Due to the decreasing birthrate and aging population in Japan, a shortage of nurses has been a challenge since the 1990s [1-3]. Most nurses leave their jobs due to marriage, pregnancy, or childcare [4, 5]. According to the 2016 Hospital Nursing Actual Survey by the Japanese Nursing Association, the turnover rates for full-time and newly graduated nurses in Japanese hospitals were 10.9% and 7.8%, respectively, in 2015. Full-time and newly graduated nurses often have higher turnover rates at small hospitals [6]. Hospitals that provide higher-quality medical care services are eligible to receive higher medical fees. One of the parameters adopted by the Ministry of Health, Labour and Welfare to measure the quality of services is the number of nurses. Indeed, the number of nurses is linked to medical compensation standards and many nurses were employed to improve nursing care, in order to increase medical fees. For hospitals, securing and staffing more nurses to care for hospitalized patients has become a method to increase profits. Thus, there is an increased demand for nurses and 75.7% of hospitals reported having insufficient nursing staff [6].

Under these circumstances, the security of the Japanese health system, addressing the existing nursing shortage, and the significance of international cooperation and contribution are essential issues. Therefore, Japan began to allow foreign nurses to obtain nursing licenses in Japan. Since 2008, Economic Partnership Agreement (EPA) nurses such as Philippines, Vietnam, Malaysia have been coming to Japan as candidate nurses or care workers. They were able to work in Japan as official nurses after obtaining Japanese nursing qualifications. Indonesian nurses and care workers were also accepted. Based on a similar EPA, nursing and care worker candidates from the Philippines and Vietnam have been accepted since 2009 and 2014, respectively [7-15]. However, no official policies for Chinese nurses were implemented. In general, receiving scholarships from Japanese hospitals and finding qualified nurses from China is difficult. After coming to Japan, in order to pass the Japanese national nursing exams, Chinese nurses must receive Japanese language and nursing examination education for 1–2 years [10]. Furthermore, the Japanese requirements for Chinese nurses are higher than those for EPA nurses; Chinese nurses must pass level N1 of the Japanese-Language Proficiency Test (JLPT), the highest level before they can take the Japanese nurse license examination. After becoming licensed, qualified nurses with Chinese and Japanese nurse licenses can be employed at medical institutions in Japan.

According to these policies, 266 foreign EPA nurses passed the national nursing examinations in Japan during 2009–2017 [11]; it was a failed nurse migration policy [16]. However, 1,211 foreign nurses from other countries passed the examinations between 2013 and 2017 [17]. Of note, most foreign nurses are Chinese. More Chinese nurses were likely to accept work as quasi-nurses by medical institutions in Japan [15]. This larger group of Chinese nurses in Japan might face many difficulties, although few studies have been performed. Therefore, in-depth studies to explore their experiences about their problems and worries from all aspects are necessary.

Previous studies found that “international exchange and cooperation,” “cooperation for national policy,” and “resolution of nursing shortages” were the main reasons why Japan wanted to hire foreign nurses [2, 18-22]. Regarding the approval of foreign nurses, the most highlighted reason was “nurse shortage and qualified nurses.” On the other hand, there is also a demand for measures that allow more qualified nurses to come to Japan and continue working for a long time. Indeed, many issues are emerging as the number of foreign nurses increases. The most dissenting opinions are related to problems of language and communication and values such as culture and religion. For this point, cultural exchange with foreign nurses, supporting the understanding of different cultures, and improving the educational system was considered necessary [2]. Moreover, a study about the living experience of Indonesian nurse returnees revealed that most could not deal with the fierce competition in the domestic nursing and non-nursing market in their country. For many, the poorer level of nursing skills they acquired in Japan made it difficult to find suitable employment [23].

The main objective of this study was to clarify the problems and difficulties faced by Chinese nurses in their daily work and life as well as their future challenges by analyzing the results of face-to-face interviews.

Characteristics of the participants are presented in Table 2. In this study, the participants were 13 Chinese nurses aged 20 to 30 years. There were 12 women. Their average stay in Japan was 2–7 (4.3) years. Regarding their educational background, 4 nurses graduated from college (3 years) and 9 nurses graduated from a medical university (4 or 5 years) and had bachelor's degrees. One nurse studied for 5 years and obtained a nursing degree. Another nurse had 1 year of education in electronic information engineering in addition to 4 years of nursing education. The participants lived in Wakayama (n=3) and Kyoto (n=10). Each interview was conducted in a single session. The longest interview lasted 50 minutes and 20 seconds, whereas the shortest lasted 27 minutes and 25 seconds. The average interview time was 37 minutes and 20 seconds.

According to our analysis, all participants had only 1 year of clinical clerkship in Chinese hospitals. However, 7 Chinese nurses achieved JLPT N1 proficiency in China, 3 came to Japan after they achieved JLPT N2 proficiency in China, and 3 came to Japan after obtaining a qualification equivalent to JLPT N2 in China.

The following 5 categories were extracted: 1) reasons for working in Japan, 2) difficulties faced by Chinese nurses while working as nurses in Japan, 3) support from Japanese hospitals, 4) solutions to these difficulties, and 5) future outlooks.

Of note, the main motivation for coming to Japan for Indonesian and Philippine nurses [18] was to provide subsidies and economic benefits to their families and to advance their careers. In the present study, however, many Chinese nurses described coming to Japan because they wanted to learn advanced medical treatment processes, improve their careers, and earn a higher salary. Moreover, the high number of violent incidences involving physicians and nurses due to the medical environment in China is a major problem that encouraged them to leave [24]. A Chinese survey in May 2017 reported that 90% of nurses were not respected by their patients and 41.2% were frequently victims of violence perpetuated by patients or their families within that year [25].

Previous studies reported that Chinese nurses need to improve their ability to respond to changes in medicine, in addition to learning terminology [26]. Many Chinese nurses claimed that communication with physicians was difficult. One reason is that many Chinese nurses think physicians are great and knowledgeable. In addition, accurately documenting nursing records in a short time was reported to be difficult for Chinese nurses [27]. Similar results were obtained in our study; several Chinese nurses felt that it is difficult to create nursing records. Therefore, time to practice creating nursing records is necessary.

A study by Bu [28] in 2017 found that it is difficult to ignore cultural differences and that it is important to understand and interact with Japanese and Chinese nurses. In the present study, difficulty in building workplace relationships due to cultural differences was commonly reported by Chinese nurses. The difference in linguistic standards due to cultural values between Chinese and Japanese was considered to be a reason for differences in the expression of interpersonal intimacy [29]. In previous reports, differences in interpersonal intimacy between Japanese and Chinese were reported to be due to a high degree of privacy. Japanese are always conscious of others and they are not used to discussing their problems with others. On the other hand, the Chinese emphasize a friendly attitude, which is a difference in the value of cultural, interpersonal intimacy, according to Bu [30, 31]. We found that Chinese nurses have to adapt to Japanese culture while working in Japanese hospitals. Moreover, Chinese nurses believed that their lack of nursing skills, medical knowledge, and ability to communicate in Japanese is related to human relationship issues. Improvement of their medical knowledge and nursing skills is necessary to adapt to Japanese culture. In addition to the language used in medical centers and hospitals, it is important to understand the cultural background of the host country [26]. In our study, most Chinese nurses hoped that the hospital could provide opportunities for communication between Chinese nurses and Japanese medical staff in order to promote understanding through workshops or meetings and to provide training about the cultures of both countries. We found that the differences between China and Japan not only cause problems at work but also negatively impacted the daily life of Chinese nurses. As such, hospitals and other workplaces need to take care of all staff members, including Chinese nurses. However, many Chinese nurses felt that they did not receive sufficient support from their hospitals.

This study clarified that loneliness is another important problem. Many Chinese nurses felt a gap between themselves and Japanese colleagues, making it difficult to make friends. While living in another country, one might not wish to let family know about troubles or annoyance to avoid worrying them. Not having friends in Japan might cause stress. The present study revealed that homesickness is an important problem for Chinese nurses. Furthermore, the psychological state might be erratic and can easily lead to diseases such as depression if stress cannot be relieved.

In terms of support, several countries, such as the United States and Singapore, offer high salaries to foreign nurses, with vacation time of 1 or 1.5 months per year and other benefits, such as free tickets for returning to their home country, free housing, permanent residency, or free medical care for them and their family members [4, 32-34]. In the present study, almost all Chinese nurses came to Japan with the support of Japanese hospitals and intermediary companies. While living in Japan, Chinese nurses may receive few living goods from hospitals, whereas other benefits may not receive the same support compared with Japanese nurses from hospitals. On the other hand, regardless of the hospital, many Chinese nurses did not feel that they were mentally supported in Japan. We found that this issue influenced not only their mental health but also their future health due to the accumulation of daily stress. A previous study revealed that staff members burn out because of accumulated anxiety, depression, lack of job satisfaction, and restricted social life due to work pressure, which may lead to suicidal tendencies [35-40]. If possible, psychiatrists and psychologists can be consulted to improve their mental health [41].

In particular, Chinese nurses were separated from Japanese employees and could not attend training sessions at their hospitals, which caused dissatisfaction. This created a feeling of unfairness because they could not get timely answers when they encountered problems in their work. They might lose confidence and thus may choose to leave the hospital. Thus, hospitals might experience difficulties in retaining Chinese nurses. Some Chinese nurses said that it is the same everywhere; the hospital does not think Chinese nurses stay long and therefore does not want to invest in them. Chinese nurses want to be treated the same as Japanese staff by their hospitals and they strongly hoped to participate in more training sessions. Training sessions are not only study or professional events; they might also be beneficial for improving interpersonal relationships. Therefore, holding workshops and training sessions for Chinese nurses will help them quickly adapt to Japan. A previous study reported that mid-term and long-term support is important for Indonesian nursing candidates and caregivers after obtaining national qualifications [35]. The present study clarified the importance of opportunities for trainings and meetings for Chinese nurses. Furthermore, we found that it was important to remove differences from Japanese staff in terms of opportunities, facilities, and support. This study emphasized that it is important to provide Chinese nurses with sufficient vacation time and psychological support. Moreover, we suggest assisting Chinese nurses after they pass the Japanese nursing national examination, which is important for their mental health.

According to a previous study, Chinese nurses are mainly assigned to specific wards, such as chronic disease, geriatric, and mental wards, which require less communication than other wards [27]. However, Chinese nurses who participated in our study were active in many wards and worked alongside Japanese nurses. Moreover, many Chinese nurses were aware that the Japanese social system and Japanese customs are different, which made it difficult for them to understand and recognize significant differences between Japanese and Chinese nursing practices. In China, excretion care, bathing care, and other care are not considered nursing tasks in general. However, Japanese nurses think differently about this issue.

Our study was carried out at 2 hospitals, a small medical rehabilitative hospital (X hospital) and a large general hospital (Y hospital). The reasons for coming to Japan reported by nurses at these 2 hospitals varied. In addition, regarding plans for the future, almost half of the Chinese nurses interviewed reported that they planned to go back to China, whereas others reported planning to stay in Japan. All Chinese nurses reported plans to return to China after finishing their contracts at the small medical rehabilitative hospital. On the other hand, more than half of the Chinese nurses at the general hospital planned to live in Japan for a while. The reason is related to the advanced medical treatment and nursing system in Japan, and gaining more experience for their careers. Although highly educated, many Chinese nurses believe that their experiences will not be helpful for their future, probably due to differences in medical treatment systems between the 2 countries. Currently in China, nurses are mainly caregivers during medical treatment of diseases.

Our study revealed many reasons for Chinese nurses to return to their country, such as marriage, childbirth, insufficient savings, a large difference between expectations and reality, and discriminatory treatment between Japanese and Chinese. We also found that due to the rapid development of China, many Chinese nurses do not have a hopeful future outlook. According to Sakuda et al. [36], it was necessary to renew the Chinese nursing license every 2 years before May 2008 and every 5 years after May 2008. For this reason, nurses need a positive attitude working in China, and they may not be able to renew their Chinese nursing license after finishing their 3-year contracts. Many participants in our study were worried about renewing their nursing license after returning to China.

All Chinese nurses in our study had no clinical experience in China, except during internship programs at Chinese universities. As novices or less experienced nurses, they had difficulty in confronting new problems, felt unaccomplished with daily work, and had to go to work with a poor outlook [37, 38]. Our participants were complete beginners when starting at Japanese hospitals, as a new worker, lacking confidence in a stressful situation. We believe that it is necessary and important for Japanese hospitals and colleagues to provide support for Chinese nurses during their working life.

An important limitation of this study was that the investigation was performed at only 2 hospitals. This might have limited the generalizability of the findings. Moreover, whether the research participants spoke honestly is of concern. Furthermore, the interviewer in our study was Chinese and was able to guess the answers to some extent, which may have influenced the answers of the Chinese nurses.

This study clarified the circumstances and difficulties of Chinese nurses working in Japan. One novel finding was that the main reason for their difficulties are their unknown career path and future workplace setting. Support for overcoming the language barrier and improving cultural understanding from hospitals is necessary to help nurses make better decisions based on their future plans. Furthermore, a support system by the hospital will enable appropriate follow-up and effective consultation regarding the mental health of Chinese nurses.

We identified the problems and concerns of Chinese nurses working at Japanese hospitals and listened to their hopes for the future in semi-structured interviews. Thus, the present study provides an important reference for Chinese nurses who will work at Japanese hospitals.