A Qualitative Study on Challenges Chinese Nurses Face while Working in Japanese Hospitals

We found that Chinese nurses were motivated to work at Japanese hospitals for several reasons. Many Chinese nurses working in Japan had difficulties with the language barrier, interpersonal relationships related to cultural differences, and loneliness in their daily life, and also experienced fewer opportunities for promotion than Japanese nurses and insufficient support from Japanese hospitals. Many Chinese nurses were anxious about their future in Japan. More than half did not have a clear future direction for their working life in Japan.


INTRODUCTION
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, 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 nonnursing 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.

Design and Setting
This qualitative inductive study was performed using a semi-structured interview. We inquired about cooperation and explained our study by phone and in writing to hospital managers in advance. We sent consent forms to hospital managers and Chinese nurses between September and October 2017. We interviewed 13 Chinese nurses working at 2 Japanese hospitals after receiving their signed consent forms. All participants gave informed consent in writing before study participation. In our study, an interview guideline ( Table 1) was followed. A semi-structured interview was conducted in Chinese.

Q7
Please discuss your future.

Q8
In conclusion, please talk freely.

Participants
The participants were nurses who satisfied the following criteria: 1) Chinese nationality, 2) having both Chinese and Japanese nursing licenses, and 3) working at Japanese hospitals or health facilities. In addition, the participants did not have any history of psychiatric disorders. In total, 13 Chinese nurses working in 2 Japanese hospitals in Wakayama and Kyoto, understood the main points of our study and provided written consent to participate.

Data Collection
We interviewed 13 Chinese nurses and recorded the entire process with their consent. Each interview was conducted in Chinese and lasted approximately 30-60 minutes. During the interviews, we discussed their troubles and difficulties in daily life and work, their future outlook, and other topics based on the interview guidelines. We used a private room provided by their hospital. Private issues were discussed as quietly as possible but in a relaxed and friendly environment. The interview included 8 key questions and topics as shown in Table 1.
The 13 participants and the interviewer in the present study were Chinese. All of them spoke Japanese and Chinese, but in order to communicate easily and smoothly, we conducted interviews in Chinese.

Analysis Method
The data were analyzed using a qualitative inductive method. A Chinese researcher with a high level of Japanese proficiency (JLPT N1 level) made verbatim records in Chinese and then translated the records into Japanese. Moreover, both serial transcripts were double-checked by another Chinese expert who had the same level of Japanese proficiency (JLPT N1 level). We encoded the records in Japanese based on both transcripts and extracted subcategories based on common themes related to the purpose of the study. In addition, we extracted categories and analyzed the relationships between different categories. Our team met several times to discuss each step and agree on the final thematic analysis. All data were digitized, processed, and analyzed using Microsoft Office software.

Ethical Considerations
This study was approved by the ethics committee of Shiga University of Medical Science Medicine . All prospective participants consented to the qualitative study both verbally and in writing. The consent form was in Japanese. All data from the interview survey were coded such that participants cannot be identified and the data cannot be used for other purposes. The participants were free to terminate the interview at any time.
In the present study, recorded data in Chinese were collected. The interviewer with JLPT N1 proficiency in Japanese translated the transcripts from Chinese to Japanese. Other Chinese researchers with JLPT N1 proficiency in Japanese checked and confirmed the Japanese and Chinese transcripts. At the same time, the researchers relayed the Chinese and Japanese versions of the transcripts to the participants and confirmed the data again to prevent inconsistencies introduced during the process of translation. Our research team members carefully assessed the accuracy and validity of data entry. Finally, we used the Japanese version was used for analysis. We improved the validity of all the analysis processes by repeating and cross-checking between faculty members and graduate students in our team. In addition, we were advised by professors with extensive experience in relevant qualitative research topics. Several checking and feedback processes were carried out with the participants and research team members to increase the accuracy of the qualitative study.

RESULTS
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.

Reasons for Working in Japan
Interviewed nurses reported several important reasons for coming to Japan. One is the chance to study another culture and medical system. Moreover, they can obtain specific valuable experiences for their future career. In addition, the higher salary in Japan was an attractive point.
"The salary in Japan is higher than in China. At the time, I came to Japan because I wanted to study more here. I know that the Japanese medical system is relatively developed (much more than in China) and the technology is more advanced. Thus, the first reason for coming was the high salary and the second reason was my wish to study relevant Japanese medical technology."

Participant A, Female
In the beginning, many Chinese nursing students wanted to go abroad to experience the Japanese language and medical system. Subsequently, they became interested in staying and became used to living in their new environment and culture. They were interested in learning more about the advanced medical system and nursing care in Japan.
"At first, I wanted to go abroad when I graduated from university. I wanted to live abroad to have a different experience from that in China."

Participant M, Female
"In China, advertisements distributed by Japanese companies only cover the positive aspects of Japanese life, hospitals, and other work locations. For example, I thought that the etiquette and environment, and the degree of development in Japan were great. Thus, I wanted to come to Japan to see this. However, when I arrived Japan, I thought that it was not too different from the situation in China."

Participant I, Female
They were also interested in living in foreign countries, improving themselves, and learning about Japanese culture. Finally, participants voiced dissatisfaction with the Chinese medical system.

Difficulties Faced by Chinese Nurses Working in Japan
Communication and language barriers in addition to the ambiguous Japanese way of speaking created problems. Lack of formal knowledge on how to create sentences led to a vicious circle of helplessness and loss of confidence in Japan.
"For example, knowledge that was easy to learn and memorize in Chinese is difficult to understand in Japanese, and even after understanding, it can be forgotten easily. This is a relatively serious problem."

Participant I, Female
"Of course, another relevant problem is the inability to present the knowledge that we learned from the Chinese education system in Japanese."

Participant I, Female
It was necessary to adapt unfamiliar habits resulting from differences between Japanese and Chinese culture. However, the mental stress and physical effects experienced by Chinese nurses due to the shortage of nurses in Japan, anxiety about work, differences from foreigners felt by Japanese nurses, and their awareness between Japanese and Chinese nurses are of concern.
"Even among Japanese nurses, the concept of the relationship between the older and younger generations is very strict. Of course, it varies by situation, but I was sometimes severely scolded. However, there are some aspects that cannot be seen in multiple ways and there is no way to answer back promptly as a foreigner because of insufficient Japanese language ability."

Participant A, Female
In addition, they felt lonely and homesick due to the lack of Japanese friends when living in Japan.
"I feel lonely and do not have Japanese friends due to the strict discipline in the work environment. When I studied Japanese in Japan, I have many Chinese friends, but only a few Japanese friends."

Support from Japanese Hospitals
The participants felt that the support from their hospitals was insufficient. They were also dissatisfied with the gap between Japanese and Chinese nurses. Dissatisfaction about salary, which differed from what they heard from intermediary companies before coming to Japan, was also present. Furthermore, they believed that because of the work culture in Japan, the hospitals could not provide a long-term vacation to foster a relaxed workplace. In addition, they wanted to integrate into Japanese culture as soon as possible and hoped that Japanese hospitals would establish an environment for communicating with Japanese coworkers. Participants hoped to receive support for attending seminars or meetings and to have the same chance of promotion as Japanese nurses. In addition, the participants were unhappy with insufficient support for their livelihood and improper behavior from the older generation coworkers in their hospitals.
"Basically, Chinese nurses are not supported to attend seminars in the hospital like Japanese nurses. I think this is discriminatory treatment. Many Chinese nurses believe that this is unfair. There are levels, positions, and promotions in each hospital that are difficult for Chinese nurses to get."

Participant D, Female
"Most nurses are single ladies. Through opportunities for communication, they might be able to meet many people and communicate more with each other. Their life may improve and be more satisfying."

Solutions to these Difficulties
Chinese nurses have to work in the same situations as local nurses in Japanese hospitals. After becoming a nurse in Japan, they worried about difficulties and feelings of unhappiness while working in Japan. Still, they were also unsure about their ability to find a desirable position after going back to China. Furthermore, they discovered that it is challenging to live and study in a foreign country. Indeed, they faced many problems during the learning phase. However, they always made great efforts to improve themselves continuously to become a qualified nurse in Japan.
"I think studying is certainly difficult because I am a firstyear nurse. If everything goes well and smoothly, improvement may be possible, but it will be difficult."

Participant E, Female
Despite the issues described above, numerous differences between Japan and China (e.g., life, medical system, nursing practices, need to update their Chinese nursing license, and high levels of air pollution in China) encourage Chinese nurses to come to Japan.

Future Outlook
Chinese nurses who participated in this study felt fearful and anxious about their future due to differences between their expectations and the realities of working in Japan. They also worried about job dissatisfaction in Chinese hospitals after going back. They saw a gap between their desired outcomes and what may happen in the future. Therefore, they did not feel secure about their future, and they were living with an unclear and uncertain outlook. Moreover, they felt that their experiences might not be helpful for their future. Thus, some participants had little confidence in their future. However, some participants remained hopeful about finding a better life with a bright future. As a result, 5 of 13 nurses planned to return to China, 6 planned to stay in Japan, and 2 were undecided.

DISCUSSION
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.

LIMITATIONS OF THIS STUDY
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.

CONCLUSION
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.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
This study was approved by the Ethics Committee of Shiga University of Medical Science Medicine .

HUMAN AND ANIMAL RIGHTS
No Animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION
All prospective participants consented both verbally and in writing.

AVAILABILITY OF DATA AND MATERIALS
The data supporting the findings of the article is available from corresponding author [M.K.] upon reasonable request.

FUNDING
None.