Southeast Asian Nurses and Caregiving Workers Transcending the National Boundaries: An Overview of Indonesian and Filipino Workers in Japan and Abroad

Ohno Shun*

*大野　俊，Center for Southeast Asian Studies, Kyoto University

e-mail: oono3905@yahoo.co.jp

Abstract

One year after Japan became a “super-aging society” in 2007, she began to receive Indonesian and Filipino nurses and caregiving workers into its labor market. This new government-to-government (G-G) program commenced in accordance with Japan’s Economic Partnership Agreements (EPAs) with the Philippines and Indonesia having large young populations. Between 2008 and 2011, a total of 1,360 Indonesian and Filipino nurse and certified care-worker “candidates” have entered Japan, and have been under training and employment across the Japanese archipelago. Expectedly or unexpectedly, they have encountered a number of problems at the hospital or the elderly-care facility that was not opened to foreign workers until recently.

This paper addresses the past implementation of the EPA provision “Movement of Natural Persons” and reactions among the nursing associations in Japan, the Philippines and Indonesia to controversial EPA programs. It also explores the current situation of Filipino and Indonesian nurses/care workers in their countries as well as abroad to deepen understanding of different views and stances of the governments and nursing/care workers in the field of “emotional labor.” Its discussions entail the possibilities and limitations of border-crossing care managed by the state in the country of linguistic homogeneity.

Keywords: Economic Partnership Agreement, JPEPA, IJEPA, Movement of Natural Persons, border-crossing care, emotional labor, deskilling

I Introduction

In 2007, Japan became a “super-aging society,” one in which the percentage of elderly people is more than 21% of the total population. This percentage is predicted to reach 32% by 2030, and 41% in 2055, when Japan’s population will be decreased to fewer than 90 million, 70% of the current population [Tokyo Daigaku Koreishakai Sogo Kenkyu Kiko 2010: 15]. If this extrapolation by the national research institute is accurate, it will require 1.2 Japanese workers to support 1 elderly person by the middle of the twenty-first century.

Before the recognition of a serious elderly care crisis in Japan, the project for accepting nursing and caregiving workers based on Economic Partnership Agreements (EPAs) between Japan and Southeast Asian countries had begun. A total of 1,360 Indonesian and Filipino candidates for registered nurse or certified care worker entered Japan between 2008 and 2011. Japan’s certified care-worker category, named “kaigo fukushishi” in Japanese, is a job category peculiar to Japan. In general, certified care workers are required to pass the national examination. Their main role is to provide support to elderly and/or disabled persons unable to meet their daily needs independently. They are also required to guide elderly, disabled persons and their assistants in caregiving matters. This differs from the primary roles of the caregiver in the Philippines and some other countries, which include care of infants and children, not required for certified care workers in Japan. The term, care worker, applies to various workers whose job is to look after those who need care. In this paper, this term implies nurse and certified care worker/caregiver.

The Indonesian and Filipino workers arriving in Japan under the EPAs are designated “candidates” on their jobs until they pass the national board examination for registered nurses or certified care workers. Not only Indonesian and Filipino candidates but also Vietnamese candidates for registered nurse and certified care worker will begin to work in Japan within a few years based on the Memorandum of Understanding signed by the two Prime Ministers of Japan and Vietnam on October 31, 2011 [Japan, Gaimu-sho 2011]. There is also the possibility that Indian nurses and care workers will enter Japan in the near future since their government has requested acceptance of Indian nurses and care workers from the Japanese government in their EPA negotiations.

It is anticipated that receiving a number of foreign workers entering the field of professional care, will not be an easy project. In the past, Japan has accepted many foreign workers, mainly Nikkeijin (people of Japanese descent) and trainees (kenshusei)/practitioners (jisshusei), particularly after the late 1980s (just before Japan’s economic bubble collapsed), mainly in industrial fields such as manufacturing and construction, which do not generally require a high level of proficiency in Japanese. However, in nursing and caregiving positions, which require the skills to manage feelings and emotions, designated “emotional labor,”[1] it is necessary to acquire proficiency in Japanese communication as well as knowledge and skills related to Japanese medicine and/or social welfare.

The success or failure of this project is also a real test of whether Japan, which has been called a “homogeneous society” by other countries, can smoothly cooperate with foreign workers even in the field of care for patients and/or disabled elder people. Although Japan’s EPA programs were not shaped by the push-pull factors of the international labor market, they might be linked to contemporary worldwide movements of “global care chain”[2] and reproduction of migration flows in the future.

Anticipating the outbreak of such problems and new global research issues, in 2007 the author organized an interdisciplinary and international research team (members from Japan, Indonesia and the Philippines) specializing in nursing, elderly welfare, migration, and international relations between Japan and Southeast Asia. By utilizing research funds provided by Kyushu University, with which the author was once affiliated, and other external funds, the author and his partner scholars have conducted a number of research projects from various angles in the sending countries and in Japan in order to find collaborative solutions. The studies include a series of surveys on the candidates’ socioeconomic characteristics, nationwide questionnaire for receiving hospitals and care facilities on consciousnesses for foreign nurse and certified care-worker candidates, case studies on nursing and elderly-care in the Philippines and Indonesia, as well as current problems and policies on migrant care workers in the United States, Europe, Asian NIEs (Newly Industrialized Economies) and Australia. This paper is a partial report of the collaborative surveys conducted in Japan, the Philippines and Indonesia since 2007.

The issue of transnational or intercultural care is becoming more important for the countries pursuing enhancement of international mobility of nurses and care workers especially after the reduction of border-barriers for skilled migrants has become part of bilateral and multilateral labor and economic agreements such as EPAs and the ASEAN (Association of Southeast Asian Nations) Mutual Recognition Arrangement on Nursing Services.[3]

This issue addresses the above-mentioned Southeast Asian nursing and caregiving workers transcending national boundaries with the goal of finding better system and policy interrelated between Japan and Southeast Asian countries. This introductory paper overviews implementation of the EPA programs in transnational mobility of nurses and care workers from Indonesia and the Philippines, their current problems in the country of origin, and discusses the possibilities and limitations of border-crossing care in the country of linguistic homogeneity.

II Progress of Movement of “Natural Persons” under the Economic Partnership Agreements

Due to the delayed and complex processes of multilateral trade negotiations in the meetings of the World Trade Organization (WTO), many countries have launched bilateral negotiations in the frame of Free Trade Agreement (FTA) or Economic Partnership Agreement (EPA) since 2000. The Japanese government has intensified its negotiations with its trading partners in the frame of EPA rather than FTA because she expects wider range of economic benefits.[4]

The government recognizes that a structural transformation is taking place in the world economy in which Japan’s status is gradually declining while the emerging economies are experiencing dramatic growth. While it continues to be important for international trade rules to be reinforced by concluding the negotiations at the WTO Doha Development Agenda, their fate remains uncertain and the networks of high-level EPA/FTAs formed by major trading countries are expanding. In order to revive its strong economy accelerating until the 1980s, the government plans to deepen economic relationships with Asian and emerging countries whose markets are expected to grow [Japan, Ministry of Foreign Affairs 2010]. To realize this, the government finally accepted a strong request made by the governments of the Philippines and Indonesia to receive nurses and care workers from the two countries, and drafted the provision of “Movement of Natural Persons” (MNP). The temporary movement of natural persons is also included as one of trade liberalization areas in WTO’s General Agreement on Trade in Services (GATS) [Panizzon 2010: 6].

Japan’s acceptance is not officially intended to solve the shortage of labor force in the medical and social welfare fields. Rather, her acceptance was agreed as an “exception” in order not to jeopardize its EPA negotiations. The government set up maximum numbers of foreign workers by considering the effects on the domestic labor market rather than a measure for labor shortage in nursing and caregiving fields [Satomi 2010: 89–98]. There were less than 400 nurse candidates and 600 certified care-worker candidates by country for the first two years.

The Japanese government’s requirement that the candidates pass the exam in Japanese results from its recognition of the importance of a high-level language ability to communicate with the patient or the elderly-care facility user (resident). The Japanese Nursing Association and the other care-worker associations of Japan strongly supported this requirement, as will be discussed later.

The Philippines is the first country to demand acceptance of its nurses and caregivers from Japan in the EPA negotiation. The Philippine government recognizes that nurses and caregivers are in demand in developed countries such as Japan. Indonesia is the second country to demand the same as the second biggest labor exporter next to the Philippines among Southeast Asian countries. Although the numbers of care workers accepted in Japan under the EPAs are limited and the requirements for those workers to work as qualified professionals are quite high, both governments anticipated larger demands and lighter requirements for their overseas workers in the most aged society in the world.

Then Prime Minister Jun’ichiro Koizumi of Japan and then President Maria Gloria Macapagal-Arroyo of the Philippines signed the Japan-Philippines Economic Partnership Agreement (JPEPA) in September 2006. JPEPA was not in effect in the Philippines immediately because it required ratification by the Philippine Senate. Since NGOs and other organizations opposed passage, the Senate held extensive hearings which delayed consent. The opposition questioned the possibility that tariff-free toxic wastes could be imported from Japan and that Filipino nurses and caregivers did not have a fair deal.[5] It took approximately two years for the Senate to ratify JPEPA in October 2008.

In contrast, the Indonesia-Japan Economic Partnership Agreement (IJEPA) was signed between then Prime Minister Shinzo Abe and President Susilo Bambang Yudhoyono in August 2007, and became effective in May 2008 after Japan’s House of Representatives and House of Councilors approved it. Indonesia did not require ratification of the agreement by its parliament.

Fig. 1 Process of Acceptance of Filipino Nurse and Certified Care-Worker “Candidates” into Japan

Filipino candidates applying for the Nurse (kangoshi) Course are required to obtain a nurse license in the Philippines, and have three or more years of experience working as a nurse. The Certified Care-Worker (kaigo fukushishi) program provides two courses: Probationer and Vocational School (two-year). Those enrolling in the Probationer Course are required to have graduated from the nursing college or from a four-year college with another major and to obtain a caregiver certificate accredited by TESDA (Technical Education and Skills Development Authority). Those enrolling in the Vocational School Course need only to have graduated from a four-year college with any major but are obliged to pay educational fees for their schooling in Japan. If Filipino candidates graduate from the Vocational School with a social welfare course in Japan, they will be automatically granted a license as a certified care worker equivalent to the Japanese graduates, and are not required to take the national exam at present.[6]

The acceptance requirements for Filipino workers became a precedent for Indonesian workers, but there are a few differences between the two. Indonesian candidates for the Nurse Course are required to obtain a nurse license in Indonesia and have two or more years experience working as a nurse. The minimum two-years’ experience, one shorter than Filipino candidates, is due to the similarity of Indonesia’s educational system to Japan’s.[7] Indonesian candidates for the Certified Care-Worker Course are able to apply only to the Probationer Course. They are required to graduate from the three-year nursing vocational school or a four-year college, or graduate from the same-year vocational school or college in any major plus obtain a caregiver certificate accredited by the Indonesian government.

Japanese language proficiency is not a pre-condition for either Filipino or Indonesian candidates. The policy became problematic after foreign nurse and certified care-worker candidates were placed in the workplace in Japan.

Arrangements for employment and placement are administered by the governments of Japan and the sending country, employing computer data-matching and the employers’ interviews if requested. All candidates have to sign a labor contract with their Japanese employers.

After arrival in Japan, Filipino and Indonesian candidates are required to study standard Japanese for six months at the language training institution.[8] Then they will be assigned to a workplace (hospital or elderly-care facility). During the period of candidacy, in addition to working, they learn Japanese sufficiently to pass the national exam in nursing or caregiving, one of main purposes of the EPA programs. Since the Japanese government does not regulate the ratio of daily work and learning hours for foreign candidates at their workplaces, and the conditions vary widely depending on the assigned hospital or care facility [see the papers of Setyowati et al. and Wako Asato in this special issue].

The nurse candidates may take the exam three times within three years whereas the certified care-worker candidates may take it only once over four years because a pre-condition for taking the certified care-worker exam even for Japanese examinees includes working three years at a care facility.[9] Candidates are guaranteed a salary at least equivalent to that of Japanese care staff who are working without a national license of a nurse or certified care worker. The Japanese government pays the candidates travel, accommodations and daily expenses during their intensive Japanese language training. In contrast, the employers must pay for the intensive Japanese language training, commission for matching, employment and the others. This amount is nearly ¥600,000 for each candidate. The employers also have to shoulder additional costs for their training in the Japanese language and the national exam. Some of the accepting hospitals and care facilities have minimized such costs by imposing nearly full-time work schedules and limited learning hours for their foreign employees [see also Asato’s paper in this issue]. Candidates who pass the national exam become formally registered nurses or certified care workers, qualified to remain in Japan and work under a “designated activity (tokutei katsudo) visa” that can be extended indefinitely.

Because of the quick passage of the IJEPA by Japan’s both Houses, Indonesia began to send care workers to Japan before the Philippines. The first batch (104) of Indonesian nurse candidates and certified care-worker candidates (104) entered Japan in August 2008. The first batch of nurse candidates (93) and certified care-worker candidates (217) from the Philippines entered in 2009. A total of 791 Indonesian candidates (363 nurse candidates) and 569 Filipino candidates (209 nurse candidates) arrived in Japan under the EPA programs by 2011.

Figs. 2 and 3 indicate that the numbers of nurse and certified care-worker candidates from Indonesia and those from the Philippines drastically decreased after 2010. Japan’s Ministry of Health, Labour and Welfare in charge of the EPA projects identified the primary reasons: 1) Japan’s worsened economic and employment situation (following the Lehman Shock in the United States) and the increase in Japanese who wanted to enter the care and medical professions; and 2) The hospitals and care facilities who employed the foreign candidates chose to concentrate their training capacity on those candidates, which might overburden their capacity to train in the case of employment of additional candidates [Ohno and Ogawa 2010: 129, 133].

Fig. 2 Indonesian and Filipino Nurse Candidates Accepted in Japan under Economic Partnership Agreements, 2008–11

Source: [Kokusai Kosei Jigyodan 2012: 5]

Fig. 3 Indonesian and Filipino Certified Care-Worker Candidates Accepted in Japan under Economic Partnership Agreements, 2008–11

Source: [Kokusai Kosei Jigyodan 2012: 5]

It is also possible that many Japanese hospitals are less inclined to employ foreign nurses because they have experienced the substantial burdens on financial and human resources in the hospitals that accepted foreign nurse candidates after 2009. This is suggested by the research team’s 2008 survey that described a relatively positive attitude in hundreds of Japanese middle-sized or big-sized hospitals on the interest of using foreign nurses. In this first nationwide survey on this issue, 46.1% of all responding hospitals expressed their intentions to employ foreign nurses at their hospitals [Kawaguchi et al. 2009].[10]

For the 2011 EPA project, it is reported that dozens of Indonesian and Filipino nurse and certified care-worker candidates already matched with Japanese employers canceled their initial commitment to work in Japan mainly due to concerns about the aftereffects of the Great East Japan Earthquake March 11, 2011 [Daily Manila Shimbun, April 20, 2011]. This unexpected, devastating natural disaster in the regions of Tohoku and Kanto negatively impacted the IJEPA and JPEPA projects.

III Complexity of Positions Held by Trade Organizations in Japan,the Philippines and Indonesia

The Japanese government’s strict policies for foreign nurses and certified care workers can be regarded as the result of its respect for the positions of associations of Japanese nurses and care workers such as the Japanese Nursing Association (JNA; Nihon Kango Kyokai). Shortly after the leaders of Japan and the Philippines signed the JPEPA, JNA released a position paper opposing the acceptance of Filipino nurses in Japan unless they met the following four requirements: 1) obtained a nurse license by passing the national examination of Japan, 2) were sufficiently proficient in Japanese for safe nursing practices, 3) were employed under the terms of the job the same as or better than those of Japanese nurses, and 4) no mutual recognition of the nurse license with the other country. The JNA was very cautious in accepting foreign nurses, considering the priority of hiring Japanese nurses first, then the ethical problems, such as shortage of skilled nurses in the sending country [Nihon Kango Kyokai 2006]. It expressed the same stance on Indonesian nurses coming to Japan under the Indonesia-Japan EPA later. The Japan Association of Certified Care Workers (Nihon Kaigo Fukushishi Kai) also took the same stance on acceptance of foreign care workers in Japan.

The Philippine Nurses Association (PNA; Pambansang Samahan ng mga Nars ng Pilipinas), which objected to inclusion of the MNP provision in the JPEPA during the Philippine Senate’s hearings, made its position statement after the first batch of Filipino nurse “candidates” entered Japan in 2009. Its then president, Leah Samaco-Paquiz, stated that it declined “the offer of Japan” because “the Filipino nurses will go to Japan not to fully practice the nursing profession but to become a trainee,” and “the language skills required by the JPEPA are so high as to constitute an almost impregnable barrier to our entry” [Philippine Nurses Association 2009].

The association made another statement after only one Filipino nurse was able to pass Japan’s national nursing examination conducted in February 2010. Its president, Teresita Irigo-Barcelo, stated, “JPEPA is a cheap labor trap for nurses and caregivers” after referring to the “plight” of Filipino nurses working in Japan as nurse assistants with salaries lower than expected during their training period, and an increasing number of halfway returnees from Japan [Philippine Nurses Association 2010].[11] The association, however, made some recommendations towards improvement of the JPEPA program, and requested that the two governments provide adequate language training prior to their deployment in Japan [ibid.].

In contrast, the Indonesian National Nurses’ Association (INNA; Persatuan Perawat Nasional Indonesia) expressed a positive position on deployment of Indonesian nurses to Japan from the beginning because “each nurse has a right to work anywhere in the world in accordance with the policy of the International Council of Nurses, and INNA is a member of the council.” But INNA, in agreement with the Philippine Nurses Association, has opposed sending Indonesian nurses as caregivers (care workers) to Japan due to the risk of “lowering their professional skills.”[12]

In line with INNA’s firm position that every nurse has a right to be treated and rewarded as same as native nurses in the host country, it requested the JNA leadership to accept Indonesian nurses working in Japan under the IJEPA as “special members of JNA.”[13] JNA has not yet responded positively to INNA’s request, and has introduced no particular program to support foreign nurse candidates, although some local nursing associations of Japan started their own programs to assist foreign nurse candidates in passing the examination.[14] After only two Indonesian nurse “candidates” passed the national nurse examination of Japan conducted in February 2010, the president of INNA made recommendations to the Japanese government to allow Indonesian nurses four chances to take the exam instead of three, and to make the exam language more easily understood.[15]

JNA has been in a sensitive position since the Japanese government adopted some requirements demanded by JNA in its requirements for acceptance of foreign nurses under the JPEPA and IJEPA. Leading Japanese mass media has often criticized this government policy as “setting too high a block to foreign nurses and care workers.” Almost all nationwide newspapers have maintained their position that Japan should be open to foreign nurses and care workers because of its rapidly aging population and the increasing need for the health-care work force in the near future. After only two Indonesian and one Filipino candidates passed the nursing exam in 2010, the media focused on the extremely low passing rate (1.2%) among Indonesian and Filipino examinees compared with the high passing rate (89.9%) among Japanese examinees, and criticized Japan’s “unrealistic” policy even more severely.[16]

Mainichi Shimbun [April 15, 2010] carried the headline “stupidities of shutting-out examination” on its editorial, and another nationwide newspaper Yomiuri Shimbun [February 9, 2011] even criticized JNA in its editorial by asserting that “it is said that the Japanese Nursing Association has a negative attitude to substantial review [of nursing exam questions for foreign examinees] because it guards against being deprived of job opportunities for Japanese nurses.”

The Japanese government’s policy on the EPAs was sternly blamed for the low passing rate. Some politicians from the opposition demanded in the Diet to substantially amend the policies. One member of the House of Representatives labeled the EPA policy as “blocking the exam pass for foreign nurse candidates by a non-tariff barrier, that is, the Japanese language” [Daily Manila Shimbun, February 21, 2011].

On the date, March 25, 2011, the Japanese government announced 16 Indonesian and 1 Filipino nurses passed the exam, JNA’s Executive Director Shinobu Ogawa advocated the organization’s previous position in a news release and reinforced the importance of understanding Japanese technical terms in order to guarantee the safety of patients in Japan’s medical workplaces. He stated that the low passing rate among foreign examinees of 2011 (only 4.0% versus 91.8% among Japanese examinees)[17] originated from the questionable government policy of accepting foreign nurse candidates regardless of their competence in the Japanese language, and recommended to the governments that they should screen language ability before accepting candidates into Japan [Nihon Kango Kyokai 2011].

JNA’s position appears to correspond with PNA’s request to facilitate adequate language training in the Philippines prior to employment of otherwise qualified Filipino nurses in Japan. In 2010, PNA also recommended to the respective governments that the association become involved in the orientation of Filipino nurses prior to their employment in Japan [Philippine Nurses Association 2010]. PNA’s stance, which appears more flexible, seems to reflect current difficult circumstances surrounding Filipino nurses in their country.

IV Oversupply of Nurses in Declining Labor Market:The Case of the Philippines

The Philippines had a reputation as the global leader in training nurses for the international market for several decades. Its labor export policy was codified in the Labor Code of the Philippines in 1972, and its policy of nurse and other worker’s exports has been adopted as a development strategy by the government [Yeates 2009: 86]. The deployment of Filipino nurses to the Middle East and North America began in the late 1960s and escalated in the late 1990s, to alleviate the widespread global nursing shortages [Ronquillo et al. 2005]. Higher salaries abroad became a strong incentive to encourage Filipino nurses to work outside their country.[18]

Consequently, a total of 119,427 Filipino nurses worked abroad between 1994 and 2006, according to Philippines’ Department of Labor and Employment [Cruz 2008: 39]. However, this trend has been hindered since 2006 when the demand for Filipino nurses reached a plateau partly due to U.S. visa retrogression and a U.K. policy shift from recruiting nurses overseas to home-grown health workers [Philippine Nurses Association 2008]. The Filipina scholar reported that the number of permanent Filipino nurse migrants to the U.S. dropped sharply from 5,790 in 2006 to 771 in 2008,[19] and that of temporary Filipino nurse migrants to the U.K. fell from 546 in 2005 to 28 in 2008 [Lorenzo 2010: 75–76]. After 2006, only Saudi Arabia has continued to accept more than a thousand Filipino nurses per year (see Fig. 4).

Fig. 4 Numbers of Filipino Nurses Deployed Abroad by Country, 2000–10

Source: Data obtained from Philippine Overseas Employment Administration (POEA) [2011]

Note: The 2005 figure of the U.S. (3,853) includes the number of nurses deployed through an employed-based immigration scheme (3,624).

Saudi Arabia has faced an acute shortage of native nurses primarily due to lack of enthusiasm among young Saudi Arabians for vocational training and religious barriers that restrict female access to education and employment [Ball 2008: 41]. For female Overseas Filipino Workers (OFWs), however, it sometimes has a reputation as a difficult destination. Some stories on abuses and discrimination against Filipino women in Saudi had been reported in the mass media. For instance, the leading Philippine newspaper published an article that Saudi religious police arrested a Filipina nurse on charges of immorality for sitting in a restaurant with a male colleague [INQUIRER.net 2008]. The Internet reported a story about Filipino Catholic nurses who were forced to convert to Islam [e.g., Digal 2010]. Moreover, their salary scale is lower than that in the U.S. and the other Western countries.[20] Thus, the rapid increase of Filipino nurses in late 2000s in Saudi can be considered a result of the shrunken labor market for foreign nurses in the other countries.

Although Saudi Arabia and the other countries of the Middle East have been main destinations for Filipino and Indonesian nurses, some of these countries are currently politically unstable, and those overseas workers tend to avoid them [e.g., Daily Manila Shimbun, April 25, 2011].

A number of Filipino nursing graduates and even registered nurses have emigrated abroad to work as “caregivers.” Until the 1980s, the occupational category “caregiver” was not familiar among Filipinos since their elderly were cared for at home. The profession developed in the 1990s when Canada and other aging countries began to actively accept Filipino care workers.[21]

Canada is one of the more preferable destinations for Filipino nurses to work not only as registered nurses but also as caregivers. Its Live-in Caregiver Program (LCP), established in 1992, enables qualified foreign workers to apply for permanent residency after working for two years.[22] Under the auspices of the LCP, thousands of Filipinos (mostly females) entered Canada.[23] Since 2008 when the global economic recession spread to Canada, the opportunities for Filipinos to work as caregivers have diminished.

Many employers in countries and states such as Taiwan prefer to employ caretakers with nursing-backgrounds in the care facilities or hospitals. Taiwan’s caretakers (“看護工” in Chinese) are required to take care of elderly or disabled persons, and also perform domestic duties in the case of live-in caretakers [Ohno 2010: 70]. Although the Taiwanese have extensively employed Filipino caretakers at home or in the elder-care facilities since the late 1990s, job opportunities have decreased since the early 2000s due to Taiwanese preference for Indonesian care workers rather than Filipinos [ibid.: 72–75; see Fig. 5].[24]

Fig. 5 Numbers of Filipino Caregivers/Caretakers Deployed Abroad by Country, 2003–10

Source: Data obtained from Philippine Overseas Employment Administration (POEA) [2011]

In midyear 2008, PNA warned about the surplus of Filipino nurses, and stated in its press release that “the domestic market is now oversaturated with nursing pools in major hospitals as high as 1,500 and with employment waiting times ranging from 6 to 12 months” [Philippine Nurses Association 2008]. In this year, there were already approximately 150,000 unemployed nurses around the country. The number of the unemployed has grown rapidly in recent years. The Department of Labor and Employment stated in its 2011 position paper that the number of unemployed or underemployed nurses would increase to 257,296 [The Philippines, Department of Labor and Employment 2011].

These figures do not establish that the Philippines has provided sufficient nursing services for its nation. Although the government has defined a hospital-staffing standard of one nurse to 12 patients ratio in regular hospital wards or one nurse per 20,000 residents in the community health setting, it was not implemented in many hospitals and areas [Philippine Nurses Association 2011b]. According to PNA, in some local provinces one nurse has to take care of 20–30 patients due to the severe shortage of nurses [Daily Manila Shimbun, January 17, 2011]. As one of solutions to such serious problems, the Department of Health launched a new program titled “Registered Nurses for Health Enhancement and Local Service,” and plans to provide a specified allowance to 10,000 unemployed nurses and send them to poor communities in the country [The Philippines, Department of Health 2011].

The serious oversupply and unemployment of Filipino nurses has resulted in widespread “volunteer nurses” during the last several years. These nurses volunteer to provide services without salary in the name of “on-the job training (OJT)” usually for the acquisition of two–three years of actual nursing experience required for overseas employment in the future. In recent years, the issue of Filipino nurses forced to pay the hospitals for their volunteer work rose to the surface. It was frequently reported in the local mass media [e.g., Jaymalin 2011]. PNA made a statement to stop the exploitation of “nurse-volunteers for a fee” [Philippine Nurses Association 2011a], and proposed a law to the House of Representatives in February 2011 that bans the exploitative practice [Philippine Nurses Association 2011b].

The quality of hundreds of commercial nursing schools also became questionable. The number of higher educational institutions offering nursing programs jumped from 182 in 2000 to 464 in 2005 [Acacio 2007], and increased to 517 in 2007 [Kanchanachitra et al. 2011: 771]. According to data obtained from the Commission on Higher Education (CHED), in the fiscal year 2006–07, 452,793 students enrolled for the Bachelor of Science degree in nursing but only 79,148 students graduated in the same year [Lorenzo 2010: 75]. Fewer than 50% of those graduates could pass the Nurse Licensure Examination in 2006 and 2007 [Philippine Nurses Association 2008].

The deteriorating labor market and overproduction of health workers may be one of the primary factors behind a considerable number of nurse applicants in the JPEPA programs. According to the Japanese Embassy in the Philippines, 235 Filipino nurses fulfilling all requirements applied to the nurse program whereas 292 nurses and other workers applied to the certified care-worker program in 2009.[25] In the following year, among approximately 6,700 applied through the POEA website, 410 fulfilled all requirements for the two programs and were interviewed by JICWELS and potential Japanese employers [Daily Manila Shimbun, February 5, 2010]. In 2011, a total of 550 applicants, selected based on application forms, were interviewed [Daily Manila Shimbun, February 4, 2011].

This reality contradicts the results of a survey of dozens of Filipino nurses and nursing students in Manila and Davao conducted by Kyushu University’s research team in 2007, one year before the implementation of JPEPA. Those results indicated that the majority of those polled were not willing to work in Japan under the JPEPA program due to the language barrier, insufficient income during the candidate period and other discouraging conditions after learning the requirements for foreign nurses to be registered nurses in Japan [Hirano and Kawaguchi 2008; Ishii and Hirano 2009].[26]

Nonetheless, several hundreds of Filipino nurses continue to apply to the JPEPA program annually, as mentioned above. The author’s research team has conducted a series of surveys on Filipino and Indonesian “candidates” bound for Japan since 2009. The outcome of the 2009 surveys conducted in the Philippines and Indonesia demonstrates that the most important reason for the first batch of Filipino nurse “candidates” to apply to the program was to “support my family economically” (47.2%), whereas the second batch of Indonesian nurse “candidates” applied primarily to “develop my professional career” (66.7%).

Regarding their economic conditions, 68.0% of Filipino respondents agreed with the statements “difficult but able to survive” or “very difficult to survive,” whereas only 25.7% of Indonesian respondents concurred. Nearly 40% of Filipino nurse “candidates” were jobless when they applied, whereas more than 10% of Indonesian “candidates” were unemployed as of 2009 [Hirano et al. 2010: 154–158].[27]

A number of Filipino nurses or nursing graduates applied to the Certified Care-Worker Course rather that the Nurse Course under the JPEPA. One of primary reasons was their lack of the requisite work experience (three years or more) as registered nurses (RN) in the Philippines to qualify as nurse “candidates” in Japan. The results of the author’s survey of the second batch of Filipino certified care-worker candidates (Vocational School Course) demonstrate that all of these candidates (10) studied nursing at college or university, but none had more than two-year work experience as a Registered Nurse. Two of them stated that they worked as “volunteer nurses” before applying to the JPEPA program because they faced difficulties getting paid-employment even after graduation from the nursing school.[28]

In general, Filipino nurses prefer to work in the U.S. because they have a reasonable opportunity to earn approximately US$4,000 [Connell 2008: 11] or even more, and many of them have relatives living there [Institute of Health Policy and Development Studies 2005: 27].

The survey data, obtained by the author and his research partners, combined with past studies on the migration of Filipino nurses suggest that Filipino nurse candidates have tended to experience more financial challenges than the Indonesian nurse candidates. Therefore some of them might have decided to work in Japan, although it was not their first priority, as steppingstone to a more favored English-speaking country.

V Newcomers in Globalizing Labor Market of Nursing and Care:The Case of Indonesia

Because of longtime abundant supply of registered nurses, the Philippines has the largest number and highest density of nurses in ASEAN (Association of Southeast Asian Nations) countries. The 2010 statistics from the World Health Organization (WHO) register 480,910 Filipino nursing and midwifery personnel with a density of 61 per 10,000 population in the 2000s.

In contrast, Indonesia has faced a serious shortfall in trained nurses compared to its massive population (227,345,000 in the 2010 WTO statistic). According to the above statistics, there were only 179,959 nursing and midwifery personnel in the entire country, with a density of eight, the lowest in ASEAN countries. This density was same as Viet Nam and Cambodia, and much lower than the world average of 28 [World Health Organization 2010: 116–124].

On the other hand, the Indonesian government’s 2006 statistics demonstrate that there were 308,306 nurses in the country. Many do not work in primary health facilities such as hospitals and health centers.[29] Only 109,210 nurses worked in hospitals, but 56,727 nurses were employed at the health center in 2006 [Indonesia, Ministry of Health 2008: 102–103].

The number of nursing students, however, has been increasing. In 2007, 40,884 nursing students graduated from polytechnic institutions [ibid.].[30] According to a government official who oversees nursing in the country, only 10% would be employed as nurses at hospitals.[31] Consequently, many nursing graduates have to engage in other occupations such as sales, clerical works and so forth similar to the Filipino nursing graduates.

A substantial number of Indonesian nurses began to emigrate only two decades ago, therefore the number of Indonesian nurses working abroad is much fewer than their Filipino counterparts. Official data shows that a total of 5,566 nurses had been deployed abroad in the years 1989–2007. The majority of them have worked in Middle East countries such as Saudi Arabia (3,297) and Kuwait (1,054). Its former colonizer, the Netherlands, accepted 269 Indonesian nurses during the same period [Panchaweda 2008: 46–50]. The United States, the favorite destination for Filipino nurses, accepted only 12 Indonesian nurse migrants between 2005 and 2008[32] and the same number in 2009 (see Fig. 6).

Fig. 6 Indonesian Nurses Deployed Abroad in 2009 by Country of Destination

Source: Data obtained from Indonesia’s Ministry of Health on August 1, 2011.

As illustrated in Fig. 7, the majority of Indonesian labor migrants are women, as a result of increased demand for migrant labor in domestic and manufacturing sectors. Feminization of Indonesian labor migration escalated especially after 2004. These unskilled or semiskilled domestic workers are considered vulnerable to exploitation [Hugo 2007]. Thus, the Indonesian government wishes to change the negative image and stigma attached to “Indonesian Migrant Workers (Tenaga Kerja Indonesia),” and accelerate overseas deployment of skilled and educated workers in health and other sectors as “Indonesian Foreign Workers (Tenaga Kerja Luar Negeri)” [Indonesia, Republic of Indonesia 2006; 2009].

Fig. 7 Numbers of Indonesian Labor Migrants by Gender, 1996–2007

Source: [International Organization for Migration Mission in Indonesia 2010: 9]

A delay in developing a system and nursing education contributes to the fact that there are fewer overseas Indonesian nurses. In Indonesia, nurses are often labeled “the helper of the medical doctor” [Setyowati 2010: 201] or “servants of the doctor” [Wardani 2007].[33] This is partly because of the limited education available to the majority of Indonesian nurses. Most of the current nurses were educated in nursing high schools called “SPK” (abbreviated from “Sekolah Perawat Kesehatan” [Nurse and Health School]). Since the early 1980s, SPK nurses have been gradually phased out.[34] Many nursing schools upgraded to diploma level after 1998 [Shields and Hartati 2003: 211] and graduated a number of nursing academy (usually three-year course) D3 students (D3 is abbreviated from “Diploma 3”) and bachelor’s degree S1 students (S1 is abbreviated from “Specialist 1”). Although INNA proposed to the government that it should make most nurses reach at the S1 level by 2015 [Setyowati 2010: 203–205], the majority of Indonesian nurses are still SPK or D3 level at present.

The absence of comprehensible job descriptions and autonomy for nurses is also a long-time problem. In this respect, the Philippines advanced rapidly after enacting the Philippine Nursing Act of 2002, which clearly defines nursing practice, examinations, registration and other areas. This has led INNA to lobby for an equivalent bill on nursing practice and regulation from their House of Representatives for years. Such a bill is expected to clarify the rights and duties of nurses, and provide a formal legal platform for nurses’ jobs. The draft bill, however, has been revised many times, and not yet passed by the House [The Jakarta Post, May 10, 2008; Wardani 2010]. These delays in defining nursing regulations and the lack of national standards for nurses have sometimes endangered Indonesian nurses, detained by the authorities for providing emergency assistance without the presence of doctors [The Jakarta Post, May 10, 2008].

The nursing board examination has not yet been standardized in the Indonesia either. In the past, only five provinces on the islands of Java and Sumatra have conducted a provincial nursing exam for nursing students and others. In the other provinces, each university and academy developed their own nursing exam for their students. Approximately 70% of nursing graduates (roughly 30,000 per year) across the country have passed the exam.[35] According to INNA, its government with the cooperation of the Canadian Nurses Association introduced a common nursing board exam in six provinces in Central Java, Northern Sumatra and Southern Sulawesi in 2009.[36]

This is a significant step towards national standardization of nursing examination in Indonesia. This measure is in line with government policy to encourage Indonesian nurses to work abroad since opportunities in domestic health institutions are quite limited — only a fraction of the new nursing graduates have a chance of employment as nurses. The Ministry of Health began a new program, International Training for Preparing Nursing Course in 2004. The course composed of several classes provides nursing courses taught in English, and graduated more than 300 D3 and S1 nurses who had English proficiency.[37] They are educated workers or Tenaga Kerja Luar Negeri, whom the government hopes to deploy actively in the global labor market.

The Indonesian government is optimistic that the IJEPA program will continue because Japan’s quota (“the maximum number” in Japanese official words) for Indonesian nurses and care workers needed in Japan is much larger than other developed countries. Indonesia anticipates that Japan will be the biggest labor market for Indonesian nurses in the world.[38] Indonesian government officials and a leading businessman involved in the IJEPA negotiations have strong expectations for their “candidates” to perfect their nursing skills in Japan, then bring back them and upgrade nursing education and practice in their country.[39]

Japanese popular culture, including anime and manga (Japanese comics), is one of the most popular foreign influences among Indonesian youth. Because of their strong interest in Japan and her culture, the number of Indonesians learning the Japanese language reached 716,653 (mostly high school students) by early 2010. This number is 32 times more than that of Filipinos (22,362) at the same time [Japan Foundation 2011].[40] Because of the immense popularity of Japanese culture and the promise of higher salaries, many Indonesian nursing students and nurses have indicated a strong interest in working in Japan.[41] This trend is manifested in the number of Indonesian applicants (mostly nurses) in the second batch of nurse and certified care-worker candidates (950),[42] and the third batch (502) that fulfilled all requirements.[43]

Indonesia’s National Board for Placement and Protection of Indonesian Overseas Workers that administers the IJEPA program has rated the program highly compared with other country’s labor-import programs, and expressed the highest appreciation to the Japanese government during the international conference for government officials and scholars hosted by the author’s research group in February 2010.[44] The above-mentioned factors are good reasons the Indonesian government continues its strong efforts to deploy Indonesian nurses and care workers to Japan even though the government is still disturbed about the continuing requirement of having to pass the national exam in Japanese.

In sharp contrast, Philippine government officials expressed dissatisfaction over the Japan’s limited requests for Filipino nurses and care workers and their difficulty in passing the national exam in Japanese after deployment of the second batch of Filipino candidates to Japan [Daily Manila Shimbun, November 6, 2010; January 20, 2011]. One of its negotiators on the JPEPA suggested at the local press conference that the Japanese government should establish a new examination system for foreign nurses if Japan really needed Filipino qualified nurses [Daily Manila Shimbun, January 20, 2011]. The controversy over the examination system for foreign workers has escalated between the Philippines and Japan since only two EPA Filipino nurses had passed the nursing exam by 2011.

VI Foreign “Candidates” and Japanese Staff Caught in a Dilemma

As mentioned above, before foreign nurses and care workers pass the national exam in Japan, they are treated as nurse or certified care-worker “candidates.” Although many of them may have valuable experience working as registered nurses in their country of origin, they are not allowed to perform any medical interventions for the patients until they have a national nursing license in Japan. Their job descriptions and salaries are equivalent as those for Japanese nurse assistants or non-licensed care staff. Their duties at the workplace are outlined in Table 1.

Table 1 Duties of Indonesian (and Filipino) Candidates for Nurse (Kangoshi) and Certified Care Worker (Kaigo Fukushishi)

For those candidates not well informed about the specifics of their duties as “candidates” by their government before their departure, it was shocking and demeaning to their status as professionals to perform basic care works such as changing diapers and collecting urine or other garbage, assisting in taking meals and tea to the patients, which are usually performed by family members or nurse aides in their home country, but by nurses and other care workers in Japan. Such tasks are sometimes contradictory to their pre-departure expectations of “developing my professional career” and “learning about advanced Japanese technology” in Japan [see also Yuko Hirano’s paper in this issue]. Non-utilization of their nursing knowledge and skills or deskilling (erosion of a person’s skill or mastery) is a serious annoyance to Filipino and Indonesian candidates who had years of experience working as nurses and thrived on professional work in their homeland [refer to the paper by Bachtiar Alam and Sri Ayu Wulansari in this issue].[45]

Their only path to eliminate the candidate status and classify as a formal nurse is to pass the national exam in Japan. This is an intimidating task for Filipinos and Indonesians who use the Latin alphabet and never learned kanji (Chinese characters) in their countries. There are numerous and complicated kanji words embedded in the questions of national examinations for nurses as well as those for certified care workers. These technical and colloquial words are very difficult for the candidates to master and read [see papers contributed by Setyowati et al. and Alam and Wulansari in this issue].

The candidates must manage many everyday tasks such as studying the Japanese language, preparing for the national examination conducted in Japanese, and working as assistants to Japanese nurses or care workers. They also must try to overcome their uncomfortable feelings and mental stresses caused by insufficient Japanese language ability, deskilling and other difficulties [see Alam and Wulansari’s paper]. Even though they have many challenges, most of the foreign workers are positively evaluated by their Japanese employers and coworkers. The outcome of the author team’s survey conducted with the questionnaires sent to all care facilities and hospitals that accepted the first batch of Indonesian nurse and certified care-worker candidates in Japan related relatively positive evaluation of those candidates. Their attitudes such as respect for the elderly are generally welcomed and positive factors that vitalize their workplaces [see Reiko Ogawa’s paper in this issue].

In addition, Japan International Corporation of Welfare Services (JICWELS), an extra-governmental organization in charge of the EPA projects, made public its survey report on Japanese staff in charge of personnel management of foreign nurse and certified care-worker candidates, and demonstrated that approximately 70–80% of Japanese respondents replied that they learned (nursing or care) through their instructions to the candidates. One third of them replied that the acceptance of the candidates acts as a stimulus to the Japanese staff [Kokusai Kosei Jigyodan 2011].

Furthermore, the outcome of the Japanese government’s questionnaire survey given to Japanese patients and elderly users (residents) , taken care of by Indonesian candidates, also demonstrated that many of them feel that medical or care services at their facility were relatively or remarkably improved after the candidates arrived at the facility. Only a negligible number of patients, elderly users and their families felt that the services were deteriorated (see Figs. 8 and 9).

Fig. 8 Patients and Their Families’ Evaluations of Indonesian Nurse Candidates in Medical Services

Source: Data obtained from Japan, Kosei Rodo-sho [2010a]

Note: Survey conducted in February 2010; n=86 in patients, n=74 in their families.

Fig. 9 Elderly Users’ and Their Families’ Evaluations of Indonesian Certified Care-Worker Candidates in Care Services

Source: Data obtained from Japan, Kosei Rodo-sho [2010b]

Note: Survey conducted in January and February 2010; n=108 in users, n=105 in their families.

On the other hand, Japanese hospitals and care facilities employing Indonesian and/or Filipino candidates have encountered some difficulties such as financial burdens and the increasing workload shouldered by the Japanese preceptors (mostly nurses and certified care workers). They were also puzzled about lack of the government’s support regarding the proper requirements for the learning presented to the candidates. These difficult situations were clearly manifested in the author team’s questionnaire survey [see Ogawa’s paper in this issue]. There is no doubt that both the Southeast Asian candidates and the Japanese employers are in the midst of serious dilemma that cannot be easily solved by themselves.

On March 11, 2011, just before the Japanese government announced the results of the national nursing examination, the government decided to extend by a year the stay of Indonesian and Filipino nurse and certified care-worker candidates who came to Japan between 2008 and 2009. In consideration of the national policy to “open the country to the world” and its diplomatic relations with Indonesia and the Philippines, it gave candidates who scored over a certain grade in previous national exams an extra chance to retake the yearly national exam [Japan, Shusho Kantei 2011]. It is still uncertain whether this new measure will be effective in increasing the number of those who pass the exams conducted after 2012.

The G-G substantial consultations to review the JPEPA began in 2011, and those to review the IJEPA are scheduled in 2013. In these renegotiations, Japan plans to add a minimum level of Japanese proficiency as a precondition for the EPA candidates. Such pre-condition was already agreed by the Vietnamese government that wishes to deploy its care workers to Japan soon, but it became controversial between Japan and the Philippines because of the increased opportunity to reduce the number of applicants [Nihon Keizai Shimbun, May 7, 2010]. The provision of MNP will be core of heated discussions because it is deeply challenging national emotions and nationalism among those in both countries.

VII Conclusion: Toward a Sustainable System

The provision for movements of nurses and care workers between Japan and Southeast Asian countries was included in the EPAs after the governments compromised as on free-trade deals. It can be seen as a quid-pro-quo that reduces trade barriers. After implementation of the EPA programs, the difficulty of the Japanese language barrier for Indonesian and Filipino nurses and care workers coming from non-kanji countries became illuminated. In addition, insufficient coordination between the government and trade organizations has caused friction similar to that between nurse associations in Japan and the sending countries, as described above. Yet even under these difficult conditions, the spread of overproduction and unemployment among nurses and the government’s active strategy to upgrade its nursing level in the competitive global labor market became push factors driving a number of applicants to the EPA program in the sending countries.

The initial enthusiasm has declined somewhat after the challenges for foreign candidates and the employing hospitals/care facilities proved more difficult than expected. Due to inadequate information on job descriptions, including those related to deskilling, provided to the candidates before their departure, limited support from the governments to groom them for the national exam, various problems have occurred in some areas such as Japanese language acquisition and preparation for the national board exam. The crisis of sustainability of the EPA projects is manifested in decreased numbers of Japanese employers who choose to hire Indonesian and/or Filipino candidates since 2010, despite the fact that many care facilities and hospitals are impressed with their foreign employees’ caring attitudes and recognize their valuable role in vitalizing their workplaces. It can be said that the current reality is far from a “win-win” situatiorn.

The author’s research team has already determined that the difficulty in passing the exam in Japan for Filipino nurses was not only due to the language barrier but also differences in nursing education and basic nursing policy between Japan and the Philippines/Indonesia [see Kawaguchi 2009 and also the paper contributed by Yoshichika Kawaguchi et al. in this issue]. Apparently, it would be difficult to activate movement of foreign nurses and care workers to Japan without the formation of transnational networks among nursing and care professionals in addition to promoting mutual understanding and trust between both countries.

Japan’s policy of not requiring language proficiency during recruitment was obviously a problem in the area of “emotional labor,” which requires high proficiency of the language in any country. Past G-G arrangements and projects that have not established a comprehensive migration policy with due consideration of demands and supplies in the global labor market as well as gaining insufficient support from private stakeholders and/or non-state actors showed their limitations in smooth operation of the migration project. Nonetheless, it would be true that the Indonesian and Filipino candidates who passed the national exam in Japan, even though its number is still very limited, can become “transnational carers” interacting and connecting Japan with their home countries in the future. By obtaining the right to work steadily and developing a high mobility to shuttle between the two countries as professionals, they may become frontrunners in the field of cross-border care and develop their potential in bridging new human relations between super-aging Japan and less-aged Southeast Asia.

Acknowledgements

The author wishes to thank Kyushu University, the Japan Society for the Promotion of Science and the Directorate General of Higher Education (DGHE), Ministry of National Education, Indonesia, for their support to the following researches: 1) “A Global Sociological Study on the Opening of Japan’s Labor Market: Focusing on the Fields of Care and Nursing” (Research representative: Shun Ohno, fiscal years 2007–09), 2) “An International Study on Care Services, Lives and Mental Health of Indonesian Care Workers Coming to Japan” (Research representatives: Shun Ohno/Reiko Ogawa and Bachtiar Alam, fiscal years 2009–11), 3) “A Study on Transnational Movement of Foreign Nurses Working in Japan under the Economic Partnership Agreement and Establishment of Accepting System” (Research representative: Yuko Hirano O., KAKENHI No. 213901066, fiscal years 2009–12), and 4) “Comparative Studies on the Policies of Acceptance of Foreign Workers in the Fields of Nursing and Care”(Research representative: Shun Ohno, KAKENHI No. 23530664, fiscal years 2011–13).

Glossary and Abbreviations

AOTS : Association for Overseas Technical Scholarship

ASEAN : Association of Southeast Asian Nations

CHED : Commission on Higher Education

D3 : Diploma 3

EPA : Economic Partnership Agreement

IJEPA : Indonesia-Japan Economic Partnership Agreement

INNA : Indonesian National Nurses’ Association (Persatuan Perawat Nasional Indonesia)

JICWELS : Japan International Corporation of Welfare Services

JLPT : Japanese Language Proficiency Test

JNA : Japanese Nursing Association

JPEPA : Japan-Philippines Economic Partnership Agreement

jun-kangoshi : “assistant nurse” in Japanese

kaigo fukushishi : “certified care worker” in Japanese

kangoshi : “nurse” in Japanese

LCP : Live-in Caregiver Program

MHLW : Ministry of Health, Labour and Welfare (of Japan)

PNA : Philippine Nurses Association (Pambansang Samahan ng mga Nars ng Pilipinas)

POEA : Philippine Overseas Employment Administration

RN : registered nurse

S1 : Specialist 1

SPK : Sekolah Perawat Kesehatan (nurse and health school)

TESDA : Technical Education and Skills Development Authority

WHO : World Health Organization

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1) Arlie Russell Hochschild [2003: 7] defines the term “emotional labor” as “the management of feeling to create a publicly observable facial and bodily display,” and “is sold for a wage and therefore has exchange value.”

2) The concept of “global care chain” originated as a way of capturing “a series of personal links between people across the globe based on the paid or unpaid work of caring” [Hochschild 2000: 131].

3) Economic ministers of the ASEAN singed a package of Economic Integrated Agreements including a Mutual Recognition Arrangement (MRA) in December 2006. MRA intends to facilitate mobility of nursing professionals within ASEAN and expertise on standards and qualifications [ASEAN Secretariat 2009].

4) The FTA is a trade agreement between the trading partners mainly by liberalization of trade of goods and services whereas the EPA is a comprehensive economic agreement between them by not only liberalization of trade but also other measures such as deregulation of investment rules and enhancement of movement of workers and other persons [Japan, Zaimu-sho 2011].

5) Some Philippine NGOs opposed the JPEPA partly because it was a “lopsided deal” and “difficult to comply with” for Filipino nurses and care workers who were not allowed to work as full-fledged nurses or care workers before they passed the exam in Japanese [Aning 2007].

6) The Philippine government has discontinued sending Filipino workers to Japan for the Vocational School Course since 2011 because it is concerned over the Japanese government’s future plan to oblige Japanese and foreign graduates of vocational schools to take the national exam [Daily Manila Shimbun, August 20, 2011].

7) As the Japanese nurses, Indonesian nurses have studied at the elementary school level (six years), junior high school (three years) and senior high school (three years) before enrollment in the three-year vocational nursing school or four-year nursing college. On the other hand, Filipino nurses have studied at the elementary level (six years) but only four years in high school before enrollment to the four-year nursing college.

8) The Japanese government arranged for the second batch of Indonesian candidates to study Japanese in Indonesia for the first four months and in Japan for the last two months. It arranged for the third batch of Indonesians to study in Indonesia for the first two months and in Japan for the last four months. These changes of learning location were made in order to economize a governmental budget for their learning. It arranged for the first and second batches of Filipino candidates to let them learn in Japan for full six months.

9) Care workers working at the care facility in Japan are classified mainly into three categories, namely, certified care worker (kaigo fukushishi), “home helper” and care staff (having no license and certificate). The qualification of home helper is given to persons who finished studying at the class and job training provided by municipality offices, vocational schools and private companies on care. The course for home helper Level 2 (standard) requires the applicants to study at the class and training totally for 130 hours, but does not require them to take the exam.

10) Our survey questionnaires were delivered to 1,604 hospitals having more than 300 beds located across Japan in January 2008. A total of 541 hospitals responded (response rate: 34.1%) by February 2008.

11) According to data that the author obtained from JICWELS, 23 Filipino nurse candidates and 22 Filipino certified care-worker candidates in all had returned to the Philippines by April 1, 2011 after dissolutions of their employment contracts in Japan due to dissatisfaction at the workplace, and other reasons.

12) Interview with Achir Yani S. Hamid, then president of Indonesian National Nurses’ Association in Jakarta June 10, 2008.

13) [ibid.]

14) For instance, Osaka Nursing Association with the largest number of nursing members (approximately 43,000) in Japan launched its own introductory training program for Filipino nurse candidates at its facilities in 2009.

15) Interview with Achir Yani S. Hamid, former president of Indonesian National Nurses’ Association in Jakarta August 5, 2010.

16) For instance, Nishinippon Shimbun [April 15, 2010] based in Fukuoka fiercely criticized the EPA scheme in its editorial by asserting that “the purpose of acceptance (of foreign nurses) would be unclear if the majority of them could not pass the exam and have to return to their countries,” and “(the EPA program) could be blamed for making them throwaway.”

17) The passing rate of Japan’s Nursing National Examination among the first batch of Indonesian nurse candidates who took the exam in 2010 and/or 2011 (93 persons) was 16.1%.

18) According to the chairperson of the Professional Regulatory Commission, nurses in private and public hospitals in the Philippines were paid between US$58 and US$115 per month as of 2006. In the U.S. and U.K., however, they could earn as much as US$5,000 per month [Llorito 2006].

19) Filipino nurses enter the U.S. as immigrants under the 1965 Amendment to the U.S. Immigration and Nationality Act [Venzon and Venzon 2005: 64].

20) According to Philippine Overseas Employment Administration [2008], the salary of Filipino nurses employed by the Saudi Ministry of Health ranged from SR2,250 (US$600) to SR4,000 (US$1,070) as of March 2008. On the other hand, the salary of Filipino nurses in the U.S. was reported to range roughly from US$3,000 to US$4,000 as of 2004 [Conde 2004].

21) Interview with Fercival Encarnado, then School Administrator of Fil-Canadian Training and Development Center for Caregivers, Inc. in Manila February 16, 2009.

22) Under a new regulation adopted by the Canadian government in 2009, foreign live-in caregivers would be eligible to apply for permanent residency after working 3,900 hours [INQUIRER.net 2009].

23) A total of 36,640 migrants came to Canada between 1993 and 2006 under the auspices of the LCP. The majority of them possessed Philippine citizenship [Spitzer and Torres 2008: 10–12].

24) As of October 2009, the number of Filipino care workers in Taiwan was approximately 22,000, whereas that of Indonesians was approximately 120,000. It is a popular notion among Taiwanese employers that Filipino workers tend to be well educated and have stronger self-assertion whereas Indonesian workers tend to be obedient to the employer and avoid quarrels with others [Ohno 2010: 74].

25) Interview with a Japanese official in charge of the JPEPA program at the Embassy of Japan in Manila February 13, 2009.

26) The subjects of surveys done by Ishii and Hirano [2009] were 81 nursing students from two universities in Manila and four universities in Davao. Hirano and Kawaguchi [2008] had focus-group discussions with 66 nurses in the same areas.

27) These surveys were conducted during the predeparture orientation hosted by POEA in Manila in May 2009 and the Japanese language training conducted by Human Resocia, a Japanese placement company, in Bandung, Indonesia, in August 2009. One hundred Filipino nurses and 144 Indonesian nurses were given the same questionnaires.

28) The author’s research team conducted questionnaire and interview surveys on 10 second-batch Filipino certified care-worker candidates (Vocational School Course) under training provided by the AOTS Kansai Training Center in Osaka City January 31, 2011.

29) In Indonesia, the health center is a technical unit of the district/municipal health office that implements integrated health programs. It functions as the center of health development, community-based health-effort mobilization and primary health care [Indonesia, Ministry of Health 2010: 110].

30) Polytechnic academies (institutions) are classified into four by length of years at school, namely, D1, D2, D3, and D4. The majority of polytechnic students are D3 [Kokusai Kosei Jigyodan 2008: 9].

31) Interview with Ilham Setyo Budi, Director of Nursing Services of Ministry of Health in Jakarta June 7, 2008.

32) Interview with Dr. Asjikin Iman Dahlan, then Chief of National Center for Empowerment of Health Professions and International Workforce, Ministry of Health in Jakarta June 6, 2008.

33) The social status of Indonesian nurses is similar to that of Vietnamese nurses, often called “y tá” in Vietnamese, which means “assistant to the doctor.”

34) Interview with Achir Yani Hamid, then president of Indonesian National Nurses’ Association in Jakarta June 10, 2008.

35) Interview with Ilham Setyo Budi, Director of Nursing Services, Ministry of Health in Jakarta June 7, 2008.

36) Interview with Achir Yani Hamid, former president of Indonesian National Nurses’ Association in Jakarta August 5, 2010.

37) Interview with Dr. Asjikin Iman Dahlan, then Chief of National Center for Empowerment of Health Professions and International Workforce, Ministry of Health in Jakarta June 6, 2008.

38) [ibid.]

39) For instance, Rachmat Gobel, president of the Indonesia-Japan Friendship Association and one of the Indonesian government members of the IJEPA negotitation, told the author, “This (IJEPA) is the best chance for Indonesia to develop human resources in nursing. Indonesian nurses and care workers should challenge for the national exam in Japan even though Japan’s standard is very high” (Interview with Rachmat Gobel in Jakarta June 3, 2008).

40) In respect to the number of Japanese-language learners, South Korea has the most (964,014 persons) and China is the second (827,171 persons), in the world as of 2009–10 [Japan Foundation 2011].

41) For instance, the results of a survey conducted for nursing students of Gajah Mada University late 2008 show that 59.5% of 251 respondents expressed their wishes to work in Japan [Hapsari 2009].

42) Interview with an official of Japan Embassy in Indonesia in Jakarta August 11, 2009.

43) Interview with Haposan Saragih, director of National Board for Placement and Protection of Indonesian Overseas Workers, in Jakarta August 4, 2010.

44) During the international conference titled “Transnational Care Workers from Southeast Asia to Japan: A Dialogue between Government Officials and Scholars” held in Fukuoka City in February 2010, Haposan Saragih, director of National Board for Placement and Protection of Indonesian Overseas Workers, stated: “This employment corporation has been bringing hope to thousands of Indonesian young job seekers, and even more when they see those who succeeded to work in Japan” [Ohno and Ogawa 2010: 111, 114].

45) The outcome of JICWELS’ survey on 92 Indonesian nurses conducted between November 2007 and January 2008 in Indonesia show that 39% of all respondents chose the statement, “being able to demonstrate their profession (as nurse)” as their happiest thing during their working time [Kokusai Kosei Jigyodan 2008: 36].

Globalization of Care and the Context of Reception of Southeast Asian Care Workers in Japan

Ogawa Reiko*

*小川玲子，Faculty of Law, Kyushu University, 6-10-1 Hakozaki, Higashi-ku, Fukuoka 812-8581, Japan

e-mail: reiogawa@law.kyushu-u.ac.jp

Abstract

The signing of the Economic Partnership Agreement (EPA) between Japan and the Philippines (2006) and Japan and Indonesia (2007)[1] introduced a new field of inquiry which was never experienced in Japan, migration and care. This paper examines the nexus of two issues to position the migration of long-term care workers from Southeast Asia to Japan under the EPA within the context of globalization of care work by examining the three areas: 1. The institutional framework; 2. Acceptance of foreign care workers at care facilities; and 3. Dilemmas resulting from this migration project.

The paper first explores the nature of the migration project under EPA and the socio-economic forces that shape the project. Second, it examines the opinions of the care facilities that employed the first batch of Indonesian care workers through quantitative and qualitative research. Finally, it discusses the dilemma that the state-sponsored migration project under EPA introduces. While the migrant care workers are well integrated and have contributed positively to the quality of care, the current scheme does not appear to mitigate the labor shortage and it may not be sustainable in the long run.

Keywords: globalization, migration, care, Southeast Asia, gender, Economic Partnership Agreement (EPA)

I Introduction

The migration of health and care workers including doctors, nurses, long-term care workers and domestic workers is inextricably linked to the globalization process that is increasing cross-border movements of capital, commodities, information and people. Numerous scholarships on migration and care have enriched the theoretical and empirical understanding of globalization, gender and care work in the past decades. Scholars have shed light on the central role women migrants from developing countries play in filling the gap between the state’s capacity to provide care and the actual need for care. While global capitalism mobilizes highly educated professionals toward urban centers, a large number of women migrants tend to concentrate in the lower circuit, characterized by “informalization,” where employers downgrade the working conditions away from public scrutiny, where labor costs are lower and difficult to regulate [Sassen 2002: 258].

Sassen succinctly points out the link between economic globalization and migration; however, her theoretical formulation does not take into account policies and institutional settings that allow the migration to take place at the national level. The author argues that the response toward globalization has been embedded within the national territory, structured by internal constraints, and shaped by local policies and institutions. Contrary to the popular belief that the state is declining under globalization, the globalization of care, as instituted in Japan, establishes that the state is creatively responding to the challenges posed by globalization and the rapid demographic change within Japan.

The two issues new to Japan, migration and care, have not yet been studied comprehensively.[2] Compared to the West where migrants filter into different sectors of the society, the integration of migrants in Japan remains limited both in terms of quantity and quality [Miyajima 2003; Komai 2003].[3] The migration of nurses and care workers[4] under the bilateral agreement enabled Japanese medical and long-term care institutions to employ foreign workers on a substantial scale[5] for the first time. Since this is almost the first experience to employ foreign workers, various hospitals expressed concerns regarding the migrants’ communication and nursing skills, adjustment to the workplace and the reactions of the patients and families [Kawaguchi et al. 2008]. Similarly, Japanese care workers, expressed anxieties about the differences in language and culture.[6] Despite these concerns, 47 hospitals and 53 care facilities agreed to accept the first batch of 208 Indonesian nurse and certified care-worker candidates[7] in 2008.

This paper aims to situate the migration of care workers from Southeast Asia to Japan within the context of the globalization of care work. It focuses on the institutional structures and policies that shape the requirements under the Economic Partnership Agreement (EPA) and discusses the dilemma that it produces. Unlike the migration of care workers elsewhere, the program under EPA is governed by a bilateral agreement, and underpinned by the intention to promote free trade. In other words, the promotion of the migration of care workers to Japan is neither an immigration policy nor a social policy, but a political decision to expand Japan’s market to Southeast Asia. However, the nature of care work, which provides personal services within an intimate relationship, raises several questions, which were not relevant in the case of earlier migrants, who were largely engaged in production work.

How are the foreign care workers accepted in those Japanese long-term care institutions that have little experience employing foreign workers? What are the intentions and expectations of the long-term care institutions in accepting foreign care workers? What are the reactions of Japanese staff, the elderly patients and the community? What are the prospects of incorporating foreign care workers into the care labor market in Japan in the long run?

With these questions in mind, this paper will examine first the nature of the migration project under the EPA and the socio-economic forces that shape it. It outlines the institutional structure that governs the migration of care workers and the global and local dynamics that shape the migratory framework. Second, it will review the responses of the care facilities, which employed the first batch of Indonesian care workers based on the quantitative and qualitative research. Finally, it will address the dilemma that the global migration of care workers under EPA entails. Its goal is to provide empirical data about the concrete sites of encounter and engagement in the field of caregiving that might shape future immigration policy in Japan.

II Migration of Care Workers under Economic Partnership Agreements

There is an extensive body of research that has examined migration and care work through a plethora of approaches: within different temporalities from historical to more contemporary forms of migration, and within different analytical frameworks ranging from macro-level social systems, meso-level social institutions and micro-level caregiving practices, or the combination of all three [Ehrenreich and Hochschild 2002; Sassen 2002; Parreñas 2003; Choy 2003; Aguilar 2005; Oishi 2005; Zimmerman et al. 2006; Constable 2007; Yeates 2009; Ito and Adachi 2008]. Many scholarly works have investigated the migration of women from developing countries to the developed countries to undertake feminized work as domestic helpers, nannies and sex workers. These works raise important issues such as the “international division of reproductive labor” [Parreñas 2000], or “global care chain” [Hochschild 2000], which conceptualizes the unequal distribution of care resources and global stratification according to gender and ethnicity.

Among these works, in order to locate the forces that perpetuate globalization of care theoretically, Zimmerman et al. [2006] identify four crises of care: 1) care deficit; 2) commodification of care; 3) role of supranational organizations in shaping care work; and 4) reinforcing race and class stratification. These four issues, identified by Zimmerman, partially explain the migration of care workers to Japan under the EPA.

According to Zimmerman, first there is a care deficit for both paid and unpaid care. The demographics of Japan, including the world’s longest life expectancy and the unprecedented increase of the aging population, aggravated by the low fertility rate, have precipitated a situation where care is becoming chronically short. Elderly caring for the elderly (ro-ro kaigo) is increasingly becoming a common practice. Today, it is not uncommon to see a 65-year-old daughter taking care of a 90-year-old mother. In 2010, the percentage of the elderly over 65 years constituted 23.1% of the total population with those more than 75 sharing 11.2%. This proportion will continue to increase. By 2013, 25.2% of the population will be more than 65 years old and by 2035, it will rise to 33.7% [Japan, Naikaku-fu 2011]. From October 2006 to September 2007, approximately 144,800 workers had left or changed jobs because they needed to provide care for family members [Asahi Shimbun, October 31, 2009]. This drastic transformation in the composition of the population makes a deep impact on the supply of and demand for care work.

Second, care has become a commodity and has shifted from unpaid work to a service that can be purchased in the market. Responding to the demographic changes and decreasing capacity of families to provide care themselves, an effort to shift care from the domestic sphere to the public sphere was supported through the introduction of Long-term Care Insurance (LTCI) in 2000. The LTCI was intended to socialize two facets: providing the means to employ professional care and furnishing a paid workforce. As a consequence, care became partially relegated to the market. Reflecting the growing numbers of the aging, the expenditure for LTCI continued to increase from 3.24 trillion yen in 2000 to 6.16 trillion yen in 2007 [Asahi Shimbun, June 24, 2009].[8] In 2006, the number of people over 65 years old was 26 million among which 3.6 million or 13.8% used the LTCI [Soeda 2008: 23]. However, the retrenchment in social welfare expenditures and the economic downturn downgraded the value of care work in social and monetary terms resulting in the ongoing shortage of care workers [Morikawa 2004].

Third, the growing influence of supranational organizations and their impact in shaping care work. Zimmerman argues that the loans provided by supranational economic organizations such as the International Monetary Fund and the World Bank require a decrease in public services, facilitate privatization and serve as a powerful force in determining care provisions especially in developing countries. Although the EPA between Japan and Southeast Asian countries is a bilateral agreement to promote free trade between the two states, it superseded the policies of the state in an unexpected way. The migration of care workers was introduced not as a labor policy but was attached to the free trade agreement.

For the fourth point, Zimmerman demonstrates the reinforcement of stratification of race and class at the global level. Many studies on gender and migration confirm the theory that the migration of women from developing countries results in new international division of labor, which is hierarchically organized according to race, gender and class.

While the four crises of care, described by Zimmerman above, are concomitant to the process of the globalization of care in Japan, this paper discusses several issues that were not well examined in the earlier research. First, building on the theories, the subjectivity of the migrant care workers is constituted within the nexus of immigration policy and social welfare policy thus differently constructed. The author argues that the ways in which the globalization of care is taking place reflects nation-specific patterns largely shaped by policies and institutions in the receiving countries that need further elaboration.

Second, aside from the migration of nurses, the skills of the migrants have not being carefully discussed. The author’s research team’s findings suggest that although nurses and care workers are lumped together under the same EPA scheme, the occupations are very different [Hirano et al. 2010]. While the term, nurse, represents the same occupation universally, long-term caregiving is a relatively new occupation developed in response to the aging population and the term, care worker, can imply different meanings in different countries. The distinctions between “skilled” and “unskilled” vary based on political decisions within each country and obscures the diversity within the various occupations engaged in care work.

Finally, following Sassen’s work [2001; 2002] which conceptualizes the global city that serves as magnets for migrant women working in low-paying jobs in less regulated informal spaces, many studies on domestic workers and nannies focus on private homes as the workplace and raises the issue of protection of human rights under less regulated working conditions [Constable 2007; Parreñas 2003; Anderson 2000]. In many countries, care work has been performed by migrant domestic workers who provide around-the-clock care. The author argues that the vulnerability of migrant women may come not only from their occupations as domestic helpers or care workers per se but the organization of their job location also contributes to their social status and affects working conditions. In the institutional settings where government regulations such as staff ratio and working conditions are enforced, the working environment has been regulated and formalized, decreasing the vulnerability of the migrant workers.

Although the care-worker migration to Japan is underpinned by the similar logic of “feminization of migration,” migration under EPA differs sharply from the other waves of immigrants in three distinct ways: 1) the involvement of the state institutions; 2) skills of the care workers; and 3) the sites of the work. To understand the process of incorporation of Japan as part of the globalization of care through the EPAs, this section examines how the migration of care workers and the state’s response to rapid demographic change is occurring in Japan. It illustrates the complex interplay between the crisis of care and its convergence with the global capital institution, which consequently defined the condition of migrant care workers as well as the sites of care.

1. EPA as a State-sponsored Migration Project

The intensification of globalization processes evoked various attempts to coordinate efforts for free trade at the regional level and organizations such as North American Free Trade Agreement (NAFTA), Mercosur (Common Southern Market), and ASEAN Free Trade Area (AFTA) started to emerge in the 1990s. Although market economy and trade liberalization lies at the heart of Japan’s post-war economic policy, Japan has been rather slow in responding to the regional cooperative initiatives. The Japanese government maintains its position to resolve trade issues mainly through multilateral trade negotiations of WTO until the progress of the Doha Development Round slowed due to the political situations in member countries and the confrontations between developed and developing countries.

In the meantime, the bilateral or multilateral agreements of the Economic Partnership Agreement (EPA) and Free Trade Agreement (FTA) emerged as a “complement” [Japan, Gaimu-sho 2002] or policy reaction to WTO in order to enhance trade, expand its market and pursue diplomatic goals. As of May 2011, WTO lists 489 regional trade agreements and it became apparent that multiple networks of EPA/FTAs have quickly proliferated throughout the world [WTO n/a]. The disadvantage of not establishing EPA/FTA became exposed when the export share from Japan to Mexico declined from 6.0% in 1993 to 3.7% in 2000 following the establishment of NAFTA [Watanabe 2007; Japan, Gaimu-sho 2002].

The shift in economic policy has been further accelerated by the internal condition of the change in demographic structure. The low fertility rate and dramatic increase in an aging population began to hinder the development of the economy. The working population started to decrease in 1996 and depopulation of the nation registered since 2005 [Japan, Kokuritsu Shakaihosho Jinko Mondai Kenkyujo 2002]. Major structural reform and deregulation took place in the late 1990s in an effort to increase productivity and efficiency in order to respond to the global economy but the growth remained limited. One remedy offered to revitalize the shrinking economy in the depopulating nation was to pursue further liberalization and increase the transnational flow of goods, services, capital and people to take advantage of the rapid economic development of the Asian region.

Japan’s first EPA negotiation was with Singapore in 1999, a country, which did not have any conflict of interest over agricultural products, and was established in 2002. It was expected that the EPA with Singapore would strengthen the relationship between Japan and ASEAN and would become the basis for East Asian economic co-operation [Tanaka 2000; Japan, Gaimu-sho 2002].

The EPA negotiations between Japan and the Philippines started in 2003, were drafted in 2006 and ratified in 2008. During the negotiations with Japan, the Philippines proposed that Japan accept domestic helpers, nannies, nurses, and care workers [Asato 2007: 33]. However, Japan’s immigration policy permits the entry of “skilled” workers but not “unskilled”[9] so only the nurses and certified care workers (kaigo fukushishi) qualified. Whether care workers should be regarded “skilled” remains contested but lobbying by certain stakeholders kept the care workers on the list.[10] Finally, considering the overall economic benefit of establishing the EPA, the entry of foreign care workers was accepted as a “compromise” or “political decision” in order not to jeopardize the agreement [Iguchi 2005; Asato 2007].

The article for migration of nurses and care workers is derived from WTO’s General Agreement on Trade in Services (GATS) Mode 4, which became a separate article of Movement of Natural Persons (MNP) under the EPA. In general, provisions on MNP include business travel, intra-corporate transferees and investors but considering the crisis of care in Japan, nurses and care workers were accepted for the first time as a new item in the Japan-Philippine EPA and included in the Japan-Indonesia EPA.

The Japan-Philippine EPA was signed in 2006, however, the ratification was delayed until October 2008,[11] so Indonesia recruited the first batch of migrant workers in May 2008. Unlike the Philippines, which had established a certified care-worker course in the 1990s, the first care-worker applicants from Indonesia were recruited from nursing-school graduates since Indonesia did not have a certified care-worker system.[12] Applicants with more than two years of clinical experience applied as nurses and those with less than two years of experience applied as care workers.

In August 2008, the first batch of Indonesian care workers arrived in Japan and after completing six months of language training, they were placed in hospitals and care facilities and started working as nurse and care-worker candidates. The cost of migration, including fees for recruitment, matching, airfare and the Japanese language training, which costs approximately 3.6 million yen per person, is shouldered by the Japanese government and the receiving hospitals/care facilities. The state agencies; namely Japan International Corporation of Welfare Services (JICWELS), National Board for the Placement and Protection of Indonesian Overseas Workers (BNP2TKI) and Philippine Overseas Employment Administration (POEA) are responsible for the recruitment, deployment and training of care workers, thus in principle, leaving no space for the private agencies to maneuver.[13] The conditions for employment are required to be the same as those of Japanese workers (i.e., nurse candidates are paid a salary equal to that of Japanese nurse assistants and the care-worker candidates are paid equivalent or more to the home helpers)[14] in accordance with the employment policy of the receiving institutions.[15] Also, they are entitled to the same benefits as Japanese staff and are protected under the standard labor law.[16] Unlike other migrants, the state strictly controls and supervises the process shouldering a heavy financial cost, which confirms that the purpose of introducing migrant care workers is not to recruit cheap labor.

Apparently, this experiment goes against the “informalization” processes in the labor market where the deregulated low-cost jobs are being relegated to immigrants and women in global cities [Sassen 2002]. Then how does the state calculate the cost of migration if the workers are neither flexible nor cheap?

The migration of care workers under EPA emerged as a result of negotiations not only between the governments of Japan and Southeast Asia but also among several ministries within Japan. It was formulated as a compromise of different interests among the local stakeholders including the Ministry of Foreign Affairs, the Ministry of Economy Trade and Industries, the Ministry of Finance, and the Ministry of Health, Labour and Welfare (MHLW). Their first priority, to maximize the economic opportunity for the benefit of the nation, is considered an important state mandate that gives legitimacy to pursuing the free trade agreement. Second in importance, although the immigration policy reform under the imploding population has become a political agenda,[17] the consensus-building process has stagnated due to the precarious political climate and lack of leadership. Third, the crisis of care both in terms of human and financial resources will continue for the foreseeable future. MHLW estimates there are 200,000 care workers who are qualified but are not in the labor market and Japan will need 400,000–600,000 care workers by 2014 [Japan, Kosei Rodo-sho 2009]. This exposes the reality that because of poor working conditions, the turnover ratio of the care workers is 22.6%, considerably higher than 17.5% for the average workers and the long-term care institutions are continually facing a shortage of care workers [Yomiuri Shimbun, March 6, 2007]. However, considering the domestic labor market, MHLW maintains the firm position that the entry of migrant care workers under EPA is an “exceptional case” [Japan, Kosei Rodo-sho 2011].

The primary aim of EPA is to gain an overall economic benefit through promoting free trade with Southeast Asia, which may also lay the groundwork for future regional integration in Asia. More importantly, Japan’s acceptance of care workers under EPA serves as an excuse that Japan is accepting the care workers in exchange for selling goods to Southeast Asian markets especially when there is a lack of consensus in the society toward acceptance of immigrants. Even though MHLW claims that EPA was not intended to ameliorate the shortage of labor, it is the major care-crisis in Japanese society that created an environment that allowed the migration of care workers to be accepted.

The migration of care workers under the EPA can be hypothesized as the creative response of the state toward the challenges of globalization that, on the one hand, are being caught by liberal logic to promote free trade and, on the other hand, are protecting the interest of its nations by imposing certain conditions which I will discuss in the next section. In short, the migration of care workers under EPA serves as a litmus test for the state and society that can lead to the formation of the future immigration policy as one of the options to cope with the crises of care and depopulation.

2. Skills of Foreign Care Workers

The entry of foreign care workers generated a public debate in Japan and the strongest opposition came from the professional groups. MHLW as well as the Japanese Nursing Association (JNA) were guarded about the entry of migrant care workers because of the potential effects on the domestic labor market, including deterioration of the working conditions and the undermining of the professionalism of Japanese nurses. During the negotiations, JNA made a counterproposal, which largely defined the framework of the migration of care workers under EPA [see Shun Ohno’s paper in this issue]. Based on its recommendations, EPA included a condition that the foreign care workers pass the national licensure exam within a limited period of time and if they fail, they cannot remain in Japan any longer.

This framework opens an opportunity for foreign care workers to be incorporated into the Japanese care labor market at the same level as the Japanese but the educational investment needed for them to pass the exam has proven costly for both the state and the accepting facilities. Also, the migrants need to study very hard while working, and until they pass the exam, they are treated as candidates.

3. Site of Care Work

Since the foreign care workers are mandated to pass the national exam within four years, their workplaces double as training institutions and must comply with certain standards. First, the care facilities must have more than 30 beds with a professional staff capable of providing training. Second, the staff ratio has to comply with government regulations. Third, more than 40% of the full-time care workers have to have the certified care worker or national kaigo fukushishi license. In summary, the migrant care workers are only allowed to work in highly regulated institutions, not in private homes. This is in stark difference from the placement of domestic helpers and care workers in other countries. The foreign care workers always work as part of the team with Japanese co-workers in care facilities and in principle, are allowed time to study Japanese and prepare for the national exam often with either a volunteer or professional teacher. Compared to the earlier migrants who arrived in much larger numbers,[18] public awareness of the EPA migrant care workers is extremely high.[19] The response is largely sympathetic making this migration project highly visible.

III Assessment of Indonesian Care Workers Assigned to Care Facilities

The Kyushu University Research Team[20] undertook a quantitative survey of 53 long-term care facilities that accepted the first batch of Indonesian candidates. They queried the facilities’ staff about the reasons for employing the candidates, assessment of the Indonesian care workers and their opinions of the EPA program. The survey was conducted in mid-January 2010, approximately one year after the candidates were assigned to care facilities. The questionnaire was distributed to care facilities and 19 were returned, a response rate of 35%. The low response rate makes it necessary to evaluate the responses carefully by comparing and supplementing them with the survey data from other institutions such as MHLW and triangulate the survey data with interviews at care facilities. The respondents were primarily the executive managers or directors of the care facilities. Fig. 1 summarizes the reasons for accepting the foreign care workers.

Fig. 1 Motives for Accepting Indonesian Certified Care-Worker Candidates

Fig. 1 demonstrates that among the reasons for accepting the foreign care workers “To revitalize the workplace” and “To prepare for future ‘internationalization’ of the workplace” stand out. It also shows that “To resolve the shortage of care workforce” was least important of the options. This is due to the fact that the care facilities eligible to accept the candidates have to comply with certain guidelines and expected to provide continuous training to the candidates so that they will pass the exam. Also, in addition to the monthly salary equivalent to that of Japanese staff, the care facilities have to spend approximately 600,000 yen as the initial cost of the commission and training fees for the candidates. Considering the high cost and rigorous requirements, it can be said that only the resourceful care facilities are eligible to apply and not the ones who are in need of “cheap labor.”

Similar results are evident in the survey conducted by Japan’s Kosei Rodo-sho (MHLW) [2010b] with the same sample a week later.[21] Statistics from that survey identified the reason for acceptance “as an experiment for future employment of foreigners” (89.2%), “to contribute to international exchange and co-operation” (81.1%), “to revitalize the workplace” (78.4%), and “to resolve the shortage of labor” (48.6%).

In the author’s interviews with eight care facilities in Japan, many echoed this view. Anticipating that they may need to employ migrant care workers in the near future, they wanted to prepare while they still have enough resources. Since the government initiated this migratory scheme, many care facilities assumed quality of the care workers was guaranteed. Three facilities even pointed out their expectation that the candidates would become leaders in the workplace, managing the foreign staff when the necessity to employ more foreign workers became a reality. In sum, the data indicates that the care facilities that employed the first batch of Indonesians are resourceful and have a vision in employing foreign staff in the future and not in need to seek for cheap labor.

According to Fig. 2, despite concerns over language and cultural differences expressed prior to the acceptance of foreign workers, once the Indonesian candidates were placed in care facilities, 89.5% replied “Applicable” or “Somewhat applicable” that the “Workplace became revitalized.” Also, 78.9% replied “Applicable” or “Somewhat applicable” that Indonesian care workers “Motivated Japanese staff to understand different cultures.” Moreover, more than half replied the “Elderly became more lively.”

Fig. 2 Positive Changes in the Workplace after Accepting Indonesian Candidates

When interviewed, an elderly woman in her 80s who stays in the care facility in Western Japan said: “They (two Indonesians) are very kind and gentle. I think it must be hard for them to travel such a long way to work here, but they are working very hard. All of us count on them because they always come running whenever we call them.”[22]

Many other interviews with Japanese co-workers and supervisors in the care facilities confirm this view. Indonesians (and Filipinos) are popular in spite of their language deficiencies. The presence of foreign care workers triggered Japanese staff to rethink and reflect on the purpose of care work because they had to explain the reasons behind one’s behavior in simple words. All the care facilities interviewed reported that communication in the workplace has improved because having co-workers not fluent in Japanese among the staff forced them to convey messages clearly and confirm that everyone understands and shares the same information. Japanese staff are taking extra effort to support the candidates and as a consequence the capacity to work as a team has improved.

A Japanese care worker, responsible for training candidates, narrates: “There are no complaints against the candidates. They are well received and liked. They are welcomed especially by the elderly as they are pleased to have a cheerful person in their boring daily lives. They (candidates) look into their eyes when they talk with the elderly and provide support in a natural manner. So the facility became lively. We can count on the care they provide.”[23]

Candidates are welcomed warmly by the supportive Japanese staff and are contributing to the quality of care in multiple ways. In some cases, Japanese care workers were reluctant to accept the foreigners because they feared that the foreign care workers would not be able to communicate well, which would increase their burden. However, in the places the author interviewed, once the candidates had arrived, the Japanese staff members, impressed by the candidates’ skill levels and warm personalities, became helpful in trying to teach them everything they needed to know. In turn, the candidates are working hard to learn both language and work skills. As a consequence, the foreign care workers have contributed to the revitalization and internationalization of the workplace as intended.

Before accepting the candidates, the care facilities articulated a different concern. Some worried about racial discrimination by Japanese toward other Asians. However, once the candidates started working, the relationship between Japanese elderly and the candidates proved smooth and comforting.

The director of a care facility said: “I was worried in the beginning because the elderly of this generation carry the memories of war, and (many) Japanese harbor racial prejudice (against Asians). But there was no objection among the elderly (to have Indonesian care workers). There is no difference in nationality insofar as they have a caring heart.”[24]

The memories of war may already have become a distant past for those living a peaceful life in care facilities. Their day-to-day concerns center around who will help them in time of need. For that reason, the candidates are popular despite any language deficiency.

While this qualitative data points to the trust developed between the care receiver and migrant care worker, the MHLW survey also supports this data. Among the elderly, 12.6% responded that the candidates are providing better service than Japanese staff, 59.2% judged their service satisfactory, and 31.1% rank it average. None of the elderly selected the “unsatisfactory” option in describing the candidates’ service [Japan, Kosei Rodo-sho 2010b].

However, Fig. 3 illustrates the negative effects of acceptance. Nearly 90% of the respondents in our research felt that the “Financial burden increased” or somewhat increased and 100% of the respondents replied that the “Workload of supervisor/educator increased.” The EPA stipulates that the care facilities must educate the candidates so that they can pass the national exam in Japanese. Apparently, an increasing load on financial and human resources to support the migrant care workers has been a burden for the care facilities.

Fig. 3 Negative Changes in the Workplace after Accepting Indonesian Candidates

In the interviews, all the facilities targeted the problem of not knowing the most efficient way to support the candidates. Care facilities are not educational institutions, so teaching the Japanese language to foreign staff is not part of their expertise. A number of educational materials have been developed to teach Japanese to the care workers but Japanese care workers are not language teachers and the Japanese language teachers are not familiar with the caregiving vocabulary so neither group has the pedagogical skills to teach candidates well enough to pass the national exam. In addition, many care facilities are located in remote areas, which makes it difficult to access resources such as Japanese language or caregiving schools that are concentrated in large cities. Therefore, when questioned about what kind of study support they are providing for the candidates, all the care facilities repeatedly reported “We are trying to do our best through trial and error,” implying a lack of systematic support from the government.

Fig. 3 indicates that 68.4% replied that religion was also a concern since it is almost the first time that Japanese care facilities employed any Muslim staff members. With little knowledge of Islam, the care facilities prepared a praying room available to Indonesians during the day, respected religious practices such as halal food and fasting, and some facilities allowed the women’s veil in workplace. The religious differences did not become a major issue due to the flexibility on both sides [Alam and Wulansari 2010].

As indicated in the interview above, Fig. 3 also attests that despite the weakness of the candidates’ Japanese language skills, none of the care facilities “Need to resolve the problems with (the candidates and) the elderly.” In our interviews, minor tensions with Japanese staff surfaced but no major trouble has been identified between the candidates and the elderly.

Fig. 4 shows the candidates’ language proficiency at workplace. After six months of language training and one year of work experience, more than 70% of the facilities replied that the candidates communicate fairly well with the co-workers and the elderly.

Fig. 4 Level of Japanese Language at Workplace

Japan’s Kosei Rodo-sho [2010b] survey on the first batch of Indonesian candidates for certified care worker indicates a higher result: 35.1% of the directors of the care facilities, 23.7% of the supervisors, 19.2% of the co-workers, and 62.1% of the elderly replied, “There is no problem in the communication”; 59.5% of the directors, 73.7% of the supervisors, 72.5% of the co-workers, and 34.0% of the elderly responded, “Sometimes they don’t understand but if we speak slowly it can be understood.” Therefore, 90–95% of the Japanese working with the candidates reported that Indonesians have acquired a level of communication which can be understood.

However, the level of communication required for professional work is extremely high and the language achievements of the Indonesian care workers do not seem to be satisfactory. The same report suggests that a lack of language skills has resulted in problems at the workplace. As such 32.4% of the directors, 50% of the supervisors, and 24.6% of the co-workers responded that they experienced problems because of communication difficulties. Specific obstacles include: “Although they do not understand, they say ‘yes,’” “They did not understand the order and could not keep the time,” “They did not understand what the elderly was saying,” “They could not understand the information at the staff meeting,” “They forgot to give medicine,” and “Minor accident.” The space for care has to ensure a safe environment and to guarantee that care workers must be equipped with the professional skills including language essential for clear and smooth communication.

Fig. 5 illustrates care facilities’ assessment of works performed by Indonesian care workers in the author’s team survey. If we combine “Applicable” and “Somewhat applicable” as responses, “Have respect toward the elderly” rates 100% and “Good at building relationship with the elderly” ranks close to 100%.

Fig. 5 Assessment of the Indonesian Candidates

In the interview, a care facility pointed out that although the candidates lack the language skills, they have brought the most important thing for care with them, which is the heart. In all eight care facilities, the candidates are described as “gentle,” “polite,” “warm” and popular among the elderly. Care work involves two dimensions: caring for (physical care) and caring about (psychological care), involving the development of relationships between the caregiver and care receiver [Himmelweit 2007; Glenn 2000]. The favorable response toward the migrant care workers attests that the host society benefits not just from their physical labor but also from their “emotional labor” [Hochschild 1983].

In Japan’s Kosei Rodo-sho [2010b] survey, only 0.9% of the elderly and none of the family members responded that “The tension of the facility increased because the Japanese staff in charge of education became burdened (to teach the Indonesian candidate).” Rather, 45.4% of the elderly and 56.2% of the family members said that “compared to before, the atmosphere of the facility became cheerful because the candidates are lively and cheerful.”

The author’s team survey that researched the overall assessment of the Indonesian candidates asked the question: “Are you satisfied with the Indonesian care workers you accepted?” As such 33.3% replied “Satisfied” and 44.4% replied “Somewhat satisfied.” In total, nearly 80% of the care facilities are satisfied with the candidates. The care facilities which praised the Indonesian candidates are likely to accept Indonesian nurses and care workers whether or not they have a shortage in Japanese workers [Ogawa et al. 2010].

Fig. 6 reflects the opinions of the care facilities toward the ongoing acceptance of foreign care workers under EPA. Nearly 90% responded that the “Foreign care workers should be counted in the staff ratio.” If the foreign care workers cannot be counted in the staff ratio, the financial burden of the care facilities will increase because their salaries could not be covered by the LTCI. At the same time, it also hinders the candidates to become full-fledged care workers until they pass the exam. Several care facilities complained that the candidates are not allowed to work night shifts because they are not counted in the staff ratio regulated by the government. Considering the possibility of accidents occurring because of the language deficiency, it may be wise not to assign candidates during night shifts where the responsibility to oversee the numbers of elderly increases. Also, it gives the candidates more regular working hours so that they can concentrate on their studies. But on the other hand, some pointed out that if they want to become a full-fledged care worker, it is important to work the night shift. If the caregiver only interfaces with the person during the day, he or she cannot comprehend the holistic situation of the care receiver, thus affecting the overall quality of care. Others expressed the more practical reason that a care worker earns more by working the night shift because of the additional payment.

Fig. 6 Recommendations Expressed by Care Facilities Employing Indonesian Candidates to EPA

Regarding the lack of necessity in acquiring the national certificate within four years and extending permission for candidates to continue working without the certificate, 84.2% of respondents replied “Applicable” and “Somewhat applicable.” Unlike “nurse,” which is established as a medical profession, in the area of long-term care, staff from different backgrounds are engaged in the same work whether they have a certificate or not. Often, a fresh university graduate with a certificate can be less effective than a high school graduate without a certificate but with extensive working experience. The research result indicates that within this area of care, certification is important in the long run but not as an immediate prerequisite.

Anticipating the future shortage of labor and recognizing the good quality of foreign care workers, 79% of the respondents are supporting the opening up of the care labor market and granting permanent resident status once the candidates acquire the certificate. Interestingly, only 21.1% are in favor of opening the recruitment to private agencies. This indicates their trust in the state to ensure that the competence of the candidates is guaranteed.

After two years, the Indonesian care workers seemed to be well integrated into the care facilities and the community.[25] The site of caregiving became a new ground for “global interconnections” [Tsing 2000], mediated by institutions, which have been supportive and accommodating. Seen from the perspective of migrants, the institutional framework of the EPA has drastically decreased the cost and risk for migration and created a space which is supportive and sensitive to cultural differences.

We are at the historical juncture which will determine whether some of the Indonesian care workers will pass the national exam and become full-fledged care workers equivalent to the Japanese care workers and become incorporated within the Japanese care labor market[26] or whether they will rotate every four years much like the circular migration system albeit a very costly one.

IV The EPA Project and Its Dilemmas

The nature of the migration of care workers under the EPA requires the combination of work and study because the candidates are expected to pass the national examination within four years. This resonates with the similar discourse for “trainees” in not officially admitting them as “workers” under the designation of “technological transfer” but serves as a source of de facto cheap labor. However, this research reveals that the efforts to provide support to the foreign care workers and their smooth acceptance has differed from the previous forms of migration. Many care facilities, if not all, are struggling to provide appropriate support to the foreign care workers and the Indonesian candidates are bringing a positive impact to care work. However, this state-sponsored migration of care workers is contested at least in three different aspects.

First, there is a tension between the state and the market. Sassen [1996] argues that the globalization brings the denationalization of economy and renationalization of politics. While the nation-state is increasingly losing its grip over global finance and capitalism, it strives to maintain strict border control through its immigration policy. Driven from the global financial institutions of WTO-GATS Mode 4, Japan’s EPA manifests the dilemma of the liberal state to promote free trade of goods but at the same time protect its labor market and maintain the social welfare system, which is still largely confined within the national territory. Moreover, EPA reflects the tension within the state apparatus, such as that among MHLW, Ministry of Foreign Affairs and Ministry of Economy, Trade and Industry reflecting the interest of different stakeholders including professional organizations of health workers and business associations. The care facilities and the candidates are caught in-between the contradictory movement of the demand of the market in pursuing economic globalization and the divided state response in maintaining the EPA.

Compared to the migration of care workers to Taiwan, which is market-dominated [Wang 2010], migration under the EPA is state-dominated. Neither looks sustainable in the long run. The former raises concern about the protection of the human rights of the migrants; and the latter, although regulated, is too costly for the state to shoulder all the costs of migration. Under the EPA, the initial cost of employing one foreign care worker is equivalent or even more expensive than the annual salary of a certified Japanese care worker. Considering the cost and pressure for privatization, the EPA may be too burdensome to be sustained by the unreasonable combination of the state, which is in huge debt, and care facilities already overstretched by limited financial and human resources. As anticipated, the initial enthusiasm for the employment of foreign care workers has gradually turned into disappointment not because of the quality of the candidates but because of the system that is not economically viable.

Knowing the limitation of the state-sponsored migration, the private agencies, which used to recruit Filipino entertainers or Indonesian trainees, are already at work managing entry from a side door or back door by using other mechanisms such as Nikkei or student visas. While the global interconnections developed in Japanese care facilities are accommodating, it is too naïve to think that this will not converge with the more exploitative type of global interconnections of brokers. The abundant supply of prospective migrants-to-be from Southeast Asia and the vulnerable position of care workers in the host country [Lim and Oishi 1996] reflect the murky future of the migration project of care workers both for the migrants and the elderly. The question is where to draw an appropriate line to divide the cost, risk and responsibility between the state and the market in order to make this migration project sustainable.

Second, there is a question on how we define the work of long-term care. Compared with the profession of nurse, where the occupation is defined universally thus allowing mutual accreditation in certain countries, the skills required in long-term caregiving is far more ambiguous. In the West, care work in private households has been an important sector of work for newly arrived immigrants [Yeates 2009; Rivas 2002]. In Hong Kong and Taiwan, the live-in foreign domestic helpers provide care to the elderly without any professional training [Constable 2007; Tsai 2008]. Japan introduced the certified care-worker (kaigo fukushishi) system in late 1980s, although the exact meaning of skill has not been clearly defined.[27]

The author’s team research findings suggest that if Japan continues to enforce the condition for the foreign workers to pass the national exam of kaigo fukushishi, and if the chances of passing remains to be low, the care facilities may eventually stop accepting them because of the large financial and human cost incurred. If that is the case, the facilities that do not provide educational support to the candidates may benefit most by retaining them for four years at the least possible expense.[28] In addition, if only a few candidates are able to pass the exam this migration project will neither relieve the labor shortage nor enhance the diplomatic relationship between Japan and Southeast Asian countries.

However, if Japan designates care work as “unskilled” it has to change its immigration policy that does not accept unskilled laborers.[29] Moreover, the difficulty arises in the ways in which the foreign care workers are incorporated into the Japanese care system. If care work is defined as “unskilled” without any credentials, it may attract a large number of migrants, but they may eventually become “cheap labor” in the dual labor market. This could also strengthen global stratification based on gender and ethnicity situating the women from the less-developed countries at the bottom of the hierarchy.

Third, there is a dilemma in the gendered division of labor. According to the author’s team research regarding the care worker candidates who arrived in 2009, 77% of the Indonesians and 88.8% of the Filipinos are women [Adachi et al. 2010]. When the reproductive work become relegated to women from economically poor countries, the relationship between the global north and global south resembles the traditional sexual division of labor, the north not being able to do anything by its own and the south undertaking the reproductive work [Ehrenreich and Hochschild 2002: 11]. The socialization of care has shifted the unpaid work of Japanese women to paid work purchased in the market, but we need to consider for whom the market has been open and why. As suggested by the migration systems theory, migration streams do not happen randomly but are connected to prior links developed through colonialism or preexisting cultural and economic ties [Castles and Miller 2009; Sassen 1996; 2007]. Southeast Asia has always been under the economic and political interest for postwar Japan investing a large amount of Official Development Assistance (ODA) in exchange for natural resources, markets and in later stages, cheap labor.

Although the government-sponsored migration of care workers under the EPA may have a different outlook when we situate the program within a historical context, it intersects with the previous importation of Southeast Asian women whether in the forms of wives or entertainers, which was tacitly condoned. The new international division of reproductive labor does not necessarily challenge the existing gendered division of labor but rather reinforces it by stereotyping the Southeast Asian women as “natural caregivers,” “warm-hearted care providers,” and “submissive workers,” echoing the discource of “nimble fingers” imposed on Asian women in the Export Processing Zones.

Currently, the Filipina ex-entertainers, who are in their 30s and 40s, are taking the training operated by private organizations to qualify as care workers by obtaining the home-helper license in different parts of Japan.[30] The shift in occupation from an entertainer to a care worker requires a different construct of the self as the worker has to sell herself to a presumably different market. The Filipina care-workers-to-be are taught to appear simple without dyed-hair, colorful manicures, transparent clothes, mesh stockings, shiny makeup or perfumes and should walk quietly.[31] Although the external appearance of a care worker may look the complete opposite of the entertainer who is expected to be sexy and seductive, it is underpinned by the same logic of control of a docile body and the importation of love. In both cases, the women’s body has been controlled to fit into the role of the “love provider” to fulfill the desire of the “love receiver,” who needs love and care. “Love,” which has an exchange value in both occupations, is constantly negotiated through physical contact that makes the worker vulnerable to sexual harassment in the case of entertainers and justifies the poor working conditions in the case of care workers.

Among the first batch of Filipino care workers under the EPA, some had a nursing background, some had worked in Japan as entertainers and now reentered the country as certified care-worker candidates. The host society imposes different categories on migrants but the boundary between the “nurse,” “care worker,” and “entertainer” are not as sharply defined as has been presumed. As Sassen [2002; 2007] suggests, the individuals may decide to migrate as a personal decision but the option to migrate is itself “socially produced,” and the women are increasingly mobilized into the global “survival circuit.” The transnational flow of care workers under EPA is racialised and gendered and has a certain commonality with the earlier forms of female migration from Southeast Asia. The dilemma remains for the women in the North to decide whether the globalization of care is merely reproducing the unequal gender order across the globe [Ehrenreich and Hochschild 2002: 17].

V Conclusion

The migration of care workers from Southeast Asia to Japan represents different dynamics at macro and micro levels. At the macro level of the state, the migration project did not come out as demand-driven in order to ameliorate the local care deficit but rather it came out as supply-driven through trade negotiations. It also stems from a convergence of different interests in which the state is responding creatively to a shrinking and aging population by promoting further economic growth through trade liberalization. As a consequence of negotiations and compromises, the state has exercised its power to condition migrants to pass the national exam.

Seen from the perspective of globalization studies, the migration of care workers under the EPA goes against the general trend of informalization of labor, which employs migrant women as cheap and flexible labor in a less-regulated private sphere to enable the global North to sustain the dual-income families [Sassen 2002]. Rather this migration has been underpinned by an institutional structure, which subsequently made the workforce “formal” and “inflexible.” Theoretically, the imposition of the national exam provides a way for the migrants to be incorporated into the Japanese care labor market but the conditions, which require that they pass within a specified time frame, is neither feasible nor economically viable. Evaluating the state-sponsored migration project, the cost is too high for the state to continue to shoulder expenses and care facilities are overburdened with preparations for the national exam.

At the micro level of the care facilities, this research demonstrates that institutional support and personal engagement is indispensable in accepting and integrating migrant care workers. The care facilities, which accepted the first batch of Indonesian care workers, were well prepared, sensitive and supportive to the foreign staff. Consequently, most of the Indonesian care workers have adapted well to their facilities, integrated into the local community, and are contributing to the quality care. Although the migration of care workers under EPA does not mitigate a care workforce deficit, the global interconnection developed at the grass-root level enriches the quality of care contributing to the revitalization of the workplace.

Considering the contestations embedded in the EPA one would question the sustainability of the project. What can we learn from the experiences of the transnational migration of nurses and care workers under EPA? How can we turn this experience into an alternative policy suggestion? Japan has yet to envision a post-EPA strategy but what is clear is that the cross-cultural experiences and engagements espoused at care facilities should be ensured so that the migrants can fully develop their capacities which in turn will be beneficial in providing quality care. Care is an act of reciprocity so the principle of fairness and respect to human rights should be the core in the formulation and implementation of future immigration and social welfare policy. Finally, it is necessary for the state to remain committed to ensure that the globalization of care work will create conditions which are acceptable and respectable for both the elderly and migrants alike.

Acknowledgements

This research has been supported by the Kyushu University’s fund for education and research program and projects (P&P), “A Global Sociological Study on Japan’s Opening of Its Labor Market in the Field of Care and Nursing” (2007–09) (Representative: Shun OHNO); Bilateral Programs with University of Indonesia (JSPS), “International Study on Care Services, Lives and Mental Health of Indonesian Care Workers in Japan” (2009–11) (Representative: Reiko OGAWA), and Grant-in-Aid for Scientific Research (C) “International Movement of Care Workers and Cross-Cultural Care-upon Entry of Care Workers from Southeast Asia” (2009–11) (Representative: Reiko OGAWA). Part of the data has been published in Japanese in R. Ogawa et al. 2010, “Rainichi Dai-ichijin no Indoneshia-jin Kangoshi, Kaigo Fukushishi Kohosha o Ukeireta Zenkoku no Byoin/Kaigo Shisetsu ni taisuru Tsuiseki Chosa (Dai-ippo): Ukeire no Genjo to Kadai o Chushin ni” [A Follow-up Survey on Hospitals and Long-term Care Facilities Accepting the First Batch of Indonesian Nurse/Certified Care-Worker Candidates (1): Analysis on the Current Status and Challenges] [2010: 85–98]. I am especially grateful for Shun Ohno, Kunio Tsubota, Caroline Hau, Mario Lopez and the anonymous reviewers who kindly provided a constructive comment on the earlier version of this paper.

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1) The Japan-Philippines EPA was signed in September 2006 and ratified in October 2008. The Japan-Indonesia EPA was signed in 2007 and approved by the Japanese Diet in May 2008.

2) In the recent six-volume publication titled Care: Its Ideas and Practices [Ueno et al. 2008], there is not a single chapter on globalization and care.

3) In 2009, the number of foreigners in Japan was 2.1 million or 1.71% of the total population, among which 56.9% do not have the permanent residency status [Japan, Homu-sho 2010].

4) In this paper, the author uses the generic term “care worker” for those engaged in long-term caregiving. The term “certified care worker” is an English translation of the Japanese “kaigo fukushishi,” which requires a national certificate. There is another category, ”home helper,” which can be obtained after training at public and private institutions.

5) The first batch of Indonesian care workers arrived in August 2008, followed by the Filipino care workers in May 2009. By 2010, a total of 455 nurses and 669 care workers from Indonesia and the Philippines have entered Japan.

6) Focus group discussion of young Japanese certified care workers conducted Oct. 14, 2008, at Kyushu University.

7) The migrant care workers under EPA are called “candidates” until they pass the national exam. However, the term “candidate” differs between nurses and care workers because the licensing is different. Although the migrant nurse candidates may have working experience as an Intensive Care or head nurse in their home countries, they will work as nurse assistants who cannot undertake any medical treatments. While the autonomy is strictly defined for nurses undertaking medical care, the role of care worker is less clearly defined and there is hardly any difference in the job description between a certified care worker and a non-certified care worker.

8) Exchange rate US$=82 Japanese yen as of April 2011.

9) However, Japan does accept de facto unskilled labors legally.

10) Interview with officials of the Ministry of Health, Labour and Welfare, Aug. 5 and 25, 2011, and to the Ministry of Foreign Affairs, July 3, 2011. In the working group to accept highly-skilled migrants under the Chief Cabinet Secretary, the care workers are classified as “unskilled” [Japan, Kodo Jinzai Ukeire Suishin Kaigi Jitsumu Sagyo Bukai 2009].

11) According to Article VII, Section 21 of the Philippine Constitution, all treaty and international agreement has to be approved by a two-thirds vote of the Senate. The controversy over the export of hazardous waste to the Philippines triggered strong opposition by the civil society both in the Philippines and Japan and delayed the ratification process. For the discussion in the Japanese Diet in July 2007, view the questions raised by Nobuto Hosaka at www.shugiin.go.jp/itdb_shitsumon.nsf/html/shitsumon/166453.htm, retrieved Aug. 19, 2011.

12) Responding to the EPA, the Indonesian government established a certified training course for care workers in 2009 but it was soon abolished because many graduates did not match with the Japanese care facilities. Interview with government officials of Indonesia in July 2010 and August 2011.

13) Various educational institutions in Indonesia and the Philippines started to provide language training to increase the chances of matching, but the government institutions hold the sole responsibility in matching.

14) Home helper is a certificate obtained after completing a training course of 130–230 hours accredited by the local government.

15) For the first batch of Indonesian careworker candidates, the average salary is 161,000 yen. The highest salary is 197,550 yen and the lowest is 120,000 yen [Satomi 2010].

16) However, there was a case of contract violation in 2011 where an Indonesian nurse candidate made a claim to the Labor Standards Inspection Office. The dispute was settled with an apology from the hospital and payment of 400,000 yen as compensation [Asahi Shimbun, July 28, 2011; Nishinippon Shimbun, July 28, 2011; Mainichi Shimbun, July 28, 2011].

17) For example, June 2008, the Liberal Democratic Party (LDP) led by former Secretary General Hidenao Nakagawa submitted a new immigration plan to accept 10 million immigrants during the next 50 years to then Prime Minister Yasuo Fukuda. See also the discussion paper of the working group to accept highly-skilled migrants under the Chief Cabinet Secretary [Japan, Kodo Jinzai Ukeire Suishin Kaigi Jitsumu Sagyo Bukai 2009].

18) The 1989 Immigration Control Law allows privileged residential status to overseas Nikkei (descendants of overseas Japanese migrants) and foreign trainees to fill the shortage of labor in manufacturing, garment, food processing and agriculture. In 2010, MHLW states that among the 562,818 foreign workers in Japan, 122,871 came from Brazil and Peru [Japan, Kosei Rodo-sho 2010a] but this excludes those who are under the spousal visa so the actual numbers are higher. The total number of trainees is also difficult to estimate. In 2009, the entry of “trainee” visa holders was 80,480 including government trainees [Japan, Ministry of Justice 2010]. In the same year, 50,064 trainees, including 954 reported cases of missing workers, were working nation-wide under the Japan International Training Cooperation Organization (JITCO), the major body coordinating the trainee system [Japan International Training Cooperation Organization 2011].

19) According to the Association for Overseas Technical Scholarship (AOTS), the institution which conducted the Japanese language training, more than 240 mass media and other institutions requested interviews in the first six months [Haruhara 2009].

20) The quantitative research was conducted under “A Global Sociological Study on Japan’s Opening of Its Labor Market in the Field of Care and Nursing” (Representative: Shun Ohno) and the collaborative team members include: Shun Ohno, Yuko Hirano, Yoshichika Kawaguchi, Kiyoshi Adachi, Takeo Ogawa and Reiko Ogawa. This has been funded by Kyushu University Interdisciplinary Programs in Education and Projects in Research Development.

21) The questionnaire was distributed to 53 care facilities from Jan. 28 to Feb. 17, 2010. Responses were obtained from 528 persons including directors, supervisors, co-workers, elderly, families of the elderly, and candidates from 39 care facilities.

22) Interviewed on April 17, 2009.

23) Interviewed on Sept. 17, 2010.

24) Interviewed on April 30, 2009.

25) Since some care facilities did not agree to be interviewed, the successful cases described here may have certain sample bias.

26) Regarding EPA migrant nurses, 3 candidates (2 Indonesian and 1 Filipino) passed the national exam for nursing in 2010 and 16 (15 Indonesian and 1 Filipino) passed and became licensed RNs in 2011.

27) The “shakai fukushishi (certified social worker) and kaigo fukushishi law” states that kaigo fukushishi is “a person who provides care based on special knowledge and skills to those who cannot live their daily lives due to physical or mental disability and provide care such as bathing and eating as well as supervise how to provide care to both the care receiver and the care provider.” For more discussions on care work as skilled work, see Soeda [2008].

28) It is up to the candidate whether he or she would like to stay until the end of the contract period. As of April 2011, 11 Indonesian and 18 Filipino care workers (excluding the schooling course candidates) have already left Japan.

29) For the discussion on Immigration Control Law of 1989, see Akashi [2010].

30) The level of home helper ranges from 1–2. Most of the Filipinas are completing level 2 by going through 130 hours training. Level 2 allows one to undertake physical care and domestic work. For further details on the resident Filipina care workers, see Takahata [2009].

31) From the training manual “To Work in a Japanese Care Facility” used at the home-helper training course.

A Comparative Study of Filipino and Indonesian Candidates for Registered Nurse and Certified Care Worker Coming to Japan under Economic Partnership Agreements: An Analysis of the Results of Questionnaire Surveys on the Socioeconomic Attribution of the Respondents and Their Motivation to Work in Japan

Hirano O. Yuko,* Ogawa Reiko** and Ohno Shun***

*平野裕子，Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan

Corresponding author’s e-mail: hirano@nagasaki-u.ac.jp

**小川玲子，Faculty of Law, Kyushu University, 6-10-1 Hakozaki, Higashi-ku, Fukuoka 812-8581, Japan

***大野　俊，Center for Southeast Asian Studies, Kyoto University

Abstract

The widely disputed issue over foreign nurse and certified care-worker candidates under the Economic Partnership Agreements in Japan seems endless. To establish more sustainable Economic Partnership Agreements, we should discuss the issue from a holistic perspective through cross-sectional and longitudinal approaches.

This article addresses the socioeconomic characteristics and motivations of nurse and certified care-worker candidates who enter Japan under the Indonesia-Japan Economic Partnership Agreement (IJEPA) and the Japan-Philippines Economic Partnership Agreement (JPEPA). The correlation between the socioeconomic characteristics of the respondents and their motivations to work in Japan were examined based on a cross-sectional analysis. In addition, the transition of nurse and certified care-worker candidates is discussed using a longitudinal approach, by comparing the data of previous groups obtained by our research team.

The results of this study indicate that the socioeconomic characteristics of the respondents differed by country, as well as by occupation. Filipino candidates are more likely to cite economic condition as the reason they chose to go to Japan than the Indonesian candidates. While Filipino nurse and certified care-worker candidates and Indonesian nurse candidates are still predominantly females, a “masculinization of migration” is being observed among Indonesian certified care-worker candidates.

Keywords: EPA (Economic Partnership Agreement), Philippines, Indonesia, Japan, nurse, certified care worker, migration

I Introduction

Since August 2008 when Japan began to accept foreign nurse and care-worker candidates under the Economic Partnership Agreement (EPA) program, many discussions among those with various social and political backgrounds, including the mass media, researchers, stakeholders and even those without any direct connection with foreign nurses and care workers have pertained to the regulations for introducing foreign nurses and care workers under the EPA program. Some of these arguments seem to miss the main point of this issue, which can lead to misunderstandings, which further confuse the problem.

Observing the discussions from a medical sociological perspective, one can say that the discussants are likely to represent their political status and benefits, but less likely to point out the issues from a holistic approach.

For example, members of Reform Mass Media which endorses “opening the country” are likely to point out that “offering the national board examination only in Japanese is too much of a burden to these foreign candidates. . . . We should therefore make the exam easier so that we can accept more foreign candidates” [Asahi Shimbun, November 29, 2009]. However, they do not refer to the fact that the foreign nurses and care workers who can only pass the “easy” examination are more likely to cause medical accidents. Downgrading the exam might also encourage a stereotype of foreign nurses and care workers as low-skilled laborers.

On the other hand, the Ministry of Health, Labour and Welfare adheres to the position that “In Japan, a potential nursing force of more than 900,000 exists. The government should utilize such a potential work force first. Accepting foreign nurse and care-worker candidates under the EPA program is therefore a special case. We open the domestic market to foreigners not due to the lack of a work force in Japan, but as a matter of trade” [Japan, Minister’s Secretariat, International Division, Ministry of Health, Labour and Welfare 2010]. The ministry does not address the fundamental issue of why the number of potential Japanese nurses who choose not to work in the nursing field is increasing nor does it offer any decisive policy to utilize the potential work force. It is therefore essential to discuss ways to improve the work environment for nurses in Japan, regardless of their nationality; otherwise, even foreign nurses who pass the board examination will choose not to work in Japan.

Other issues regarding the domestic market for care workers have not been thoroughly discussed either. The Ministry of Health, Labour and Welfare has also failed to enact any clear policies that would prevent the continual decrease in the number of Japanese care workers, nor have any concrete suggestions been made to improve the work environment for care workers in Japan.

Such narrow, one-sided perspectives may stifle any effective advocacy related to this issue. A holistic approach, generated by obtaining data from the sending countries and the host country, is required to analyze the needs and demands of migrants and the host country accurately and objectively.

The authors of this study have worked as a research team since 2007 attempting to develop a more sustainable EPA program. The authors employ a qualitative and quantitative analysis of the two major sending countries, Indonesia and the Philippines, and the receiving country (Japan) to establish a cross-sectional and longitudinal framework.

The objectives of this article are as follows:

1) To describe the socioeconomic characteristics and motivations of the nurse and certified care-worker candidates coming to Japan under IJEPA and JPEPA.

2) To determine the correlation between the socioeconomic characteristics of the respondents and their motivations to work in Japan.

3) To compare those figures with the data obtained by our research team from previous groups of candidates.

II Methodology

We developed a four-page questionnaire after carefully examining the previous studies by our research team [Hirano et al. 2010: 153–162; Adachi et al. 2010: 163–174]. It was translated into English and pretested by Filipinos living in Japan. With the cooperation of the Philippine Overseas Employment Administration (POEA), the questionnaire was distributed to all candidates who attended the predeparture orientation in May 2010. They answered and returned the questionnaires before the end of the orientation. The response rate was 100%.

For Indonesian candidates, the questionnaire was translated into Bahasa Indonesian and pretested by Indonesians who lived in Japan. In cooperation with The Association for Overseas Technical Scholarship (AOTS), the questionnaire was distributed to all candidates who attended the language-intensive course in August 2010. The response rate was 100%.

For this article, 118 Filipino candidates (46 nurse and 72 certified care-worker candidates) plus 114 Indonesian candidates (40 nurse and 74 certified care-worker candidates) were included in the analysis. The author of this study divided the data by occupation as well as by country of origin because nurses and certified care workers have different job descriptions.

Chi-square tests, Fisher’s exact tests and t-tests were performed to compare each group, using the SPSS 19.J software program. The Institutional Research Board of Nagasaki University approved this study.

III The Results

The distribution of females among the Filipino certified care-worker candidates was 98.6%, significantly higher than that of Indonesian certified care-worker candidates (p<0.001). The average age of Filipino nurse candidates was 31.8 years (SD4.7), significantly older than Indonesians’ at 26.7 (SD2.2), (p<0.001). The average age of Filipino certified care-worker candidates at 26.8 years (SD4.1) was also significantly older than that of Indonesian certified care-worker candidates at 23.7 (SD2.6), (p<0.001). Indonesian nurse candidates were more likely to be the oldest sibling than Filipino nurse candidates (p<0.01).

More of the Filipino nurse candidates (26.7%) and certified care-worker candidates (21.4%) were married than the Indonesian nurses candidates (7.7%) and certified care-worker candidates (5.6%), (p<0.05, p<0.01 respectively). Filipino nurse candidates were also more likely to have a child/children (52.2%) than Indonesian nurse candidates (27.5%), (p<0.05).

Of the Filipino nurse candidates, 34.8% had prior experience working abroad as a nurse before participating in the EPA program. This was a significantly higher percentage than for Indonesian nurse candidates (p<0.01). In addition, 12.5% of the Filipino certified care-worker candidates had experienced living in Japan previously. Again, it was significantly higher than the percentage of Indonesian certified care-worker candidates, who had previously lived in Japan (p<0.01) (Table 1).

Table 1 Socio-demographic Characteristics of the Respondents (Filipinos/Indonesians)

Table 2 shows the differences by country of origin in the distribution of reasons candidates chose to go to Japan. Filipino nurse and certified care-worker candidates were more likely to select “I was jobless at the time when I applied for this program” (p<0.01, p<0.01 respectively) than their Indonesian counterparts. This tendency also held true for “I can earn a higher salary in Japan than in other countries” (p<0.01, p<0.01 respectively) and “I was frustrated with my salary in the Philippines/Indonesia” (p<0.001, p<0.001 respectively).

Table 2 Reason to Go to Japan by Country (Filipinos/Indonesians)

Indonesian nurse candidates tended to select “I have some family/relative(s) who has (have) already lived in Japan” (p<0.05) and “I want to marry a Japanese partner” (p<0.001) than Filipino nurse candidates. Indonesian certified care-worker candidates were also more likely to choose “My family recommended me to go to Japan” (p<0.001) than Filipino certified care-worker candidates. The Filipino nurse candidates were more likely to answer, “I wish to support my family economically” (p<0.05) than Indonesian nurse candidates.

Table 3 notes the distribution of reasons a candidate wanted to go to Japan by gender. Among the Indonesian nurse candidates, females tended to answer “I want to utilize my experiences in Japan for my future work at the hospital/elder home in other countries” (p<0.05) than male nurse candidates. Among Indonesian certified care-worker candidates, males were more likely to answer “I was jobless at the time when I applied for this program,” (p<0.05) than females. The female Indonesian certified care-worker candidates were more likely to answer “I am not required to pay commission fees for overseas placement” (p<0.05) than males.

Table 3 Reason to Go to Japan by Gender (Filipinos/Indonesians)

Table 4 summarizes the distribution of reasons the participants wanted to go to Japan by marital status. Among the Filipino certified care-worker candidates, those who were unmarried were more likely to answer “I am interested in Japanese culture such as animation and comics” than the married candidates (p<0.05).

Table 4 Reason to Go to Japan by Marital Status (Filipinos/Indonesians)

Table 5 illustrates the distribution of reasons the candidates chose to go to Japan based on the present economic conditions. Among the Indonesian certified care-worker candidates, those who did not find it difficult to survive and those who found it difficult, but manageable, were more likely to answer “I wish to learn advanced Japanese technology” (p<0.05) than those who found it very difficult to survive.

Table 5 Reason to Go to Japan Based on Economic Condition (Filipinos/Indonesians)

Fig. 1 shows the frequencies of the primary reasons that motivated Filipino nurse candidates to go to Japan. Twenty-two candidates (47.8%) chose “I wish to develop my professional career,” followed by 17 (37.0%), who selected “I wish to support my family economically.”

Fig. 1 Primary Reason to Go to Japan (Filipino Nurse)

Fig. 2 displays the frequencies of the primary reasons Indonesian nurse candidates cited for going to Japan. Sixteen (40.0%) of the respondents selected “I wish to develop my professional career” followed by 10 (25.0%) who picked “I wish to support my family economically.”

Fig. 2 Primary Reason to Go to Japan (Indonesian Nurse)

Fig. 3 illustrates the frequencies of the primary reasons Filipino certified care-worker candidates named for going to Japan. Twenty-four (33.3%) of the respondents chose “I wish to support my family economically,” followed by 23 (31.9%) “I wish to develop my professional career.”

Fig. 3 Primary Reason to Go to Japan (Filipino Certified Care Worker)

Fig. 4 shows the frequencies of the primary reasons Indonesian certified care-worker candidates identified for their going to Japan. Twenty-eight (37.8%) of the respondents picked “I wish to develop my professional career,” followed by 20 (27.0%) “I wish to support my family economically.”

Fig. 4 Primary Reason to Go to Japan (Indonesian Certified Care Worker)

IV Discussions

(a) Characteristics by Country of Origin

Because there are a limited number of respondents in this study, it is necessary to interpret the statistics cautiously. Nevertheless, this study provides sufficient information for a better understanding of the EPA candidates.

Our study indicated that sociodemographic characteristics differ by country of origin. Regardless of their intended occupation, the Filipino candidates, especially the nurse candidates, were generally older and married with a child/children than their Indonesian counterparts (Table 1). This phenomenon was also observed in the previous studies [Hirano et al. 2010: 153–162; Adachi et al. 2010: 163–174].

The authors assume that one of the reasons for such differences between the Filipinos and Indonesians may be due to the respondents’ prior experiences of going abroad before they applied to this program. As Table 1 indicates, Filipino nurse candidates were more likely to have previous experience working abroad (p<0.01) than Indonesian nurse candidates. Most countries that accept foreign nurses require at least one year of clinical experience in the country of origin [Venzon 2003: 51–62], therefore, one can assume that the Filipino nurse candidates, including a large number of returnees, are likely to be older than Indonesians.

With regard to certified care-worker candidates, many repeat applicants to Japan were included (Table 1), and it was clear that Filipino certified care-worker candidates were more likely than Indonesians to have previously experienced living in Japan. According to the authors’ interviews of Filipino certified care-worker candidates, some candidates who had formerly been entertainers in Japan were included. One former entertainer in Japan, returned after the expiration of her entertainment visa, said that she was “too old” to work in Japan as an entertainer, so she decided to return as a care-worker candidate the next time. She needed to go back to Japan because she was married and had children to feed. She hoped her six-month experience working in Japan would enable her to manage average daily Japanese conversation fluently. She anticipated that her proficiency in Japanese would help her adjust to her new life in Japan as a care-worker candidate.[1] As represented by the above episode, many Filipinos have prior experience living and working abroad, and therefore, they are more likely to be older, married, and have a family.

Table 2 demonstrates another characteristic of the Filipino candidates. Although no statistically significant difference was found for the perceived economic condition of the families between Filipino candidates and Indonesian candidates, by comparing each category based on their reason for going to Japan, it became clear that reasons related to the economic condition were more likely to be cited by Filipino candidates than Indonesian candidates. Reasons such as being jobless at the time of their applications for the EPA program, having a need to support family economically, expecting a higher salary in Japan than in other countries, and being frustrated with their salary in the Philippines influenced Filipino candidates more than Indonesian candidates with regard to being recruited to Japan for work.

The interpretation of these results was consistent with the findings of previous studies. For example, Hirano [2009a: 44–47] noticed that Filipino migrants were more likely to be financially supporting families, in the name of “utang na loob” (reciprocity), a cultural value of the Filipinos [Hollunsteiner 1979: 38–43]. Based on this principle, one of the easiest ways to show love for their families is by sending money from abroad so to enable the family to enjoy a better life. Therefore, Filipinos are more likely to go to Japan to uphold this tradition.

(b) Transitions of Nurse and Certified Care-Worker Candidates

The results of this study indicate that there are several points currently in transition for nurse and certified care-worker candidates. The characteristics of the candidates differ by occupation as well as by country of origin. The authors of this article will focus on two main points currently under transition: gender distribution and the primary reason(s) for going to Japan.

Regarding the gender distribution, as Piper [2003: 21–48] recorded, a feminization of migration is commonly observed in transnational migration. In this study, the phenomenon is clearly observed among the Filipino candidates. The feminization of migration of Filipino candidates is even stronger now than was true for the previous groups of candidates. For example, the proportion of female Filipino nurse candidates has increased from 88.9% to 95.7%, and that of Filipino certified care-worker candidates has increased from 88.6% to 98.6%.

On the other hand, for Indonesian candidates, the gender distribution varies by occupation. For nurse candidates, the ratio of females has increased from 82.0% to 87.2%, while for certified care-worker candidates, the ratio of females has decreased from 77.0% to 68.9%. This may be because male Indonesian certified care-worker candidates are more likely to choose the option to go abroad than females when they are jobless, even if they are required to pay commission fees for overseas placement (Table 3). A statistically significant correlation between gender and “I am not required to pay commission fees from overseas placement” as a reason for going to Japan was not shown in the previous studies [Adachi et al. 2010: 163–174], so this must be a new phenomenon affecting Indonesian care-worker migration.

There may be several reasons for the irregular gender distribution by occupation among Indonesian candidates. One can assume that it may be caused by the different characteristics between nurses and care workers. Asakura [2005: 1120–1125] suggested that nursing is considered a female job in Japan. For this reason, many of the first Indonesians were not able to match the requirements of the Japanese hospitals and they were not able to become candidates for work in Japan [Yomiuri Shimbun, July 29, 2008].[2]

On the other hand, certified care-worker candidates are less likely to experience gender biases. A staff member at a Japanese long-term care facility said that he preferred male certified care-worker candidates, because males were stronger than females, so they could easily hold and lift the patients. Additionally, Indonesian males tended to be shorter than Japanese males in height, so physically they did not intimidate the patients. Possibly for these reasons, more Japanese institutions have begun to prefer male Indonesian care-worker candidates.[3] This is one of the reasons responsible for accelerating the increased migration of male Indonesian certified care-worker candidates, which has been proven statistically. The female distribution was 68.9% for Indonesian certified care-worker candidates, significantly lower than that of Filipino candidates (p<0.001) (Table 1). Further investigation is needed to determine why this masculinization of migration appears only among the Indonesian candidates.

Regarding the changes in the primary reasons for going to Japan, there were clear differences by country, as was also true in our previous studies [Hirano et al. 2010: 153–162; Adachi et al. 2010: 163–174]. When asked their primary reason for going to Japan, the answers of the second group of Indonesian candidates, especially nurse candidates, showed a monopolar distribution: 66.7% of the respondents answered “I wish to develop my professional career.” In contrast, the Filipino candidate constituted a bipolar distribution. For the Filipino nurses, “I wish to support my family economically” (42.7%), was closely followed by “I wish to develop my professional career” (36.5%) [Hirano et al. 2010: 153–162]. Adachi et al. [2010: 163–174] mentioned that the bipolar distribution was found also among the first group of Filipino certified care-worker candidates.

In this study, Indonesian nurse candidates’ answers showed a more bipolar distribution than the previous group (Fig. 2). One can assume that the differences in the economic backgrounds of the family resulted in the differences in their responses between Filipino and Indonesian nurse candidates. This does not contradict the premise that no statistical differences in the economic conditions of the families were established between the two groups.

More interestingly, the primary reason Filipino nurse candidates gave for emigrating to Japan differed from that of the last group of candidates. In the last group, “I wish to support my family economically” was the primary reason, but in this group, the major reason had changed to “I wish to develop my professional career” (Fig. 1). This may indicate a transition for Filipino nurse candidates in choosing Japan as a way to increase their career development. Asato [2010: 53–64] previously mentioned that EPA nursing candidates were not developing their careers; in fact they had often been degraded and deskilled by not being allowed to perform nursing interventions. Similar complaints were derived from the authors’ interviews. An Indonesian candidate complained “I am not coming here to clean windows! I was an ICU nurse in Indonesia and I come here to learn advanced Japanese technology!” [4]

That opinion was not reported during interviews with Filipino nurse candidates. Their main complaints concerned the salary and the high cost of living that makes it more difficult to send a sufficient remittance to their families in the Philippines.[5]

The authors of this study interpreted this phenomenon as follows: The act of nursing depends on the culture where it is being performed. This was clearly indicated in the authors’ interview [Hirano 2009a: 44–47]. If a nurse works in another culture, she/he may encounter different types of nursing care under the different cultural contexts. Therefore, the experience of working abroad as nurses would allow them to evaluate the nursing practices in their own countries more objectively. Indonesian nurse candidates, with less experience going abroad than Filipino nurse candidates, may have fewer opportunities to be exposed to new nursing skills developed in other countries, thus they may tend to adhere to their ethnocentrism. In other words, they believe that the standards of nursing care in Indonesia are universal, which is not true.

For example, if an ICU nurse believes that her/his work in Indonesian hospitals managing high-tech medical equipment, is typical, it might be difficult for such a candidate to work in the field of occupational therapy, which in psychiatric nursing, can include cleaning windows with patients. This interpretation of conflicting expectations is consistent with the findings of Alam and Wulansari [2010: 183–192]. From their interviews with Indonesian nurse candidates in Western Japan, they found that the initial friction encountered by Indonesian nurse candidates later developed into innovative attitudes toward nursing, namely physical intimacy, empathetic nursing, and punctuality as a work ethic. But such “creative friction” can be experienced only after they go abroad.

With their prior experiences working abroad as nurses, Filipino nurse candidates are more likely to anticipate “something to learn” from the Japanese in terms of their career development, because they understand nursing in Japan is different from that in the Philippines. Further studies on this issue are needed to follow the transition of why Filipino nurse candidates choose to go to Japan.

(c) New Findings on the Migration Patterns of Indonesian Candidates

The focus of this study was to obtain quantitative data so that the authors could present a cross-sectional, as well as a longitudinal, analysis. By utilizing a quantitative procedure, the authors can objectively clarify some myths about the migration pattern exhibited by the past studies. For instance, the belief that “the oldest siblings must go abroad to help the younger siblings go to school” is widely accepted in Filipino society. However, this was not quantitatively proven in Hirano’s previous study of the first group of Filipino candidates [Hirano et al. 2010: 153–162] nor in this study. On the contrary, respondents who were the oldest siblings were more likely to be found among the Indonesian nurse candidates. This fact should alert researchers, who obtain information through qualitative data analysis that they must test their hypothesis carefully against a quantitative analysis to prevent interpreting the facts incorrectly.

This study also applies to migration studies because it provides quantitative data about the Indonesian candidates. Because of the large gap in the number of nurses recruited from the Philippines and those from Indonesia,[6] the migration pattern of Indonesian nurses has not been investigated as extensively due to the lack of data. By analyzing the Indonesian data in comparison with the Filipino data, this study has uncovered some new findings about Indonesian migration patterns.

First, the chain migration pattern of Indonesian nurse candidates became clear. Hirano’s survey results did not address differences between the second group of Indonesian nurse candidates and the first group of Filipino nurse candidates who answered that “I have some family/relative(s) who has (have) already lived in Japan” [ibid.]. But a year later, the third group of Indonesian nurse candidates were more likely to answer that they came to Japan because they had some family/relative(s) who has (have) already lived in Japan than the second group of Filipino nurse candidates (p<0.05) (Table 2).

One can assume that the experience of having previous workers in Japan may lead to an increase in family members electing to work in Japan. This is particularly true of Indonesians, who started to send nurse candidates to Japan a year earlier than Filipinos. Such chain migration is expected to increase, particularly in Indonesians, since more Indonesian candidates answered that “I want to marry a Japanese partner” in the previous studies [ibid.; Adachi et al. 2010: 163–174] and this proved true also for this study. Marrying a Japanese partner is a key factor that allows them to become a permanent resident of Japan [Murphy-Shigematsu 2000: 198–216]. That may result in their bringing their families or siblings from Indonesia to Japan in the future.

Second, the family dynamics of Indonesian candidates must be discussed. In this study, Indonesian certified care-worker candidates were more likely to answer “My family recommended me to go to Japan” than Filipino certified care workers (p<0.001). This phenomenon can also be observed in Adachi’s findings (p<0.01) [Adachi et al. 2010: 163–174].

When interpreting this phenomenon, one can assume that family approval is especially important for Indonesian candidates. Hirano [2010: 48–50] reported that family’s opinion is very influential on the candidates and Indonesian candidates have even terminated their contacts halfway through to return home at the request of their families. The National Board for Placement and Protection of Indonesian Overseas Workers (BNP2TKI) of Indonesia, responsible for the placement of Indonesian candidates to become care workers in Japan, has also experienced a high degree of frustration because some candidates decide to withdraw from this program even after they have been officially matched to Japanese hospitals and/or care facilities. Therefore, the BNP2TKI is now considering whether the applicants should be required to submit a letter of agreement signed by their families. For the above reasons, Indonesian candidates appear to be obligated to have their family’s approval before going to Japan.

(d) Factors Required for the Development of Sustainable EPA Programs

According to the current EPA regulations, certified care-worker candidates may qualify with experience other than a nursing background [Japan, Minister’s Secretariat, International Division, Ministry of Health, Labour and Welfare 2010]. To become a Filipino certified care-worker candidate, she/he must be a college graduate (with any major). Those, who graduated with a non-nursing major, however, must complete a six-month caregiver course provided by the TESDA (Technical Education and Skills Development Authority). A similar 105-day intensive training course was offered for Indonesian certified care-worker candidates at designated training centers in Indonesia in 2009. Such scheme may attract more people with various backgrounds, including those who are interested in not only caring for the elderly, but also in learning about Japanese culture or Japanese technology. The economic condition of the family may also affect their attitudes about working in Japan. For example, unmarried Filipino certified care- worker candidates are more likely to come to Japan than married workers, in order to satisfy their interest in Japanese culture, such as animation and comics (Table 4). Some Indonesian certified care-worker candidates who are not economically burdened at home might come to Japan because they are interested in learning Japanese technology (Table 5) rather than because they can earn a better salary in Japan.

For this reason, one can postulate that certified care-worker candidates are not always suited for and enthusiastic about caring for the elderly. The authors of this study found that some Japanese staff at care facilities were embarrassed by the Indonesian certified care-worker candidates who had graduated from a Japanese language course in universities in Indonesia. A staff member said that the candidates had little motivation to care for people, since their primary purpose in coming to Japan was to improve their Japanese proficiency.[7] This attitude demonstrates the importance of maintaining benchmarks for the selection of certified care-worker candidates. Not only nursing, but also care work, is an emotional labor, which requires a commitment to deal with patients and provide them with humane care. Therefore, the careful selection of candidates, based not only on their Japanese proficiency, but also on their personality and attitude towards caring, is essential.

The review of the JPEPA will start by the end of 2011, and for the IJEPA by the end of 2012. Therefore, in order to establish improved and more sustainable EPA programs, the recommendations suggested by this study should be taken into consideration.

Acknowledgements

This work is a part of “A Global Sociological Study on Japan’s Opening of Its Labor Market Particularly in the Field of Care and Nursing” (Representative: Dr. Shun Ohno) funded by Kyushu University Program and Project on Education and Research as well as a part of “A Study on Support System for Foreign Nurses Introduced by Economic Partnership Agreement” (Representative: Dr. Yuko Ohara-Hirano) funded by KAKENHI (Grant-in-Aid for Scientific Research (B) 21390166).

References

Adachi, Kiyoshi; Ohno, Shun; Hirano, Yuko O.; Ogawa, Reiko; and Kreasita. 2010. Rainichi Indoneshia-jin, Firipin-jin Kaigo Fukushishi Kohosha no Jitsuzo [Real Images and Realities of Indonesian and Filipino Certified CareWorker Candidates under the EPA Program]. Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 163–174.

Alam, Bachtiar; and Wulansari, Sri Ayu. 2010. Creative Friction: Come Preliminary Consideration on the Socio-Cultural Issues Encountered by Indonesian Nurses in Japan. Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 183–192.

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―. 2009b. Gaikokujin Kangoshi–Kaigoshi no Donyu [Introduction of Foreign Nurse and Certified Care Workers] 6: “Kokusai Shohin” to shite no Firipin-jin Kaigai Dekasegi Rodosha: Hanayakana Sokokai to Sono Kage de [Filipino Overseas Workers as “International Commodity”: Another Story behind the Curtain of Farewell Party]. Bunkaren Joho 377: 56–59.

―. 2010. Gaikokujin Kangoshi–Kaigoshi no Donyu [Introduction of Foreign Nurse and Certified Care Workers] 17: Indoneshia-jin Kangoshi Senpatsu Kikokusha wa Ima [Interview with Indonesian Returnees]. Bunkaren Joho 390: 48–50.

Hirano, Yuko Ohara-; Ogawa, Reiko; and Ohno, Shun. 2010. Nikokukan Keizai Renkei Kyotei ni Motozuite Rainichi suru Indoneshia-jin oyobi Firipin-jin Kangoshi Kohosha ni taisuru Hikaku Chosa: Shakai Keizaiteki Zokusei to Rainichi Doki ni Kansuru Haifuhyo Chosa Kekka o Chushin ni [A Comparative Survey on Indonesian and Filipino Nurse Candidates Coming to Japan under the Economic Partnership Agreements: An Analysis of the Results of Questionnaire Surveys on Socio-economic Attribution of the Respondents and Their Motivations to Go to Japan]. Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 153–162.

Hollunsteiner, Mary R. 1979. Reciprocity as a Filipino Value. In Society, Culture and the Filipino: A Textbook of Readings in Anthropology and Society, edited by Mary R. Hollnsteriner, pp. 38–43. Quezon City, Metro Manila: Institute of Philippine Culture, Ateneo de Manila University.

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1) An interview with a former entertainer in Japan in May 2009.

2) This article reported that those who were not able to become candidates were all male. The first author of this study found that majority of them were male, but some females were also included.

3) An interview with a care-worker staff member working for an institution in the Kyushu Region in November 2008.

4) An interview with an Indonesian nurse candidate in the Kyushu Region in May 2009.

5) An interview with Filipino nurse candidates in the Kansai Region in February 2011.

6) According to the POEA statistics of 2010, more than 13,014 nurses departed to work abroad. For Indonesians, between 1989 and 2007, only 5,566 nurses left to work abroad before the IJEPA started [Panchaweda 2008: 46–51].

7) An interview with a care-facility worker in Shikoku in July 2011.

To Stay or Not to Stay: Diverse and Conflicting Interactions between Indonesian Nurses’ Socio-Cultural Backgrounds and Their Work Environment

Bachtiar Alam* and Sri Ayu Wulansari*

*Faculty of Humanities, University of Indonesia, UI Depok Campus 16424, Indonesia

Corresponding author (Alam)’s e-mail: bachtiar@centrin.net.id

Abstract

Seeking to provide an integrative account of Indonesian nurses’ encounters with a culturally and socially distinctive work environment in Japan, this article provides a number of case studies, especially important among which are the diverse and conflicting interactions between these nurses’ individual socio-cultural backgrounds as represented in their age, marital status, ethnicity, family values and relationship, work experience, self-motivation and expectation on the one hand, and the work culture as well as the institutional underpinnings of their work environment on the other. Probably the most enlightening finding of this study is that such encounters across differences can bring about “friction” — to use Anna Tsing’s felicitous term [2005] — which has turned out to be both enabling and constraining in terms of Indonesian nurses’ adjustment to unfamiliar cultural settings, and this in turn has proved to be sign cant in shaping their decision as to whether they should continue working in Japan or return to their home country.

Keywords: Indonesia, Japan, nursing, Economic Partnership Agreement (EPA), friction, socio-cultural factors, work culture

I Introduction

Something shocking began to happen during the three-year period when Indonesian nurses[1] came to work at Japanese hospitals and elderly homes under the Economic Partnership Agreement (EPA) between Indonesia and Japan.[2] In spite of the growing numbers of candidates [Hirano 2011], the changing attitudes of the Japanese hospitals, elderly homes or the patients themselves towards Indonesian nurses [Ogawa 2011], not to mention the great potential to continue the program under the EPA scheme [ibid.], there have occurred a number of unexpected phenomena. Most notable among them are a number of Indonesian nurses who still want to return to their home country even if they pass the national examination, or those who wish to go home before the completion of the program, the so-called “halfway returnees” (chuto kikokusha), which is unpredictably increasing during the three-year period. Statistics provided by the governmental institution of Japan shows that as of early April 2011, out of 686 Indonesian candidates who entered Japan by 2010, 41 persons (30 nurses and 11 care workers) cancelled or finished their employment contract and returned to Indonesia [Ohno 2011]. As foreign workers living in unfamiliar cultural settings, it is inevitable that Indonesian nurses experience varying degrees of “friction,” to use a felicitous term coined by Anna Tsing [2005], an anthropologist known for her study of marginalized people’s involvement in conflicting socio-cultural interactions. In her view, friction, defined as the imperfect connectivity between people from different cultures and socio-economic strata, can prove to be creative when it provides glue that gives meaning to cultural interactions. She points out, however, that in the absence of special effort, friction can also get in the way of the smooth adjustment process in unfamiliar cultural settings.

This study argues that the encounters across socio-cultural differences in a transnational terrain such as the one experienced by Indonesian nurses in Japan can bring about “friction.” Especially crucial in this regard is that friction arises from the diverse and conflicting interactions across these nurses’ individual socio-cultural backgrounds such as age, marital status, ethnicity, family values and relationship, work experience, self-motivation and expectation on the one hand, and the work culture as well as the institutional underpinnings of their work environment on the other. This study has found that friction produces unpredictable effects or consequences, which can be enabling or constraining. They can prove to be either enabling or constraining in terms of Indonesian nurses’ adjustment to unfamiliar cultural settings, and this in turn has proved to be extremely instrumental in shaping their decision as to whether they should continue working in Japan or return home.

It should also be noted here that friction is a concept developed by Tsing to open a possibility of an ethnography of global connections. The concept is designed to overcome the methodological dilemma looming over her innovative attempt to deploy ethnographic methods for a study of international encounters. “How does one do an ethnography of global connections? Because ethnography was originally designed for small communities, this question has puzzled social scientists for some time. My answer has been to focus on zones of awkward engagement, where words mean something different across a divide even as people agree to speak. These zones of cultural friction are transient; they arise out of encounters and interactions” [ibid.: xi]. And as such zones of cultural friction are presumably found in “narrowly conceived situations” [ibid.: 2], this study focuses on narratives told by Indonesian nurses to shed lights on the friction they have encountered in Japan.

Such being the main thrust of this study, it examines unpredictable effects of “friction” between Indonesian nurses’ individual socio-cultural factors and their work environment upon their decision to stay or not stay in Japan, by drawing upon their narratives, namely what Tsing [ibid.: xii, 267] chooses to call “their stories,” “other stories,” or stories “that should be told . . . [which] deserve . . . an ‘audible’ track.” By giving precedence to narratives, this study opts not to focus on the analysis of institutional arrangements and interconnections that may have contributed for the friction.

The aim of this study, therefore, is threefold. First, to demonstrate how friction in the form of heterogeneous and unequal encounters can lead to a rearrangement of actions, effects, or consequences. Second, to register, in a form of a detailed sociological account, the importance of cultural diversity which is not altogether banished from these interconnections. Cultural diversity is not only there, but on the very contrary, “it is,” to borrow Tsing’s [ibid.: ix] apposite assessment, “what makes them — and all their particularities — possible.” Third, by examining friction, this study seeks to highlight the central feature of all Indonesian nurses’ decision as to whether they should continue working in Japan, namely a degree to which the interactions between their personal goals, objectives and strategies — informed by their individual socio-cultural backgrounds — and the institutional underpinnings of their work environment have figured prominently in shaping their decision.

II Significance of the Study [3]

The past studies on overseas Indonesian workers tend to focus on unskilled or semi-skilled migrants working mostly in Asia and Middle East since the vast majority of them belong to such categories and over a half of them are women. These women are predominantly employed as domestic workers and caretakers [see Shun Ohno’s introductory paper in this issue]. There are also a large number of unauthorized or undocumented Indonesian workers particularly in Malaysia. Because of such characteristics of overseas Indonesian workers, many previous studies have focused primarily on their low social and economic status and vulnerability in receiving countries, and attempted to examine the structure of exploitations set up by placement agencies and others [e.g. Wong et al. 2003; Adi 2003; Tirtosudarmo 2004; Anggraeni 2006; Hugo 2007; Ogaya 2008; Asato 2009].

Most of these Indonesian workers emigrated abroad through the so-called P-P (private-private) arrangements in accordance with the demand and supply of human resources in international labor market. However, the sending of Indonesian nurses and care workers to Japan has been processed under the so-called G-G (government-government) agreement. Such arrangements are very seldom in the deployment of Indonesian overseas workers.[4] Furthermore, the number of Indonesian nurses sent abroad has been quite limited in the past due to certain factors [see Ohno’s paper in this issue], and the programs for overseas nurses employed in Saudi Arabia and others were processed through P-G (private-government) or P-P. Thus, it may fairly be presumed that experiences of Indonesian nurses and caregiving workers sent to Japan as “skilled workers” under the G-G arrangement involve challenging issues related to the development of technical skills and language proficiency as well as cultural adaptation at the workplace in the country of their destination, which have not been well examined in the past studies on Indonesian migrant workers.

Collections and analyses of frank voices and candid opinions on the above issues expressed by Japan-bound and other overseas Indonesian nurses have been also rarely made until the present. One of a few such works is the authors’ preliminary research conducted in the western part of Japan in September–October 2009, one year and a few months after the entry of first-batch Indonesian “candidates” for registered nurse and certified care worker into Japan. The study has identified several socio-cultural issues encountered by first-batch Indonesian candidates, and found that their initial friction later developed into their innovative attitudes toward nursing, namely intimacy, emphatic nursing and punctuality as a work ethic [Alam and Wulansari 2010].

The authors feel that a follow-up study is needed in order to explore the first-batch candidates’ subsequent experiences and shifting views as well as socio-cultural issues encountered by the following batches of Indonesian candidates who entered Japan. The authors believe such a work is important especially for the first-batch nurse candidates as they are required to take their third, and presumably the last, national nursing examination in February 2011, the results of which will inevitably affect their work and life in Japan.

III Methodology

The interviews upon which this article was based were conducted from February 28, 2011 to March 5, 2011, at four hospitals and one elderly home in the Western part of Japan.

The total number of Indonesian nurses interviewed was 15, 2 males and 13 females. At their departure time for Japan, and the time of interview, they were all preparing to become registered nurses or certified care workers. In other words, when the interviews were conducted, none of them had passed the National Nursing Board Examination (Kangoshi Kokka Shiken) yet.

Their ages range from 24 to 34. Their educational backgrounds vary from what in Indonesia is referred to as D3 (three-year vocational education) to S1 (four-year college education), with 2 to 10 years of working experience as a nurse in Indonesia. Most of them (i.e. 9 out of 15) were unmarried. With regard to their Japanese language proficiency, they had studied basic Japanese for six months after they arrived in Japan and they continued the language training in order to pass the exam.

Our interviews addressed how friction arises from diverse and conflicting encounters between individual socio-cultural factors such as age, marital status, ethnicity, family values and relationship, work experience, self-motivation and expectation, and the surrounding work culture and institutional underpinnings such as communication, job description and responsibilities, remuneration, working hours and workloads, and the preparation for the National Nursing Board Examination. The duration of the interviews ranged from one to two hours, conducted in hospitals and elderly homes during work hours.

From the interviews of 15 informants, this study purposively selected a number of key informants, who presumably represent diverse individual socio-cultural characteristics, and whose story and interview records can constitute the primary data for the analysis of the emerging friction as well as their decision to stay or return home. As such, the sampling method used in this study can be categorized as a purposive sampling, i.e. a “form of non-probability sampling in which decisions concerning the individuals to be included in the sample are taken by the researcher, based upon a variety of criteria which may include specialist knowledge of the research issue, or capacity and willingness to participate in the research” [Jupp 2006: 244–245].

The interview method was used in this study as a primary research tool to assess how individuals interpreted and understood their own lived experience. The main emphasis in the data analysis conducted after the completion of the interviews was to find out how Indonesian nurses shaped their decision in the face of the emerging friction.

IV The Surrounding Work Environment

The surrounding work environment of the Indonesian nurses interviewed for this study was as follows [cf. Alam and Wulansari 2010].

In terms of communication with patients, there was a sort of “communication gap” between Indonesian nurses and Japanese patients. Most of the Indonesian nurses interviewed for this study were working at a hospital or a care facility where the majority of patients or residents were elderly, and bedridden or senile, thereby in need of total care. Because of such physical or mental impairments, these patients had difficulties in verbal communication to the point where it was difficult for them even to tell which part of the bodies hurt and what they needed. In addition, elderly who live outside Tokyo normally spoke in dialect, and not in standard Japanese, therefore the communication between the two parties became even more difficult. Nevertheless, most of Indonesian nurses felt that their patients were very welcoming and appreciative.

Concerning communication with Japanese staff, most of Indonesian nurses were able to communicate with Japanese staff in elementary level Japanese. However, this did not necessarily mean that they communicate “openly and freely” about their work. This was particularly evident in their interaction with senior staff members such as the head nurse at some particular hospitals, the situation appeared to be further compounded by the cultural differences related to daily interaction patterns.

In relation to work culture, most of Indonesian nurses experienced culture shocks related to the differences of work ethic. In one such case, the rigidity of working hours in Japan, a strict division between working hours and leisure time, do not usually engage in small talk during working hours and keep things on the move, so much so that they cannot do anything else but work during working hours.

Regarding job description and responsibilities, Indonesian nurses’ status in a hospital is a “nurse candidate” or “trainee” with a limited job responsibility and authority, occupying the lowest ladder in the formal employment structure. Furthermore, this arrangement was unfavorable for them in many ways. First, since he/she was not granted the responsibility and authority as a nurse, they were not allowed to perform any medical intervention by using his/her nursing knowledge, skill and techniques. Second, most of the Indonesia nurses’ job description is limited to the fulfillment of basic human care for Japanese patients who are most elderly.

With regard to remuneration, Indonesian nurses in Japan earn a take-home pay ranging from around 120,000 yen to 180,000 yen per month, depending on the institution and the town where they are stationed. Given the fact that Indonesia’s annual income per capita is less than 2,500 dollar, it is undeniable that such a monthly take-home pay is highly attractive for Indonesian nurses. Be that as it may, there were a few nurses who were not content with their income due to the fact that they are working at a hospital in an urban area where the cost of living is substantially higher than that in the countryside. Of particular importance in this regard is that for married male nurses, the monthly take-home pay is not enough to maintain a family with a wife and children back home in Indonesia.

In the matter of working hours and workloads, the average working hours of Indonesian nurses are eight hours a day, from 8:00AM to 4:00PM. These working hours are the same with Indonesian hospitals. However, the workloads in Japanese hospitals were a little heavier than what Indonesian nurses were used to in Indonesia. The main reason for this, was that at Indonesian hospitals, daily care for the bedridden, elderly patients were normally done by their family members or personal helpers, and not by nurses, therefore when Indonesian nurses were required to perform such a duty at a Japanese hospital, they acknowledged that their workloads became heavier.

Last but not least, relating to National Nursing Board Examination, the EPA between Indonesia and Japan stipulates that Indonesian nurses are allowed to work in Japan for a maximum of three years as a nurse candidate. If they can pass the exam during this three-year period, they are allowed to remain in Japan and work as registered nurses. However, if they fail, they have to leave the country at the end of the three-year period. The Japanese hospitals are divided into two types in this regard; those who were able to provide support such as exam preparation tutoring and those who were not able to do so due to lack of time, budget and human resources [see Wako Asato’s paper in this issue].

V The Narratives of Five Nurses

Such being the work environment surrounding the Indonesian nurses, this section presents the narratives of five nurses and the subsequent emerging friction.

1. Nurse A (Age 22, Female, Single): “I’ve never been so independent in my entire life”

Ms. A is a 22 years old, radiant, and very friendly young nurse candidate who works at a hospital in Japan. After earned her bachelor degree three years ago, she came to Japan and surprisingly found herself very much enjoy her job and her life.

She is originally from Jakarta, the capital city of Indonesia. She is proud that her mother and father are loving parents; she has two young sisters. Her father works as an employee for a private company and her mother is a kindergarten teacher. As a middle class family, her family has a number of housemaids who help to take care of the household chores. She, therefore, has never really taken care of domestic tasks.

Being an eldest child, she feels that her mother has been very protective of her. She recalls that when she was working as a nurse in Jakarta, she seldom went out at night and spent more time at home with her family. In retrospect, she believes that that kind of life style gave her much time to focus on her work, but on the other hand, she became rather dependent on her family when it comes to daily chores. The situation, however, changed drastically when she came to work in Japan. At the beginning, she felt terribly tired and stressed out as she had to do by herself every housework, ranging from preparing meals to doing the dishes. But after a while, she got used to it and began to enjoy the wonderful feeling of being independent, a feeling she never had when she lived with her family. As she related in the interview, “I’m so happy to be here. Since I have to do everything myself, I’m getting more independent every day. It’s a very wonderful feeling, because at home in Indonesia it is my family and the housekeepers who did all the work for me.” [5]

She also admitted that as she enjoys living in Japan so much, she is even considering marrying a Japanese man and starting her own family in Japan. “Since I do enjoy my life here, I may want to marry a Japanese man someday. I think it will be wonderful to do so.”

In addition to her happy personal life, Ms. A feels very content with her job. As a nurse candidate, her job is no different from that of other candidates, which is to say, she is not allowed to take part in any medical intervention. However, she finds taking care of ageing patients is fun. “I love working here. My patients are just like my parents. I like to make them smile and happy. . . . Every day I have to do some physical exercise with the patients, and I really enjoy playing ball or doing any other activity with them.”

As regards her future plan in Japan, Ms. A’s intention is to work hard to pass the exam so that she can continue working in the country as a registered nurse.

2. Nurse B (Age 26, Female, Single): “I want to continue my study in Japan”

Ms. B came to Japan as a member of the third batch of Indonesian nurses sent to Japan. While she had worked as a nurse in Indonesia, she decided to become a certified care worker in Japan, and therefore at the time of the interview she had been working in a rehabilitation hospital for elderly as a care-worker trainee for a year and three months.

Unlike the other nurses, she did not have much experience in medical field before she came to Japan as she had just received her bachelor degree from a private nursing college in Bandung, West Java, about a year before her departure for Japan. After her graduation from the college, she did not take any special training in nursing, but instead worked a as part-timer at a beauty clinic for six months.

Describing the difficulties she faced at her workplace, Ms. B said that her status as a candidate for a certified care worker has made her job description limited to the fulfillment of basic human care for the elderly patients, and was not allowed to perform any medical intervention by using her nursing knowledge, skill and techniques. “The Japanese staff don’t easily trust trainees like us. Neither do the patients. But after a while, we were gradually trusted with various tasks, beginning with minor chores. They’ve never given you an important task right away.”

According to her, the Japanese staff tend to be extremely cautious about one’s capability, most notably, the foreign workers’. This attitude has made them intensely careful in delegating any work to trainees. Therefore, she thought it is good to follow their way of thinking or imitate the prevailing system at their work environment. As a result, she has been given increasing workloads these days.

However, increasing workloads with no clear job description have posed a new problem for her. In her view, the guidelines as to what she may and may not do have become increasingly blurred. Sometimes, she has to do things that, by the official rule, she is not supposed to be doing, or the other way round, occasionally she is told not to take part in what is actually part of her responsibilities. “At one time, I took an initiative to take a patient to the bathroom, because the other care workers were busy. I knew that helping the patients with bathing was part of my responsibilities, but at the time I had never done that myself. The Japanese staff immediately told me not to do so. They may be worried that as I am inexperienced, some accident, like the patient tripping on something and fell over, might happen. So I immediately said to them ‘sumimasen’ (I’m sorry) and backed off.”

She felt a similar dilemma whenever a patient asked her to do things that she was not sure if it is part of her responsibilities. She did not know exactly if it is allowed or not. The feeling of perplexity was getting even stronger when all the other nurses or care workers were unavailable at the moment. At a moment like that, she felt reluctant to bother other nurses, but at the same time she did not want to be perceived by the patients as someone who is not responsive to their request, especially because most of the patients on her floor were the elderly in need of constant care.

Despite such dilemmas she had been facing, she pointed out at the interview that she began to feel that somehow she had got used to the work culture of Japanese hospitals, thereby beginning to acquire a sense of accomplishment and pride at her work place. She said she would be delighted to continue working in Japan if she could get a certification as a care worker.

As regards the Japanese language proficiency, Ms. B emphasized the importance of acquiring some understanding of a local dialect spoken in the area where an Indonesian nurse is stationed. At her work place, almost all patients spoke in a dialect, which is different from the standard Japanese. Phrases such as “yoka-yoka” (yes, yes; in Japanese: hai-hai) or “nanshotto?” (what are you doing; in Japanese: nani shiteru no?) and many others are certainly very difficult to understand for Indonesian nurses who have but a limited mastery of Japanese. She was therefore hoping that Indonesian nurses will be given some lessons in a Japanese dialect before being stationed at a hospital or an elderly-care facility.

Regarding her future career, she said she would like to continue her study to a master’s program in Japan, majoring in gerontology. She had several reasons for continuing her study, most notably among which was the fact that she was still relatively young and also being the youngest child in her family she did not have to send money back home to help her parents. Another contributing factor is a fact that there are very few Indonesian nurses or care workers specializing in gerontology, therefore by obtaining a master degree in the field, she thinks she will have a good career prospect in the future.

3. Nurse C (Age 31, Male, Single): “I want to learn something here and give something back to my country”

While relatively young, Mr. C is a seasoned nurse. He started his education in nursing by entering a three-year non-degree program (known in Indonesia as a “diploma program”) in West Sumatra, and earned his diploma in 1999. Eight years later in 2007, he earned his bachelor degree at a nursing college located in the Riau Province, Sumatra. After the graduation, he actively took part in various nursing training courses, therefore had managed to obtain a number of nursing skill certificates before securing a permanent job at a hospital as a nurse.

He began his career at a government-owned general hospital in Bandung, West Java, where he also obtained additional training in nursing skills. After having worked there for a couple of years, he moved to another major government-owned hospital, but this time in Jakarta, and took a special cardiovascular training while working there. Finally, he went back to his home province, South Sumatra, to work at a private hospital owned by an Islamic Foundation.

“It was very disappointing,” said Mr. C when he was asked about his working conditions in Japan right after his arrival. “I was a head nurse in Indonesia, but when I came here, it was like I had to start all over again as a trainee.” What is demanded from him and many other Indonesian nurses who came to work in Japan, according to him, was to forget about what they have achieved professionally at home in order to adapt to the new and unfamiliar work environment. “In a Japanese hospital,” he noted, “I’m nobody, and therefore my opinions are rarely heard, or even worse, my capability is doubted.”

Therefore he felt he was “constantly underestimated, not allowed to do anything to the patients despite many years of experience and numerous certificates.”

Such being his feelings at the early stage of his employment, he nevertheless experienced a turning point after a while. “My disillusionment with the working conditions in Japan was quite real, but after a while I was beginning to feel that rather than allowing myself to be carried away by a sense of self-pity, I should do my best to learn as much as possible while I’m in Japan.” And he believed that such a change of mind was occasioned precisely by his amazement at the strong work culture demonstrated by the Japanese staff. “Compared to us, Indonesian nurses, they are much more precise and disciplined in time management, more committed to their job, and always willing to take the full responsibility of whatever they are doing.” He further explained, “before coming to Japan, I thought we were good enough, but in fact we were, as the Indonesian saying goes, ‘like a frog hiding under a coconut shell’, who doesn’t know the world.”

Nevertheless, it took some time for him to adjust to such a strong work ethic, and in the meantime oftentimes he felt totally exhausted just trying to emulate his Japanese counterparts. “But thanks to the efforts,” he remembered, “I was beginning to be trusted with a number of tasks that otherwise would never been given to me.”

Aside from the Japanese staff’s superiority in their discipline and consistency with the standard work procedure, he thought that Indonesian nurses had their own unique strong point, namely what he called “imaginative nursing,” by which he meant a nurse’s ability to understand what to do in any given situation unspecified in the standard operational procedure. He speculated that this sort of ability might have something to do with Indonesian nurses’ predisposition to look upon the patients as their own parents or grandparents. Along the same line, he imagined that “If Indonesian nurses had been given the chance to gain adequate knowledge in Japanese language and the Japanese health care system before they came to Japan, it was not impossible that they would have been capable of competing with Japanese nurses themselves.”

With regard to future plans, he said he was not too concerned about the National Nursing Board Exam at the moment. “For me, if I should pass the exam, that’s a gift from God, because it would mean I’ll be able to study in Japan much longer.” “But if, on the contrary, I have to go home after three years, I can take it because now I have a special dream, that is a dream of one day building a hospital in Indonesia entirely based on the Japanese system.”

He emphasized, however, that “this doesn’t mean I do not want to stay in Japan if I should get the chance to do so.” “I just want to be realistic. My chances of passing the exam are slim, as my practice tests scores are very poor; but it’s OK, because even I had to go home, there are lots of lessons I can bring back home.” He further pointed out, “I know the Japanese government is likely to allow us to extend our stay for one year, just to let us take the National Nursing Board Exam one more time, but at the moment, if I failed the exam this year, I’d rather go home right away.”

He believed that his passion for studying abroad has a lot to do with the fact that he comes from West Sumatra, where people have traditionally been upholding a value that one has to achieve success away from their home village. “We West Sumatrans, known as Minangkabaus, traditionally have always been motivated to migrate to other countries or islands to accomplish our dreams. And normally we don’t return to our native village until we’ve attained some measure of success, be it financial or career-wise.”

4. Nurse D (Age 34, Female, Married): “I’m a mother of two kids and my husband was unemployed”

Ms. D is certainly not a “rookie” in the field of nursing. Before coming to Japan, she had worked for eight years as a full-time nurse at an upscale private hospital tucked away in a leafy Jakarta suburb. She was responsible for the overall supervision of the section called “Executive Health Check Up,” which provides exclusive and expensive care for the expatriates and affluent Indonesians alike. Her nursing education started when she took a non-degree three-year program at a nursing school in Padang, West Sumatra. After the graduation, she continued her study to the undergraduate program at the Faculty of Nursing, University of Indonesia, in Jakarta.

She has two children; at the time of the interview, the eldest one was four and the youngest three. When her husband’s small trading business went bankrupt a couple of years ago, her economic situation deteriorated drastically, which was one of her main reasons to apply to go to Japan, leaving her husband and two children in Indonesia. She described the circumstances surrounding her departure as follows. “I had a lot of financial problems right before I came to Japan. Many, many debts. Even our only home had to be sold. I have nothing. My family and I were really suffering at the time. So I decided to come to Japan, never mind being separated from my children. At the time, my youngest child was just eight months and I was still breastfeeding him.”

While Ms. D was in Japan, her husband took care of her two children, but as he was unemployed, she was compelled to set aside most of her salary earned in Japan to be sent home in Indonesia. Out of her monthly take-home pay of approximately 130,000 yen, she tried hard to send the lion’s share home. “If I cut corners in just about every aspect of my life here, every month I can lay away about 90,000 yen, or roughly 10 million rupiahs, and sent it back home.”

Her hard work eventually paid off. After three years in Japan, she could redeem her house, pay off her debts, and even send some extra money home to start up her husband’s new business as well as to support her aging parents. She exuberantly related, “Now, my husband is back at work, although he is no more than a tradesman peddling from one market to another.”

Regarding her work environment in Japan, she said that throughout the three-year period in Japan, she was quite content that she never felt any pressures at work, except the demands for working professionally by the Japanese standards. Just like other Indonesian nurses, her status in Japan was a nurse candidate, but she felt that she had been always treated equally and with respect. She described her situation as follows. “Maybe every hospital in Japan is different. And I know, there may be Indonesian nurses who were not even considered as employees by their hospital, or those who were merely regarded as trainees with limited knowledge and skills. But in my case, I have always been regarded as one of their staff, part of the family, so to speak. So all the rules apply equally for all the nurses including myself. In addition, all the facilities I received as a nurse candidate are no different from theirs. So no one is better off.”

Even regarding the National Nursing Board Exam, the hospital does not set any specific target for her. When she failed the exam last year, the hospital management did not blame her and, on the very contrary, they comforted and encouraged her not to give up and try again. “Likewise,” she pointed out, “moments before the exam started, what I heard from the Japanese staff were nothing but the words of encouragement.”

But Ms. D noted that the Japanese language is quite difficult. She felt it is impossible to master the language, let alone memorizing nursing terminology, in just two-and-half years with three learning hours per day. She admitted that up to now she had not been able to speak the language well, even for everyday conversation. Luckily, the hospital showed deep understanding and readily offered encouragement.

“They are so nice. They’ve never spoken negatively about my linguistic incompetence. I’ve never heard any derogatory comment like ‘you’ve been in Japan for three years and you still can’t speak well’. They seem to have been keenly aware of the fact that the Japanese language, especially the enormous amount of nursing terminology, is awfully difficult to master. So, when I failed the second exam, they still tried to boost my spirit by offering kind words like ‘don’t worry; you can do it better next time.’”

She also felt that she managed to establish very good relations with the patients. She remarked that most of Japanese patients seem to like Indonesian nurses very much thanks to their friendly attitude. “We always smile. Although we don’t understand many things they say as our Japanese proficiency is limited, I feel we’re very welcomed. Probably our body language like smiling and touching helps us build a rapport with them.”

Despite the friendly work environment, the welcoming attitude of the Japanese staff and patients, not to mention the salary sufficient to solve her family’s financial problems, Ms. D decided to return to Indonesia, even if she passed the exam. She said she was actually uncertain as to whether she wanted to go home or stay, but her family’s insistence helped her to make up her mind. Especially, after being separated from her family for more than two years, her mother told her that her two children began to forget they had a mother.[6]

“My contract will be over on February 25, 2011. My family is asking me to go home. My mother cried over the phone and said, ‘just resign and come home. Your children have already forgotten about you. If you insist to keep working in Japan, it wouldn’t do any good to your family’. My husband also said, ‘just come home and take care of your children.’”

After all, for Ms. D, her family remained the most important factor in determining whether or not she should go home. Indeed, she went to Japan to save her family and decided to return to take care of her children, especially to mend her relationship with her young children.

5. Nurse E (Age 27, Female, Single): “I thought I could advance my knowledge and skills in Japan”

Ms. E is 27 years old nurse originally from one of Indonesia’s outer islands. She is single and has a lot of experience as a nurse before coming to Japan, the most notable of which was probably her work for two years at the Emergency Unit of an internationally renown clinic catering almost exclusively to the medical needs of the expatriates and well-to-do Indonesians.

As a nurse working for an international clinic, Ms. E was used to providing health care service to patients from various countries and had been exposed to cultural differences on a daily basis. She also believed that her employment had enabled her to acquire state-of-the-art nursing skills, especially those related to emergency medicine.

Such being her background, she came to Japan three years ago full of hope and anticipation for an exciting process of learning the cutting-edge science of nursing in an advanced country. She was, however, disillusioned right on the very first day of work, when she was asked to measure the uniform she was going to wear at the hospital. “When I arrived, the first thing they asked me to do was uniform fitting. When I saw it, I said to myself in sheer astonishment, ‘Gosh, it’s not a nurse uniform. It’s a T-shirt!’ I came all the way from Indonesia, with many years of experience as a professional nurse, but here, I’m just a nurse assistant wearing a T-shirt.”

This difference in uniform might seem trivial, but it made her extremely uncomfortable at work, being constantly reminded of the status gap between registered nurses and nurse assistants in a Japanese hospital. And it turned out that the uniform is just the smallest difference between them; she was later exposed to many other forms of disparity. “The uniform is only the beginning. When we had lunch at the canteen, we were told that there are two different sections for nurses and assistants. And that’s also the case with the lounge. In short, they keep telling us ‘to know our place’, giving us all these constant reminders of our status difference.”

But among all these status differences, it was her status as a nurse assistant that was the most difficult to accept. She had a bachelor degree in nursing, and was confident of having acquired much more advanced skills and knowledge than most of the nurse assistants in Japan. And yet, she was lumped together with nurse assistants simply because she had not passed the National Nursing Board Exam in Japan, and as a result, she had to do the work that can be done by any unskilled laborer. “My job description is limited to basic human care such as preparing meals, feeding, bathing, helping with personal hygiene, changing diapers, and even cleaning up the rooms, floors and lavatories. Of course I know as a nurse these are part and parcel of my work, but I’ve never imagined that these would be the only work I’m allowed to do in Japan!” She further pointed out, “deep in my heart, I still cannot accept this. I am a professional nurse, why do I have to do these things? What is the rationale for hiring Indonesian nurses with a minimum of two year work experience to this kind of job in Japan? Even a fresh graduate from a nursing school can easily do it.”

Due to all this, Ms. E felt that her skills and capability as a nurse were terribly underestimated by the hospital. And to make the matter worse, while she was working in Japan, she felt she came across a number of cases indicating that her knowledge and skills were possibly superior to those of the Japanese staff. “For example,” she said at the interview, “one time I was asked by the Japanese staff to use cold water or ice block for a compress to alleviate a fever, but as far as I know, the latest research on the issue indicates that we’d better use warm water because, contrary to the common belief, cold water or ice block prevents the patient’s body temperature from decreasing.” She further noted that this was but one of many examples of the fact that what was going on in a Japanese hospital was not necessarily abreast with the latest development in medicine.

In addition to this, Ms. E also felt that being part of the very first batch of nurses sent to Japan, the pre-departure preparation for her group was far from adequate. For example, the exact job description and responsibilities of their employment in Japan was never clearly explained to them. “Yes, our contract does mention that we will not be allowed to take part in any medical intervention, and that our job is to provide basic service to the patients, but we never imagined that this would be applied so strictly to the point we won’t be able even to observe medical practice in Japan.” Also, she was not told before departure that most of the patients she would take care of were elderly. “If I had been told that most of the patients were elderly, I could have studied the diseases commonly found among old people such as dementia before my departure for Japan, and that should have made a big difference.” Due to such lack of information, she felt that what actually happened to her was “very tragic,” since in order to come to Japan, she had to “make a lot of sacrifice, including quitting a job that she really loved.”

She also deplored the fact that while she had been originally very excited about learning many new things in Japan, she realized soon after her arrival that not only was she not allowed to take part in any medical intervention, but she was not even given any opportunity to observe the Japanese staff performing simple procedures such as measuring blood pressure or giving an injection. “Let me give you a simple example: cleaning a patient’s wounds. I just wanted to see how Japanese nurses clean a wound because I wished to compare it with what I used to do in Indonesia. But I was never given the opportunity to do so.”

As for the issue of language learning, she explained that she had the opportunity to learn Japanese for six months before being placed at a hospital, but that turned out to be extremely inadequate. “I think learning such a difficult language in just six months is impossible. We were just like foreigners learning English for the first time. In the text book, we learn simple sentences like ‘this is my mother’. But in the actual daily conversation, it takes much more than that to build a communication. When I started working here, I was faced with a lot of questions using totally unfamiliar words, and naturally I couldn’t answer them correctly.”

To compound the problem, some of the Japanese staff at her hospital were not exactly helpful and understanding about her language deficiency. She was under the impression that the Japanese staff did not bother about the fact that she was a foreigner who still had some difficulty speaking and listening in Japanese, nor did they care to ask her if she understood. “They speak so fast and seem just don’t care if I am a foreigner.” In addition, “there are some Japanese nurses who seem uncomfortable with my being here. I don’t know why, maybe I am considered a bother, or a burden to them as they are very busy with their own themselves, so much so that they do not have time to help me with anything. I know that helping me with my Japanese means extra work and time for them, so it’s understandable if they feel that I present a new burden to them.”

As for the issue of the National Nursing Board Exam, she was of the opinion that “the exam materials were far too complicated to be learned in just one or two years.” Moreover, she pointed out, Indonesian nurses have to study them while working at a hospital or an elderly home. And according to her, the most difficult subjects of the exam were the health care law and the insurance system in Japan, which are entirely unfamiliar subjects to Indonesian nurses.

Finally, having gone through all this, she felt that she began to feel she had lost her own identity as a professional nurse who possessed adequate skills, knowledge, capability and credibility. As a result, she could not help feeling that she was not proud of her job, as contrary to her original expectation, she could not expand her knowledge and develop her skills. “Frankly speaking,” she remarked, “I don’t feel I belong here. Oftentimes, I even feel ashamed of just sitting back without doing anything. I feel I am not myself anymore. The job I am doing is not my kind of job.”

In addition to the loss of her identity, she also felt that she had lost motivation. “Sometimes I’m just wondering where the spirit’s gone? I don’t even have any motivation to learn a new kanji character, let alone study for the exam.” She therefore explained that what she was doing at the moment is just to finish the contract. After the contract is over, she said, she would go home, “regardless of the result of the exam.” She was quite clear about this. “I feel I am not myself anymore, and this is clearly not a job for me. I came here to learn something and advance my nursing knowledge and skills, but that didn’t happen. So, even if I pass the exam, I won’t even bother to stay and had rather go home and start a new career.”

VI Analysis

As stated earlier, the main thrust of the argument proposed in this study is that the encounter across differences can bring about “friction” [cf. Tsing 2005], which has proved to be both empowering as well as disrupting in Indonesian nurses’ adjustment to the unfamiliar cultural settings, and thereby in shaping their decision as to whether continue working in Japan or to go home.

The five narratives presented in the previous section are meant to describe in detail the diverse and even conflicting interactions between the nurses’ individual socio-cultural backgrounds such as age, marital status, ethnicity, family values and relationship, work experience, self-motivation and expectation on the one hand, and the work culture as well as the institutional underpinnings of their work environment on the other.

From these narratives, however, one can discern at least two patterns of interactions between the two factors: individual socio-cultural backgrounds and the surrounding work environment in Japan. They are, the pattern of interactions which has brought about “creative friction” and the one that has given rise to “constraining friction.” And, while the creative or enabling friction was instrumental in shaping the subjects’ decision to continue to working in Japan, the constraining or restrictive friction was certainly a critical factor in their decision to go home.

The pattern of interactions which has led to creative friction can be clearly found in the narratives of Ms. A and Ms. B, and in a somewhat ambiguous fashion, that of Mr. C. In the case of Ms. A, who is a young single woman, the interactions between the two factors have opened many possibilities for her to plan her life, including marrying a Japanese man and continuing to work in Japan as a nurse. Moreover, the fact that when she lived with her family in Indonesia she felt she was very dependent and had no freedom of her own, contributed significantly for turning her friction into a creative one. As clearly shown in her remark “I’ve never been so independent in my entire life,” only after coming to Japan did she feel being truly self-reliant, which in turn has made her content and aspiring to continue working in Japan.

Ms. B’s case also presents interesting interactions between age, marital status and work experience on the one hand, and the work environment on the other. As a young single woman who just graduated from a nursing college, she very much enjoyed working as a trainee in a nursing home as this could significantly improve her work experience and gave her a sense of accomplishment and pride at her work place. She therefore decided to pursue a master’s degree in gerontology in the future. Her family background was also an enabling factor. Being the youngest child in her family, she was not required to send money back home, so she could save as much to support her own plan. Thanks to all these contributing factor, Ms. B decided to continue working in Japan if she could get a certification as a care worker.

Mr. C’s narrative presents a very interesting case. A male nurse with a distinctive ethnic background (a West Sumatran or Minangkabau), known for their belief that one has to achieve success away from their home village, he has shown a strong degree of self-motivation to advance his knowledge and skills, therefore he seems to possess all the individual characteristics of a person who would wish to continue working in Japan. However, in his case, friction arose from the fact of his being a seasoned nurse with eight years of work in Indonesia conflicted with his work environment in Japan, where as a nurse candidate he was not allowed to perform any medical intervention. But precisely because of this friction, he became motivated to adapt by enhancing his learning effort. As a result, by the time of the interview, he had made his mind that should he get to pass the exam, he would stay and continue working in Japan.

The pattern of interactions which has given rise to constraining friction can be plainly discerned in the narratives of Ms. D and Ms. E

For Ms. D, a mother with two children and a breadwinner for her family, the work culture as well as the institutional arrangements at the hospital were very supportive, but her status as a mother of two was in conflict with her intention to stay and work in Japan. As evident in her narrative, by the end of her contract, she would have been away from her children for three years and the money she had sent home had already helped her husband start a new business, therefore despite the conducive work environment, she could not resist both her own desire and her family’s urging for going home. Furthermore, as she is a mid-career nurse, her motivation to pursue further her study abroad does not seem as resolute as her younger colleagues such as Ms. A and Ms. B, and this too seems to be a factor in her decision not to go home.

The last narrative by Ms. E seems to present a quintessential case of constraining friction arising from the interactions between individual socio-cultural factors and the work environment. As an experienced nurse at an international clinic in Indonesia with substantial work experience, including with the patients from all over the world, when she came to Japan, she was full of hope for an exciting process of learning the cutting-edge science of nursing in an advanced country. However, friction arose when the work culture and arrangements at her hospital did not meet her high expectations. The effects of this friction were destructive, by any standards. She soon lost her confidence, and eventually she felt that she lost her identity as a nurse too. It should be noted here, however, that such detrimental effects were felt by her not only because as an experienced nurse it was terribly difficult to put up with the work environment which does not allow her to take part in any medical intervention, but also — and this one is undoubtedly far more important — because of the fact that throughout her employment there she was constantly reminded of her “inferior” status as a nurse trainee. It was obvious that these circumstances were more than sufficient to drive her to a resolute determination for not extending her work in Japan any longer.

VII Conclusion

The question asked in the title of this article, “To Stay or Not to Stay,” is admittedly a hypothetical question implying “if you should pass the exam, would you stay or go home?” But in addition to that, as the Japanese government decided in March 2011 to allow the first batch of Indonesian nurses sent to Japan in 2008 to extend their stay for one more year to take the National Nursing Board Exam one more time, the question is also meant to ascertain whether those who can extend their stay would make use of the facility.

At the time writing of this article in October 2011, it has been known that out of 104 nurse candidates departed for Japan in 2008 as part of the first batch of the program, only 15 have passed the exam, and all of them but 1 have decided to stay in Japan. On the other hand, out of 89 nurse candidates who did not pass the exam in the last three years, only 27 have applied for the extension. In other words, 62 nurse candidates who did not pass the exam, plus 1 who passed the exam, have decided to go home in 2011.

The narratives and the analysis presented in this article purport to shed lights on the fact that, behind these statistics, Indonesian nurses’ individual socio-cultural backgrounds and the institutional underpinnings of their work environment have figured prominently in shaping their decision to stay or not to stay.

While the findings of this study cannot be generalized for all Indonesian nurses working in Japan, they have demonstrated how friction in the form of heterogeneous and unequal encounters can lead to a rearrangement of actions, effects, or consequences. This in turn constitutes a detailed sociological account of the importance of cultural diversity, which, as shown in the vivid narratives presented above, is not only there, but on the very contrary, it is what makes them — and all their particularities — possible. The use of friction as an analytical tool, therefore, has been instrumental in achieving the aims of the study as it enables the examination of unpredictable effects of “friction” between Indonesian nurses’ individual socio-cultural factors and their work environment upon their decision to stay or not to stay in Japan. And this in turn drives home a point that in order to understand adequately the diverse and intricate processes of foreign workers living in unfamiliar cultural settings, one should not homogenize their backgrounds, perspectives and experiences, but rather need to appreciate and understand their startling diversity.

Acknowledgements

The authors wish to express their sincere appreciation to the other members of our bi-national research team, who provided invaluable advice and support, both academically and personally, for the completion of this study. They are Professor Shun Ohno, Professor Yuko Ohara-Hirano, Professor Kiyoshi Adachi, Associate Professor Reiko Ogawa, Professor Yoshichika Kawaguchi, Dr. Setyowati, Ms. Jenny Simulja, M. A., Ms. Krisna Yetty, M. A., Ms. Herni Susanti, M. A., and Ms. Kreasita.

We would like to express our gratitude to our two outstanding students at the Japanese Studies Program, Faculty of Humanities, University of Indonesia, i.e. Mr. Charis Christiawan Nugroho and Ms. Monica, who have helped us with comprehensive transcripts of the in-depth interviews.

Our heartfelt gratitude is also due to hospital officials, nurses and care workers, who kindly agreed to help us as resource persons, informants and respondents.

Last but not least, it should be gratefully acknowledged that this project was made possible by a generous research grant administered by the Japan Society for the Promotion of Science (JSPS) and the Directorate General of Higher Education (DHGE), Ministry of National Education, Republic of Indonesia.

References

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Alam, Bachtiar; and Wulansari, Sri Ayu. 2010. Creative Friction: Some Preliminary Considerations on the Socio-Cultural Issues Encountered by Indonesian Nurses in Japan. Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 183–192.

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Hirano, O. Yuko. 2011. Transition of Indonesian Nurses and Certified Worker Candidates Bound for Japan. A presentation at the international seminar, “Preparation Program for Indonesian Nurses Who Will Work in Japan in Order to Prevent Job Stress and Social-cultural Stress,” in the Center for Japanese Studies, University of Indonesia on July 28, 2011.

Hugo, Graeme. 2007. Country Profiles: Indonesia’s Labor Looks Abroad. Accessed at http://www.migrationinformation.org/Feature/display.cfm?ID=594 (on Nov. 10, 2011).

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Ogawa, Reiko. 2008. Migration of Southeast Asian Care Workers to Japan: Issues and Contestations. Journal of Asian Women’s Studies 17: 1–16.

―. 2011. Potential and Risk for Migration of Indonesian Care Workers. A presentation at the international seminar, “Preparation Program for Indonesian Nurses Who Will Work in Japan in Order to Prevent Job Stress and Social-cultural Stress,” in the Center for Japanese Studies, University of Indonesia on July 28, 2011.

Ogaya, Chiho. 2008. Iju Kaji Rodosha ni okeru Barunarabiriti no Kozo to Soshiki-ka no Kanosei [Structure of Vulnerability of Migrant Domestic Workers and Possibilities of Their Organization]. In Kokusai Ido to Rensa-suru Jenda [International Movements and Chained Gender], edited by Ruri Ito and Mariko Adachi, pp. 93–113. Tokyo: Sakuhin-sha.

Ohno, Shun. 2011. Sustainability and Uniqueness of Japan’s Policy for Accepting Foreign Nurses and Care Workers: Evaluation 3 Years After the First Entry of Indonesian “Candidates” into Japan. A presentation at the international seminar, “Preparation Program for Indonesian Nurses Who Will Work in Japan in Order to Prevent Job Stress and Social-cultural Stress,” in the Center for Japanese Studies, University of Indonesia on July 28, 2011.

Parreñas, Rhacel S. 2003. Servants of Globalization: Women Migration and Domestic Work. Manila: Ateneo de Manila University Press.

Tirtosudarmo, Riwanto. 2004. Cross-Border Migration in Indonesia and the Nunukan Tragedy. In International Migration in Southeast Asia, edited by Aris Ananta and Evi Nurvidya Arifin. Singapore: Institute of Southeast Asian Studies.

Tsing, Anna. 2005. Friction: An Ethnography of Global Connection. Princeton: Princeton University Press.

Wong, Diana T.; and Teuku Afrizal Teuku Anwar. 2003. Migran Gelap: Indonesian Migrants in Malaysia’s Irregular Labor Economy. In Unauthorized Migration in Southeast Asia, edited by Graziano Battistella and Maruja M. B. Asis, pp. 169–227. Manila: Scalabrini Migration Center.

1) Throughout this article, Indonesians working in Japan under the Economic Partnership Agreement (EPA), either as registered-nurse candidates or certified care-worker candidates, are referred to as “Indonesian nurses,” except where the distinction between the two is needed. We believe such a designation is justified as they have worked as professional nurses in Indonesia.

2) For the EPA between Indonesia and Japan, see Shun Ohno’s paper in this issue.

3) The authors wish to thank Professor Shun Ohno for his kind assistance in providing all the information needed to put together this section.

4) As of July 2011, the Indonesian government has concluded only three G-G agreements for the dispatch of Indonesian workers overseas. They are 1) its EPA project with Japan, 2) its arrangement with the South Korean government, and 3) its agreement with the Eastern Timor government for the dispatch of Indonesian midwives (data obtained from the National Board for Placement and Protection of Indonesian Overseas Workers on July 29, 2011).

5) For similar experience of a feeling of independence by Asian migrant women, see Parreñas [2003] and Ogawa [2008].

6) For similar experience by Asian migrant women, see Parreñas [2003].

Indonesian Nurses’ Challenges for Passing the National Board Examination for Registered Nurse in Japanese: Suggestions for Solutions

Setyowati,* Ohno Shun,** Hirano O. Yuko*** and Krisna Yetti*

*Faculty of Nursing, University of Indonesia, UI Depok Campus 16424, Indonesia

Corresponding author (Setyowati)’s email: watisetyowati@yahoo.com.au

**大野　俊，Center for Southeast Asian Studies, Kyoto University

***平野裕子，Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan

Abstract

Between 2008 and 2011, nearly 800 Indonesian nurses and care workers have entered Japan as candidates for registered nurse (kangoshi) or certified care worker (kaigo fukushishi) under the Indonesia-Japan Economic Partnership Agreement (IJEPA). The most serious problem in their everyday life is the difficulty in mastering the Japanese language, which presents a high hurdle for passing the national board examination for registered nurse. Until 2011, only 17 Indonesian nurse examinees have been able to pass the examination, and become registered nurses in Japan. To contribute the developing of a more sustainable IJEPA program, this research aims to explore Indonesian nurse candidates’ learning strategies for passing the national examination in Japan, and identify other factors that hinder their success. Although the number of Indonesian and Japanese interviewees was limited, the analysis of the research demonstrates that strong material and moral support by the management and staff of the receiving hospital is essential in motivating Indonesian candidates to do their best to pass the examination. It also suggests that such support is critical especially in the early stage of training at the workplace even for improving the efficiency of educational investment that makes nurse candidates pass the national exam and become registered nurses in Japan.

Keywords: Indonesia-Japan Economic Partnership Agreement (IJEPA), learning strategies, nursing national examination, Indonesian nurses

I Introduction

Japan’s nursing examination is administered every February. The first group of Indonesian candidates (104) for the position of registered nurse arrived in Japan in August 2008, and 82 of them took the national exam in February 2009. None of them passed [Shukan Igakukai Shimbun, April 20, 2009]. The first candidates under the EPA programs succeeded in the next exam, given in February 2010. Two Indonesian nurses (who had taken it and failed the previous year) and one Filipino nurse (from the first group of Filipinos) passed the exam.

In Japan’s nursing exam, conducted in February 2011, 15 Indonesians (13 from the first group and 2 from the second group) and 1 Filipino (from the first group) passed the examination. The passing rate among 91 Indonesian examinees from the first group was 14.3%, compared with a passing rate among all examinees (54,138 persons) of 91.8% [Japan, Kosei Rodo-sho Kangoka 2011]. Because of the low passing rate among EPA candidates, the Japanese government extended eligibility one additional year for the first and second groups of Indonesian candidates and the first group of Filipino candidates to allow them to stay and study for the exam again.

In most countries, foreign nurses must pass the board examination in the language of the host country. Thus, nurses, who cross borders, need to undergo didactic studies of the language and culture of their destination country [Buchan 2002; Calman 2005; Friss 1994; Greenglass and Burke 2001; Goodin 2003; Jamal and Baba 2000]. In the case of the United States, foreign nurses are required to pass the CGFNS (Commission on Graduates of Foreign Nursing Schools) examination, and also pass the State Board Examination in the individual state where they will work within six months of their arrival [Venzon and Venzon 2005: 68–70]. Since Filipino nurses are educated with English textbooks at the nursing schools in their country, they have less difficulty passing foreign nursing examinations in English.

In Japan, however, Filipino and Indonesian nurses experience serious difficulties when they study nursing in the Japanese language. Japan’s national exam questions are written entirely in Japanese (Nihongo), which consists of three types of characters, hiragana, katakana and kanji. Kanji was introduced from China in ancient times and has been developed in Japan. Hiragana and katakana are original Japanese characters simplified from kanji. Each hiragana and katakana includes approximately only 50 letters so that foreign learners can master them more quickly. However, kanji is composed of several thousands and more letters, and thus it demands enormous effort for foreign learners especially from non-kanji countries such as Indonesia and the Philippines to master Nihongo adequately.

Kyushu University’s research team found that most of Japanese hospitals that received the first group of Indonesian candidates for registered nurse have recommended that the national nursing exam for foreign examinees should be more flexible.[1] Some hospitals have requested the Japanese government to offer the exam in English or Bahasa Indonesian because the Japanese language is too difficult for the Indonesian and Filipino candidates educated in alphabet characters in their home countries.

The language difficulty is not only the problem. Kawaguchi [2009: 91–104], who researched nursing education in Indonesia as well as that in the Philippines, found that Indonesian and Philippine curricula and required credits at nursing school or college vary considerably from Japanese ones.[2] Hirano [2011: 52–56] also noticed that job descriptions for nurses differ between such Southeast Asian countries and Japan to some extent. If the foreign nurses cannot overcome the above gaps, they may misread the questions on Japan’s nursing examination and fail to answer correctly even if they have achieved proficiency in Japanese.

Japan’s Ministry of Health, Labour and Welfare (MHLW) has expressed its position that the ministry has no plan to implement the national exam in English or Bahasa Indonesian for Filipino and Indonesian nurse candidates. Its position is in accord with that of the Japanese Nursing Association, which strongly insists that high proficiency of Japanese is essential for safe nursing practices in Japan.

However, if the passing rate of EPA foreign nurses does not increase to a certain minimum level, this may harm diplomatic relations between the sending and receiving countries. This is a serious dilemma for the governments concerned.

To cope with the present conditions, MHLW increased the budget for the training and guidance of foreign candidates for registered nurse and certified care worker from 80 million yen in fiscal year 2009 to 870 million yen in the fiscal year 2010. This introduced a concerted effort to enable more foreign candidates to pass the national exam in Japan.[3] The ministry and its extra-governmental body, Japan International Corporation of Welfare Services (JICWELS), initiated routine guidance for all accepting hospitals and care facilities. MHLW has allocated a subsidy for training to each hospital and care facility since 2010.[4] JICWELS provided copies of the previous Japanese national examination sheets translated in English or Bahasa Indonesian [Satomi 2010: 89–98].

However, it is still uncertain that such financial assistance will be effective in increasing the passing rate among foreign candidates. University of Indonesia and Kyushu University’s joint quality research conducted at six accepting hospitals in Western Japan in mid-2009 found that all the Indonesian candidates (12) for registered nurse felt psychological stress preparing for the national board examination in Japanese. They felt that Japanese health-care system, included in the national exam, was very different from Indonesia’s and too complex to understand. In addition, some Japanese nursing and medical technical terms are different from those the Japanese nursing staff use in their daily conversation, especially words spoken in the local dialect [Setyowati et al. 2010: 177–179]. Thus, they have to break through layers of language barriers in their institutional setting and everyday lives.

Based on the above findings, this research aims to explore effective and suitable learning strategies that could enable Indonesian and other foreign candidates to overcome the high hurdles and pass the national nursing exam. It also attempts to identify several factors behind the failure or success in passing the examination, and suggest their implications for EPA policy.

II Methodology

This research employed qualitative surveys using a phenomenology method in order to explore the learning experiences related to preparation for Japan’s nursing national examination. The authors applied purposive sampling which included the following criteria: 1) members of the first group of Indonesian nurse candidates, who already took Japan’s nursing national examination twice until 2010; 2) those who had no proficiency in the Japanese language before their departure to Japan; 3) those who obtained a diploma and/or a bachelor’s degree in nursing in Indonesia; and 4) those who were willing to cooperate with our research team’s interviews. As a result, four candidates employed by two hospitals in the Kansai Region and another two candidates employed by two hospitals in the Hokuriku Region participated in the survey.[5] It was administered in their hospitals in early November 2010. The authors’ intensive interviews with Indonesian nurses were conducted mostly in Bahasa Indonesian.

Participants, who arrived in Japan in August 2008, had received full-time Japanese language training for six months before their assignment to the contracting Japanese hospitals. The Association for Overseas Technical Scholarship (AOTS), an extra-governmental body that employs a number of Japanese-language instructors, conducted the Japanese language instruction in their facilities.

Two of the participants passed the national exam in 2010 after failing in 2009. Both are employed by the same private hospital in the Hokuriku Region. They are the only Indonesians who passed the 2010 exam. One is a male and another is a female. The four participants who failed the examination are all females and employed by two private hospitals in the Kansai Region. Regarding educational background, five of them are D3 graduates and one is a S1 graduate.[6] The two successful candidates presented their preparation techniques in a seminar held in Osaka City on July 23, 2010.[7] Their presentation data include PowerPoint slides, which are included in this study.

Additionally, Japanese co-authors conducted interviews with Japanese head nurses (3), preceptors (2), executive secretary (1), and director (1) of the hospitals employing Indonesian participants. They cross-checked the accuracy of statements made by the participants with the results of the past surveys conducted by our research team and the Japanese government.

III The Results

(a) Problems in Learning the Japanese Language

When the AOTS began the Japanese language training for the first group of Indonesian nurse candidates, it estimated they would reach Semi-Level 2 of the Japanese Language Proficiency Test (JLPT)[8] after six-month language and sociocultural adaptation training (858 hours) at its facilities.[9] However, it is probable that the majority were not able to attain this level.[10] Consequently, they faced difficulties in communicating with their Japanese co-workers and patients for a certain period after their assignment to the workplace.

In this survey, all participants expressed difficulties in learning kanji, especially those of Japanese nursing/medical terminology and jargons/abbreviation. The following are their narratives:

Participant 1 (28 year-old female Indonesian): “We have difficulty answering the exam questions especially those that including Japanese medical terminology, insurance and health-care terms that are all written in kanji, hiragana and katakana.”

Participant 2 (another 28 year-old female Indonesian): “We have not yet learned many of the kanji letters that appeared in the exam. Our problems are not only the difficulty in mastering the Japanese language but also the difficulty in understanding particular medical and nursing technical terms.”

Participant 3 (32 year-old female Indonesian): “It is difficult to memorize many Japanese technical terms in a short period. If we could be equipped with a high proficiency of Japanese when we were assigned to the hospital, we would only have to improve it, and could concentrate on studying Japan’s nursing. We hope that the Indonesian government would improve its language-training program in Indonesia.”

The local dialect is also one of the communication barriers between foreign nurses and Japanese patients and staff. One Japanese head nurse working in the Kansai Region expresses her findings:

Japanese Head Nurse 1: “Most patients speak a dialect in this region. They (Indonesian nurses) said that our dialect is too harsh for them, and sometimes they felt that they were scolded even though they were not scolded in fact. The AOTS taught them a standard form of Japanese (“kireina Nihongo” in her Japanese words) in the language-training program. Such formal Japanese is not commonly used at our hospital. One Indonesian nurse cried because when she received instructions in the [Kansai] dialect, she misunderstood and thought that she was scolded.”

Their Japanese language ability has improved gradually. This tendency is confirmed by the outcome of the Kyushu University research team’s nationwide survey on the hospitals that accepted candidates from the first group of Indonesians one year after their assignment. The results demonstrate that the majority of those candidates had little or no problem communicating with Japanese staff and patients in Japanese conversation. The vast majority of them, however, continued to struggle with Japanese proficiency sufficient for reading and writing nursing records.[11]

Two head nurses who supervised Indonesian candidates who failed the national exam explained the circumstances to Japanese researchers:

Japanese Head Nurse 1: “We learned that teaching enough Japanese to pass the national exam is difficult. It took approximately 30 minutes just to explain one question on the national exam. It requires time to discover techniques of instruction by on our own. I hope that candidates start studying Japanese before coming to Japan.”

Japanese Head Nurse 2: “We needed an interpreter for half or all of a year after the candidates arrived at our hospital. During this period communication was difficult for both sides. I think that our Indonesian candidate will encounter some difficulties communicating with patients even after she passed the N3 of the JLPT. We expect Japanese language school could do something for us.”

Japanese preceptors who instruct the Indonesian nurse candidates are predominately senior nurses at a similar level as the head nurses interviewed above. Although they are competent in nursing practices, they are not experts in instructing foreigners in the Japanese language. It is obvious that the absence of “bridging human resources,” who understand the language and the nursing practices of both the sending and receiving countries (Indonesia or the Philippines and Japan), at the workplace is a major obstacle to training foreign nurse candidates to license them as registered nurses in Japan.

(b) Varied Learning Hours

Under the Indonesia-Japan EPA, Indonesian candidates for registered nurse or certified care worker are required to continue to study the Japanese language and Japan’s nursing in order to pass the national exam in Japan. On the other hand, their employers set their daily schedules. The EPA does not regulate the division of working and learning hours.

Most survey participants recognized that the study hours at the workplace were too short for passing the national examination. One hospital in Kansai allows two candidates to study from 2 p.m. until 5 p.m. and work for the remaining hours every day. Their instructors are Japanese nurses and a volunteer Japanese-language instructor. The hospital encouraged them to take the JLPT. After one candidate passed the N3 of the JLPT, and another failed the same test in 2010, the head nurse increased study hours of the candidate who passed from three hours to five hours because she had to demonstrate the possibility of passing the national exam. The head nurse recognized that the other candidate already realized that she could not pass the next national exam, thus her study hours were not increased.

Another hospital in the same region let two candidates study from 2:30 p.m. until 5:30 p.m. every weekday, and planned to extend their study hours to prepare for the 2011 exam after December 2010. Their instructors are Japanese nurses and volunteer Japanese-language instructors.

Regarding their study hours, one Japanese head nurse explained the reason she and her Japanese staff were not able to allow the Indonesian candidates more hours for their study: “Indonesian nurses have ever complained that they needed more time to study. But, the policy of our hospital is to let them work for certain hours. We cannot let them study for a whole day as long as we are paying (the) salary for their work.”

Two Indonesians who passed the exam had been provided enough time to study even during working hours.

Participant 4 (26 year-old female Indonesian who passed the exam): “We are required to work from 9 a.m. until 1 p.m. and study with our preceptors from 2 p.m. until 6 p.m. every weekday. Our study hours are counted equivalent to working ones in our salary. At home, I have continued to study from 9 p.m. until going to sleep, and restart at 3 a.m. just after I wake up, and continue through the morning. During my holidays, I review my previous studies for approximately two hours.”

The management carefully considered the importance of well-balanced study and working hours. The director of the hospital explained: “We decided to support the candidates to pass the exam as far as we were able. We did not want to have them disappointed by failing. If we allowed them to study all day, they might feel too stressed. So, we have them work half the day so that they can concentrate on studying during the other hours.”

The EPA did not mandate required working and study hours, which caused large differences among the accepting hospitals [see also Wako Asato’s paper in this special issue]. According to MHLW’s nationwide survey conducted in February 2010 on the first group of Indonesian nurse candidates, 53% of all responding candidates (N=66) studied the Japanese language and for the national board examination for 11 hours or more within working hours per week, 24.2% studied for 6–10 hours, and 15.2% studied for only 1–5 hours [Japan, Kosei Rodo-sho 2010].

The Indonesian candidates are aware of these differences as they frequently exchange information on their work and study conditions through the Internet and other communication methods. Consequently, some candidates have felt that their learning hours at the workplace are too short, compared to fellow Indonesian candidates assigned to other hospitals, as one head nurse admitted in the above narrative. This absence of standardized working and learning hours opens the door for candidates to judge the accepting hospitals unequal, and has inevitably affected their commitments for passing the national exam in Japan.

(c) Differences of Nursing Education and Practices between Japan and Indonesia

The participants with D3 educational backgrounds recognize that they have to study nursing knowledge and skills intensely, especially the particular diseases and symptoms of the elderly, which they had not well learned in Indonesia. Their narratives follow:

Participant 5 (35-year female Indonesian): “In our hospital (in Japan), the majority of patients are elderly. In Indonesian hospitals, there are not as many elderly patients. That is why Japanese diseases such as cancer and cerebral infarction are common, which is quite different from Indonesia, where most patients suffer from infectious diseases.”

Participant 2: “Learning about diseases is important in Japan unlike in Indonesia, and there are many details to absorb. After you have mastered the details, you realize that the exam questions are good and can be answered. The questions related to incubation, symptoms and others are only simple.”

Participant 3: “Since what I had learned at my vocational school (in Indonesia) was limited, I need to study and gain more experiences. Here, all the regulations are very detailed, so Japanese nurses must know a great deal of science and the regulations. Japanese nursing students have class all day. The Indonesian students had half a day allocated for study and must work at the hospital the other half. That limits the amount the other Indonesian classmates and I can learn in the same period.”

Japanese preceptors have also recognized the learning difficulties caused by the differences in nursing education and practices between Japan and Indonesia. Two Japanese head nurses who instructed participants who failed the exam explain:

Japanese Head Nurse 1: “We found that the level of Indonesian nursing education was different from the Japanese one. They lack some basic nursing knowledge. We even have to teach about insulin and symptoms of low blood sugar. When I instructed them to exercise the drill, they usually missed a few things. They lack accuracy (in medical knowledge).”

Japanese Head Nurse 2: “In the past, I imagined that basic nursing was similar throughout the world and that the language was the only difference. After working with two Indonesian nurses at our hospital, I realized my idea was incorrect. I found many differences between Japan and Indonesia in fundamental nursing practices. For example, when the patient has a fever, Japanese nurses try to lower the body temperature by cooling, but Indonesians try to do it by warming. When we clean a patient’s body, we use a steam towel at approximately 50 degrees, they use the towel warmed to 40–42 degrees. Japanese nursing staff clean the patient’s body once each day; Indonesian nurses clean patients twice per day.”

The narratives from the Indonesian candidates and Japanese preceptors clarify that neither group clearly understood the differences between Indonesia and Japan in nursing education and practices before the entry of Indonesian nurses. After the candidates were assigned to Japanese hospitals, both parties recognized that the diseases prevalent among inpatients differ considerably between the two countries.

This could be partly attributed to the variation in demography of the two countries. The numbers of the elderly (60 years old and older) in Indonesia was 17,767,709 or 7.79% of the total population in 2000. It is estimated to increase to 9.7% in 2010 and to reach 11.43% by 2020 [Adioetomo and MCicih 2009]. In Japan, the percentage of the elderly (65 years old and older) had already reached 21% in 2007, and is projected to reach 32% by 2030 [Tokyo Daigaku Koreishakai Sogo Kenkyu Kiko 2010: 15]. It would be difficult for foreign nurse candidates to pass the exam and become model nurses in Japan unless they profoundly understand the differences in nursing education and practices and the most common diseases, which vary because of the differences in demography, culture and other factors.

(d) Learning Strategies and Factors behind Passing the National Examination

Two participants who work at the same hospital and passed the exam explained the learning strategies that brought them success in the exam in Japanese:

Participant 4: “I reviewed Japan’s past nursing examinations from the 93rd exam (2004) to the 98th exam (2009), and took them as if I were taking the real exam. When I identified my weak points, I learned everything I could about these points. Before the 99th exam, I concentrated on studying hisshu-mondai (mandatory questions).

I set a target for reading Japanese books. If I could read through one book in one month, I would be able to read 100 questions or at least 50 questions in the same period. Then, I shortened the target to finish reading through the book within two days in order to finish answering 150 new questions and 120 old questions (from the examinations conducted in the previous years).

I placed learning materials including pictures of things I did not understand well (at the workplace) on the wall, doors and other places inside my room. I continued this practice during the first three-to-four months after my assignment to the hospital.”

Participant 6 (26-year old male Indonesian who passed the exam): “Whenever I didn’t understand Japanese words and terms, I wrote them in my small notebook. On separate pages, I wrote the hiragana letters in word order. Under each word, I wrote its meaning either in Bahasa Indonesian or English. I brought these notes with me at all times anywhere I went.

As long as I could recognize the kanji letters, I could understand their meanings. Even when I didn’t know how to read them, but learned to recognize the structure of kanji letters so that I eventually remembered every letter. After studying for 10 months, I could read many kanji words because I enjoyed reading them. When I went to the bookstore once or twice a month, I bought new Japanese books. Eleven months into my assignment to the hospital, I could read a small pocketbook and understand it. The hospital set up a time target for us. We had to finish reading one Japanese book assigned to us within one month. We finished reading seven books during the first seven months.

After mastering a prescribed number of kanji, I tried to increase my vocabulary by using a common kanji character. When I memorized the words “no-kosoku” (脳梗塞; cerebral infarction) and “no-kessen” (脳血栓; cerebral thromboembolism), I realized the kanji “no” (脳; brain) was an important component of the word. Thereafter, whenever I saw a word containing “no,” I realized that it related to the brain. This was very helpful in increasing my vocabulary. I used Wikipedia online to find explanations of medical terminology.

The national board exam in Japan is likely to focus on current issues in the health status of the Japanese people. Based on current demographics and experience, geriatric and dementia nursing will be included in the tests. It is important to find the information on these issues and to study them intensively. Regarding questions on the social welfare system in Japan, all you need to do is memorize its requirements accurately. Japan’s laws and acts are changeable, so you (foreign candidates) should wait to learn them in the later stages of preparation for the exam, so that you don’t need to waste your study hours learning changes it what you already studied.”

Both successful candidates stressed the importance of strong support by the director and preceptors at the hospital as they prepared for the exam.

Participant 4: “The Japanese staff around me were always working hard. This motivated me to study hard. Incho-sensei (director of the hospital) is very good and supportive. I feel that he is like my father. So, everyone here has made me feel at home. They welcomed us so graciously that I am strongly motivated by the director and also another senior nurse who monitors me.”

Participant 6: “The hospital staff provided us with many references, books and the Internet. They provided a computer for us in our apartment so that one was available whenever we needed it. We took turns using it. I had access Monday through Wednesday and the remaining days were for my Indonesian co-worker. Someone supervises our studies every day. The director of nursing supervised us every Monday, and another nurse or staff member explained things to us and answered our questions. Sometimes, even the hospital director has lectured to us on his specialty, neurology. Whenever Japan’s laws and acts related to nursing were changed, our secretariat informed us.”

The management of their hospital had organized the systematic support system even before the hospital received the Indonesian candidates. According to its secretary general, it hosted a two-day orientation for the entire Japanese staff before the Indonesians arrived. This orientation included lectures on Indonesian culture, language and society as well as explanation of the hospital’s intention in accepting foreign nurses. By stressing the contribution to an international exchange program without any intention to overcome the shortage of Japanese personnel by employing foreign nurses, the management tried to relieve the Japanese staff’s concerns that they would be fired in the future. Following the orientation, each division of the hospital appointed responsible persons in charge of supporting the foreign nurses. Those divisions included not only the nursing departments in the wards but also radiology, pharmacy, inspection section, secretariat and others. Management directed senior nurses to teach the candidates nursing and Japanese on Mondays, Tuesdays and Thursdays, and clerical staff to teach them Japanese on Wednesdays and Fridays. The staff distributed copies of the previous national nursing exams to their Indonesian co-workers after they obtained a satisfactory proficiency of Japanese.

It is noteworthy that the hospital, which succeeded in making its employing two Indonesian nurses pass the exam, adopted thoughtful tactics even in the process of selection and matching of Indonesian applicants. The hospital’s executive explained the procedures, as follows:

Japanese Executive Secretary: “After JICWELS released the list of applicants and the results of their personal tests, we carefully selected the best applicants from the list. We nominated the applicants who received a grade higher than the average score in all areas of the personal test, and then selected the two who scored higher than the average on each item.”

The executive secretary emphasized the effectiveness of the monetary reward for passing the exam. According to him, he always told the two candidates: “To study hard and pass the exam is your work. We are paying you a certain amount of salary in order to let you pass the national exam. You may pay us back after you pass the exam. After you pass, you can earn twice what you are receiving now.”

From the above narratives, the authors infer that the two successful Indonesian candidates were able to focus on their common goal and maintain strong motivations for passing the exam because they received systematic and well-organized support from the management and staff from the beginning. It was also established that the educational performance in Indonesia (S1 or D3) is not a determinate for passing the exam as long as the management of foreign candidates is well maintained.

IV Discussions and Implications for Policy

The results of this limited qualitative survey show that the most difficult task for all Indonesian participants is to master a number of Japanese words including medical and nursing technical terms written in complicated kanji. Most participants of this study feel that their studying hours are too short for passing the exam. However, the narratives of those who did pass demonstrate that the number of hours studying is not the only factor in determining the results of the exam. Those who passed have always kept their strong motivation to study and find their own way of effective learning.

Effective learning strategies can be summarized: 1) Always ask questions and discuss the answers with your Japanese preceptors or supervisors, 2) Study the past nursing examinations, 3) Set a time-target to finish reading Japanese books and other materials, and make efforts to read as many as possible, 4) Make your own notes and keep them handy at all times and places, and 5) Place learning materials on the wall or other visible places at home.

In the case of Filipino nurse candidates employed in Japan, Yoshichika Kawaguchi and his research partners found in their research that intensive studies of past nursing exams might help in upgrading their scores on the practice exam [see the paper contributed by Kawaguchi and other scholars in this issue]. Indonesian nurse passers’ narratives confirm that it would be true for them.

One point worth mentioning here is that the strong leadership of the management of the hospital and its provision of a comfortable study environment for foreign nurse candidates at their workplace and home contributes to maintaining the candidates’ high motivation to pass the exam. The hospital allocated enough hours (a half day) for studying at the workplace and those hours counted as work hours. Management acknowledged that the educational costs for the candidates would be curtailed if they could pass the national exam in a shorter period than its previous support program for Japanese assistant nurses (jun-kangoshi).[12] It has had a scholarship program for assistant nurses who wish to study at the nursing school and become registered nurses (kangoshi). It costs approximately three to four million yen per person before they pass the national examination. Assistant nurses who have worked for the hospital for three to four years can complete paying back their scholarship to the management of their hospital.

Compared to the costs for Japanese assistant nurses, the total expense for foreign nurse candidates (including tuition fees for instructors) was not excessive (approximately two million yen per person per year in this hospital). If the hospital assisted foreign nurse candidates to pass the exam more quickly, it can reduce the cost of the candidates. Such “cost-oriented management” would be fruitful especially when the hospital became successful in hiring high potential candidates through careful screening and selection during the matching process. This is an important issue to clarify as the Japanese government has earmarked hundreds of million yen to increase the exam passing rate among EPA foreign candidates for registered nurse and certified care-worker candidates since 2010.

The hospital referenced is the one of the few Japanese hospitals that emphasized the foreign employees’ learning rather than their working since their assignment to the workplace. Many other hospitals tended to employ those candidates as “workers” mostly because their salary was the same as the Japanese nursing assistants, but they do not work as many hours because of their study time at the workplace, as shown in the results of the Japanese government’s nationwide survey on the Japanese hospitals that employed first-group Indonesian nurse candidates [Japan, Kosei Rodo-sho 2010: 16]. It reflects ambiguity of treatment of foreign candidates as workers or trainees. Since the balance between work and study hours became an important issue among accepting hospitals and foreign candidates, it should be clearly regulated by the Japanese government.

Low passing rates in the national nursing exam among EPA foreign nurses may be partially explained by the present conditions and schemes of the EPA programs that were drafted without careful consideration of social, cultural and educational differences between Japan and Indonesia or the Philippines. Most Japanese hospitals’ poor capability to instructing foreign candidates efficiently with limited human resources also constitutes a serious obstacle to increasing the passing rate among foreign candidates. It is an urgent matter for Japan and the sending countries to nurture “bridging human resources” who are capable of integrating the two nursing cultures and languages.

It is also found that Indonesian nurses, especially those who failed the national exam, recognize the importance of learning the Japanese language before their entry into Japan. This view was commonly shared by Japanese nurses and other staff that the authors interviewed as well as the Japanese hospitals employing first-group Indonesian nurse and certified care-worker candidates [Ogawa et al. 2010: 93–95].

Data collected in this survey suggest that the governments of Indonesia and Japan must provide efficient Japanese-language training as well as sufficient information about Japan-style nursing that differs considerably from Indonesia’s to incoming Indonesian nurses before their arrival in Japan. The data also imply that both governments need to examine successful cases such as the one exemplified in this survey, and incorporate the ideas and methods into its orientation and guidance programs. Since the number of research subjects is quite limited in this survey, further studies to define a more effective way of supporting foreign nurses are essential for improvement.

Acknowledgements

The authors wish to thank the Japan Society for the Promotion of Science (JSPS) and the Directorate General of Higher Education (DGHE), Ministry of National Education, Indonesia, for their support with the following research projects: 1) “An International Study on Care Services, Lives and Mental Health of Indonesian Care Workers Coming to Japan” (Research representatives: Shun Ohno/Reiko Ogawa and Bachtiar Alam, fiscal years 2009–11); 2) “A Study on Transnational Movement of Foreign Nurses Working in Japan under the Economic Partnership Agreement and Establishment of Accepting System” (Research representative: Yuko Hirano O., KAKENHI No. 213901066, fiscal years 2009–12).

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Kawaguchi, Yoshichika. 2009. Nihon, Firipin, Indoneshia no Kango Kyoiku Karikyuramu no Hikaku [A Comparative Study of the Curricula of Nursing Education in Japan, the Philippines and Indonesia]. Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 3: 91–104.

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1) According to the Kyushu University’s research team’s survey, 59.3% of responding hospitals (28 hospitals; responding rate: 59.6%) that received Indonesian nurse candidates since 2008 had a request to the Japanese government to implement the national exam for the EPA nurses in more flexible way [Hirano et al. 2010: 118].

2) According to Kawaguchi [2009], the Philippines’ nursing curriculum includes many more units than Japan’s. Indonesia’s program is almost as same as Japan’s.

3) MHLW’s EPA-related budget for fiscal year 2010 included subsidies for training in accepting hospitals of foreign nurse candidates (370 million yen), for training in accepting care facilities of certified care-worker candidates (350 million yen) and introductory training for both, JICWELS’ routine guidance and others (150 million yen) [Satomi 2010: 98].

4) According to a paper provided to the authors by the MHLW official August 25, 2011, the total amount of MHLW’s EPA-related budget for fiscal year 2011 is approximately 790 million yen. This budget funds several programs comparable to those for fiscal year 2010.

5) According to official documents provided to the authors by Japan’s Ministry of Health, Labour and Welfare in 2008, 12 hospitals employed a total of 24 first-group Indonesian nurse candidates in the Kansai Region as of July 31, 2008, and only 2 hospitals have employed a total of 3 first-group Indonesian nurse candidates in the Hokuriku Region as of the same date.

6) D3 graduates have studied nursing at the vocational school level for three years. S1 graduates have studied at a four-year college or university and have another year in an internship.

7) The seminar focusing on the successful experiences of the two Indonesians who passed was hosted by Garuda Supporters, a Japanese citizen group supporting the Indonesian candidates in Japan.

8) The Japanese Language Proficiency Test (JLPT) had four levels from the highest, Level 1 to the lowest, Level 4. Level 2 requires foreign learners to master approximately 1,000 Chinese characters (kanji) and 6,000 items of vocabulary, Level 3 requires mastery of approximately 300 and 1,500 respectively. Semi-Level 2 was situated between Level 2 and Level 3. In 2010, a new classification system was introduced and a new category, N3 was established between former Level 2 and Level 3, and reclassified into five categories, from N1 to N5. N3 requires the learners to understand the Japanese language used in Japanese everyday life to some extent.

9) Interview with officials of the AOTS in charge of the EPA project in Tokyo July 17, 2008. The learning of sociocultural adaptation (140 hours) includes Japanese culture, customs and social circumstances.

10) Their Japanese-language proficiency level was uncertain when they were assigned to their workplace because they did not take the JLPT during their learning period at the AOTS facility.

11) According to the Kyushu University research team’s nationwide survey on the hospitals accepting first-group Indonesian nurse candidates one year after their assignment to the workplace, 96% of the respondents (n=28, responding rate: 59%) replied that their employing candidates could converse with their patients without problem, but only 18% replied that their candidates could read and write Japanese nursing records to some extent [Ogawa et al. 2010: 92–93].

12) As of 2009, the number of assistant nurses (jun-kangoshi) was 394,430 whereas that of registered nurses (kangoshi) was 954,818. Assistant nurses must work under instruction of registered nurses. Their license is granted by the prefectural government whereas that of registered nurses is granted by the central government of Japan [Kobayashi 2011: 166–169].

Exploring Learning Problems of Filipino Nurse Candidates Working in Japan: Based on the Results of a Practice National Board Examination of Japan Given in English

Kawaguchi Yoshichika,* Hirano O. Yuko,**Ogawa Reiko,† and Ohno Shun††

*川口貞親，Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu, Fukuoka 807-8555, Japan

Corresponding author's e-mail: kawaguch@health.uoeh-u.ac.jp

**平野裕子，Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520, Japan

†小川玲子，Faculty of Law, Kyushu University, 6-10-1 Hakozaki, Higashi-ku, Fukuoka 812-8581, Japan

††大野　俊，Center for Southeast Asian Studies, Kyoto University

Abstract

This article investigates the status of the education and training of Filipino nurse candidates who have been working in Japan under the Japan-Philippine Economic Partnership Agreement (JPEPA). A survey was conducted among Filipino nurse candidates, using a practice examination based on the English version of Japan’s National Board Examination for Registered Nurses in 2009.

Categorized by area, the mean correct answer rate for nursing-related questions ranged between 61% and 73%; the rate for questions concerning basic knowledge of body functions and diseases ranged between 55% and 57%. There was a large gap in terms of the results of the examination between those who had previously seen the exam questions and those who had never seen them. While 57.1% of those who had previously seen the questions satisfied the acceptance criteria, only 23.7% of those who had never viewed the test satisfied it. Based on these results, the factors which serve as obstacles that Filipino nurse candidates encounter in passing the national examination include not only difficulties in acquiring Japanese proficiency but also differences between Japan and the Philippines in respect to the nursing education curriculum and basic nursing policies.

Keywords: Economic Partnership Agreement (EPA), foreign nurse candidates, practice national board examination in English

I Introduction

With the EPAs between Japan and Southeast Asian nations in effect, candidates for registered nurse and certified care-worker positions have arrived in Japan — from Indonesia beginning in fiscal year 2008 and from the Philippines from 2009. They have been assigned to the hospitals and care facilities throughout Japan for education and training, which has been left to the discretion of each host institution. Preparation for the national examination was also assigned to the host institutions and the candidates themselves.

Both Filipino and Indonesian nurse candidates may take the national examination for nurses up to three times during their stay in Japan as a general rule. The question of how many candidates will eventually pass the examination has become an important social issue publicized widely by the mass media.

Because the national examination is given in Japanese for foreign nurse and care person candidates as well as the Japanese candidates, the language barrier can be a major problem. Some officials and mass media reporters argue that, rather than requiring foreign candidates to take the examination in Japanese, a separate examination for foreigners should be formulated, with questions available in Roman characters as well as kanji and permitting dictionaries during the tests. However, Japan’s Ministry of Health, Labour and Welfare (MHLW), which governs the national examination maintains the policy of “not discriminating against foreign candidates” as of May 2010.

In this study, the authors investigated the status of the education and training of foreign nurse candidates currently training or working at various health-care facilities in Japan and reviewed relevant issues. Concurrently, we conducted a survey among the first group of Filipino nurse candidates, using a practice examination based on the English version. This was to test the theory that if a score was high in the English practice examination, the primary language used in education in the Philippines, it would imply that the issue to be overcome is primarily a language problem. In contrast, if high scores were not achieved, that would indicate that the problems are not just language based: there must also be additional factors that prevent the foreign candidates from knowing the correct answers. The goal of this study is to evaluate and interpret this matter.

II Subjects and Methods

The subjects of this study were the first group of 93 Filipino nurse candidates who came to Japan under the Japan-Philippine EPA project, May 10, 2009. Following Japanese language training at the Association for Overseas Technical Scholarship (AOTS), they were assigned to hospitals October 29. Of these 93 candidates, 59 agreed to participate in the survey, representing 63.4% of the first group of Filipino nurse candidates.

The Kyushu University’s research team and AOTS conducted the survey simultaneously on December 26, 2009 at four locations throughout Japan (Adachi Ward in Tokyo, Osaka City, Nagoya City and Fukuoka City). The time allocation was the same as that used for national examinations in Japan, i.e., 2 hours 40 minutes in the morning and the same hours and minutes in the afternoon. The English version of the 98th National Board Examination for Registered Nurses as administered February 22, 2009, prepared by Kyushu University and reviewed by health workers fluent in English, was used in the survey. The 59 candidates took the practice examination approximately two months after they were assigned to health-care facilities following Japanese language training.

The computer-scored questions are listed in Table 1. There were a total of 240 questions, 120 for each session.

Table 1 The Contents of the National Board Examination for Registered Nurses in Japan

Most questions required candidates to select the correct answer from four possible choices, but some questions offered five choices or wanted two answers from among five options. Questions were divided into 11 sections: ① Compulsory Questions, ② Structures and Functions of the Human Body, ③ Constitution of Disease and Promotion of Recovery, ④ Social Security System and Health of Living People, ⑤ Fundamentals of Nursing, ⑥ Home Health-Care Nursing, ⑦ Adult Nursing, ⑧ Geriatric Nursing, ⑨ Pediatric Nursing, ⑩ Maternal Nursing, and ⑪ Psychiatric Nursing (see Table 1). Compulsory Questions are defined as basic questions across all areas.

The acceptance criteria for the 98th National Board Examination for Registered Nurses are shown in Table 2. There are 30 questions under the Compulsory Questions section, each with a value of one point. In order to obtain a passing grade, a score of 24 or higher was required. If the score for the Compulsory Questions section was 24 or higher, the candidate could pass the examination if she/he scored 174 or higher out of the total 270 points for the General Questions/Situational Questions. The score was calculated giving 1 point for each correct General Question and 2 points per correct Situational Questions.

Table 2 Acceptance Standards for the 98th National Examination for Nurses

III The Results

The percentage of correct answers in each section are listed in descending order: 79% for Compulsory Questions, 73% for Home Health-Care Nursing, 67% for Pediatric Nursing, 66% for Psychiatric Nursing, 65% for Adult Nursing, 63% for Geriatric Nursing, 61% for Maternal Nursing, 60% for Fundamentals of Nursing, 57% for Social Security System and Health of Living People, 56% for Constitution of Disease and Promotion of Recovery and 55% for Structures and Functions of the Human Body.

Table 3 shows the distribution of scores per area. Examination of the results exposed a large gap between the 21 candidates who had previously seen the questions in the 98th National Examination for nurses (either in Japanese or in English) and 38 who responded that they had never seen the questions. Those who had seen the questions had higher scores in all areas. Seven gave correct answers to more than 90% of the questions across the board.

Table 3 The Distribution of Scores by Area Achieved by 59 Filipino Nurse Candidates

The final scores of the 59 Filipino nurse candidates relative to the acceptance criteria are shown in Table 4. Of the 21 nurse candidates who had previously seen the exam questions, 12 (57.1%) satisfied the acceptance criteria. Only 9 of the 38 candidates (23.7%) who had never seen the exam questions satisfied the acceptance criteria; 29 (76.3%) failed.

Table 4 Scores of 59 Filipino Nurse Candidates Who Took the Exam in English

An analysis of the answer rates demonstrates identifiable differences between those with high correct answer rates and those which were low. Table 5 shows that the 48th question in the afternoon session concerning cancer patient care posted the lowest correct response, 12%. It required one answer from among four options, therefore the 12% correct rate indicated that the majority of candidates selected the incorrect option.

Table 5 Correct Answer Rate, 12% — General Question

Questions for which the correct answer rate was 27% are shown in Tables 6 and 7. The question in Table 6 is the 26th question in the morning session concerning adult acute care and that in Table 7 is the 111th question in the morning session concerning the maternal and child health plans formulated by Japan’s Ministry of Health, Labour and Welfare.

Table 6 Correct Answer Rate, 27% — General Question

Table 7 Correct Answer Rate, 27% — General Question

In contrast, Tables 8 and 9 show the questions for which the correct answer rate was high. The only question that received a 100% correct response was the 2nd question in the afternoon session concerning national health insurance (Compulsory Questions, refer to Table 8).

Table 8 Correct Answer Rate, 100% — Compulsory Question

Table 9 Correct Answer Rate, 98% — Compulsory Question

The second highest correct response was for the 10th question in the morning session concerning nitroglycerin with a 98% correct answer rate (Compulsory Questions, refer to Table 9).

IV Analysis

The 59 Filipino candidates that took the practice examination posted a mean correct answer rate for Compulsory Questions of nearly 80%. This suggests that the majority of the candidates had sufficient basic knowledge. Compulsory Questions included those concerning Japan’s birth rate, national health insurance and Act on Public Health Nurses, Midwives and Nurses. However, the correct answer rate for these questions were not substantially lower than those for other questions. Therefore, it can be concluded that candidates have made efforts to gain sufficient basic knowledge of nursing in Japan.

While the mean correct answer rates in the nursing area ranged between 61% and 73%, those for the questions concerning basic knowledge of body functions and diseases dropped to between 55% and 57%. The degree of difficulty in different sections of the National Examination is not equivalent and the Ministry of Health, Labour and Welfare does not publish the results. It is therefore impossible to generalize the results.

Narrowing the conclusions to the candidates who sat in on this examination, it was possible to determine that, while the score level was more or less acceptable with respect to the questions concerning the actual nursing assessment and nursing assistance in clinical settings, it was not very satisfactory with respect to the questions concerning physical features, basic knowledge of diseases, and the social welfare system.

As is also the case with Japanese nurses, the expert knowledge required for competent performance in the assigned department (ward) is retained but knowledge that is not essential tends to be lost. Also the Filipino nurse candidates may have a lapse in time since they left their nursing jobs.[1] Their most recent focus may have been on improving their Japanese language and the measures needed to adapt to living in Japan. The results indicate that at the time of the practice examination, they had not fully acquired comprehensive knowledge in nursing and medicine. In this respect, it is necessary for those who plan to take the national examinations in the future to study in such a manner as to be able to recall the knowledge they already should have acquired.

There was a clear difference in scores between those who had previously seen the exam questions and those who had not. While 12 (57.1%) of those who had seen the questions satisfied the acceptance criteria, only 9 (23.7%) of the others passed.

The authors do not have sufficient information to determine how those respondents accessed and reviewed the questions of the 98th National Board Examination. Some may have obtained the contents by themselves or through their Japanese preceptor. The authors learned that some Japanese hospitals obtained the English version of the national exam and used it as teaching materials for foreign nurse candidates assigned to those hospitals.

The questions on the national exam for registered nurses in Japan are released to the examinees and made public in the home page of the Ministry of Health, Labour and Welfare following the examination. This may be the reason some Filipino candidates were able to access the exam but others could not.

One of the candidates who had previously seen the questions gave the correct answers to all 240 questions for a perfect score of 300. Seven others achieved nearly perfect scores. This suggests that these candidates may have prepared for the practice examination by studying the questions in the English version of the national examination for registered nurses, that the scores do not accurately assess the status of education and training of foreign nurse candidates, and that it may not necessarily be a factor to take into account when formulating study modules to help prepare for national examinations.

It would be possible for the authors to analyze the results of the survey in comparison with the level of attainment of Japanese nursing examinees if the results of the national examination by content for Japanese examinees were available. Such results are not disclosed to the public in accordance with Japan’s Ministry of Health, Labour and Welfare’s policy. The Philippine government also conducts a national board examination for registered nurses every year but it has never released the contents of the exam. Thus, it is quite difficult to compare them with Japan’s nursing exam.

The question with the lowest answer rate (12%) was that concerning cancer patient care. It is considered difficult even for Japanese students. The correct answer is: “2 – Oral administration of morphine solution,” but many candidates incorrectly selected “4 – Oral administration of controlled-release morphine sulfate earlier than 21:00 hours.” This result may reflect the differences between Japan and the Philippines with respect to nursing education curriculum and policies.

The author found that the Philippine nursing curriculum required completion of many more classes and clinical training courses, than the Japanese equivalent [Kawaguchi 2009]. The results from this practice national examination for Filipino nurses indicate that their average correct results are relatively high for questions concerning home health-care nursing (73%), pediatric nursing (67%) and psychiatric nursing (66%), but relatively low in those concerning the structures and functions of the human body (55%). This tendency (relatively good knowledge in nursing but relatively poor knowledge in medicine) can be found even among Japanese nursing students.

It remains difficult to correlate the interrelations between the Philippine nursing curriculum and the results of the practice examination for Filipino nurses. Identifing the differences between the content of nursing lectures and examinations in the Philippines and those in Japan will be important for valid studies.

The 111th question in the morning session, for which the correct answer rate was 27%, concerns the maternal and child health plans formulated by the Ministry of Health, Labour and Welfare. The candidates would have no knowledge of the question unless they had studied for the National Examination. In this context, it was unrealistic to expect a high correct answer rate for this question only a few months after candidates were assigned to health-care facilities.

The only question that had a correct answer rate of 100% was the second question in the afternoon session (Compulsory Questions) concerning national health insurance. It concerns the proportion of medical expenses that the general insured person should assume. On arrival in Japan, the candidates subscribed to health insurance. At that time, the officer in charge is required to provide an explanation of the program. The incoming Filipino candidates would consider this knowledge necessary for their personal benefit. As the correct answer rate was less than 100% for other, relatively easy nursing-related questions, the fact that the correct answer rate was 100% exclusively for this question is interesting. The 10th question in the morning session (Compulsory Questions) concerning nitroglycerin posted the second-highest correct answer rate (98%). Even though this is basic knowledge, necessary for nurses to know, not all managed to give the correct answer.

V Conclusion

This article is based on the results of the survey using the English version of the national examination. What can be concluded is that obstacles for the Filipino nurse candidates in passing the national examination might include not only language problems but also differences in the nursing education curriculum and basic nursing policies between Japan and the Philippines. These factors may provide some suggestions for assisting the candidates in improving on the exam in Japan. Study modules designed to help them prepare for national examinations should take the issues discussed in this article into account.

Acknowledgements

This article was revised from the following original Japanese version: Yoshchika Kawaguchi, O. Yuko Hirano, Reiko Ogawa and Shun Ohno, 2010, “Gaikokujin Kangoshi Kohosha no Kyoiku to Kenshu no Kadai: Firipin-jin Kohosha o Taisho to shita Kokka-shiken Mogi-shiken Chosa o Toshite [Issues in the Education and Training of Foreign Nurse Candidates: A Mock National Examination of Filipino Candidates]” Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 141–146.

The authors wish to thank the Japan Society of the Promotion of Science for its support to the following research project: “A Study on Support System for Foreign Nurses Introduced by Economic Partnership Agreement” (Representative: Dr. Yuko Ohara-Hirano, KAKENHI (B), 21390166).

References

Japan, Kosei Rodo-sho [Ministry of Health, Labour and Welfare]. 2009. Dai Kyuju-hachi-kai Kangoshi Kokka Shiken Mondai [Questions in the 98th National Examination for Nurses] (the examination took place on February 22, 2009). Tokyo: Ministry of Health, Labour and Welfare.

Kawaguchi, Yoshichika. 2009. Nihon, Firipin, Indoneshia no Kango Kyoiku Karikyuramu no Hikaku [A Comparative Study of the Curricula of Nursing Education in Japan, the Philippines and Indonesia]. Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 3: 91–104.

1) Under the Japan-Philippine EPA, Filipino nurses accepted to Japan as nurse candidates are required to have work experiences as registered nurses for at least three years.

Nurses from Abroad and the Formation of a Dual Labor Market in Japan

Asato Wako*

*安里和晃, Graduate School of Letters, Kyoto University, Yoshida-Honmachi, Sakyo-ku, Kyoto 606-8501, Japan

e-mail: w_asato@hotmail.com

Abstract

This article examines concerns regarding the formation of a dual labor market in Japan-Indonesia/Philippines projects under the Economic Partnership Agreements (EPAs) by comparing legal framework, rules, guidelines and actual conditions. These potential problems were identified before the agreements went into effect. An institutional framework has also noted different alternatives that might mitigate these difficulties.

Ensuring equal remuneration for Japanese and migrant workers and providing sustainable Japanese language skills and adequate exam preparation might prevent the worsening of wage and working conditions in the labor market.

Through an analysis of three surveys, this article argues that the accepting organizations have introduced an increasing bipolarization of training hours. Furthermore, the numbers of accepting organizations are decreasing due to this imposed burden. The first cause of this is the weakness of the educational infrastructure in overcoming examination difficulties in Japanese. This is partly due to the fact that the EPAs began before their terms and conditions were clearly defined. The early formative years show that the Japanese government took a noninterventionist stance and continuous learning has been difficult for some candidates because the accepting organizations, hospitals and care facilities, are not educational institutions. Even though the Japanese government has spent 1.5 billion yen over the last two years to improve the training infrastructure, bipolarization continues to be a major issue.

Even with the higher satisfaction ratio of patients under EPA, the number of accepting organizations is declining, and concurrently, the number of licensed nurses entering Japan through non-EPA channels is increasing. The examination pass-ratio of these non-EPA nurses greatly outnumbers that of the EPA candidates, which seriously calls into question the significance and sustainability of EPA in its current form.

Keywords: EPA, dual labor market, deskilling, level of care

I Introduction

As demographic changes increase, the risks of a new deficit in the labor force have become a salient issue, especially in the case of insufficiency in care. Care is defined as paid or unpaid work essential for maintaining regular daily life, supplied by government, market, family, or community [Esping-Andersen 1990]. The welfare system has clarified the supply mechanism of welfare such as that care in different countries and the issues related to the aging process are not limited to which sector will provide the care. It is also a question of who will compensate the providers for the mushrooming “care deficit.” The sustainability and security of care is a significant issue for aging societies, as the populations in developed nations continue to decline. Unlike manufacturing, care provision cannot be automated, cannot attract a labor force by raising wages in a welfare state constrained to institutionalized wages determined by the state, and cannot be outsourced overseas. Hence, care cannot be seen in terms of productivity that can easily be increased. Thus, securing care providers is now a crucial matter for aging societies suffering from a declining workforce as will be discussed later.

According to Japan’s National Forum on Social Security, between 2007 and 2025, the demand for elderly care workers will double and that for nurses will increase 30–60% [National Forum on Social Security 2008]. Elderly care and nursing are two fields with a chronic lack of workers; an issue shared by all the developed countries to a certain extent. However, it is a job market that potentially can absorb a great number of the unemployed, thus it is expected to help decrease current and future unemployment rates. A Cabinet decision by the Democratic Party of Japan set a goal of turning the occupations of elderly care and nursing into a 50 trillion-yen market and creating an additional 2,840,000 jobs by 2020.[1]

Nevertheless, there remains a strong concern about these promising fields because of the demographic dilemma. First, it is hard to believe that the country can find an additional 2,840,000 people to accept these jobs when the qualified working-population (aged between 15 and 64) is forecast to decrease by eight million over the next 10 years (2010–20), thus causing a severe shortage in the workforce.

Second, the ability to supply this labor continues to be an unstable factor that depends on changes linked to the present economic climate. As the economy recovers, people tend to gravitate to fields that can offer higher incentives; and if the economy shows a downward trend, they will return to care work. In particular, as more of the baby-boomer generation requires elderly care, the demand will increase dramatically. In other words, contrary to the steadily increasing demand for elderly care, the ability to supply that care is unstable. Unless an adequate number of workers in the care sector can be guaranteed regardless of the economic climate, the quality of elderly care will inevitably decline.

Third, a shortage of elderly care providers will not lead necessarily to higher wages. Wages in the medical and welfare sectors are dependent on the insurance system and, to a certain extent, already established. System-based wages are not flexible as in the labor market and do not increase significantly even when the workforce is inadequate.

Two reasons can be given for the mobilization of a potential workforce for elderly care. One is the problem of compatibility between unpaid care at home and paid work outside the home. The pressure for family care is expected to increase in the future, based on the anticipated slashes to care-related services under Long-term Care Insurance.[2] Therefore, utilizing the potential workforce will become more difficult.[3] In order to encourage women to continue working, compensation is necessary. That would necessitate securing outsourcing methods in the market, within communities, and/or in the workplace, as well as reconsidering the gendered division of labor. The second reason is that the wage standard discourages mobilization. This is not related exclusively to compensation for elderly care under the Long-term Care Insurance set by the government institutionally. In Japan, the minimum wage is often lower than the standard of public assistance, which discourages people who potentially would be willing to work. Thus, the minimum wage is set at a lower point as a reservation wage.[4] Unless these systemic contradictions are resolved, attracting an adequate workforce into the labor market will remain difficult.

In general, a “deficit of care” makes it hard to utilize the potential workforce, a problem that is not limited to elderly care. If we attempt to compensate for the deficit of care at home through other outsourcing methods — including public facilities — we will be required to compensate for the deficit of care in their families generated by those working in outsourcing facilities. The title, “care chain dilemma,” applied to this situation, implies that outsourcing may not solve the care-deficit problem. The problems of an increase in care demand are due to changes in the demographic composition and also to the increase in the workforce demand, caused by a decline in the working-age population. These issues will become even more obvious in the future and may be difficult to solve within the country’s labor market.

Although aware of this global concern, Japan’s migration policy has continued to fluctuate and remains ambiguous, even after accepting the EPA candidates as potential registered nurses and certified care workers. Having denied that there is a shortage of nursing and care staff, Japan’s Ministry of Health, Labour and Welfare (MHLW) announced it would accept human resources from Asian countries due to national interests in terms of trade liberalization.[5] This political inconsistency has introduced confusion into the implementation of the program. Although the MHLW and associations such as Japanese Nursing Association (JNA) are reluctant to accept foreign health-care staff due to the fear of the formation of a dual labor market in Japan, bipolarization is becoming a reality due to unclear purposes and confusion among accepting organizations.

This article examines the authenticity of these fears regarding the formation of a dual labor market in the case of the EPAs by comparing existent legal frameworks, rules, guidelines and actual conditions. The author conducted a series of interviews with EPA candidates (n=40), those who accepted them at hospitals and facilities (n=10), Japanese governmental bodies such as the Ministry of Economy, Trade and Industry (METI), MHLW, Ministry of Justice (MOJ) and the Ministry of Foreign Affairs (MOFA), Japan Foundation, AOTS (The Association for Overseas Technical Scholarship), government officials of the Philippines such as POEA (Philippines Overseas Employment Administration), TESDA (Technical Education and Skills Development Authority), the Embassy of the Philippines in Japan, the Philippines Nurse Association and officials of Indonesia such as the Ministry of Health, National Board for Placement and Protection of Indonesian Overseas Workers (Badan Nasional Penempatan dan Perlindungan Tenaga Kerja Indonesia, abbreviated as BNP2TKI), the Embassy of Indonesia in Japan, the Indonesian Nurses Association, hospitals, nursing colleges, recruitment agencies, etc., over a period from 2004 to 2011.

II Fears of the Formation of Dual Labor Market

Anxiety over the formation of a dual labor market had been noted before the EPA programs were implemented [Hasegawa 2006; Kawara 2005; Okaya 2005]. Major causes include low wages that reduce the wages of local workers and skill levels not compatible with local settings in the areas of language, education and qualification. Goto [1990], for example, notes how accepting migrant workers increases the labor supply as well as reducing personnel costs, thus increasing profits. However, we must also note that this lowers the wage levels of local workers, which may motivate them to transfer to other sectors to compensate. Though this theory is widely accepted, it may not be applicable to medical and welfare sectors where labor demand is both stable and strong due to demographic changes, much more stable than in the manufacturing sector which is vulnerable to economic cycles.

One commonly accepted dual labor-market theory is the following: When migrant workers’ wage levels are low, employers’ incentives towards investment to increase productivity such as mechanization and automation may be reduced because low wages compensate for productivity. The reliance on low-wage workers may sustain the industry’s low productivity and enable it to rely on low-wage workers to be more internationally competitive, which in itself becomes a vicious cycle. Therefore, if this is the case within an industry, the result can be sluggish investment, innovation and low productivity. An example of this would be a sweatshop. However, this argument is based on the premise that migrant workers are low-wage workers, but that is not always the case. Asato [2005; 2007] have clarified that the employment costs of migrant workers is not lower than predicted and sometimes, can be higher than the local workers due to costs of recruitment, education, management and lodging. In the case of Japan, excluding trainee programs, the remuneration for local workers is equivalent to that for migrant workers, which prevents the formation of a dual labor market.

Asato has also clarified the complementary position between local and foreign workers in the labor market [Asato 2007, forthcoming], and establishes that employability is socially and institutionally constructed in the process of recruitment. There are a number of examples that illustrate this position: (1) when migrant workers pay large recruitment fees to brokers, they are inclined to accept difficult working conditions such as overtime to maximize income and lower turnover rates; (2) when migrant workers are obliged to stay in a workplace, they are inclined to accept night and holiday shifts; (3) migrant workers are inclined to accept lower wages because of their weakened negotiating power; and (4) though migrant workers often possess higher skills than the local workers in host countries, they experience downward mobility in their social position due to the fact that their skills may not be recognized. This enables employers to shape migrant workers’ labor to match the employers’ needs. Thus, a dual market is socially constructed and affected by recruitment processes and employment but it is not formed automatically after accepting migrant workers. Thereby, foreign workers are transformed in a way that complements local workers such as through high wages, a high turnover rate, operating on holidays, the aging of employees, gender composition and so forth.

This article, based on the previous studies, clarifies how the institutional settings and policy implementation affect the actual conditions of the EPA candidates and accepting institutions.

III The Labor Market and the Position of the EPAs

Even faced with the present tight conditions of the care-labor market, the MHLW denies there is a shortage of nurses and care workers. Examination of the supply versus demand estimates of available nurses, based on the estimates of the Japanese nurse workforce by MHLW, makes this clear. Tables 1, 2 and 3 offer comparisons of three consecutive five-year plans. The MHLW estimates predict that the demand-supply gap will narrow within each five-year plan. For example, according to the 2,000 estimates, the gap of 35,400 persons recorded in 2001 would be solved by 2005 by the mobilization of potential nurses not yet in the labor market. The next five-year plan, released in 2005 estimated that a gap of 41,600 nurses would be narrowed down to 15,900 nurses by 2010. The logic here is that the gap will be filled due to a mobilization policy, identical in all the estimates. Reality contradicts these optimistic estimates. The gap has been widening in every report, until by 2011, it is estimated at more than 56,000. Even with the statistical evidence of ongoing chronic shortages, the MHLW and the Japanese Nursing Association (JNA) maintain that the shortages can be solved through the mobilization of potential nurses. This is the basis of their resistance to receiving foreign nurses.

Table 1 Five-Year Estimate on Nurse Workforce (2000)

Table 2 Five-Year Estimate on Nurse Workforce (2005)

Table 3 Five-Year Estimate on Nurse Workforce (2010)

From its beginning, one of the prime difficulties in effectively implementing the EPA program has been the opposition of the ministries and other organizations.

IV Position of the EPA Program in Official Documents

Even with this reluctance from related organizations, it is very clear from the official documents in Japan that the EPA program is a training program for the enhancement of candidates’ knowledge and skills so that nurses from both sending countries can earn recognition as nurses or certified care workers in Japan, safeguarded by labor laws that prevent them from being underpaid without allowing a decrease in the wage level of local workers.

Let us examine the official position of the EPA program from the perspective of Indonesian nurse candidates. First, they are defined as persons who enter and stay in Japan for the purpose of obtaining national licensure as registered nurses, as defined in the Indonesia-Japan Economic Partnership Agreement (IJEPA) according to a guideline issued by MOJ May 26, 2008.

Second, MHLW Notification No. 312, issued May 29, 2008, clearly states that the responsibility of Indonesian nurse candidates is to make an effort to acquire the necessary knowledge and skills to qualify for a national license to work as nurses or certified care workers and to contribute to the promotion of the public health of both countries after passing the national board examination. Notification No. 312 defines the responsibility of accepting institutions to provide an environment that allows candidates to learn the necessary knowledge and skills to practice their profession in the field of public health. This clause also designates that candidates should be provided appropriate labor conditions in accordance with Japan’s labor-related laws. What this makes clear is that both parties share responsibility for the candidate’s acquisition of the nursing license.

Third, according to the MHLW, acceptance of the EPA candidates is a program connected with training for the national board examinations in Japan. Notification issued September 8, 2010, stipulates that after language training the candidates are to work based on contracts with accepting institutions while receiving training for the national board examination for registered nurses and certified care workers.

The purpose of the program is defined primarily as a training program, which operates under the labor laws, as in a standard contract. However, ambiguity in the application of this program becomes evident soon after the program was launched.

V Conflict between Work and Study

A particularly common source of friction between accepting institutions and candidates is employers’ refusal to acknowledge learning time as work time. The following chart clarifies the issue by quantifying learning hours employed in preparation for the national board exam including Japanese language study.

Fig. 1 indicates that learning hours became bipolarized among institutions that accepted the first batch of Indonesian candidates.[6] According to the survey in August 2009 conducted by the Sasakawa Peace Foundation (n=17),[7] training hours were approximately 13.2 hours per week. The hours are split between exam preparation and Japanese language study. The Sasakawa survey’s average, 13.2 hours, is divided into 8.8 hours for the former and 4.4 hours for the latter. Approximately 15% of the surveyed institutions provide the fewest training hours, 0–5 hours per week. However, according to the survey conducted by the MHLW in February 2010 (n=36), the distribution of learning hours has become bipolarized. The average of weekly training hours has remained comparable at 13.3 hours.

Fig. 1 Distribution of Weekly Learning Hours

Source: [Asato 2010a, 2010b; Japan, MHLW 2010b; JICWELS 2010]

However, the ratio of institutions that provide less than 5 hours rose to approximately 30%, while those allotting 20–25 hours per week, 4–5 hours per day, equals 30% as well. The increase in the number of institutions that provide more learning hours is largely due to the results of the board examination conducted in February. Nonetheless, there is a clear decrease in the ratio of institutions that provide the fewest learning hours. Even though institutions recognized the importance of allowing sufficient time for exam preparation, the fact that they decided it was more important to emphasize work rather than studying for the national board examination, may have caused the bipolarization. This dichotomy puts into question the purpose of the program. The tendency does not change in Japan International Corporation of Welfare Services (JICWELS hereafter) visitation survey in May 2010. The bipolarization is, in a way, a rational choice of an employer to save the additional expenses, which do not directly contribute to training and invest the funds to raise productivity so that a candidate can perform capably after obtaining the license.

No definitive solution was found in these cases despite the fact that the candidates involved refused to accept their situations and consulted with their superiors and/or JICWELS. Since migrant workers are not generally familiar with external support agencies such as the Labor Standards Supervision Office, they tend to feel that they cannot do more.

VI Pressure toward Segmentation of Labor Market

There have also been cases where, in order to ease their burden, accepting organizations have not paid their workers for training time. According to Ministry regulations, since the original provision that training time should be compensated as work hours is binding, this training time should always be paid unless there is a separate agreement between the employee and the employer.

Filipino nursing candidates and the Philippine Embassy in Tokyo regarded this as a serious problem. According to the embassy, candidates most frequently mentioned that although they thought that they were guaranteed 40 work-hours a week, as stipulated in their contracts, training time was not being paid — therefore, they did not earn as much as they expected. Recently, employment contracts have factored this training into the accounting and include ways of paying employees for less than 40 hours work, for example by paying them for “four days per week” instead. Beginning with the third group of candidates, the embassy examined the possibility of not entering into contracts with any accepting organizations that do not pay for training during work hours.[8]

Furthermore, from the viewpoint of the Japanese government, the Philippines’ Department of Labor and Employment (DOLE) was not so cooperative in regard to the EPA language program when Japan’s MOFA began a pre-departure Japanese-language training program in Indonesia and the Philippines. The department authorized only two to three months of training in the Philippines instead of the six months scheduled for implementation in Indonesia beginning in late 2011, even though this program is funded by the Japanese government.

The Philippine government is also reluctant to accept Japan’s request to impose a Japanese-language quiz on Filipino applicants for the EPA program and release the results as information for matchmaking between the Filipino applicant and the Japanese employer. According to the Labor Office of the Philippine Embassy in Tokyo, the current EPA implementation is far from what its government expected due to a number of reasons. One is the working-hour issue explained above; the second is an issue regarding jun-kaigo fukushishi (certified assistant care worker).[9] Countering this, the MHLW recognizes that precisely 40 hours of work per week is not essential, as long as social insurance remains applicable.[10] This means that each accepting institution can determine working hours at its discretion.

It is not only the Philippine government that has expressed difficulties. Before the implementation of the EPA program, the National Board for Placement and Protection of Indonesian Overseas Workers and Department of Health (abbreviated as Depkes from Departemen Kesehatan) of the Indonesian government negotiated with its Japanese counterpart over the wage level of candidates to maximize their income. The Indonesian government asserted that the maximization of income for candidates should be prioritized, as passing the board examination was considered almost impossible. In other words, the negotiation strategy of the government was to maximize gains through work within a limited duration but not depend on a longer stay in Japan after passing the board examination.

This shows that the issue is whether the primary purpose is to accept EPA migrants for work or for training. The MHLW guidelines emphasize “it is important for accepting institutions to implement suitable training which is targeted at the passing of national qualification examinations.”[11] Therefore, foreign candidates are expected to prepare for the national examination while working as agreed in the work contract. That is why some candidates returned to their home countries on the grounds that they did not have the determination to prepare adequately for the exam. One candidate recalls that when she consulted with the staff of JICWELS, she was informed through a text message from an interpreter at JICWELS that her apathy toward the exam preparation is “illegal,” and thus the hospital’s decision to cancel its employment contract was deemed appropriate. This implies that if the accepting institution does not provide adequate training for the exam, it also violates the purpose of the program. As the results of the surveys on study conditions indicate, the bipolarization of study hours is clearly obvious. It reflects differences in the treatment of the candidates and the understanding of the current situation by employing institutions.

This is not merely an issue of legal interpretation. The working conditions described above are not only potentially illegal but also capable of destroying the principle of accepting EPA candidates, while attempting to avoid a negative effect on the labor market. The bipolarization of learning conditions reflects the high costs shouldered by each institution. It is both rational for the accepting institutions to save additional costs such as those for education or to provide maximum training time to enhance high productivity by letting the candidates obtain a national license. Even though the provision of minimum training violates the notification and works against the purpose of the scheme, the government cannot intervene even if some candidates were returned to their home country on the grounds of apathy toward training. The minimum provisioning indicates EPA candidates are limited to nursing-aide work and this makes it clear that there is a hierarchy forming between Japanese staff and EPA candidates. This clearly has a negative impact on the labor market. Therefore, it is necessary to avoid bipolarization.

VII High Institutional Costs and Bipolarization

Candidates are not the only ones who face difficulties — accepting organizations have also encountered various problems of their own. Similarly, according to a MHLW survey on Japanese staff in charge of training [Japan, MHLW 2010b], 14 of the 24 institutions requested educational guidelines and teaching materials for their candidates. A survey by the Sasakawa Peace Foundation found that many respondents were critical of the fact that all the planning had been passed on to the accepting institution. The majority of Japanese hospitals do not have sufficient educational facilities because Japan does not require the renewal of nurse licenses, as does the United States, therefore additional education was not instituted at hospitals. The most serious aspect of this problem is that almost all foreign candidates’ education is entrusted to the institution where they work, despite the fact that the majority of accepting institutions had no prior experience in employing foreign workers. In other words, the accepting institutions need to provide education in the Japanese-language as well as exam preparation. By 2010, an educational guideline was established.

This is in addition to the actual expense of accepting candidates. It is true that the cost shouldered by accepting institutions is not small. Until the time when candidates begin working after six-month language training, the initial cost of accepting one candidate, including mediation fees, Japanese language training, and commission paid to the National Board is approximately 600,000 yen.[12] Furthermore, if we presume that an accepting organization has two candidates and provides 13.2 hours of training per week for each of them, in addition to providing a tutor, then nearly 40 additional man-hours of work is dedicated to training each week. If administration and other costs are included, the total is much higher. Employers consider this a burden. Consequently, they elect to reduce the time allocated to training, schedule training during non-working hours or refuse to pay candidates for their training. The other side of bipolarization is based on the perception that a successful candidate could return the economic investment and/or bring recognition to the institution and above all, provide for the training, all responsibilities of the EPA program.

VIII Role of the Government in International Migration

In addition to the expense, international migration necessitates many more elements to efficiently coordinate and manage it. Let us examine one of the core causes of the high burden imposed on accepting organizations by the recruitment processes of the EPA programs.

JICWELS is the only matching agency on the Japanese side for the EPA projects. The role of international mediators is not solely to act as intermediaries matching candidates with accepting organizations. They also have a role to play in education, management, labor-management regulation and communication. According to guidelines, MHLW’s role in relation to JICWELS is to report on the training of workers such as Filipino and Indonesian care workers, supervise activities, etc. In practice, this means monitoring activities such as recruitment and mediation, receiving reports from accepting organizations, implementing training in areas such as care work, supporting those who are entering and leaving the country and consulting with both candidates and the accepting organizations.

Furthermore, duties itemized in the operating plan for 2010 include finding potential accepting organizations, reviewing requirements, translating and supplying candidate information, operating a matching system and supporting the drafting of employment contracts. Its goal is to ensure smooth implementation and administration of the acceptance of foreign nurses and care workers.[13]

Mediation agencies, especially when it comes to mediating professional human resources,[14] tend to emphasize matching demand and supply. The EPA candidates and ordinary workers, however, are restricted in their movements and choice of work. In this case of tightly binding migration, the migration itself involves more than mediation work. Mediation agencies therefore have no choice but to address the frictions arising from cultural and language differences, such as making arrangements for workers entering or leaving the country, managing migrant workers and coping with labor-management issues that differ from those of local Japanese workers. This is because foreign workers are deprived of their bargaining power when their freedom of movement and occupation is limited and when they are given limited knowledge of labor-related laws. As a result, the employment of migrant workers brings with it the need for labor-management coordination. Employers must assume greater responsibility and a higher level of employee coordination. This differs from what is required for the employment of Japanese workers.

The acceptance of migrant workers causes various problems regarding lifestyle, immigration administration, work and other areas. Management of these problems is often entrusted to other organizations such as mediation or placement agencies. Initially, the government’s position on its role was limited to controlling the entry of the candidates and matchmaking. The government’s position was one of nonintervention especially in regard to contracts between the employer and the employee. That is why training was placed on the shoulders of accepting institutions. However, those institutions do not have the expertise or staff to develop the skills of foreign workers to pass licensure examinations. The majority of them have accepted foreign workers for the first time and are not sufficiently equipped to deal with them. Hospitals are not educational institutions. They lack know-how and did not have an established educational curriculum until 2010.[15]

As a result, the accepting organizations have experienced difficulties in educating candidates. The accepting organizations conceded the accuracy of the opinions reported in the survey of the Sasakawa Peace Foundation and MHLW regarding their fumbling, trial-and-error approaches. Since there is a lack of clarity regarding the effectiveness of the training or the necessity to get involved with supporting workers’ duties, training them in Japanese and preparing them for examinations, while also providing lifestyle support, drains the staff of many hospitals and care facilities that offer training.[16]

Japanese-language teachers can teach colloquial, basic Japanese. However, they often lack sufficient knowledge of the terminology and jargon required for nursing and care work. Training instructors are informed that collaborating with experts in the field can be an effective solution but they are required to develop the curriculum and educational materials.[17] After the program began, materials were developed based on Japanese teaching methods for nurse and certified care-worker candidates by the Japan Foundation AOTS and instructors of the Japanese Teaching Group “Y.”[18] Until those materials were available, there had been a shortage of resources and lack of external organizations with the necessary know-how, especially in nonurban areas. The criticism from one organization, below, reflects the position of accepting organizations:

“The most frequently raised concern was the lack of clarity about who was responsible for this program. Though the goal of all those on the accepting side was to get their candidates to pass the national examinations, the methodology was left to each individual institution. Those who come to Japan are also doing so in order to get a license to work in Japan and to improve their skills. As a nation, however, Japan is not presenting them with a certifiable curriculum to achieve this.” (A staff member of hospital “A” in the Kanto Region)[19]

The above opinion was valid at the time of the survey.[20] Accepting institutions often criticize the government for its reluctance to support the scheme even though it is a national project. However, considering the fact that the employment contracts are negotiated between accepting organizations and candidates, MHLW dismissed the criticism that the government was passing the work to others and asserted that each individual organization should take responsibility and deal with employment contracts on their own. This was the institution’s first experience accepting and training foreign workers. Without a solid foundation in place, entrusting the training of workers to the accepting institution is inefficient.[21]

The complaint of “having all the work dumped on us” is often found in reports, and the national budget for teaching support has rapidly swelled. Initially, the role of the government was to consider opening up the Japanese labor market to the entry of foreigners by changing immigration laws and regulations and to develop a mediation function to protect migrant workers from exploitation in the recruitment process. However, as pointed out, the mediating agencies in the cases of migration must do more than just mediate. Above all, migration under the EPAs is not simply the case of free movement in the labor market but preparation for the national licensure examination, where there is almost no infrastructure at the time of implementation as discussed later. Poor educational infrastructure for foreign workers has proven a barrier in gaining equal opportunities on par with Japanese examinees. This is another reason for pointing out an urgent need to develop a more efficient infrastructure.

In 2009, JICWELS received a 125 million-yen subsidy from MHLW to implement introductory training for care workers and nurses, establish a consultation service, inspect relevant sites, distribute resources, implement mock tests, etc. This sum was an increase over the 20 million yen received in 2008; in 2010, the subsidy increased sharply once again to 870 million yen. This was not solely because of the escalation in the number of candidates. Another contributing factor was the high number of cases where candidates had not acquired the required skill level in the Japanese language. Reports and surveys indicated that many accepting institutions were struggling to implement training programs. Fears that communication problems in the workplace could result in medical accidents prompted the increased subsidy. It was also intended to lighten the burden on the accepting organizations. Many of the accepting organizations struggling with education have requested improvements in the Japanese-language training. It is evident that at present, there are limits to what can be learned during the current six-month Japanese-language study period. MHLW insists it is essential to improve the candidates’ Japanese level before they arrive in Japan and has requested the Ministry of Economy, Trade and Industry (METI) and MOFA to take appropriate steps to improve the Japanese-language training program for the candidates before and after their entry into Japan. To address these issues, MOFA’s new predeparture language training has been implemented in both the Philippines and Indonesia.

The overall budget for MHLW relating to EPA in 2010 amounts to 870 million yen. Continuing from the previous year, the Ministry provides introductory training for nurses and care workers, visits accepting organizations, provides consultation and translates national examination questions. For the first time, it must provide training support for accepting organizations. The Ministry allocates 295,000 yen to each accepting organization, which trains nurse candidates; and each nurse candidate is allotted 117,000 yen to support his or her work and the study of nursing or the Japanese language.[22] While these budgetary measures are expected to be effective in providing motivation and lightening the economic load on accepting organizations, establishing an infrastructure to allow continuous learning is also essential. Since this is a purpose-specific subsidiary disbursed through prefectural governments, it has proven effective in improving the educational infrastructure that some organizations were reluctant to implement to reduce expenses for candidates.

Other budgetary operations include introductory training for candidates, JICWEL’s visit to all accepting hospitals and care facilities, the establishment of a trouble-shooting hotline, the translation and distribution of national board examinations from previous years, a workshop for trainers, the provision of an e-learning system and study materials, schooling for preparation of the exam, etc. In 2011, the MHLW proposed an allocation of 850 million yen for the EPA project. A major difference from the 2010 budget is the sharp increase in the training support fund for each hospital that employs nurse candidates from 295,000 yen to 461,000 yen.[23] The fact that the budget shifted from high costs of establishing the learning system to a maintenance level accounts for the slight decrease in the amount of the proposed budget.

IX The Sustainability of the EPA Projects and Growth of Non-EPA Nurse License Holders

In 2010, the results of the national nursing examination, including the names of the three foreign candidates who passed, were made public. Two were Indonesian candidates from Niigata Prefecture and the other, a Filipino candidate from Tochigi Prefecture. Those are not urban areas such as Tokyo or Osaka. This fact indicates that the better infrastructures for learning that might be expected in the urban institutions are not a significant factor in passing the exam. The other significant datum is that the two Indonesians who passed are from the same hospital, where the training and learning method proved highly effective [see Setyowati et al. in this issue]. The success of the three EPA candidates clearly refuted the preconceived idea that it is impossible for foreign candidates from non-kanji countries to pass the national exam.

The intensification of MHLW’s support of the training infrastructure may show significant improvement in the next year. In the nursing exam administered in February 2011, 16 candidates passed the exam; 13 are candidates from the first batch of Indonesians and 2 are from the second batch. Only one Filipino candidate passed from the first batch. The pass rate of first-batch nurse candidates from Indonesia remains 14% out of a total of 104 entrants. There are differences in opinion whether this is a satisfactory level. Unless the pass rate rapidly increases, the EPA program could result in treating the majority of nurse candidates as “nursing aides” for three years at the cost of more than a billion yen in government subsidies — for what the author calls a “deskilling training project.”

However, it is interesting to note that the level of care is not on the decline since the acceptance of foreign workers as had been suggested elsewhere. MHLW has disclosed that the satisfaction level of the care recipient or level of care improved after introducing EPA candidates, according to research by MHLW,[24] JICWELS[25] and Sasakawa Peace Foundation [see papers contributed by Shun Ohno and also Reiko Ogawa to this issue].[26]

In contrast, behind the shadow of the EPA programs, there is a rapid increase in new licensed nurses among Chinese[27] examination applicants (see Fig. 2). In 2005, a revision of a MOJ extended the duration of residency for foreign nurses who acquired a nursing license in Japan. This opens the application for the examination to more foreign license-holders under certain conditions.[28] One of the requirements is the previous passage of the N1 Japanese Language Proficiency Test. This is in spite of the fact that the majority of the EPA candidates entered Japan without holding the N3 or upper level of Japanese proficiency.[29] An academic record overseas equivalent to the Japanese nursing curriculum standard is also required.

Fig. 2 Transition of Numbers of Non-EPA Foreign Nursing Examinees and Passers

Source: [Japan, MHLW 2011 (unpublished data)]

Since 2006, the number of non-EPA foreign applicants has been increasing as have the numbers who have passed the nursing exam in Japan. It is worthwhile to note that the pass rate is far better than that of the EPA candidates. The ratio for non-EPA applicants was 50% in 2006, and rose to nearly 100% in 2011. This framework is not based on a government-to-government scheme but individuals. Thus the respective governments do not have to budget for exam preparation, an important difference between the EPA program candidates and non-EPA license-holders.

Fig. 3 shows the trend in the number of the EPA entrants and non-EPA foreign license-holders. The figures for non-EPA license holders do not necessarily indicate that they reside and are employed in Japan at this time. The EPA nurse-candidate trend and that of non-EPA applicants for registered nurse are contrastive. Although the number of EPA candidates who entered Japan sharply declined in 2010, that of non-EPA foreign nurses has increased steadily.

Fig. 3 Transition of Numbers of EPA Entrants to Japan and Non-EPA Nurse License-holder

Note: The data on non-EPA entrants is not published by the MHLW.

The author’s interview with employees of one hospital that accepts non-EPA nurses discloses that politicians and an intermediary group have connected non-EPA new license-holders with hospitals and targeted the hospitals that have experience employing EPA nurses. According to those interviewed, the advantages of recruiting Chinese nurses are: 1) they have a head start in Japanese language education particularly in their understanding and knowledge of kanji or Chinese characters and preparation for the national licensure examination and 2) they are industrious. They are ready to work immediately upon entering Japan since they already have the N1-level of proficiency in Japanese as well as Japan’s license as a registered nurse.

Under the EPA program, a number of Japanese hospitals and care facilities have accepted EPA candidates as a form of international support or as preparation for the future internationalization of nursing [see Ogawa in this issue], but are not committing to recruit Indonesian or Filipino workers exclusively. Furthermore, the expenses incurred, such as the cost of acceptance, special OJT and off-JT, various provisions for the candidates, the long duration of training and above all, teaching proficiency in the Japanese language, are significant.

It may be more convenient and cost-effective for the institutions to recruit foreign nurses who have Japanese-language competency and nursing licenses upon employment. Whether they continue to hire EPA candidates or employ through other routes will be determined by the future progress of the EPA program.

X Conclusion

In this article, the author has examined the threat of the formation of a dual labor market by the entry of EPA candidates for registered nurse and certified care worker in Japan. In particular, the article has investigated these fears by comparing differing legal frameworks, rules, guidelines and actual conditions. The concern over the formation of a dual labor market was raised before current agreements came into effect. Official memorandums and policies recommended mitigating the issue by ensuring equal remuneration for Japanese and EPA foreign workers and providing adequate training for Japanese proficiency and passing the national exam.

Nevertheless, it is clear that there is an increasing bipolarization regarding the number of training hours provided by accepting organizations. This is supported by interviews with those connected to the EPA venture. The first cause is the weakness of the educational infrastructure to succeed in passing the examination in Japanese. This is partly due to the fact that the EPA programs were introduced before infrastructure reconstruction took place. The noninterventionist approach of the Japanese government in the initial years contributed to this, even though EPA migration is very different from the recruitment and management of local workers.

This remains the main reason for the bipolarization of training and learning hours. Some candidates cannot cope with continuous instruction in Japanese plus preparation for the exam. Although the Japanese government has spent 1.5 billion yen in two years to improve the training infrastructure, bipolarization shows no signs of decreasing. In other words, the reality that the level of care improved under the existing programs, according to feedback from accepting organizations and care recipients, reinforced the policy of providing the least amount of study time to minimize cost.

Meanwhile, the number of incoming foreigners with nursing licenses is gradually increasing without attendant recognition from the public, something that stands in stark contrast to the EPA program. Their pass rate has already significantly outdone that of the EPA candidates. The EPA program may become one that trains nurses as nurse aides for three years unless this rate increases. This phenomenon seriously questions the program’s effectiveness and the benefits for the stakeholders both those in Japan and in the participating Southeast Asian countries.

Acknowledgements

This work has been funded by Health Labour Sciences Research Grant of the Ministry of Health, Labour and Welfare and by Sasakawa Peace Foundation.

References

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―. 2010a. EPA Kangoshi Kohosha ni kansuru Rodo-joken to Niju Rodoshijo Keisei [Labor Market Dichotomization and EPA Nursing Candidates]. In Rodo Saishin [Re-evaluate the Meaning of Work], edited by Yasumasa Igarashi, pp. 79–113. Tokyo: Otsuki Shoten.

―. 2010b. Shoshi Korei Shakai ni okeru Imin Seisaku to Nihongo Kyoiku [Immigration and Language Policy under Demographic Change]. In Gengo Seisaku o Tou [Questioning Language Policy], edited by Eizo Tajiri and Yukio Otsu, pp. 199–208. Kobe: Hitsuji Shobo.

―. 2011. Social Reproduction, Care and Immigration in Ageing Societies with a Declining Population. In Research on Careworker Migration and Construction of International Collaboration, Annual Report on Grant-in-Aide Research of MHLW, pp. 3–19.

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―. 2010b. Indoneshia-jin Kangoshi Kohosha Ukeire Jittai Chosa Kekka Gaiyo [General Findings on “Condition of Accepting Indonesian Nurse Candidates”], available online at http://www.mhlw.go.jp/stf/houdou/ 2r985200000054my.html (accessed on Aug. 14, 2011)

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1) The decision was made June 18, 2010. See, http://www.kantei.go.jp/jp/sinseichousenryaku/sinseichou01.pdf (accessed Sept. 19, 2011). Examples of post-crisis employment policies are Comprehensive Immediate Policy Package to Ease Public Anxiety, Measures to Support People’s Daily Lives, Immediate Policy Package to Safeguard People’s Daily Live and Policy Package to Address the Economic Crisis amount to 3,000 billion yen in by 2008 and 2009. Care work is one of the target jobs.

2) Long-term Care Insurance is a universal long-term care system introduced in 2000 with the aim of supporting independence and preventing overextension of family care. However, based on the increase in service recipients, the sustainability of the budget has become a social issue.

3) This is as in the case of a cut in in-home services for those who live with family despite the fact that MHLW mentioned that cutbacks to services should be determined based on the availability of family members on care.

4) Reservation wage is the point of wage level that mobilizes a person to accept a job.

5) The Ministry has been denying the reason for its acceptance as labor market is demand since the negotiations with the Philippines. Current official position is available from the following, http://www.mhlw.go.jp/bunya/koyou/other22/ (accessed Sept. 20, 2011).

6) The first batch of Indonesian nurse candidates included 104 candidates placed in 47 hospitals.

7) This is an unpublished report by the Sasakawa Peace Foundation. The author was part of the research team.

8) Interview with an official of the Labor Office of the Philippine Embassy in Tokyo, Aug. 19, 2010.

9) The author will not go into the details here. According to the Labor Office, the jun-kaigo fukushishi issue was not raised in the negotiation at all, and the Japanese government brought this issue after ratification of the JPEPA at the Philippine Senate.

10) Based on the author’s interview with an official of the MHLW in 2010.

11) Notification No. 0519001 of Health Policy Bureau, No. 0908001 of Labour Standards Bureau, No. 0519001 of Health Policy Bureau, No. 059001 of Employment Security Bureau, No. 0519001 of Social Welfare and War Veteran’s Relief Bureau and No. 0519004 of Health and Welfare Bureau for the Elderly of the MHLW.

12) See JICWELS website which is the only permitted matchmaking agency in Japan. http://www.jicwels.or.jp/(accessed Sept. 20, 2011).

13) This can be accessed from the JICWELS website, http://www.jicwels.or.jp/html/H22_information.pdf/H22_ Business_plan.pdf (accessed Sept. 4, 2010).

14) The EPA candidates are basically not allowed to change their workplace. Many candidates have already asked the JICWELS whether they can change employers on the grounds of working and training conditions.

15) A model curriculum was drafted. However, this is a guideline only, with no obligation for institutions to follow it.

16) The Sasakawa Peace Foundation and MHLW survey, as well as the interviews, indicate exhaustion of the person in charge is another major factor.

17) An instruction by Chairman Osaki (Remark 4) of the Society for Teaching Japanese as a Foreign Language.

18) References, for instance, given by instructors of Japanese Teaching Group “Y” and the Japan Foundation’s Kansai Training Center in 2009.

19) Based on a survey conducted by the Sasakawa Peace Foundation Population Team, August 2009.

20) See one of the results of surveys conducted by MHLW. http://www.mhlw.go.jp/stf/houdou/2r98520000005ltf-img/2r98520000005lvz.pdf (accessed Aug. 14, 2011).

21) Particularly in the case of Japanese-language training, aspects of the training system planned by organizations such as the AOT which has previous experience in training are strong. So are the aspects supported by volunteers, including Japanese teachers all over Japan and citizen’s groups. The effective use of resources such as these, however, are mainly concentrated in urban areas and have not spread throughout the country.

22) Regarding certified care-worker candidates, 235,000 yen is allotted for each candidate.

23) The other differences are related to subsidies for care facilities employing certified care-worker candidates. The MHLW’s subsidies were restricted to Japanese-language learning originally, but widened to support the study of specialized knowledge and skills.

24) See the MHLW website. http://www.mhlw.go.jp/stf/houdou/2r98520000005ltf-img/2r98520000005lvz.pdf (accessed Nov. 22, 2011).

25) See the following page, http://www.jicwels.or.jp/html/hp_images/h24_ukeire_setumei_2.pdf (accessed Aug. 21, 2010).

26) According to the unpublished survey (n=34), accepting organizations responded positively about the following points: communication skills and feedback from care recipients, etc. The only negative perception after accepting EPA candidates was the cost of employment.

27) Nationality is not represented in the graph. However, because some nursing schools in China provide Japanese courses, nearly all those who passed are from China.

28) Regarding requirements for foreigners who wish to take the national nursing exam in Japan, see the following HP, http://www.mhlw.go.jp/kouseiroudoushou/shikaku_shiken/kangoshi/ jukenshikaku.html (accessed Aug. 21, 2010).

29) The standard for N3 is approximately 300 kanji letters and 1,500 vocabulary words; N1 mandates approximately 2,000 kanji letters with 10,000 vocabulary words.

Table of Contents

Cover

OHNO S.: Southeast Asian Nurses and Caregiving Workers Transcending the National Boundaries

OGAWA R.: Globalization of Care and the Context of Reception of Southeast Asian Care Workers in Japan

HIRANO O.Y. et al.: A Comparative Study of Filipino and Indonesian Candidates for Registered Nurse and Certified Care Worker

B. ALAM and S.A. WULANSARI: To Stay or Not to Stay: Diverse and Conflicting Interactions

SETYOWATI et al.: Indonesian Nurses’ Challenges for Passing the National Board Examination

KAWAGUCHI Y. et al.: Exploring Learning Problems of Filipino Nurse Candidates Working in Japan

ASATO W.: Nurses from Abroad and the Formation of a Dual Labor Market in Japan