MD Anderson Cancer Center Japanese Medical Exchange
ProgramJME Program 2018

From 30th August 2018 to 6th October 2018

Nao Kawamura
Certified Nurse Specialist in Cancer Nurse
Shizuoka Cancer Center
1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka Prefecture
411-8777 Japan
Tel:+81-55-989-5222 Fax:+81-55-989-5783

Mission
To protect patient's wishes by providing education to gastrointestinal
cancer patients at end of life and their families who receiving
chemotherapy while living at home

VisionEnd-of-life gastrointestinal cancer patients live their own way at home,who receiving cancer treatment by creating a premier educational team
to patient’s wishes

1Objectives
1. To learn the skills of the multidisciplinary team of MD AndersonCancer Center (MDACC)
2. To learn the American nurse system and think about activities as acertified nurse specialist in cancer nursing
3. To develop a project related to an oncology program by taking
advantage of the expertise of our team members.
4. To rebuild individual vision and mission and clarify career formation.
MethodTo participate in the Japan Medical Exchange 2018 program atMDACC from August 30, 2018 to October 6, 20182

1. To learn the skills of the multidisciplinary team of MDACC
To understand the multidisciplinary team of MDACC
The medical clinic examination style performed at MDACC was very different
from the style in Japan. A registered nurse (RN) led the patients to the exam
room and commenced with an interview while viewing the patient’s medical
record, checking responses to questions on a form. The overall examination
time varied from 30 minutes to 1 hour depending on the situation, but
generally longer than that in Japan. I had the impression that patients werecalm when undergoing examination. When not performing medicalexaminations, the team waited in another room, discussed the patient's
situation and treatment, and confirmed and described the medical record. I feltthat it would be desirable for the medical team to have time to discuss thepatient and treatment over time on the occasion where is visiting outpatient. I
felt that nurses could easily consult doctors and pharmacists, but nurses
needed to acquire skills to assess the information they acquired during their
examination from their job category and tell them briefly to multiple jobs. I feltthat it was a technique that should not be done. As medical expertise isincreasing, to raise the quality of nursing provided to patients, it is importantfor nurses to provide their own nursing perspective in team medical care. I
want to pay special attention to this idea when working in team medical care.
In the MDACC examination system, I felt that the clinical practice of doctors
and pharmacists with outpatients was calmer than in Japan, but RNs andnurse practitioners (NP) must participate in patient examination and respondto patient inquiries over time. I saw nurses going from one examination to theother, confirming that the busy practice of nurses is the same all over theworld.
It was interesting to see the existence of members of the team who are notcommon in Japan.
There are chaplains in Japanese hospitals, although they may belong to3

palliative care teams and are in a minority of settings. In Japan, there are few
religious activities, and I felt that it was difficult to understand spiritual pains.
From speaking with the chaplain who worked in hospice care, I learned that it
was important to start with what the patient and their family treasured at thedeepest level. After hearing the patient's story, establishing a relationship oftrust with the patient was the place to start. I perceived that it was notnecessary to talk about God but to have everyday conversations. I realized thatin both the United States (US) and Japan, the underlying care did not changeeven if there was a difference in religion. I felt that the most important thing.
A bereavement coordinator was a counselor in charge of family grief care after
a patient died in hospice. Care for the family was desirable for a long time,nearly a year. I experienced a lot of patients' attention in the digestive organs
inpatient ward and respiratory inpatient ward for the past two years, but I feltthat I did not provide grief care for families. I gained knowledge and skills
about grief care as a nurse involved in caring for patients in the terminal
stages of life. And I would like to support the family who lost the patient toreturn the spirit to the original life.
I also saw a difference in the role of a social worker (SW). Because thecoverage for medical treatment is determined by the patient's insurance, theSW was added to medical team to assist with navigating care. I think that it
would be an unusual situation in Japan to closely consult with doctors,
pharmacists, and nurses about treatment. The ward was always full, and it
was a common practice to have new hospitalized patients in the afternoon if
other patients were discharged in the morning. The result was amultidisciplinary conference held every day by the RN, NP, clinical nurse
leader, and others, including the SW. This conference helped everyone caring
for the patient to grasp the situation of the patient and assist in a good
hospitalization experience. One area of care that I felt was weak was thedischarge process. This was because nurses might not have the time tocooperate with SW, because Ns did not communicate with the doctor about a4

patient's treatment. I was able to confirm the necessity of smooth discharge
from the hospital.
On the importance of the role of mid-level providers
At MDACC, physician assistants (PAs) and NPs play an active role. The NP
system has also been started in Japan, but the range of areas where they canwork and their roles in prescribing medications is greatly different from theUS. Patient examinations may be completed by PAs and NPs without physician
involvement. I was surprised that this style of medical care was satisfactoryfor patients. The roles of PAs and NPs in the US are similar to doctors, I feelthat Japan's CNS (Certified Nurse Specialist) and NPs are still nursing staff.
However, I do not think that it is desirable for nurses to be able to expand theirrights to prescribe medication and medical practice, but the enhancement andfulfillment of care as part of a system that provides satisfactory outpatient
services may be helpful. In the future, it is expected that nurses will increase
their knowledge and skills as medical professionals, and their importance andnecessity will be established in Japan. I would like to continue my efforts every
day to increase medical knowledge and technology, so that I can also be an
active mid-level provider.

2. To learn the American nurse system and think about activities as acertified nurse specialist in cancer nursing
I studied the American nurse system and think about activities as a certified
nurse specialist in cancer nursing.
During the JME2018 period, I observed the work of various nurses. Theduties I normally perform include the content of RN, NP from Assistant Ns in
the United States. I believe that in the future, the work of nursing is going todivision. The merit is that IVNs can boost their expertise; however, there is a
disadvantage of difficulty in adaptation if there are many departmental
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movements, such as in Japan. In order to divide nursing duties,
communication is necessary. I felt that incidents and accidents occur easily
unless each member clearly describes his/her work, reports circumstances, andrequests them. As my plan, at the chemotherapy center, I want to divide workof nurses. It is to separate the nurse who checks the data with the nurse
exchanging the infusion and supports side effects. I would like to start workingon.
And I felt the need to interact with various nurses, deepen their learning
about the specialty and generality of nursing, and provide in-depth
information about creating a system that can provide better nursing.
There is a difference between Japan and the United States in terms of theextent to which advanced medical nursing practices can be performed.
However, the role of caring for patients from a nursing point of view and highly
specialized medical knowledge remains unchanged. I feel that NP is a nurse
who provides high knowledge and skills to patients, while CNL (Clinical NurseLeader) is a nurse who follows the care of nurses with high knowledge and skill
in clinical practice. I’m a CNS for a ward and perform activities to raise theproficiency of ward nurses while improving ward nursing practice to enhancenursing care for patients; I am working on CNL similar activities. I would liketo continue my own activities in the future with reference to the role andactivities of CNL.
During the JME2018, I met several international nurses. MDACC started
recruiting foreign nurses after a history of nurse shortage and is now acquiring
Magnet Designation as a hospital that attracts nurses. There is an obvious
improvement in the education system and resources in the MDACC. Even aforeign nurse felt that in this environment, career advancement from RA to NP
is possible, and it is obvious that I would like to work here. In Japan, there is asystem that recruits nurses who are foreign nationals; however, the passing
rate for the national nursing exam is about 10%. I believe that there areseveral hurdles for nurses who are foreign nationals and work in Japan. Japan6

provides a closed environment of an island country and a culture country to beconceived. If you understand this background and provide nursing, I can also
understand that foreign nurses feel difficulty in working. I perceived thatinternationalization of nurses is still a challenge in Japan.

3. To develop a project related to an oncology program by taking
advantage of the expertise of our team members.
The 2018 JME program has greatly contributed to the improvement of mycommunication, collaboration, and cooperation skills with other participants
through practice. In addition, this training also aimed to highlight the high“patient power” in MDACC. Patient power refers to the patient’s own
understanding of his condition and treatment and his willingness and attitude
toward understanding it. We decided to create a vision and mission with thetheme “Patient Education” to focus on the improvement of our patient skills.
The team encountered difficulty in creating the vision and mission due to thedifferent viewpoints that exist due to different job categories. Even though weare seeing the same patient and wish to provide better treatment and medicalcare to the patient, the team has different viewpoints because of different
occupations and our perception of them. We have also understood that this isnatural. As professionals, the team conducted repeated discussions andanalysis to understand each other’s ideas, which subsequently led to thecreation of vision, mission, goal, and plan with a common agreement. In thediscussion, I realized that further learn need to be conducted to deepen theunderstanding on the different kinds of communication using direct technologythat simplifies not only my opinion but also that of others.
4. To rebuild Individual Vision and Mission and Clarify Career Formation
In creating my own vision and mission, I faced three issues. The first is how tocreate a vision and mission that is appealing to the people. As a nurse, I was7

interested in working in the field that is related to outpatient cancer
chemotherapy. Outpatient cancer chemotherapy is a limited field amongnurses, but it was surprising to discover that the subject is too broad. In Japan,
nurses are generally required to work and continuous education has beentaken into account so as not to limit their ability in one field. However,according to Dr. Ueno, to achieve the vision and mission, firstly, subjects
should be narrowed down, from the advantages of contributing one’s ownexpertise to spreading the vision and mission, to understanding the necessity.
The second issue concerns about nursing life. To date, I have thought about
the fields in nursing I would like to explore, as well as the annual goals;
however, in my nursing life, no opportunity was provided to concentrate on
developing vision and mission. Also, I have not previously thought of exploringother nursing fields. However, based on the previous experiences, there is an
opportunity to learn the strategic way of thinking to achieve the vision more
efficiently in the future. I became a professional nurse last year specializing incancer nursing, with great opportunities for continuing education, but I havebeen working without a particular goal. Based on these experiences, I havelearned that maximizing opportunities in exploring other activities as a cancer
nurse is essential, considering that time is limited in developing my own visionand mission.
The third is how to come up with a unique vision and mission. I have learned
that distinctness of a vision and mission is necessary for it to be recognized;
however, I knew that this vision and mission still lack a sense of uniqueness.
In the future, the issue on uniqueness should be considered as vision andmission changes over time.

Acknowledgments
I would like to express my sincere gratitude to Dr. Ueno, Joyce L. Neuman,
my mentor Nicholas A. Szewczyk, and the tutors who supported the JME 20188

program. Thank you very much for your oncology education promotion project
as well as to all corporate people. Finally, I thank the team members who havealways supported me, and I am very thankful for this life-changing experience.

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