Southeast Asian Studies, Vol. 49, No. 4, March 2012

Indonesian Nurses’ Challenges for Passing the National Board
Examination for Registered Nurse in Japanese:
Suggestions for Solutions
SETYOWATI,* OHNO Shun,** HIRANO O. Yuko*** and Krisna YETTI*

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

I Introduction
Japan’s nursing examination is administered every February. The first group of Indonesian candidates(104) for the position of registered nurse arrived in Japan in August 2008, and 82 of them took thenational exam in February 2009. None of them passed [Shukan Igakukai Shimbun, April 20, 2009].
The first candidates under the EPA programs succeeded in the next exam, given in February 2010.
Two Indonesian nurses (who had taken it and failed the previous year) and one Filipino nurse (from thefirst group of Filipinos) passed the exam.
In Japan’s nursing exam, conducted in February 2011, 15 Indonesians (13 from the first group and* Faculty of Nursing, University of Indonesia, UI Depok Campus 16424, Indonesia
Corresponding author (Setyowati)’s email: watisetyowati@yahoo.com.au** 大野 俊，Center for Southeast Asian Studies, Kyoto University*** 平野裕子，Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8520,
Japan
629

東南アジア研究 49 巻 4 号

2 from the second group) and 1 Filipino (from the first group) passed the examination. The passing rate
among 91 Indonesian examinees from the first group was 14.3%, compared with a passing rate among
all examinees (54,138 persons) of 91.8% [Japan, Kosei Rodo-sho Kangoka 2011]. Because of the low
passing rate among EPA candidates, the Japanese government extended eligibility one additional year
for the first and second groups of Indonesian candidates and the first group of Filipino candidates toallow them to stay and study for the exam again.
In most countries, foreign nurses must pass the board examination in the language of the hostcountry. Thus, nurses, who cross borders, need to undergo didactic studies of the language and cultureof their destination country [Buchan 2002; Calman 2005; Friss 1994; Greenglass and Burke 2001;
Goodin 2003; Jamal and Baba 2000]. In the case of the United States, foreign nurses are required topass the CGFNS (Commission on Graduates of Foreign Nursing Schools) examination, and also pass
the State Board Examination in the individual state where they will work within six months of theirarrival [Venzon and Venzon 2005: 68–70]. Since Filipino nurses are educated with English textbooks
at the nursing schools in their country, they have less difficulty passing foreign nursing examinations
in English.
In Japan, however, Filipino and Indonesian nurses experience serious difficulties when they study
nursing in the Japanese language. Japan’s national exam questions are written entirely in Japanese((Nihongo), which consists of three types of characters, hiragana, katakana and kanji. Kanji was introduced from China in ancient times and has been developed in Japan. Hiragana and katakana are
original Japanese characters simplified from kanji. Each hiragana and katakana includes approximately only 50 letters so that foreign learners can master them more quickly. However, kanji iscomposed of several thousands and more letters, and thus it demands enormous effort for foreign
learners especially from non-kanji countries such as Indonesia and the Philippines to master Nihongo
adequately.
Kyushu University’s research team found that most of Japanese hospitals that received the firstgroup of Indonesian candidates for registered nurse have recommended that the national nursing exam
for foreign examinees should be more flexible.1) Some hospitals have requested the Japanese government to offer the exam in English or Bahasa Indonesian because the Japanese language is too difficult
for the Indonesian and Filipino candidates educated in alphabet characters in their home countries.
The language difficulty is not only the problem. Kawaguchi [2009: 91–104], who researchednursing education in Indonesia as well as that in the Philippines, found that Indonesian and Philippine
curricula and required credits at nursing school or college vary considerably from Japanese ones.2)
Hirano [2011: 52–56] also noticed that job descriptions for nurses differ between such Southeast Asian
countries and Japan to some extent. If the foreign nurses cannot overcome the above gaps, they may
1) According to the Kyushu University’s research team’s survey, 59.3% of responding hospitals (28 hospitals;
responding rate: 59.6%) that received Indonesian nurse candidates since 2008 had a request to the Japanese
government to implement the national exam for the EPA nurses in more flexible way [Hirano et al. 2010:
118].
2) According to Kawaguchi [2009], the Philippines’ nursing curriculum includes many more units than Japan’s.
Indonesia’s program is almost as same as Japan’s.
630

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

misread the questions on Japan’s nursing examination and fail to answer correctly even if they haveachieved proficiency in Japanese.
Japan’s Ministry of Health, Labour and Welfare (MHLW) has expressed its position that theministry has no plan to implement the national exam in English or Bahasa Indonesian for Filipino andIndonesian nurse candidates. Its position is in accord with that of the Japanese Nursing Association,
which strongly insists that high proficiency of Japanese is essential for safe nursing practices in Japan.
However, if the passing rate of EPA foreign nurses does not increase to a certain minimum level,
this may harm diplomatic relations between the sending and receiving countries. This is a serious
dilemma for the governments concerned.
To cope with the present conditions, MHLW increased the budget for the training and guidance of
foreign candidates for registered nurse and certified care worker from 80 million yen in fiscal year 2009
to 870 million yen in the fiscal year 2010. This introduced a concerted effort to enable more foreign
candidates to pass the national exam in Japan.3) The ministry and its extra-governmental body, Japan
International Corporation of Welfare Services (JICWELS), initiated routine guidance for all accepting
hospitals and care facilities. MHLW has allocated a subsidy for training to each hospital and care facility
since 2010.4) JICWELS provided copies of the previous Japanese national examination sheets translated in English or Bahasa Indonesian [Satomi 2010: 89–98].
However, it is still uncertain that such financial assistance will be effective in increasing thepassing rate among foreign candidates. University of Indonesia and Kyushu University’s joint quality
research conducted at six accepting hospitals in Western Japan in mid-2009 found that all the Indonesiancandidates (12) for registered nurse felt psychological stress preparing for the national board examination in Japanese. They felt that Japanese health-care system, included in the national exam, was very
different from Indonesia’s and too complex to understand. In addition, some Japanese nursing andmedical technical terms are different from those the Japanese nursing staff use in their daily conversation, especially words spoken in the local dialect [Setyowati et al. 2010: 177–179]. Thus, they have to
break through layers of language barriers in their institutional setting and everyday lives.
Based on the above findings, this research aims to explore effective and suitable learning strategies
that could enable Indonesian and other foreign candidates to overcome the high hurdles and pass thenational nursing exam. It also attempts to identify several factors behind the failure or success in passing the examination, and suggest their implications for EPA policy.

3) MHLW’s EPA-related budget for fiscal year 2010 included subsidies for training in accepting hospitals of foreign
nurse candidates (370 million yen), for training in accepting care facilities of certified care-worker candidates(350 million yen) and introductory training for both, JICWELS’ routine guidance and others (150 million yen)
[Satomi 2010: 98].
4) According to a paper provided to the authors by the MHLW official August 25, 2011, the total amount of MHLW’s
EPA-related budget for fiscal year 2011 is approximately 790 million yen. This budget funds several programs
comparable to those for fiscal year 2010.
631

東南アジア研究 49 巻 4 号

II Methodology
This research employed qualitative surveys using a phenomenology method in order to explore thelearning experiences related to preparation for Japan’s nursing national examination. The authors
applied purposive sampling which included the following criteria: 1) members of the first group ofIndonesian nurse candidates, who already took Japan’s nursing national examination twice until 2010;2) those who had no proficiency in the Japanese language before their departure to Japan; 3) those who
obtained a diploma and/or a bachelor’s degree in nursing in Indonesia; and 4) those who were willing tocooperate with our research team’s interviews. As a result, four candidates employed by two hospitals
in the Kansai Region and another two candidates employed by two hospitals in the Hokuriku Region
participated in the survey.5) It was administered in their hospitals in early November 2010. The authors’
intensive interviews with Indonesian nurses were conducted mostly in Bahasa Indonesian.
Participants, who arrived in Japan in August 2008, had received full-time Japanese language training for six months before their assignment to the contracting Japanese hospitals. The Association for
Overseas Technical Scholarship (AOTS), an extra-governmental body that employs a number ofJapanese-language instructors, conducted the Japanese language instruction in their facilities.
Two of the participants passed the national exam in 2010 after failing in 2009. Both are employedby the same private hospital in the Hokuriku Region. They are the only Indonesians who passed the2010 exam. One is a male and another is a female. The four participants who failed the examination
are all females and employed by two private hospitals in the Kansai Region. Regarding educational
background, five of them are D3 graduates and one is a S1 graduate.6) The two successful candidates
presented their preparation techniques in a seminar held in Osaka City on July 23, 2010.7) Their presentation data include PowerPoint slides, which are included in this study.
Additionally, Japanese co-authors conducted interviews with Japanese head nurses (3), preceptors(2), executive secretary (1), and director (1) of the hospitals employing Indonesian participants. They
cross-checked the accuracy of statements made by the participants with the results of the past surveys
conducted by our research team and the Japanese government.

III The Results(a) Problems in Learning the Japanese Language
When the AOTS began the Japanese language training for the first group of Indonesian nurse candidates,

5) According to official documents provided to the authors by Japan’s Ministry of Health, Labour and Welfare in
2008, 12 hospitals employed a total of 24 first-group Indonesian nurse candidates in the Kansai Region as ofJuly 31, 2008, and only 2 hospitals have employed a total of 3 first-group Indonesian nurse candidates in the
Hokuriku Region as of the same date.
6) D3 graduates have studied nursing at the vocational school level for three years. S1 graduates have studied ata four-year college or university and have another year in an internship.
7) The seminar focusing on the successful experiences of the two Indonesians who passed was hosted by Garuda
Supporters, a Japanese citizen group supporting the Indonesian candidates in Japan.
632

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

it estimated they would reach Semi-Level 2 of the Japanese Language Proficiency Test (JLPT)8) aftersix-month language and sociocultural adaptation training (858 hours) at its facilities.9) However, it isprobable that the majority were not able to attain this level.10) Consequently, they faced difficulties incommunicating with their Japanese co-workers and patients for a certain period after their assignment
to the workplace.
In this survey, all participants expressed difficulties in learning kanji, especially those of Japanesenursing/medical terminology and jargons/abbreviation. The following are their narratives:
Participant 1 (28 year-old female Indonesian): “We have difficulty answering the exam questions especially those that including Japanese medical terminology, insurance and health-care terms that are
all written in kanji, hiragana and katakana.”
Participant 2 (another 28 year-old female Indonesian): “We have not yet learned many of the kanji letters that appeared in the exam. Our problems are not only the difficulty in mastering the Japanese
language but also the difficulty in understanding particular medical and nursing technical terms.”
Participant 3 (32 year-old female Indonesian): “It is difficult to memorize many Japanese technical terms
in a short period. If we could be equipped with a high proficiency of Japanese when we were assigned
to the hospital, we would only have to improve it, and could concentrate on studying Japan’s nursing.
We hope that the Indonesian government would improve its language-training program in Indonesia.”
The local dialect is also one of the communication barriers between foreign nurses and Japanesepatients and staff. One Japanese head nurse working in the Kansai Region expresses her findings:
Japanese Head Nurse 1: “Most patients speak a dialect in this region. They (Indonesian nurses) said
that our dialect is too harsh for them, and sometimes they felt that they were scolded even though
they were not scolded in fact. The AOTS taught them a standard form of Japanese (“kireina Nihongo”
in her Japanese words) in the language-training program. Such formal Japanese is not commonlyused at our hospital. One Indonesian nurse cried because when she received instructions in the[Kansai] dialect, she misunderstood and thought that she was scolded.”8) The Japanese Language Proficiency Test (JLPT) had four levels from the highest, Level 1 to the lowest, Level
4. Level 2 requires foreign learners to master approximately 1,000 Chinese characters ((kanji) and 6,000 itemsof vocabulary, Level 3 requires mastery of approximately 300 and 1,500 respectively. Semi-Level 2 was situated between Level 2 and Level 3. In 2010, a new classification system was introduced and a new category, N3
was established between former Level 2 and Level 3, and reclassified into five categories, from N1 to N5. N3
requires the learners to understand the Japanese language used in Japanese everyday life to some extent.
9) Interview with officials of the AOTS in charge of the EPA project in Tokyo July 17, 2008. The learning of sociocultural adaptation (140 hours) includes Japanese culture, customs and social circumstances.
10) Their Japanese-language proficiency level was uncertain when they were assigned to their workplace because
they did not take the JLPT during their learning period at the AOTS facility.
633

東南アジア研究 49 巻 4 号

Their Japanese language ability has improved gradually. This tendency is confirmed by the outcomeof the Kyushu University research team’s nationwide survey on the hospitals that accepted candidates
from the first group of Indonesians one year after their assignment. The results demonstrate that the
majority of those candidates had little or no problem communicating with Japanese staff and patients inJapanese conversation. The vast majority of them, however, continued to struggle with Japanese proficiency sufficient for reading and writing nursing records.11)
Two head nurses who supervised Indonesian candidates who failed the national exam explained
the circumstances to Japanese researchers:
Japanese Head Nurse 1: “We learned that teaching enough Japanese to pass the national exam is difficult.
It took approximately 30 minutes just to explain one question on the national exam. It requires time
to discover techniques of instruction by on our own. I hope that candidates start studying Japanese
before coming to Japan.”Japanese Head Nurse 2: “We needed an interpreter for half or all of a year after the candidates arrived
at our hospital. During this period communication was difficult for both sides. I think that our Indonesian candidate will encounter some difficulties communicating with patients even after she passed
the N3 of the JLPT. We expect Japanese language school could do something for us.”Japanese preceptors who instruct the Indonesian nurse candidates are predominately senior nurses
at a similar level as the head nurses interviewed above. Although they are competent in nursing practices, they are not experts in instructing foreigners in the Japanese language. It is obvious that theabsence of “bridging human resources,” who understand the language and the nursing practices of boththe sending and receiving countries (Indonesia or the Philippines and Japan), at the workplace is amajor obstacle to training foreign nurse candidates to license them as registered nurses in Japan.
(b) Varied Learning Hours
Under the Indonesia-Japan EPA, Indonesian candidates for registered nurse or certified care worker
are required to continue to study the Japanese language and Japan’s nursing in order to pass the national exam in Japan. On the other hand, their employers set their daily schedules. The EPA does not
regulate the division of working and learning hours.
Most survey participants recognized that the study hours at the workplace were too short for
passing the national examination. One hospital in Kansai allows two candidates to study from 2 p.m.
until 5 p.m. and work for the remaining hours every day. Their instructors are Japanese nurses and a11) According to the Kyushu University research team’s nationwide survey on the hospitals accepting first-groupIndonesian nurse candidates one year after their assignment to the workplace, 96% of the respondents (n=28,
responding rate: 59%) replied that their employing candidates could converse with their patients without
problem, but only 18% replied that their candidates could read and write Japanese nursing records to someextent [Ogawa et al. 2010: 92–93].
634

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

volunteer Japanese-language instructor. The hospital encouraged them to take the JLPT. After one
candidate passed the N3 of the JLPT, and another failed the same test in 2010, the head nurse increased
study hours of the candidate who passed from three hours to five hours because she had to demonstrate
the possibility of passing the national exam. The head nurse recognized that the other candidate alreadyrealized that she could not pass the next national exam, thus her study hours were not increased.
Another hospital in the same region let two candidates study from 2:30 p.m. until 5:30 p.m. every
weekday, and planned to extend their study hours to prepare for the 2011 exam after December 2010.
Their instructors are Japanese nurses and volunteer Japanese-language instructors.
Regarding their study hours, one Japanese head nurse explained the reason she and her Japanese
staff were not able to allow the Indonesian candidates more hours for their study: “Indonesian nurses
have ever complained that they needed more time to study. But, the policy of our hospital is to let themwork for certain hours. We cannot let them study for a whole day as long as we are paying (the) salary
for their work.”
Two Indonesians who passed the exam had been provided enough time to study even during working hours.
Participant 4 (26 year-old female Indonesian who passed the exam): “We are required to work from
9 a.m. until 1 p.m. and study with our preceptors from 2 p.m. until 6 p.m. every weekday. Our study
hours are counted equivalent to working ones in our salary. At home, I have continued to study from
9 p.m. until going to sleep, and restart at 3 a.m. just after I wake up, and continue through the morning.
During my holidays, I review my previous studies for approximately two hours.”
The management carefully considered the importance of well-balanced study and working hours.
The director of the hospital explained: “We decided to support the candidates to pass the exam as far
as we were able. We did not want to have them disappointed by failing. If we allowed them to study allday, they might feel too stressed. So, we have them work half the day so that they can concentrate on
studying during the other hours.”
The EPA did not mandate required working and study hours, which caused large differences among
the accepting hospitals [see also Wako Asato’s paper in this special issue]. According to MHLW’s
nationwide survey conducted in February 2010 on the first group of Indonesian nurse candidates, 53%
of all responding candidates (N=66) studied the Japanese language and for the national board examination for 11 hours or more within working hours per week, 24.2% studied for 6–10 hours, and 15.2%
studied for only 1–5 hours [ Japan, Kosei Rodo-sho 2010].
The Indonesian candidates are aware of these differences as they frequently exchange informationon their work and study conditions through the Internet and other communication methods. Consequently, some candidates have felt that their learning hours at the workplace are too short, comparedto fellow Indonesian candidates assigned to other hospitals, as one head nurse admitted in the above
narrative. This absence of standardized working and learning hours opens the door for candidates tojudge the accepting hospitals unequal, and has inevitably affected their commitments for passing thenational exam in Japan.
635

東南アジア研究 49 巻 4 号(c) Differences of Nursing Education and Practices between Japan and Indonesia
The participants with D3 educational backgrounds recognize that they have to study nursing knowledge
and skills intensely, especially the particular diseases and symptoms of the elderly, which they had not
well learned in Indonesia. Their narratives follow:
Participant 5 (35-year female Indonesian): “In our hospital (in Japan), the majority of patients are elderly.
In Indonesian hospitals, there are not as many elderly patients. That is why Japanese diseases suchas cancer and cerebral infarction are common, which is quite different from Indonesia, where mostpatients suffer from infectious diseases.”Participant 2: “Learning about diseases is important in Japan unlike in Indonesia, and there are many
details to absorb. After you have mastered the details, you realize that the exam questions are goodand can be answered. The questions related to incubation, symptoms and others are only simple.”
Participant 3: “Since what I had learned at my vocational school (in Indonesia) was limited, I need to
study and gain more experiences. Here, all the regulations are very detailed, so Japanese nurses
must know a great deal of science and the regulations. Japanese nursing students have class all day.
The Indonesian students had half a day allocated for study and must work at the hospital the otherhalf. That limits the amount the other Indonesian classmates and I can learn in the same period.”
Japanese preceptors have also recognized the learning difficulties caused by the differences innursing education and practices between Japan and Indonesia. Two Japanese head nurses who instructed participants who failed the exam explain:
Japanese Head Nurse 1: “We found that the level of Indonesian nursing education was different fromthe Japanese one. They lack some basic nursing knowledge. We even have to teach about insulin
and symptoms of low blood sugar. When I instructed them to exercise the drill, they usually misseda few things. They lack accuracy (in medical knowledge).”
Japanese Head Nurse 2: “In the past, I imagined that basic nursing was similar throughout the world
and that the language was the only difference. After working with two Indonesian nurses at our
hospital, I realized my idea was incorrect. I found many differences between Japan and Indonesia in
fundamental nursing practices. For example, when the patient has a fever, Japanese nurses try tolower the body temperature by cooling, but Indonesians try to do it by warming. When we clean apatient’s body, we use a steam towel at approximately 50 degrees, they use the towel warmed to
40–42 degrees. Japanese nursing staff clean the patient’s body once each day; Indonesian nurses
clean patients twice per day.”
The narratives from the Indonesian candidates and Japanese preceptors clarify that neither groupclearly understood the differences between Indonesia and Japan in nursing education and practices
636

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

before the entry of Indonesian nurses. After the candidates were assigned to Japanese hospitals, bothparties recognized that the diseases prevalent among inpatients differ considerably between the twocountries.
This could be partly attributed to the variation in demography of the two countries. The numbersof the elderly (60 years old and older) in Indonesia was 17,767,709 or 7.79% of the total population in
2000. It is estimated to increase to 9.7% in 2010 and to reach 11.43% by 2020 [Adioetomo and MCicih
2009]. In Japan, the percentage of the elderly (65 years old and older) had already reached 21% in 2007,
and is projected to reach 32% by 2030 [Tokyo Daigaku Koreishakai Sogo Kenkyu Kiko 2010: 15]. It
would be difficult for foreign nurse candidates to pass the exam and become model nurses in Japan unless they profoundly understand the differences in nursing education and practices and the most common
diseases, which vary because of the differences in demography, culture and other factors.
(d) Learning Strategies and Factors behind Passing the National Examination
Two participants who work at the same hospital and passed the exam explained the learning strategies
that brought them success in the exam in Japanese:
Participant 4: “I reviewed Japan’s past nursing examinations from the 93rd exam (2004) to the 98th exam
(2009), and took them as if I were taking the real exam. When I identified my weak points, I learned
everything I could about these points. Before the 99th exam, I concentrated on studying hisshumondai (mandatory questions).
I set a target for reading Japanese books. If I could read through one book in one month, I would
be able to read 100 questions or at least 50 questions in the same period. Then, I shortened thetarget to finish reading through the book within two days in order to finish answering 150 new questions and 120 old questions (from the examinations conducted in the previous years).
I placed learning materials including pictures of things I did not understand well (at the workplace) on the wall, doors and other places inside my room. I continued this practice during the first
three-to-four months after my assignment to the hospital.”
Participant 6 (26-year old male Indonesian who passed the exam): “Whenever I didn’t understandJapanese words and terms, I wrote them in my small notebook. On separate pages, I wrote thehiragana letters in word order. Under each word, I wrote its meaning either in Bahasa Indonesianor English. I brought these notes with me at all times anywhere I went.
As long as I could recognize the kanji letters, I could understand their meanings. Even when I
didn’t know how to read them, but learned to recognize the structure off kanji letters so that I eventually remembered every letter. After studying for 10 months, I could read many kanji words because
I enjoyed reading them. When I went to the bookstore once or twice a month, I bought new Japanesebooks. Eleven months into my assignment to the hospital, I could read a small pocketbook and understand it. The hospital set up a time target for us. We had to finish reading one Japanese book assigned
to us within one month. We finished reading seven books during the first seven months.
After mastering a prescribed number of kanji, I tried to increase my vocabulary by using a com637

東南アジア研究 49 巻 4 号

mon kanji character. When I memorized the words “no-kosoku” (脳梗塞; cerebral infarction) and“no-kessen” (脳血栓; cerebral thromboembolism), I realized the kanji “no” (脳; brain) was an important component of the word. Thereafter, whenever I saw a word containing “no,” I realized that it
related to the brain. This was very helpful in increasing my vocabulary. I used Wikipedia online tofind explanations of medical terminology.
The national board exam in Japan is likely to focus on current issues in the health status of theJapanese people. Based on current demographics and experience, geriatric and dementia nursing
will be included in the tests. It is important to find the information on these issues and to study themintensively. Regarding questions on the social welfare system in Japan, all you need to do is memorize its requirements accurately. Japan’s laws and acts are changeable, so you (foreign candidates)
should wait to learn them in the later stages of preparation for the exam, so that you don’t need towaste your study hours learning changes it what you already studied.”
Both successful candidates stressed the importance of strong support by the director and preceptors at the hospital as they prepared for the exam.
Participant 4: “The Japanese staff around me were always working hard. This motivated me to study
hard. Incho-sensei (director of the hospital) is very good and supportive. I feel that he is like my father.
So, everyone here has made me feel at home. They welcomed us so graciously that I am strongly
motivated by the director and also another senior nurse who monitors me.”Participant 6: “The hospital staff provided us with many references, books and the Internet. They
provided a computer for us in our apartment so that one was available whenever we needed it. We
took turns using it. I had access Monday through Wednesday and the remaining days were for myIndonesian co-worker. Someone supervises our studies every day. The director of nursing supervised us every Monday, and another nurse or staff member explained things to us and answered ourquestions. Sometimes, even the hospital director has lectured to us on his specialty, neurology.
Whenever Japan’s laws and acts related to nursing were changed, our secretariat informed us.”The management of their hospital had organized the systematic support system even before thehospital received the Indonesian candidates. According to its secretary general, it hosted a two-day
orientation for the entire Japanese staff before the Indonesians arrived. This orientation included lectures on Indonesian culture, language and society as well as explanation of the hospital’s intention in
accepting foreign nurses. By stressing the contribution to an international exchange program without
any intention to overcome the shortage of Japanese personnel by employing foreign nurses, the management tried to relieve the Japanese staff’s concerns that they would be fired in the future. Following theorientation, each division of the hospital appointed responsible persons in charge of supporting theforeign nurses. Those divisions included not only the nursing departments in the wards but alsoradiology, pharmacy, inspection section, secretariat and others. Management directed senior nurses
to teach the candidates nursing and Japanese on Mondays, Tuesdays and Thursdays, and clerical staff
638

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

to teach them Japanese on Wednesdays and Fridays. The staff distributed copies of the previous national nursing exams to their Indonesian co-workers after they obtained a satisfactory proficiency ofJapanese.
It is noteworthy that the hospital, which succeeded in making its employing two Indonesian nurses
pass the exam, adopted thoughtful tactics even in the process of selection and matching of Indonesian
applicants. The hospital’s executive explained the procedures, as follows:
Japanese Executive Secretary: “After JICWELS released the list of applicants and the results of theirpersonal tests, we carefully selected the best applicants from the list. We nominated the applicants
who received a grade higher than the average score in all areas of the personal test, and then selected
the two who scored higher than the average on each item.”
The executive secretary emphasized the effectiveness of the monetary reward for passing theexam. According to him, he always told the two candidates: “To study hard and pass the exam is yourwork. We are paying you a certain amount of salary in order to let you pass the national exam. You
may pay us back after you pass the exam. After you pass, you can earn twice what you are receiving
now.”
From the above narratives, the authors infer that the two successful Indonesian candidates wereable to focus on their common goal and maintain strong motivations for passing the exam because theyreceived systematic and well-organized support from the management and staff from the beginning. It
was also established that the educational performance in Indonesia (S1 or D3) is not a determinate forpassing the exam as long as the management of foreign candidates is well maintained.

IV Discussions and Implications for Policy
The results of this limited qualitative survey show that the most difficult task for all Indonesian participants is to master a number of Japanese words including medical and nursing technical terms written
in complicated kanji. Most participants of this study feel that their studying hours are too short for
passing the exam. However, the narratives of those who did pass demonstrate that the number of hours
studying is not the only factor in determining the results of the exam. Those who passed have always
kept their strong motivation to study and find their own way of effective learning.
Effective learning strategies can be summarized: 1) Always ask questions and discuss the answers
with your Japanese preceptors or supervisors, 2) Study the past nursing examinations, 3) Set a timetarget to finish reading Japanese books and other materials, and make efforts to read as many as possible,
4) Make your own notes and keep them handy at all times and places, and 5) Place learning materials
on the wall or other visible places at home.
In the case of Filipino nurse candidates employed in Japan, Yoshichika Kawaguchi and his research
partners found in their research that intensive studies of past nursing exams might help in upgrading
their scores on the practice exam [see the paper contributed by Kawaguchi and other scholars in thisissue]. Indonesian nurse passers’ narratives confirm that it would be true for them.
639

東南アジア研究 49 巻 4 号

One point worth mentioning here is that the strong leadership of the management of the hospitaland its provision of a comfortable study environment for foreign nurse candidates at their workplaceand home contributes to maintaining the candidates’ high motivation to pass the exam. The hospital
allocated enough hours (a half day) for studying at the workplace and those hours counted as work hours.
Management acknowledged that the educational costs for the candidates would be curtailed if they could
pass the national exam in a shorter period than its previous support program for Japanese assistant().12) It has had a scholarship program for assistant nurses who wish to study at thenurses (jun-kangoshi
nursing school and become registered nurses ((kangoshi). It costs approximately three to four million
yen per person before they pass the national examination. Assistant nurses who have worked for thehospital for three to four years can complete paying back their scholarship to the management of their
hospital.
Compared to the costs for Japanese assistant nurses, the total expense for foreign nurse candidates(including tuition fees for instructors) was not excessive (approximately two million yen per person peryear in this hospital). If the hospital assisted foreign nurse candidates to pass the exam more quickly,
it can reduce the cost of the candidates. Such “cost-oriented management” would be fruitful especially when the hospital became successful in hiring high potential candidates through careful screening
and selection during the matching process. This is an important issue to clarify as the Japanese government has earmarked hundreds of million yen to increase the exam passing rate among EPA foreign
candidates for registered nurse and certified care-worker candidates since 2010.
The hospital referenced is the one of the few Japanese hospitals that emphasized the foreign employees’ learning rather than their working since their assignment to the workplace. Many otherhospitals tended to employ those candidates as “workers” mostly because their salary was the same as
the Japanese nursing assistants, but they do not work as many hours because of their study time at theworkplace, as shown in the results of the Japanese government’s nationwide survey on the Japanesehospitals that employed first-group Indonesian nurse candidates [Japan, Kosei Rodo-sho 2010: 16]. It
reflects ambiguity of treatment of foreign candidates as workers or trainees. Since the balance between
work and study hours became an important issue among accepting hospitals and foreign candidates, it
should be clearly regulated by the Japanese government.
Low passing rates in the national nursing exam among EPA foreign nurses may be partially explained by the present conditions and schemes of the EPA programs that were drafted without carefulconsideration of social, cultural and educational differences between Japan and Indonesia or the Philippines. Most Japanese hospitals’ poor capability to instructing foreign candidates efficiently with limited
human resources also constitutes a serious obstacle to increasing the passing rate among foreign
candidates. It is an urgent matter for Japan and the sending countries to nurture “bridging humanresources” who are capable of integrating the two nursing cultures and languages.

12) As of 2009, the number of assistant nurses ((jun-kangoshi) was 394,430 whereas that of registered nurses((kangoshi) was 954,818. Assistant nurses must work under instruction of registered nurses. Their license is
granted by the prefectural government whereas that of registered nurses is granted by the central governmentof Japan [Kobayashi 2011: 166–169].
640

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

It is also found that Indonesian nurses, especially those who failed the national exam, recognize
the importance of learning the Japanese language before their entry into Japan. This view was commonly shared by Japanese nurses and other staff that the authors interviewed as well as the Japanesehospitals employing first-group Indonesian nurse and certified care-worker candidates [Ogawa et al.
2010: 93–95].
Data collected in this survey suggest that the governments of Indonesia and Japan must provide
efficient Japanese-language training as well as sufficient information about Japan-style nursing thatdiffers considerably from Indonesia’s to incoming Indonesian nurses before their arrival in Japan. The
data also imply that both governments need to examine successful cases such as the one exemplified
in this survey, and incorporate the ideas and methods into its orientation and guidance programs. Since
the number of research subjects is quite limited in this survey, further studies to define a more effective
way of supporting foreign nurses are essential for improvement.

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

References
Adioetomo, Sri Moertiningsih; and MCicih, Lilis. 2009. Indonesia’s Demographic Dividened and Ageing. Presented
in Symposium on Global Ageing and the Development of Education and Research in Gerontology — Geriatric,
Depok, Indonesia (on June 3, 2009).
Buchan, James. 2002. Global Nursing Shortages. BMJJ 324: 751–752.
Calman, Lynn. 2005. The Global Shortage of Registered Nurses: An Overview of Issues and Actions. International
Council of Nurses (ICN). Accessed at http://www.icn.ch/global/summary.pdf (on January 18, 2010).
Friss, Lois.1994. Nursing Studies Laid End to End Form a Circle. Journal of Health Politics, Policy and Law 19(3):597–631
Goodin, H. J. 2003. The Nursing Shortage in the United States of America: An Integrative Review of the Literature.
Journal of Advanced Nursingg 43(4): 335–350.
Greenglass, E. R.; and Burke, R. J. 2001. Stress and the Effects of Hospital Restructuring in Nurses. Canadian
Journal of Nursing Research 33(2): 93–107.
Hirano, Yuko Ohara-. 2011. Gaikokujin Kangoshi, Kaigo Fukushishi no Donyu [Introduction of Foreign Nurses andCertified Care Workers] 24: Kokai Koza, Ajia no Kango o Rikai Shiyo [Public Forum “Let’s Understand Nursing
in Asia”]. Bunkaren Joho 397: 52–56.
Hirano, Yuko Ohara-; Ogawa, Reiko; Kawaguchi, Yoshichika; and Ohno, Shun. 2010. Rainichi Dai-ichijin no Indoneshiajin Kangoshi Kaigoshi Koho o Ukeireta Zenkoku no Byoin Kaigo-shisetsu ni taisuru Tsuiseki Chosa Dai-sanpo:
Ukeire no Jittai ni kansuru Byoin Kaigo-shisetsu no Hikaku o Chushin ni [A Follow-up Survey on Hospitals andLong-term Care Facilities Accepting the First Batch of Indonesian Nurse/Certified Care Worker Candidates(3): A Comparative Study of Current Status between Hospitals and Long-term Care Facilities]. Kyushu Daigaku
Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 113–125.
641

東南アジア研究 49 巻 4 号

Jamal, M.; and Baba, V. 2000. Job Stress and Burnout among Canadian Managers and Nurses: An Empirical Evaluation. Canadian Journal of Public Health 91(6): 454–458.
Japan, Kosei Rodo-sho [Ministry of Health, Labour and Welfare]. 2010. Indoneshia-jin Kangoshi Kohosha Ukeire
Jittai Chosa no Kekka ni tsuite [The Results of a Survey on the Actual Conditions of Acceptance of Indonesian
Nurse Candidates]. Tokyo: Ministry of Health, Welfare and Labour. Accessed at http://www.mhlw.go.jp/stf/
houdou/2r98520000005ltf.html (on April 24, 2011).
Japan, Kosei Rodo-sho Kangoka [Department of Nursing, Ministry of Health, Labour and Welfare]. 2011. Dai Hyakkai
Kangoshi Kokka-shiken Gokaku Jokyo [The Situation of Passing in the 100th Nursing National Board Examination]. Accessed at http://www.mhlw.go.jp/stf/houdou/2r98520000016bot-att/2r98520000016bqj.pdf (on April 24,2011).
Kawaguchi, Yoshichika. 2009. Nihon, Firipin, Indoneshia no Kango Kyoiku Karikyuramu no Hikaku [A Comparative
Study of the Curricula of Nursing Education in Japan, the Philippines and Indonesia]. Kyushu Daigaku Ajia Sogo
Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 3: 91–104.
Kobayashi, Miki. 2011. Kango Hokai [Collapse of Nursing]. Ascii Shinsho, No. 178. Tokyo: Ascii Media Works.
Ogawa, Reiko; Hirano, Yuko; Kawaguchi, Yoshichika; and Ohno, Shun. 2010. Rainichi Dai-ichijin no Indoneshia-jin
Kangoshi Kaigo Fukushishi Kohosha o Ukeireta Zenkoku no Byoin Kaigo-shisetsu ni taisuru Tsuiseki Chosa
Dai-ippo, Ukeire no Genjo to Kadai o Chushin ni [A Follow-up Survey on Hospitals and Long-term Care Facilities Accepting the First Batch of Indonesian Nurse/Certified Care Worker Candidates (1): An Analysis on the
Current Status and Challenges]. Kyushu Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University
Asia Center] 5: 85–98.
Satomi, Ryuji. 2010. Keizai Renkei Kyotei ni Motozuku Gaikokujin Kangoshi Kaigo Fukushishi Kohosha no Ukeire
ni tsuite [Acceptance of Foreign Candidates for “Kangoshi” and “Kaigo Fukushishi” under the Economic Partnership Agreement (EPA)]. In Kokusai Shimpojiumu, Tonan-ajia kara Nihon eno Keawaka no Ido o Meguru
Kokusai Kaigi, Seisaku-tantosha to Kenkyusha no Taiwa, Hokokusho [Report of the International Symposium,
Transnational Care Workers from Southeast Asia to Japan: A Dialogue between Government Officials andScholars], edited by Shun Ohno and Reiko Ogawa, pp. 89–98. Fukuoka: Kyushu University Asia Center.
Setyowati. 2010. The Health Care Services and Nursing Education in Indonesia. Kyushu Daigaku Ajia Sogo Seisaku
Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 199–208.
Setyowati; Susanti, Herni; Yetti, Krisna; Hirano, Yuko O.; and Kawaguchi, Yoshichika. 2010. The Experiences ofIndonesian Nurses in Japan Who Face the Job and Cultural Stress in Their Work: A Qualitative Study. Kyushu
Daigaku Ajia Sogo Seisaku Senta Kiyo [Bulletin of Kyushu University Asia Center] 5: 175–181.
Shukan Igakukai Shimbun [New Medical World Weekly]. April 20, 2009.
Tokyo Daigaku Koreishakai Sogo Kenkyu Kiko [The Institute of Gerontology, The University of Tokyo]. 2010.
2030 Nen Cho Korei Mirai [The Year 2030, the Future of the Super-aged]. Tokyo: Toyo Keizai Shinpo-sha.
Venzon, Lydia M.; and Venzon, Ronald M. 2005. Professional Nursing in the Philippines, 10th ed. Manila: C&E
Publishing.

642