Yonago Acta medica 1999;42:211–215

Implementation of Home Health Care Nursing Education in Japan
Ikuko Miyabayashi, Betty K. Mitsunaga† and Mihoko Miyawaki*
Division of Child Neurology, Institute of Neurological Sciences and *Major in Nursing, Schoolof Health Sciences, Faculty of Medicine, Tottori University, Yonago 683-0826, Japan
In Japan, the focus on health care has been shifted from hospital-based to communitybased care. In nursing fields, home health care nursing is expected to become well
implemented. Although our society is facing the problem of care for the elderly
population, the target patients of home health care nursing range from children to theelderly. In home health care nursing education, geriatric nursing focuses on various
nursing care techniques in home care settings rather than management skills andleadership. In 1997, the new home health care nursing curriculum was mandated by acommittee appointed by the Japanese Government. How have nursing junior colleges
incorporated the new curriculum? We expected that the new curriculum might causechanges in nursing lectures and clinical practicum, which have been run so-far on a 3year associate degree program in Japanese national junior colleges of nursing. We
analyzed the results of the survey, with a discussion of the current problems: among 17
junior colleges studied, 4 (23.5%) had incorporated the new curriculum, and the rest
had made a plan of implementation. The methods of implementation varied among thecolleges probably due to a lack of common definition. Among many problems recognized,
the main ones were: i) shortage of faculty members who can be in charge, ii) problems
related with clinical sites, iii) absence of common background among the faculty members, and iv) limitation of lecture hours. Training of faculty members in these fields
was an immediate concern to the colleges.
Key words: home health care; nursing education

Recently in Japan, the public has been interested in community-based rather than hospitalbased health care. This is because of: i) improved knowledge and change in the health consciousness of the public due to the mass media,ii) increases in medical costs, iii) an increased
prevalence of chronic illness due to prolonged
longevity with improved medical care and living standards, iv) shortened hospital stays due
to changes in medical insurance policies, and v)
improved home health care. In 1994, the Japanese
Government implemented a 10-year plan for
new elderly health care and welfare, referred toas “the New Gold Plan”. In this plan, home healthcare for the elderly was emphasized. A practi-

cal example is to build 5,000 visiting nursing
stations by the end of 1999. In 1997, the number of the stations reached 2,048, approximately
40% of the goal. From 1996 to 1997, this increased to 49.1%. The Government appointed
the Nursing Committee on Social Problems
with Low Birth Rates and Long Longevity to
study the situation further. The Committee submitted a report asking for enrichment of nursing
programs to meet the needs of our society. In
response, the “Study Group on Improvement ofCurriculum to Train Nursing Staff Members”
was formed. In 1997, the Group mandated the
addition of home health nursing to the 3-year
nursing program. The 1st nursing students†Formerly Associate Dean at the University of Wisconsin School of Nursing, Graduate Program, and consultant
about US nursing for the Dept. of Nursing, Tottori University College of Medical Care Technology: evaluated thecurrent nursing curriculum at the College, and gave them visions of nursing education.

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under this program will graduate in March
2000.
The goal has been set. However, how havethe 3-year-course nursing colleges handled theneeds of society? Are they responding yet?
Prior to this discussion, changing expectations
for nurses and a brief explanation of the current
3-year nursing program are addressed.
Change in the public view for nurses: In thepast, the public expected nurses to comfort
them when they were in pain or ill. However,with prolonged longevity and development of
the mass media, the public now knows more
about medical care than before and is interested
in their health status. Furthermore, the publicdemands choices in decision making in medicalcare and treatment (Fukase, 1998). They also
expects nurses to have scientifically sound andmedically proper nursing knowledge and skills.
In home health care, nurses are expected to becapable of utilizing all resources in health andwelfare sectors and have case management
skills.
To perform these functions, nurses must be
highly skilled professionals who can: i) understand health problems of patients and types ofcare needed, ii) utilize various resources, andiii) make the best health care plan for a patient.
In Japan, more than 80% of nurses have
graduated from nursing schools with a 2- or 3year program. The basic nursing curriculum inthe program includes general lectures on publichealth, excluding courses on community healthnursing. Thus, there is no opportunity to systematically learn primary care, community careand home health care. After finishing the basic
nursing curriculum, Japanese students must
make the choice of going on or attending aseparate 6- to 12-month course that offers requirements for taking the national board examination for public health nurses and/or nurse
midwives.
The new curriculum proposed for the 3year-course nursing schools requires an additional 6 months for the public health nurse ornurse midwife program. In the public healthnurse program, community nursing is emphasized. These extended programs require a totalof 111 units for graduation. The extended programs are supposed to be attractive, since they
offer various professional opportunities. In
contrast, as determined by the 4-year program
for the Bachelor of Science in Nursing or the
Bachelor of Science, a systematic curriculum
often includes community health nursing, primary health care and home health care nursing.
Further, there are graduate programs on community health nursing, but there is no specialist
course on home health care nursing.
In 1998, the Committee on Home HealthNursing Education* organized by national nursing junior colleges in Japan conducted a survey.
The purpose of the survey was to investigate
how the national nursing junior colleges with 3year Associate Dedgree programs were incorporating the new curriculum, namely homehealth care nursing lectures and clinical sessions (Miyabayashi et al., 1999).
In the present paper, the results of the survey
are reviewed, and current problems and implication for future planning are discussed.

Subjects and Methods
The 1st survey was conducted in March 1998 toinvestigate the current situation of the curriculum and clinical practicum related to homehealth nursing. Seventeen out of 19 national
nursing junior colleges (89.5%) responded.
The 2nd survey was also carried out in August
1998 to investigate what changes or improvement were made after the beginning of the newschool year (school year in Japan, April to
March the next year). Sixteen colleges responded that time. There was a discrepancy between these numbers, because two colleges
from the 1st survey and three from the 2nd survey had already approved or completed runninga 4-year nursing program. The survey forms
were used and committee members in each college were responsible for completing the form.
Questions on the survey focused on: i) incor-*Committee of Home Health Care Nursing Education, National Nursing Junior Colleges. [A report for homecare nursing curriculum.] Unpublished observation. 1999 (in Japanese).

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Table. 1. Problems in home health care nursing courses
YesNo

Not clear

Presence of specific faculty members in charge of lectures
10/16 (62.5) 5/16 (31.2) 1/16 (7.0)
Presence of specific faculty members in charge of clinical practicum 9/16 (56.3) 7/16 (43.7)
Presence of faculty members experienced in home health care nursing 9/16 (56.3) 7/16 (43.7)
Problems in home health care nursing lecturesa. There is no common background among faculty members
b. Shortage of faculty members
c. Limited number of lecture hours
d. Limited or shortage of demonstration facilities
Problems in home health care nursing clinical practicum
a. Shortage of clinical sites
b. Difficulty in selecting clinical sitesc. Economical burden and distance between colleges and facilities
d. Accidents related to clinical practicum
e. Difficulty in supervision( ), percentage.

poration of a home health care nursing course(new curriculum) after the 1997 curriculum
change, ii) objectives, contents, class level,
hours and units in the home health care lecture
course, and iii) objectives, clinical practicum
sites, class level, hours and units in clinical practicum. In the 2nd survey, additional commentsor changes and current problems were asked.

Results
Four out of the 17 junior colleges (23. 5%) had
incorporated the new curriculum, while the rest
had made some plan of implementation.
There were 3 types of curriculum implementation : i) home health care nursing as anindependent subject, ii) courses within community nursing courses and iii) course materials
in other core courses. The goals were differentiated by type: i) mastering or learning thedefinition of home health care nursing, its purposes, understanding its characteristics, andknowledge and skills in delivering care, and ii)
understanding activity structures that support
community health care, mastering basic skills
in delivering home health care. The contents ofeach type were: i) separated into courses as
principles and practical or applied methodology, and ii) principles of community nursing
and applied community nursing.

Lecture and clinical practicum hours orunits varied by type. However, the colleges that
had home health care nursing as an independent
subject and the colleges that included the course
within community nursing courses had between
60 h (3 units) and 90 h (4 units) of lecture and90 h (2 units) of clinical practicum. Class levels
also varied.
In the 2nd survey, all 16 colleges answeredthat the goal was to extend nursing care fromhealth care facilities to homes, deepen the understanding of home health care by patients andtheir family, and discuss the delivery of homehealth care nursing. Some current problems(Table 1) recognized were a shortage of faculty
members who have academically and clinicallygained experience in this field, shortage of clinical sites, difficulty in selecting clinical sites,
economical burden and distance between colleges and facilities, accidents related to clinicalpracticum, and difficulty in supervision.

Discussion
Bradley (1996) stated the difference between
community health nursing and home health carenursing: community care nursing is continuous
and focuses on primary prevention and healthpromotion of populations; while home healthcare nursing is episodic and focuses on individ-

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uals and families who have illness and disability. Long (1995) suggested that home healthcare curriculum should be an independent
subject, because targets are different. Providing community nursing and gerontologicalnursing is essential as a prerequisite. Although
the goals of the home health care nursing course
were similar among the national nursing juniorcolleges, there were no clear statements about
the subjects to be focused on. This may cause
several problems such as when and how muchneeds to be taught, and whether the subject
needs to be independent. Although the demandfor home care services is increasing rapidly
with the aging of the population, the target patients of home health care nursing range fromchildren to the elderly (Harrington, 1991). The
subject of home health care nursing is alsotaught as an extension of principles of hospitalnursing care to continued home health carenursing that requires management skills andleadership; promoting the proper understanding
and application of home health care nursing isessential (Pender et al., 1992; Milone-Nuzzo,1997). According to the present analysis, thelevel, hours and units were dependent on thetype which each college chose. In order to understand the principle properly, the subject
should not be taught at the entry level of nursing. Variations or differences in course titles,
contents and teaching methodology are probably due to different definitions of home healthcare nursing subjects among the colleges.
Shortage of faculty members deteriorates thissituation. Thus, it is imperative to have open
communication with faculty members in otherdisciplines. When communication is weak, theteaching objectives of home health care nursing
are blurred. The present results indicated thatthe majority of colleges have planned to implement the curriculum but have not yet implemented it. Neighbors and Monahan (1997) reported that basic skills were required in homehealth care nursing in junior college nursing
students, suggesting that those skills could be
supplemented by having various related courses,
demonstrations and clinical practicum (externship). However, there are additional technicalprocedures common to the home care setting

because patients’ acuity level becomes higher
in home care (Neal, 1997): nursing curriculum
should be adjusted, and associate degree programs should be adopted for changing the healthcare system and patients’ needs.
In Japan, more than 80% of nurses are graduates of nursing schools or junior colleges. The
majority of nurses in home health care nursing
will most likely be from these schools. However, limitations in teaching hours and a shortage of faculty members make it impossible toteach case management skills, patient educationand guidance, application of techniques andskills, and research methodology to prospective
nursing students who may make home healthcare nursing their career choice. Keating and
Kelman (1988) suggested that home health carenursing should be divided into 2 areas: general
home health care nursing managed by college
graduates; and specialty home health care nursing by graduates of graduate or specialty programs. According to the American Nurses Association (1986), general home health care nurses
should have assessment skills to diagnose complex biopsychosocial problems in the family,
guidance skills in health, and skills in counseling and referrals.
The social needs for home health care nursing is high, but it is not a satisfactory solution tosimply add a home health care nursing courseand clinical practicum in the nursing curriculum. The majority of answers to this survey
have demonstrated that home health care nursing should be taught systematically under community nursing. However, current conditions in
national nursing junior colleges do not allow this,and conversion of junior colleges to 4-yearcourse nursing colleges is desired. Further,training of faculty members in this discipline isneeded immediately. Otherwise, it is difficult
to teach the subject to nursing students. Therefore, it is imperative to make a plan or policy fortraining of faculty members.

Acknowledgments: The authors greatly appreciate
the advice and support of the former Dean, Prof. K.
Takeshita, Div. of Child Neurology, Inst. of Neuro-214

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logical Sciences, Faculty of Medicine, Tottori University. The authors would also like to express theirappreciation to the members of the Committee on
Home Health Care Nursing Education, National Nursing Junior Colleges for their efforts in collecting data.
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(Received August 20, Accepted September 30, 1999)

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