moral, responsible in delivering nursing services based on valid regulation.
2.2.2 Method of qualification
Currently, there is no national board examination for nursing qualification in Indonesia, and Indonesian government and Indonesian nurse association are working toward on creating the national standardization for the nurses.
However, the current valid system is based on the regulation on Decree of Ministry of Health No. 1239/2001 about Nurse Registration and Practice. Having graduated from the nursing school (D-3 and S-1 programs), a student should apply a nursing permit (Surat Ijin Perawat) to the local government at least one month after graduation. Since they hold the nursing permit, they can apply to work in the hospital or other health care center. In addition, each hospital has their own standard on accepting the nurse. In general, the nurses have to pass the hospital pre-employment examination in written and clinical practice test. Having been accepted as an employee of a hospital or health care center, the nurse should apply a working permit (Surat Ijin kerja) which is published according to the results of skill and knowledge assessments, and compliance on nursing ethics.
3.1 Present nursing conditions based on educational path
3.1.1 Educational institution
There are several educational institutions to be professional nurses in Japan. For registered nurses, the basic route would be to complete senior high school, after that, study at a nursing university (4-year bachelor degree course), junior nursing college (3-year associate degree course) or nursing school (3-year course) (Figure 2). Besides a registered nurse, there is a 2-year course for a nurse assistant. A nurse assistant is defined as a nurse engaged in providing nursing care under instructions from medical doctors or registered nurses.

Figure 2. Japanese nursing educational path

In addition 6-month (normally one year) education is prepared in nursing schools and universities for public health nurses and midwives. Students who graduate from these educational institutions are entitled to take the examination for a registered nurse. In 2006, the numbers of nursing educational institutions in Japan were 158 for universities, 37 for junior colleges, and 512 for nursing schools. 11,906 or 32.7% of nurses graduated from universities, whereas 1,982 or 5.4% of nurses were from junior college, and 22,549 or 61.9 % were from nursing school.
3.1.2 Curriculum
This part would be focused on the curriculum for a registered nurse. The educational institutions provide curriculums for the applicable qualifications as stipulated by law. The credits required to be entitled to take the governmental examination are 97 units for a registered nurse (in 2009, the public health nurse, midwife and nurse regulation have been revised in credits for the enrichment of nursing skills and the ability to deal with nursing ethics, nursing administration and residential nursing in nursing students). The duration of the curriculums is three years (over 3,000 hours of lectures and clinical training).
Each institution determines class hour equivalent to a credit. The nursing school curriculum guideline stipulates the range of class hours per credit i.e. 15-30 hours for lectures, 30-45 hours for experiment and skill practices, and 45 hours for clinical trainings.

Table 2. Japanese national curriculum for D-3 program
3.2 Professional nurse
3.2.1 Qualifications of the nurses
A registered nurse is qualified as a professional nurse by government examination. Having graduated from educational institution that provides curriculum for the applicable qualifications, graduates are entitled to take the governmental examination that was conducted by The Minister of Health, Labor and Welfare, for a license of a registered nurse.
3.2.2 Method of qualification
The national examination for registered nurses consists of essential questions (30 items), general questions (150 items) and questions concerning certain clinical cases (60 items). Questions concerning clinical cases evaluate the ability of nurse in understanding and judgment the situations in which nurses would meet in hospital. Information about the patient such as symptoms, physical and mental condition, age, sex and sociological background are given to answer the questions. Areas of questions are the structure and function of the human body (anatomy, physiology, biochemistry, nutritional science), disease mechanisms and recovery promotion (pathology, pharmacology, microbiology), social security systems and people’s health (public health, social welfare, related lows), fundamental nursing, residential nursing, adult nursing, geriatric nursing, pediatric health nursing, maternal nursing and mental health nursing. All items in the examination are multiple-choice.
Students are required to get a score over a passing standard. Essential questions must be correctly answered in order to pass, otherwise in the case that there are errors these questions the student will fail the examination. The examination pass rates were 90.6% in 2007 and 90.3% in 2008.
In term of educational path, there is no specific difference between Indonesian and Japanese nursing educational systems, as shown on Table 3. The basic difference is on the method of qualification for the nurses. Japanese nurses should undertake national board examination to be a qualified nurse, whereas there is no national board examination for Indonesian nurses. In addition, current health condition of the countries remains the majority of the curriculums. Indonesian nursing education is focusing on communicable disease and surgery nursing, whereas Japanese is focusing on gerontology and chronic disease nursing.
Table 3. Nursing educational background in Japan and Indonesia for D-3 program
Aspect Indonesia Japan
Content of curriculums Majority in medical surgical nursing Majority in geriatric nursing and adult nursing
Qualification method

No national board examination.  The capability to work selected based on hospital pre-employee examination.
Capability to work selected by the Nursing national board examination. Hospitals conduct an employment test to hire registered nurses.

Contents of the test Written and clinical practice test Written test
Midwife and public health nurse course Separately given in different institution for minimum 3 years course. Given after completing the nursing course in minimum 6 month.

To be qualified as a nurse in Japan, Indonesian nurse also have to pass Japan nursing national board examination, which is held once a year at the end of February. Upon arrival nurses and caregivers will be taught Japanese language and introduced Japanese nursing systems for six months. For the first period of the arrival in the middle of August, the nurse will have 3 chances of examination, and will finish in the middle of February. The probability of Indonesian nurses to pass the first chance of examinations would be questionable, since there is no special preparation on Japanese language and Japanese nursing systems before coming to Japan.
Japanese people are very respect on psychological condition of the patients, and Japanese nurse thought to always pay special attention on their psychological condition. Therefore, intensive learning on Japanese language, culture and Japanese nursing systems in the working field would be an important point to help Indonesian nurses to pass the nursing examination and be accepted to work as a real nurse. Consequently, a regulation from Japanese government is needed for the hospitals which recruit foreign nurses to reach this purpose.
People believe it is unreasonable to insist that the Indonesian nurses take exactly same examination that Japanese nurses do, and such a strict requirement could cause a lot of valuable workers to be simply thrown away ( However, based on the long term experiences on sending the nurses abroad, most of Indonesian nurses have been acknowledged by the receiving countries as having good personalities, such as kind, sympathetic attitudes for patients, and are likely to have a good relationship with the patients, and this in turn supports their job effectively. These conditions were believed those Indonesian nurses are able to survive against the language and difference nursing system.
This paper describes insights about nursing education and nursing system of Indonesia and Japan. Nevertheless, the illustration only given in general appearance, further research would be needed to describe in details. Comprehension in educational background of nursing and nursing system of both countries will enhance the relationship between the nurse from Indonesia and Japan.

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