(2020) 18:88
Hirano et al. Hum Resour Healthhttps://doi.org/10.1186/s12960-020-00532-5

Open Access

RESEARCH

Factors associated with the recruitmentof foreign nurses in Japan: a nationwide studyof hospitals
Yuko O. Hirano1* , Kunio Tsubota2 and Shun Ohno3

Abstract
Background: Nurse migration under bilateral agreements is a recent global trend, although lack of consultation withthe health industries has led to challenges in the recruitment of foreign nurses by hospitals. To analyze the prevailing perception of hospitals on the Economic Partnership Agreement (EPA), under which Japan opened the doors toforeign nurses, we surveyed hospitals that are yet to employ foreign nurses.
Methods: An anonymous questionnaire was developed and distributed to eligible hospitals; it assessed managers’
perception of Japan’s policy on the recruitment of foreign nurses and their intentions to hire foreign nurses under the
EPA (hereafter called EPA nurses). We randomly selected 1879 hospitals, or 22% of the hospitals in Japan (n = 8540),with more than 20 beds. We used descriptive statistics, a Chi-square test, and logistic regression analysis to identify thepredictors and developed a model to predict the likelihood of their intention to recruit EPA nurses in the future.
Results: In total, 432 hospitals were eligible for further analysis (response rate: 22.9%). Half (50%) of the hospital managers were considerably interested in Japan’s policy on recruiting EPA nurses, although only 20% intended to recruit
EPA nurses in the future. Willingness to recruit EPA nurses was associated with the degree of interest in the policy (OR9.38; 95% CI 4.42–19.90) and managers’ perception of EPA nurses (OR 5.32, 95% CI 2.38–11.89).
Conclusions: To attract more hospitals to recruit foreign nurses, it is essential for the Japanese government and thesending countries to review their EPA systems. Utilizing returning nurses to assist language acquisition by the forthcoming EPA nurses could be a provisional solution. For a more fundamental solution, long-term provision, from prior
to their migration until their return migration, is needed to encourage brain circulation, as opposed to brain drain,
between sending and receiving countries.
Keywords: Foreign nurse, Economic partnership agreement, Japan, Hospital
Background
Nurse migration under bilateral agreements is one of therecent global trends, which can be observed in South
Africa [1], ASEAN countries [2], Mexico [3], and India[4], and it may affect the migration flow of nurses by rapidly expanding market activities [5]. Previous studies on*Correspondence: hirano@nagasaki‑u.ac.jp1
Institute of Biomedical Sciences, Nagasaki University, 1‑7‑1 Sakamoto,Nagasaki, Nagasaki 852‑8520, Japan
Full list of author information is available at the end of the article

nurse migration under bilateral agreements indicatedthat bilateral agreements offer the flexibility to enableeasier negotiation and quicker resolutions [6] between
the signed countries. It aims to improve the relationship and accelerate the trade between source and target
countries [7]. It also increases the temporary migration ofnurses who offer healthcare services to countries facing
significant shortages of nurses [8]. However, nurse migration under bilateral agreements adversely affects nurses.
For example, it may lead to potential de-skilling [9] andrender them vulnerable to the global economic crisis© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat​iveco​
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Hirano et al. Hum Resour Health(2020) 18:88

Page 2 of 9[3, 10]. Previous studies have indicated an insufficient
involvement of health professionals in trade negotiations
relating to public health [8, 11]; this may adversely impact
nurses and healthcare institutions. Therefore, it is important to analyze the provision of bilateral agreements fromthe perspective of the healthcare industry.
In this study, we analyzed nurse migration under the
Economic Partnership Agreement (EPA), signed between
Japan and Indonesia (in 2007), between Japan and thePhilippines (in 2006), and between Japan and Vietnam(in 2008). As of January 2019, only 136 foreign registerednurses remained in Japan [12], which is merely 10.5% of
the 1300 EPA nurse candidates who had entered Japan
since 2008.
The flow of receiving EPA nurses is shown in Fig. 1.
The qualifications and conditions for the eligibility criteria are stipulated in the EPAs signed between Japanand each of the source countries. Both applicants andthe employer agree to the terms and conditions of training and work, and sign the contract. The employer pays
a commission fee (131,400 yen per person) and a management fee (20,000 yen per person) to Japan International Corporation of Welfare Services (JICWELS), theonly official agency for recruiting EPA nurses. Employers
also pay 450 US dollars as agency fees to the Philippine
Overseas Employment Administration of the Philippines

Indonesia

for a Filipino nurse and the Department of Labor of Vietnam for a Vietnamese nurse. They pay 4055,000 Indonesian rupiahs (approximately 380,000 yen) to the National
Board for the Placement and Protection of IndonesianOverseas Workers for an Indonesian nurse. In addition,
Japanese language training fees, which costs 360,000
yen per person, are shouldered by employers [13]. Upon
entry into Japan, EPA nurses are provided with a “Special Activities, Nurse Candidates” visa that is extensible
for up to 3 years. After they pass the National Board
Examination (NBE), they become entitled to the “Special
Activities, Registered Nurse” visa, which can be extended
indefinitely.
The focus of previous studies was that the system
struggled to persuade EPA nurses to work as “nurse candidates” until they pass the NBE for nurses in the Japanese language to become “registered nurses” [14–17].
As “nurse candidates”, they cannot fully conduct nursing
interventions, which they did in their country of origin.
This system may disappoint EPA nurses. In fact, obtaining a high level of proficiency in the Japanese language
is one of the biggest challenges for EPA nurses [15, 16,18]. Differences in language, aside from differences inculture-based lifestyle, are considered barriers to theadjustment of Filipino [19], Chinese [20], Jordanian [21],and nurses of different nationalities who migrate to other

Philippines

Vietnam

Graduate of 4year-nursing college +3 year clinical working experience

Graduate of 3/4year-nursing college +2 year clinical working experience

JLPT N2 equivalent

JLPT N2 equivalent

Sign work contract through JICWELS

Graduate of 3/4year-nursing college ++work permission of Vietnam + 2 year clinicalworking experience

Sign work contract through JICWELS

Pre-departure Japanese language
training (6 months) + JLPT N5
equivalent

Pre-departure Japanese language
training (6 months) + JLPT N5
equivalent

Post-departure Japanese language
training (6 months) + JLPT N5
equivalent, nursing training,
guidance

Post-departure Japanese language
training (6 months) + JLPT N5
equivalent, nursing training,
guidance

JLPT N2 equivalent

Pre-departure Japanese language
training (12 months) + JLPT N3
Sign work contract through JICWELS

Post-departure Japanese language training(2.5 months), Nursing training, Guidance

To be assigned to hospital/medical institutions to be trained as nurse candidate/training nursing skill; Japanese language

National Board Examination (max:3 times)
Success

Fail

Return to home country

Re-taking national board exam

Registered Nurse

Fig. 1 Flowchart of receiving EPA nurses in Japan by country

Hirano et al. Hum Resour Health(2020) 18:88

countries [22, 23]. Further, the language skills have beenshown to affect pass rates for those taking the English
licensure exam [24, 25], and this may be worse when theexam is conducted in Japanese, as the language is lesscommonly spoken worldwide. EPA nurses also require
additional effort to prepare for NBE. However, Japanese
language proficiency does not necessarily guarantee success on the NBE [26] since the examination questions
are based on Japan’s unique nursing practices [27]. For
instance, Japan’s nursing practice involves “basic nursing
tasks” including bed bath and toileting, and such nursing
practices are particularly important in Japan, which is asuper-aged society.
It is noteworthy that the challenges are faced not onlyby the nurses, but also by the hospitals employing EPA
nurses. Especially at the outset of EPA, they struggledwith instructing EPA nurses to pass the NBE, which isaffected by the level of Japanese language proficiency of
the EPA nurses [18]. The hospitals also struggled withdifferences in socio-cultural contexts between Japanand the EPA nurses’ countries of origin; such differences
may widen the gaps in terms of nursing practice thatdiverges from the regulations or system of the country
where these nurses originally worked [26]. This is a crucial detail when instructing EPA nurses to prepare for
the NBE. This results in enormous costs to the hospitals,
not only economically [28] but also psychologically [29],because they are responsible for assisting EPA nurses’
training and education [30].
The authors assume that Japan’s EPA, which underlies
the “incompatibilities” between the right to employment
and that to practice nursing [31], was not well consented
by stakeholders [32, 33], especially at the outset of the
EPA. Given sufficient information, the employment status of nurses would be well consented, and recruitment
of EPA nurses would be better implemented. In thisstudy, we analyzed the challenges of the EPA from theperspective of the hospital management. The study population included hospitals that had never accepted EPA
nurses until the time of conducting the survey. This is dueto the following reasons. First, some managers accepted
EPA nurses after being asked by the Ministry of Health,Labour and Welfare (MHLW) to fill the EPA quota sothey might receive benefits from the government thatenable them to maintain a position of prestige in the
medical community in Japan. They may be reluctant todisclose problems related to EPA nurses and may evendisregard them because they wish to maintain links withthe government [31]. Contrarily, hospitals that do not
accept EPA nurses may express their perceptions morecandidly, as they are not loyal to the government. Second,
hospitals that do not accept EPA nurses may express theirperceptions freely, which widens our view on recruiting

Page 3 of 9

EPA nurses. However, only a few studies have been conducted on this study population to investigate factors
associated with the employment of EPA nurses in termsof hospital management. This study investigated the EPA
policy by analyzing the perceptions of the hospital managers who have not yet employed EPA nurses. They neednot surmise the intentions of the government; therefore,
they can express their perceptions freely and objectively
evaluate the advantages and disadvantages of the EPA
without any constraints.

Methods
This study aims to investigate the factors associated withthe recruitment of EPA nurses among managers of hospitals in Japan who have not previously employed thesenurses. A questionnaire was developed and distributed tothe hospitals randomly selected from the stratified target
population.
Respondents

Respondents included managers in Japanese hospitals
that had not employed EPA nurses. The lists of registeredhospitals in each prefectural branch of MHLW were used
for sampling. The selection criterion used the number ofhospitals per prefecture. We selected hospitals with morethan 20 beds to meet the condition of the JICWELS [34].
Questionnaires were mailed to 2000 selected hospitals.
Of these, 121 questionnaires did not reach their destination, because of closure or removal. The rate of sampling,
therefore, was 22% (1879 of 8540 hospitals registered inJapan).
Instruments

We developed an 8-page questionnaire by examining
previous similar surveys on hospitals that employed EPA
nurses and unpublished interviews conducted by the
research team. The questionnaire contained questions
about the following: (1) the attributes of the hospitals,
including their type (privately owned hospitals enacted
by Medical Care Act Article 6 and publicly owned hospitals enacted by Medical Care Act Article 31) and thenumber of beds; (2) the possible factors that may affectthe decision of recruiting EPA nurses (independent variables), including the difficulties in recruiting Japanesenurses, knowledge on recruiting EPA nurses, perceptions of EPA nurses, and perceptions of Japan’s policy on
recruiting EPA nurses; and (3) the degree of willingness
to recruit EPA nurses under the EPA program (dependent variable). The perception of EPA nurses was asked
with respect to eight items on a four-point Likert-type
scale (ranging from 1 = not agree at all to 4 = fully agree).
The item scores were aggregated to an “image score” torepresent the image of EPA nurses. The content validity

Hirano et al. Hum Resour Health(2020) 18:88

was examined by the research team through discussions, and reliability was examined by Cronbach’s alpha.
Respondents were divided into two groups by the average
image score.
As for the policies on EPA nurses, respondents wereasked about their views on the nine items listed in Table 2
and answered with a four-point Likert-type scale (ranging
from 1 = do not agree at all to 4 = strongly agree). Willingness to recruit EPA nurses in the future under the EPA
was measured on a four-point Likert-type scale (ranging from 1 = not at all to 4 = definitely will). Respondents
were divided into two groups with average scores: those
who were likely to recruit and those who were not.
Data analysis

We used IBM SPSS Statistics for Windows, Version 25J
for the statistical analyses. Descriptive statistics wereused for the characteristics of hospitals and respondents,
and Chi-square tests were used to test the correlation
between the willingness to recruit EPA nurses, the attributes, and each independent variable. A logistic regression
analysis was used to identify factors influencing willingness to recruit EPA nurses in the future. To develop
the econometric model, eligible independent variables,
selected from previous studies, were chosen from thelist of perceptions on the government policy regarding
the recruitment of EPA nurses, image score, and current
conditions of recruiting Japanese nurses [18, 26, 28, 29,35]. The independent variables were selected from theresults of the Chi-square tests, which revealed statisticalassociations with dependent variables such as the intention to recruit EPA nurses in the future to be significant.
A stepwise method was used to select the independent
variables to develop the most appropriate models. The
level of statistical significance was set at p < 0.05.
Ethical considerations

Ethics approval was granted by the Biomedical Sciences
Ethics Board at Nagasaki University (Permission number:
18030817).

Results
Respondents

A total of 485 hospital managers responded to questionnaires. Of these, 53 hospitals were excluded because they
had either employed EPA nurses or did not answer thequestion. In total, 432 samples were analyzed (respondent rate: 23.0%) (Table 1).
Managers’ perception of EPA nurses

Approximately 96.3% of the hospital managers felt thattraining EPA nurses would be difficult, that EPA nurses
found it difficult to master the Japanese language byPage 4 of 9

working (94.8%), and that very few passed the NBE(93.4%). A large proportion also thought that accepting
EPA nurses was costly (61.9%). However, a few managers
thought that EPA nurses had high nursing skills (33.3%),
acquired good reputations among patients and families(27.3%), remained in Japan for a long time (25.1%), andadjusted easily to Japanese hospitals (22.6%). Neither thetype/size of hospitals nor the managers’ profession weresignificantly associated with the willingness to recruit
EPA nurses. Therefore, in the following part of this study,
we did not divide hospitals by type or size and did notview the manager’s profession as an influencing factor.
The mean image score was 15.17 (standard deviation[SD] = 2.98) with a minimum of eight and a maximumof 25. Cronbach’s alpha was 0.636. We divided the image
score into two groups: lower image (less than 14) andhigher image (15 or above).
Perception of policy reform on recruitment of EPA nurses

The respondents’ perception of policy reform for EPA
nurses is shown in Table 2 (left side).
Chi‑square test

The results of the Chi-square test indicated that willingness to recruit EPA nurses was significantly correlatedwith perceived difficulties in recruiting Japanese nurses(p = 0.040), image score (p < 0.001), and degree of interest in Japan’s policy on EPA nurses (p < 0.001). The resultof the Chi-square test between perception on policy andwillingness to recruit EPA nurses in the future is shownin Table 2 (right side).
Logistic regression analysis

Table 3 presents the final model of logistic regression,
which was significant (p < 0.0001) and accounted for
37.6% of the variance (Nagelkerke R2 = 0.376).

Discussion
Although the respondents had not employed EPA nurses
previously, they offered several insights to identify the
problems with and improve the policies on EPA nurses.
The EPA nurse policies are not widely known, and hospitals in Japan are not adequately informed of them.
Only 20% of the respondents answered that they wish
to recruit EPA nurses. However, this does not necessarily mean that the rest are not interested in EPA nurses atall, as half (50%) of the respondents answered that they
are interested in the government’s policy on EPA nurse
recruitment. Given that over 80% of the respondents
found it very hard/hard to recruit Japanese nurses, it may
be interpreted that half of the respondents carefully monitor EPA policies, wondering if the current system would
help fill the shortage of nurses. As such attitudes toward

Hirano et al. Hum Resour Health(2020) 18:88

Page 5 of 9

Table 1 Characteristics of the respondents and willingness to recruit EPA nurses (n = 432)
Item

n

(%)

Willingness to recruit EPA
nursesp value

0.651

Respondents
Directors/CEOs

166

38.4

22.6

Managers

163

38.2

18.9

Head nurses

98

23.0

19.4

Type of hospital
Private hospitals

381

88.2

21.0

Public hospitals

50

11.6

12.5

N.A

1

0.2

0.113

Number of beds
Less than 99

305

70.6

18.3

100–499

116

26.9

25.2

500 and above

11

2.5

10.0

0.211

Recruiting Japanese nurses
Very hard/hard

347

80.3

21.8

Not so hard/not hard

75

17.4

12.5

N.A

10

2.3

0.047

Knowledge about EPA
Know very much/much

136

31.5

19.4

Not so much/not at all

292

67.6

20.3

4

0.9

N.A

0.473

Interest in policies on EPA nurses
Very much/much

216

50.0

34.9

Not so much/not at all

211

48.8

4.8

5

1.2

N.A

< 0.0001

Willingness to recruit EPA nurses in the future
Very much/much

86

20.4

–

–

Not so much/not at all

336

79.6

–

–

N.A

10

2.3

Table 2 Perception of EPA policy reform by degree of intention to recruit EPA nurses (n = 432)
Perception of reform measures

Require nurses to pass certain level of Japanese language test before coming toJapan

Perceptionsof the reform
measures

Willingness to recruit EPA nurses
in the future (n = 432)

Strongly agree/agree Strongly
agree/agree(%)

Not agree/
not at all
(%)

85.5

80.9

19.1

p value

0.067

Support hospitals in preparing nurses for the NBE

83.5

17.9

81.1

0.006

Require EPA nurses who pass the NBE to stay for several years

82.8

21.3

78.7

0.272

Organize to introduce EPA nurses to combat the shortage of nurses

70.8

26.1

73.9

< 0.0001

Invite private agencies under government supervision to stimulate the principle ofmarket mechanism

58.1

22.6

77.4

0.115

Admit the multi-recognition of nursing licenses between Japan and the partnercountries

56.8

26.5

73.5

< 0.0001

Admit jun-kangoshi (certified prefectural nurses) under the EPA

48.6

26.9

73.1

0.001

Prepare EPA nurses to pass the NBE

38.4

28.8

71.2

0.001

Not require EPA nurses to pass the NBE, but to accept them as Japanese nurses’
assistants

32.4

25.9

74.1

0.037

Hirano et al. Hum Resour Health(2020) 18:88

Page 6 of 9

Table 3 Factors affecting the willingness to recruit EPA nurses
Factors

OR(95% CI)p value

Interest in policies on EPA nurses

9.38(4.42–19.90)< 0.001

Image score

5.32(2.38–11.89)< 0.001

The Japanese government should articulate to introduce EPA nurses to overcome the shortage of nurses

3.09(1.38–7.51)

0.013

The Japanese government should admit the mutual recognition of nursing licenses between Japan and thepartner countries

1.89(1.01–3.53)

0.048

EPA nurses were observed regardless of type and size ofthe hospitals, or the managerial position of the respondents, and it seems that this perception is widely shared byhospitals in Japan.
One of the strongest factors associated with hesitation
toward EPA nurses is their image. The image score mirrors a conviction of hospital staff that EPA nurses would
encounter various difficulties arising from their limited
Japanese language proficiency, which is crucial for their
daily hospital work and for passing the NBE. We assume
that there are some prejudices against EPA nurses. The
respondents seem to be unaware of the many EPA nursesthat had acquired a good reputation among patients andfamilies. In fact, 75% of the hospitals that employed thefirst batch of Indonesian nurses in 2008 were satisfied
or very satisfied with them because they had a bright
personality (92.9%) and an appropriate attitude toward
patients (89.3%) [35]. We assume that biases against EPA
nurses are not the EPA nurses’ responsibility, but of the
EPA system. The low Japanese language proficiency of
EPA nurses may be due to an inadequate time period set
for pre-departure Japanese language training. This is particularly true among nurses of the first, second, and third
batches of nurses from Indonesia and the first and second
batches from the Philippines, who were not given any
pre-departure Japanese language training. It may be thatthe image scores of this study reflect the shortcomings ofthe EPA in the early stages. Vietnamese nurses, who have
12 months of pre-departure Japanese language training,
have higher language proficiency. Therefore, they havefewer language problems than Indonesian or Filipino
nurses. In this light, the governments of Japan and thesending countries are recommended to employ returning
EPA nurses to teach the Japanese language and provide
information on Japan’s unique nursing practices to theincoming EPA nurses, so that they will be well prepared
to work and train in Japan. This may lessen the economic
and psychological burden of hospitals.
This study also revealed the crucial conditions of hospitals that were struggling with a shortage of nurses.
Twenty percent of the hospitals answered that they
wished to recruit EPA nurses because they found it very
hard/hard to recruit Japanese nurses. We assume thatthe hospitals attempted to employ EPA nurses to alleviate the shortage of Japanese nurses. A mid-term report
released by MHLW [36] indicated that nursing shortages
are especially severe in rural Japan. Hospitals in rural
regions are assumed to be more likely to substitute EPA
nurses for Japanese nurses than those in big cities, suchas the Tokyo area. Regional differences cannot be provedby our survey because, due to the anonymity of the questionnaire, we could not identify the location of the hospitals. However, we take the excerpt from the narrative ofa doctor respondent, who called the researchers to add
comments on the survey, to strengthen the hypothesis.
The respondent was the owner of a small private hospital but unfortunately was not successful in recruiting EPA
nurses because nurses prefer to work in hospitals in the
big cities. He expressed his opinion to the first author(HY) as follows: “I think the Japanese government should
invite more EPA nurses to Japan. Please tell the government that there are some small-sized hospitals, especially in rural areas, that badly needs nurses. Even those
who are from abroad will do to maintain our hospital tosecure the health of people in this region.”
However, the current EPA system does not seem to beeffective in solving the imminent problems of hospitals.
The EPA sets a quota of 200 nurses per country per year,
which falls well short of the deficit of nurses. The country
needs at least 30,000 nurses by the year 2025 [37]. Nurses
are needed in Japan, especially in rural areas, although
EPA regulations seem not to secure them effectively.
Therefore, a fundamental solution must be implemented.
Recently, hospitals in Japan interested in recruiting EPA
nurses have noticed a higher number of Chinese nurses
being hired through private agencies. The actual numberof Chinese nurses is unclear, as the Japanese government
does not disclose the nationality of persons who obtain“medical visas”, although the number of visas issued has
been increasing. This phenomenon assumes that many
Japanese hospitals are not satisfied with the system ofrecruiting nurses under the EPA and are thereby seeking other means of recruiting foreign nurses. Nearly 60%of the respondents of this study agreed to invite private
agencies to the EPA under the supervision of the government to stimulate the principle of market mechanism,

Hirano et al. Hum Resour Health(2020) 18:88

regardless of their intention of recruiting EPA nurses.
The idea of implementing other means to address the
manpower shortage seems to be widely accepted by hospitals nationwide. This is exemplified by the fact that theJapan Hospital Association, one of the biggest associations of hospitals in Japan, introduced the International
Medical Human Resource Foundation in its website[38], a recruitment agency of Chinese nurses for member hospitals that claims to “provide a better service thanthe EPA”. According to the foundation [39], they recruit
eligible Chinese nursing students to be educated in theJapanese language for 1 to 3 years prior to entering Japan.
After entry, the Chinese nurses will enroll in Japanese
language schools to improve their language skills to passthe N1 level (the ability to understand Japanese used in avariety of circumstances [40]) of the Japanese Language
Proficiency Test to be eligible to take the NBE. After they
pass the NBE, they can work in Japanese hospitals as registered nurses. Contrary to JICWELS, who clearly statedthe recruitment costs and previous NBE passing rates of
EPA nurses, these private agencies did not disclose such
key information. Therefore, the authors are careful not tojudge this business model prematurely, as many counties
reported problems caused by improper nurse recruitment [41, 42]. Nonetheless, these recruitment agencies
seem to be attracting more hospitals because Chinese
nurses can read Chinese characters in the NBE, thereby
presenting higher passing rates than EPA nurses. The
new business model also attracts nurses. Since they are
not entering Japan under the EPA, Chinese nurses areoffered a “medical visa”. The visa is unlimited and allows
nurses to work more flexibly than the “Special Activities,
Registered Nurse” visa issued to EPA nurses. This flexibility is an advantage of the business.
Given these conditions, it is understandable that hospitals in Japan would be attracted to this model because, as
shown in this study, 82.2% of the hospitals, regardless of
their intention of recruiting EPA nurses, agreed with thestatement “The Japanese government should require EPA
nurses who pass the NBE to stay for several years.” This
represents the severe need of the hospitals suffering fromthe shortfall of nurses. They wish for nurses to work for
as long as possible. If nurses are given visas that permit
more flexible work, they would spend more time working in Japan. If Japan wishes to employ more EPA nurses,
attracting more hospitals by reviewing the EPA schemeso that it would satisfy the needs of the hospitals is key.
As the logistic regression model indicates, the more hospitals that are interested in the EPA, the more chances
they take to recruit EPA nurses.
However, the Japanese government does not seem keen
to fill the nursing job vacancies with EPA nurses. We
assume that the MHLW, who is in charge of monitoring

Page 7 of 9

the EPA nurses’ recruitment, cannot articulate the needto introduce EPA nurses to secure the nurse labor force,even though they know that there is a nursing labor
shortage, as per their estimation [37].
Yeats et al. underscored that bilateral agreements offer
governments more control and regulatory discretion [6].
As long as the government of Japan denies the recruitment of foreign labor in the name of immigration policy[43], it can only explain the significance of the present
EPA as follows: “introducing EPA nurses is not to combat the shortage of nurses in Japan, but to respond to therequest of the partner countries to accept the nurses”[30]. However, the statement is not helpful in assisting
hospitals with nurse shortages, especially in rural regions[36]. Its ambiguity also confuses Japanese taxpayers, who
paid more than 380,000,000 yen per year [44] in 2016
toward the costs of EPA nurses. It is, therefore, necessary
for the Japanese government to make clear that the main
purpose of bringing EPA nurses to Japan is to address theshortage of nurses.
Limitations

This study is not immune to respondent bias. The majority of participants were from privately owned hospitals(88.2%) and small institutions with fewer than 99 beds
(70.6%). Recruiting foreign nurses will help to secure thenurse supply and reduce the risk of building an “inefficient medical service system” that was set out in the
mid-term report published by the National Committee for Social Security in 2008 [45]. The report called forchanges in hospitals in Japan, the majority of which aresmall privately owned hospitals with too few medical
staff. Further research, including publicly owned hospitals equipped with more beds, is therefore needed toconfirm these results.

Conclusion
This study revealed that the current EPA system is
not the solution to counter the deficiency of nurses inJapan. This is because, as a form of trade agreement,
the governments treat EPA nurses as a commodity [9].
In bartering Toyota cars with Filipino nurses and liquified petroleum gas with Indonesian nurses, they disregard the challenges of hospitals as well as those of EPA
nurses. Similarly, Latin American nurses who migrated
to Spain under the bilateral trade agreements realizedthat credential approvals were not transparent [10]. The
trade agreement, as discussed above, sometimes confuses hospitals and nurses of the receiving countries,
as it prioritizes accelerating the relationship with othercountries in the global economy. Therefore, there may
not be harmony in policy decisions that can achieveboth health policy goals and economic trade goals [8].

Hirano et al. Hum Resour Health(2020) 18:88

Notably, EPA may also be harmful to the source countries because the health workforce strategies of theirgovernments, focused on exports, may frustrate theefforts to ensure an adequate workforce of nurses [6,17]. Better inclusion of trade agreement provisions into
domestic health care policies is suggested. For instance,
integrating the nurse education sector and labor market dynamics of both the sending and receiving countries can be a solution. The authors recommend that
the Japanese government, in cooperation with nurse
sending countries, develop the educational institutions in each sending country, to train nurses in fields
in which Japan has good practices (i.e., gerontology
nursing or psychiatry nursing). This may contribute toenhancing the opportunities of graduates of such institutions to remain in their country, which is becoming
an aged society, or go to other destination countries,
including Japan (through the EPA), with highly skilled
nursing. Furthermore, facilitating returning migrants[46] should also be considered. Under such a longterm provision, this system may contribute to avoiding de-skilling and brain drain, but rather encourage
brain circulation between sending and receiving countries. Simultaneously, the Japanese government is recommended to alleviate the regional shortage of nurses
by subsidizing hospitals, particularly in rural areas,
to raise the basic salary and compensations of nurses,
regardless of their nationality, so that they can practicein more decent working conditions. Both internationaland domestic intervention are crucial for developing
fundamental solutions to create a sustainable healthworkforce.
Abbreviations
EPA: Economic Partnership Agreement; JICWELS: Japan International Corporation of Welfare Services; NBE: National Board Examination.
Acknowledgements
We thank those who participated in our study.
Authors’ contributions
YH developed the questionnaire and conducted the analysis and basic writing. SO and KT advised YH in developing the questionnaire. All authors readand approved the final manuscript.
Funding
This research was supported by the Ministry of Education, Science, Sports andCulture, Grant-in-Aid for Scientific Research (B), 2014–2018 (26293113).
Availability of data and materials
Data will be released upon completion of the study and is available upon
reasonable request from the first author.
Ethics approval and consent to participate
Ethics approval was granted by the Biomedical Sciences Ethics Board at Nagasaki University (Permission number: 18030817).
Consent for publication
Not applicable.

Page 8 of 9Competing interests
The authors declare that they have no competing interests.
Author details
Institute of Biomedical Sciences, Nagasaki University, 1‑7‑1 Sakamoto, Nagasaki, Nagasaki 852‑8520, Japan. 2 The Nippon Agricultural Research Institute,
3‑29. Kioi‑cho, Chiyoda‑ku, Tokyo 102‑0094, Japan. 3 Seisen University, 3‑16‑21,
Higashigotanda, Shinagawa‑ku, Tokyo 141‑8642, Japan.
1

Received: 29 June 2020 Accepted: 2 November 2020

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