61

An Analysis of the Performanceof Filipino EPA Nurses in the
Practice National Board Examinationof Japan Conducted in English
Yoshichika KAWAGUCHIa
Cora A. AÑONUEVOb
Yuko O. HIRANOc
Abstract
Japan has been receiving Filipino nurses under the Economic Partnership
Agreement (EPA) since 2009. Under the agreement, they must pass the
National Board Examination (NBE)—conducted in the Japanese
language—so that they can continue working (as fully fledged nurses) inJapan. It is a challenging requirement for foreign nurses. Indeed, thepassing rate in the NBEs turned out to be considerably low (approximately
10 percent). It is essential for both Philippine and Japanese stakeholders
to identify the factors contributing thereto. In this light, this article presents
the result of the study that observes the distribution of the accuracy rateof Filipino EPA nurses who entered Japan in 2009 in a practice exam of
the NBE, which comprised 240 questions. The performance of Japaneseexaminees in the actual NBE for nurses in 2009 conducted in Japanese
was referred to as a benchmark. Among the eleven officially designatedcategories of nursing, including seven categories from clinical nursing
and four categories from the basics of nursing sciences, the average scorein each category in clinical nursing ranged from 60.2 percent to 73.2
percent. For the basics of nursing sciences, it was from 55.3 percent to78.9 percent. Among the Filipino examinees, there was a huge gap in
accuracy rate between those who had seen the questions of NBE for
nurses of any of the previous years on the one hand, and those who had
never seen them on the other. While 57.1 percent of those who had
a Professor of Psychiatric Nursing, University of Occupational and Environmental Health, Japanb Former Professor and Director of the National Graduate School of Health Sciences,

University of the Philippines Manilac Professor, Graduate School of Biomedical Sciences, Nagasaki University

55 2 (2016)
Volume 52:

62
56

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

previously seen the exam questions could satisfy the passing rate, only
23.7 percent of those who had never seen them could do that. The study
also shows that Filipino nurses in average marked higher points in questions
on the knowledge on pharmacology and physiology than their Japanesecounterparts, while they marked in average lower points in gerontology
nursing than their Japanese peers. From the practice examination result,
it is suggested that the obstacles facing the Filipino EPA nurse in passing
the National Board Examination concern not only Japanese language
proficiency but also differences in examination style, nursing education
curriculum, and basic nursing policies in the Philippines and Japan.
Keywords: Economic Partnership Agreement (EPA), foreign nurse,
practice national board examination in English

Introduction
In the late 2000s, Japan began to receive foreign nurses from Asian
countries under bilateral Economic Partnership Agreements (EPAs). In 2008,
the first batch of Indonesian nurses entered Japan under the Japan–Indonesia
Economic Partnership Agreement (JIEPA). In 2009, they were followed bytheir Filipino counterparts under the Japan–Philippines Economic Partnership
Agreement (JPEPA). In 2014, Vietnam started to send nurses to Japan under
the Japan-Vietnam Economic Partnership Agreement (JVEPA).
Such movement of nurses is covered in the provisions on the
movement of natural persons (MNP) of each EPA. Although the basic schemeof these MNPs is common among these EPAs, the details for each differ.
For instance, Indonesian and Filipino nurses must acquire at least the N5
level in the Japanese Language Proficiency Test (JLPT) after six months ofpredeparture study in their respective countries before they can enter Japan.1
JVEPA requires Vietnamese nurses the JLPT N3 certificate, in addition to
twelve months of predeparture Japanese language training in Vietnam.
Required qualifications for application to the EPAs vary with each sending
country, too. Indonesian nurses are required to have at least two years ofclinical work experience, Filipino nurses at least three years,2 and Vietnamese
nurses at least two years.

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

57
63

Despite such differences, all foreign nurses who enter Japan under
the EPA program (EPA nurses) are commonly expected to pass the National
Board Examination (NBE) for nurses in Japan within three years of theirentry to the country.3 Through the great efforts of EPA nurses—and thoseby receiving hospitals that support nurses—the EPA nurses’ passing rates in
the NBE have improved.4 In conducting the NBE for EPA nurses, Japan’s
Ministry of Health, Labor and Welfare (MHLW) has also made someadjustments, like (a) extension of the examination time from two hours andforty minutes to three hours and thirty minutes in each of the two sessionsof the examination, (b) providing English names of diseases and historicallyfamous persons, (c) providing phonetic guide to every Chinese character, (d)paraphrasing sentences with irregular structure into regular ones, and (e)simplifying difficult Japanese technical terms. These measures may havepartly contributed to the improvement of the passing rate. Nevertheless, thepassing rate of the EPA nurse candidates in the NBE remains low (7.9 percent
in 2015), while the passing rate of non-EPA examinees was 90.5 percent(MHLW 2015a). There remains a wide discrepancy between the passing
rate of the EPA nurse candidates and that of the rest—almost entirely
Japanese, thus “Japanese examinees” hereafter. However, can the low passing
rate be attributed only to the language barrier? Would differences in
educational systems and clinical experiences in each country affect theexamination result as well? In the first place, 90 percent of the Japaneseexaminees were fresh graduates—they might have been very well trained
for the examination, but they have lesser clinical experiences, except for the
mandatory practicum. Remarkably, they registered a passing rate of 95.5
percent. It is noted that the passing rate of nurses who were neither fresh
graduates nor EPA candidates was 41.2 percent (MHLW 2015a, 2015b).
EPA nurses, on the other hand, have at least two to three years of work
experience in clinical settings. This means several years must have passed
since they graduated from nursing college. This fact alone implies anotherdisadvantage for the EPA nurses, aside from the language barrier. Although
they have improved their skills in nursing, their “textbook” knowledge is nolonger fresh; they have not taken an exam for a long time and are no longer

Volume 52: 2 (2016)

64
58

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

used to answering them. At any rate, passing the NBE is a requirement for
the EPA nurses.5 Therefore, EPA nurses, as well as the staff in the hospitals
where they work, have been exerting great efforts to achieve this goal.
Previous studies (Setyowati et al. 2010, 2012; Furukawa et al. 2012;
Nakamura and Ozaki 2013) suggest that the support system for both EPA
nurses and receiving hospitals be improved in order for EPA nurse candidates
to pass the NBE.
Under the EPAs, foreign nurses who are licensed in their respective
home countries but have yet to pass Japan’s NBE are called “nurse candidates”
in Japan. They are designated to work under the instruction of registerednurses in the country, with a salary equivalent to that of a nonlicensed staff.
This condition is considered one of the primary causes of stress for the EPA
nurses and often weakens their self-esteem (Setyowati et al. 2010, 2012).
Therefore, the authors of this article suggest that it is important to shorten
the period of their being nurse candidates by developing a better support
system. To develop a support system for nurse candidates is also to assist
hospitals, which shoulder more than two million yen per year per candidate,including salary and miscellaneous expenses, such as that incurred in hiring
tutors for review exercises for the NBE (Tsubota et al. 2015). Therefore, it isessential to identify the problems and challenges that EPA nurses candidates
encounter with regard to the NBE.
The language barrier is certainly one of the significant hurdles the
EPA nurse candidates face. Okuda (2011) analyzed the vocabulary used in
the NBE by comparing it with the standardized word list for the JLPT. He
points out that only 40 percent of the words in the JLPT word list was usedin the NBE. This indicates that the NBE uses highly technical terms comparedwith the Japanese language of daily use. But is language the only problem
the EPA nurse candidates face and the only cause of their low passing ratein the NBE? Language proficiency is definitely a key determinant of theresult. However, it is equally crucial to understand the sociocultural context
behind the words and/or terms used in the NBE. This essay explores possible
elements other than language in the NBE that make it difficult for EPA
nurse candidates to pass the NBE. With such assumption, the authors of thisASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

59
65

article conducted a practice examination of the NBE for nurses in Japan inEnglish—by translating the questions from Japanese—among the EPA nurses
from the Philippines.6 By analyzing the accuracy rate for each question of
the examination, it became easier to determine if the problems really pertain
to language or to something else. If the Filipino EPA nurse candidates
marked a higher score in the practice examination in English translation, it
was assumed that language was the primary obstacle. If not, one can surmised
other extralinguistic factors.
The accuracy rate of Filipino examinees for each question in the NBE
in English translation was analyzed in relation to that of the Japanese examinees
who took the same examination in Japanese in 2009. This was done in orderto observe trends in the NBE results between Filipino and Japanese examinees,
and to identify the areas in which the Filipino EPA nurses are strong or weak.
The Practice Examination
In Japan, the NBE for nurses is conducted annually (usually in late
February, and the result is released in late March of the same year). Each
year, a new set of questions is prepared by a committee. The NBE questions
become a public document after the examination. Eligible participants inthis study were the first batch of Filipino EPA nurses—93 all in all—who
entered Japan on 10 May 2009. They were given a six-month Japanese
language training at the Association for Overseas Technical Scholarship(AOTS) in Osaka upon arrival, and they had been receiving clinical training
at their individual healthcare facilities for about two months before thedate of the practice examination.7
The authors of the article translated the questions of the 98th NBE,
held previously on 22 February 2009. They asked health workers who
possess a high command of English to guarantee the validity and reliabilityof the translation from Japanese to English. The questions were then usedas part of the practice examination for the NBE nurse candidates. The
questions of the 98th NBE for nurses were categorized into the following
eleven areas: (1) Compulsory Questions (Basics of Nursing),8 (2) Structures

Volume 52: 2 (2016)

66
60

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

and Functions of the Human Body, (3) Constitution of Disease andPromotion of Recovery, (4) Social Security System and Health of Living
People, (5) Fundamentals of Nursing, (6) Home Health Care Nursing, (7)Adult Nursing, (8) Pediatric Nursing, (9) Maternal Nursing, (10) PsychiatricNursing, and (11) Gerontology Nursing. Areas 1–4 were grouped andlabeled as Basics of Nursing Sciences, and areas 5–11 as Clinical Nursing(MHLW 2009a). The Compulsory Questions (Basics of Nursing) cover
all the areas mentioned above. The total number of questions in the 98th
NBE was 240, 120 questions each for the morning and the afternoon
sessions. Out of the 120 questions for each session, 15 questions (a totalof 30) were Compulsory Questions (Basics of Nursing). The rest of thequestions were composed of General Questions and Situational Questions.
In the examination, examinees were asked to choose an answer from four
options, an answer from five options, or two answers from five options.
Computer-scored answer sheets were used.
The results of the Filipino EPA nurses’ practice exam in English werecompared with those of the 98th NBE for nurses, as announced by the
MHLW.9 The passing scores for the three designations—Compulsory
Questions, General Questions, and Situational Questions—were as follows:
For the Compulsory Questions (Basics of Nursing), with thirty questions
and one point per question, the passing point was 24. (A score of 23 points
or less is a failing grade.) As for the General Questions/Situational Questions,the passing score was 174, out of the total 270 points; 1 point was given forevery General Question and 2 points for every Situational Question.
To help compare the accuracy rates for each question between the
EPA nurses and the non-EPA nurses, the authors of this study used, withpermission, the estimated accuracy rate of the Japanese examinees, which
was prepared by Tokyo Academy Co. Ltd. from careful calculations basedon the data of the practice examinations the institution had conducted for theJapanese would-be-examinees.10
The authors of this study also collaborated with the AOTS to holdthe practice examination in English on 26 December 2009 in Tokyo, Osaka,

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

61
67

Nagoya, and Fukuoka. The exam was given simultaneously in all four
locations, and examinees received the same time as the nurses who took
the actual 98th NBE (i.e., two hours and forty minutes for both morningand afternoon sessions). Fifty-nine out of the 93 Filipino EPA nurses (thefirst batch) consented to the study, which accounted for 63.4 percent of
the group.
The comparison of the distribution of the accuracy rates between thetwo groups was conducted for each question, and for each of the elevenareas of nursing in the NBE. In this study, the questions were grouped into
four types in accordance with the analysis of Tokyo Academy Co. Ltd.—
namely, Recall, Estimation, Interpretative, and Problem Solving. Recall
questions involve remembering basic information. Estimation questions ask
examinees to determine the correct answer by using common sense and on
knowledge of the basics of nursing education. Interpretative questions require
understanding of the situation in clinical settings. Problem Solving questions
test the examinees’ thought processes both in understanding and interpretingthe clinical scenario. The Problem Solving questions require examinees tohave both knowledge and analytical skills.
In assessing the distribution of the accuracy rates of the Filipino
EPA nurses in relation to those of the Japanese examinees, the authors of
this study particularly focused on questions where there was at least a tenpercent gap in the accuracy rate between Filipino EPA nurses and Japaneseexaminees. Results were labeled or grouped either as “high accuracy rate”
or “low accuracy rate.”
Results
For analytical purposes, the 59 EPA nurse participants were divided
into two groups: those who had seen the questions of any of the NBEs fornurses in Japan of the previous years either in English or in Japanese (21participants), and those who had not (38 participants). There was a significant
difference in the total score of participants between the two groups (p<0.01).
Those who had previously seen the questions had a higher accuracy ratio in

Volume 52: 2 (2016)

68
62

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

all areas. The average score of those who had seen the examination was
226.3 (SD 54.1), while the average score of those who had not seen theexamination was 179.1 (SD 42.8). Twelve or 57.1 percent of the participants
who had seen the exam questions scored above the passing rate, while only
nine or 23.7 percent of the participants who had not seen the examination
did so. Familiarity with the trends of the questions seems help achieve thepassing rate.
Seven of those who had previously seen the questions correctly
answered more than 90 percent of the questions across the entire
examination, and one even got a perfect score (100 percent). On the other
hand, those who had not seen the examination marked a comparatively
low accuracy rate, although many of them achieved approximately 60
percent score across the different areas.
FIGURE 1
The distribution of scores by area achieved
by fifty-nine Filipino nurse candidates** Basics of Nursing

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

63
69

FIGURE 2
Familiarity with Japan’s NBE style and passing rate

The group consisted of the participants who had been presumably
preparing for the NBE more seriously. They could have been alreadyfamiliar with the particular styles of the NBE for nurses in Japan and evenwith some of the questions. Considering probable bias in the performanceof the practice examination, the authors chose the second group consistingof 38 participants for further analysis.
Accuracy Rate by Area of Nursing
The accuracy rates by area of nursing of the 38 participants
and those of the Japanese examinees are shown in Table 1. Across allareas of nursing, the average accuracy rate of Filipino EPA nurses
who had not seen the examination was 59.3 percent, while their
Japanese counterpart obtained 77.5 percent. This gap also manifests
that language is not the sole barrier for EPA nurses, but the probabledifference in the content of the licensure examinations between thetwo countries is also a possible factor in Filipino nurses’ low passing
rate in Japan’s NBE.
In order to calculate the proportion of the accuracy rate of the
EPA nurses against the accuracy rate of the Japanese examinees, theVolume 52: 2 (2016)

70
64

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

Table 1. Comparison of average score by area of nursing between Filipino nurse
candidates who have never seen the examination sheet and Japanese counterpart (%)
Filipino nurse
candidates who
have never seen
the exam questions(a)Basics of Nursing
Sciences

Clinical Nursing

General Questions
Structures and Functionsof the Human Body
Constitution of Disease andPromotion of Recovery
Social Security System and
Health of Living People

Japanese (a)/(b)
(b)

74.3

92.2

80.6

58.0

83.9

69.1

49.8

59.0

84.4

49.5

64.8

76.4

Fundamentals of Nursing
Adult Nursing
Gerontology Nursing
Pediatric Nursing
Maternal Nursing
Psychiatric Nursing
Home Health Care Nursing

51.8
58.3
58.0
63.2
56.4
61.0
69.2

76.2
81.2
83.9
68.1
77.5
80.3
90.8

68.0
71.8
69.1
92.8
72.8
76.0
76.2

Total

59.3

77.5

76.6

authors divided the EPA nurses’ accuracy rate by that of their Japanesecounterpart. The bigger the proportion, the lesser the gap between
the two parties. Across all areas of nursing, the proportion was 76.6
percent. A comparison made by area of nursing indicated thefollowing: the lowest proportion was marked in Fundamentals of
Nursing (68.0 percent); the second to the lowest in Gerontology
Nursing (69.1 percent) and Structure and Functions of the Human
Body (69.1 percent). On the other hand, the highest proportion wasmarked in Pediatric Nursing (92.8 percent).

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

71
65

Questions where Japanese Examinees Got Higher Accuracy Rate
than Filipino Examinees
In 195 questions out of 240 questions, the accuracy rate was higher
among Japanese examinees than among their Filipino counterparts. On
the other hand, in 44 questions out of 240 questions, the accuracy rate
was higher among Filipino EPA nurses than Japanese examinees. There
was one question in which the two groups obtained the same accuracy
rate. Among the 195 questions where the Japanese examinees got a higher
accuracy rate, 39 questions had a wide gap of at least 40 percent between
the Filipino examinees and the Japanese examinees.
These are found in the following areas of nursing in descendingorder: Adult Nursing (11 questions, representing 28.2 percent of thequestions), Gerontology Nursing (nine questions, 23.1 percent),
Fundamentals of Nursing (five questions, 12.8 percent), andPsychiatric Nursing (four questions, 10.3 percent). By type, these areas follows: 21 Recall questions out of 39 questions (53.8 percent),
seven Estimation questions (17.9 percent), seven Interpretative
questions (17.9 percent), and four Problem Solving questions (10.3
percent).

Volume 52: 2 (2016)

72
66

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANOTABLE 2. List of questions where Japanese examinees got accuracy rates higher
by 40 percent or more
Questions

Area

AM18

Structures and Functionsof the Human Body
Fundamentals of Nursing
Fundamentals of Nursing
Fundamentals of Nursing
Fundamentals of Nursing
Fundamentals of Nursing
Home Health Care Nursing
Adult Nursing
Adult Nursing
Adult Nursing
Adult Nursing
Gerontology Nursing
Gerontology Nursing
Gerontology Nursing
Gerontology Nursing
Adult Nursing
Adult Nursing
Gerontology Nursing
Maternal Nursing
Psychiatric Nursing
Compulsory Questions
Compulsory Questions
Compulsory Questions
Social Security System and
Health of Living People
Adult Nursing
Adult Nursing
Adult Nursing
Adult Nursing
Gerontology Nursing
Pediatric Nursing
Psychiatric Nursing
Adult Nursing
Gerontology Nursing
Home Health Care Nursing
Gerontology Nursing
Gerontology Nursing
Maternal Nursing
Psychiatric Nursing
Psychiatric Nursing

AM35
AM38
AM39
AM41
AM42
AM46
AM50
AM51
AM58
AM62
AM67
AM68
AM69
AM70
AM99
AM105
AM108
AM116
AM118
PM5
PM8
PM14
PM31
PM47
PM48
PM52
PM57
PM61
PM69
PM78
PM87
PM88
PM92
PM104
PM105
PM114
PM118
PM119

Type

Accuracy rate Accuracy rate (A)-(B)of Japaneseof Filipino
examinees
examinees(A)(B)

RecallEstimation
RecallRecallRecallRecallEstimation
Estimation
Interpretative
RecallRecallRecallEstimation
Interpretative
RecallProblem Solving
Problem Solving
Interpretative
Interpretative
Interpretative
RecallRecallRecall

90.1
96.2
82.2
88.7
91.1
86.5
98.8
94.6
81.2
89.7
96.9
96.5
89.7
93.1
95.8
70.1
93.4
95.9
98.2
95.0
99.4
97.9
88.5

47.4
52.6
39.5
39.5
29.0
36.8
52.6
36.8
39.5
31.6
44.7
55.3
42.1
36.8
50.0
26.3
44.7
50.0
42.1
18.4
50.0
52.6
44.7

42.7
43.6
42.7
49.2
62.1
49.7
46.2
57.8
41.7
58.1
52.2
41.2
47.6
56.3
45.8
43.8
48.7
45.9
56.1
76.6
49.4
45.3
43.8

RecallInterpretative
Problem Solving
RecallRecallRecallRecallRecallEstimation
RecallRecallEstimation
Estimation
Interpretative
RecallProblem Solving

84.2
90.1
75.4
95.5
68.5
91.5
86.4
92.7
89.0
69.7
97.5
90.4
90.3
56.5
85.0
81.3

34.2
50.0
10.5
52.6
23.7
47.4
15.8
52.6
29.0
23.7
52.6
50.0
36.8
15.8
42.1
36.8

50.0
40.1
64.9
42.9
44.8
44.1
70.6
40.1
60.0
46.0
44.9
40.4
53.5
40.7
42.9
44.5

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

67
73

FIGURE 3
Question no. 68 of the morning session (Estimation question)

Q. Which of the following adjustments for communication is appropriate in
response to age-related auditory changes at old age?
1. Speak to the person in a higher pitched voice.
2. Clearly pronounce consonants in particular. (correct answer)
3. Choose a room with strong auditory echoing, such as a living room.
4. Speak to the person in a loud voice at a slight distance.

1.
2.
3.
4.
Correct answer rate:
Japanese 89.7%
Filipinos who have seen the question:55.9%
Filipinos who have never seen the question:42.1%

To cite some examples, question no. 68 of the morning session on
age-related auditory changes, which is categorized under Gerontology
Nursing and considered an Estimation question, had a high accuracy rate
among Japanese examinees (89.7 percent) but quite low accuracy rate
among Filipino examinees (42.1 percent).

Volume 52: 2 (2016)

74
68

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANOFIGURE 4
Question no. 41 of the morning session (Recall question)

Q. Which of the following methods is appropriate for blood collection?
1. Fasten a tourniquet at approximately 2 cm above the puncture site.
2. Sterilize the puncture site from the outside to the center.
3. Collect blood within 2 minutes after fastening a tourniquet.
(correct answer)
4. Remove the tourniquet after removing the blood-drawing needle.

1.
2.
3.
4.
Correct answer rate:
Japanese 91.1%
Filipinos who have seen the question:47.5%
Filipinos who have never seen the question:29.0%

Question no. 41 of the morning session on blood collection,categorized under Fundamentals of Nursing and considered a Recall
question, had a very higher accuracy rate among Japanese examinees (91.1
percent) but seemed to have been challenging for Filipino examinees (29.0
percent).

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

69
75

TABLE 3: List of questions where Filipino examinees got higher accuracy rate
than Japanese examinees (10 percent gap or more)
Questions

Area

Taxonomy

AM8
AM16

Compulsary Questions
Structures and Functionsof the Human Body
Structures and Functionsof the Human Body
Social Security System
and Health of Living People
Fundamentals of Nursing
Adult Nursing
Gerontology Nursing
Psychiatric Nursing
Adult Nursing
Pediatric Nursing
Pediatric Nursing
Structures and Functionsof the Human Body
Social Security System
and Health of Living People
Adult Nursing
Gerontology Nursing
Constitution of Disease
and Promotion of Recovery
Constitution of Disease
and Promotion of Recovery
Adult Nursing
Pediatric Nursing
Pediatric Nursing

Recall

77.6

89.5

-11.9

Recall

21.8

39.5

-17.7

Recall

35.9

60.5

-24.6

RecallRecallRecallRecallRecallRecallRecallInterpretative

45.2
26.7
73.8
62.6
23.3
57.2
66.1
64.9

57.9
39.5
89.5
73.7
34.2
84.2
94.7
81.6

-12.7
-12.8
-15.7
-11.1
-10.9
-27.0
-28.6
-16.7

Recall

11.9

42.1

-30.2

RecallRecallRecall

41.8
32.3
52.4

86.8
44.7
63.2

-45.0
-12.4
-10.8

Recall

27.3

63.2

-35.9

RecallProblem Solving
RecallProblem Solving

26.0
11.5
53.9
23.9

50.0
31.6
81.6
73.7

-24.0
-20.1
-27.7
-49.8

AM21
AM31
AM37
AM63
AM66
AM85
AM97
AM110
AM112
PM21
PM29
PM51
PM62
PM82
PM85
PM99
PM106
PM108

Accuracy rate Accuracy rate (A)-(B)of Japaneseof Filipino
examinees
examinees(A)(B)

Questions Where Filipino Examinees Got Higher Accuracy Rates
than the Japanese
Table 3 lists the questions where Filipino examinees outscored Japaneseexaminees by more than 10 percent. By area of nursing, Adult Nursing (fourquestions) and Pediatric Nursing (four questions) marked the highest, followedby Structures and Functions of the Human Body (three questions). By type,these consisted of seventeen Recall questions, one Interpretative question,
two Problem Solving questions, but no Estimation questions.

Volume 52: 2 (2016)

76
70

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANOFIGURE 5
Question no. 82 of the afternoon session (Recall question)

Q. Which of the following acts most rapidly to anaphylactic shock?
1. Potassium chloride
2. Theophylline
3. Adrenaline•@(Correct Answer)
4. Prednisolone
5. Magnesium sulfate

1.
2.
3.
4.
5.
Correct answer rate:
Japanese 27.3%
Filipinos who have seen the question:72.9%
Filipinos who have never seen the question:63.2%

Question no. 82 of the afternoon session is an example of a fairly
higher accuracy rate among Filipino examinees (63.2 percent) thanJapanese examinees (27.3 percent). This question is categorized as a Recall
question, which requires basic knowledge of Pharmacology andPhysiology.
Similar types of questions—such as question no. 21 of the morning
session about the element in the blood for respiration, and question no.
21 of the afternoon session about what stimulates appetite—show a similar
trend.

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

71
77

FIGURE 6
Question no. 21 of the morning session (Recall question)

Q. Which of the following facilitates respiration when its level increases in the blood?
1. Hydrogen ion (Correct answer)
2. Chloride ion
3. Bicarbonate ion
4. Sodium ion

1.
2.
3.
4.
Correct answer rate:
Japanese 35.9%
Filipinos who have seen the question:57.8%
Filipinos who have never seen the question:60.5%

FIGURE 7
Question no. 21 of the afternoon session (Recall question).

Q. Which of the following stimulates appetite?
1. Warmer environment
2. Extension of stomach wall
3. Leptin secretion
4. Elevated level of free fatty acid in the blood (Correct Answer)

1.
2.
3.
4.
Correct answer rate:
Japanese 11.9%
Filipinos who have seen the question:52.5%
Filipinos who have never seen the question:42.1%

Volume 52: 2 (2016)

78
72

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

Questions where Filipino and Japanese Examinees Obtained the SameHigh Accuracy Rates
Question no. 77 of the morning session is about the proper care foran asthma patient suffering from an attack who has made an emergency
visit. More than 90 percent of the examinees of both groups answered
correctly.
FIGURE 8
Question no. 77 of the morning session (Interpretive question).

Q. The case is an elementary school child who made an emergency visit due toan asthma attack. The wheezing was significant and transdermal arterial
oxygen saturation (SpO2) was 91%.
Which of the following is appropriate?
1. Encourage having a conversation.
2. Place the child in the uplift sitting position. (Correct Answer)
3. Encourage water intake.
4. Encourage thoracic respiration.

1.
2.
3.
4.
Correct answer rate:
Japanese 95.8%
Filipinos who have seen the question:94.9%
Filipinos who have never seen the question:94.7%

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

79
73

Questions where Filipino and Japanese Examinees Obtained Low Accuracy
Rates
Question no. 33 of the morning session is a Recall question asking
about the amendment of the Act on Public Health Nurses, Midwives andNurses.11 Only one-third of the examinees or less were able to answer
correctly.
FIGURE 9
Question no. 33 of the morning session (Recall question)

Q. Which of the following was added to the items regarding nurses in the
Amendment of the Act on Public Health Nurses, Midwives and Nursesthat came into effect in April 2007?
1. Title exclusiveness (Correct Answer)
2. Practice exclusiveness3. Reasons for disqualification
4. Licensing criteria

1.
2.
3.
4.
Correct answer rate:
Japanese 33.5%
Filipinos who have seen the question:35.6%
Filipinos who have never seen the question:21.1%

Volume 52: 2 (2016)

74
80

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

Discussion
The study results indicate that the Filipino EPA nurses who had notseen the NBE questions were able to answer correctly nearly 60 percent of
the practice examination questions conducted in English (those who had
seen the questions nearly 64 percent), while the average accuracy rate of
the Japanese examinees (in Japanese) was 78 percent. Assuming that mostof the Japanese examinees were fresh graduates and had been preparing
well for the examination, the accuracy rate of Filipino EPA nurses was notvery low. In fact, the Filipino EPA nurses did a good job in general consideringthat they had not seen the questions of the Japanese NBEs beforehand.
Although their accuracy rate is lower than that of their Japanese counterparts,
the study demonstrated that most of the Filipino EPA nurses have answered
correctly most of the questions on Basic Knowledge in Nursing, even thequestions unique to Japan’s NBE.12 It can be assumed that this is the resultof the great efforts of the Filipino EPA nurses and their instructors in preparing
for the NBE/
The comparison of the accuracy rate of the Filipino and Japaneseexaminees reveals some significant aspects of Japan’s NBE for nurses in
implementing EPAs.
First, both groups performed really well in the area of ClinicalNursing, as shown, for example, in question no. 77. It is safe to assume
that the core concepts of Clinical Nursing are universal, as Nightingale’s(1859, 4) note reminds us.
[Nursing] ought to signify the proper use of fresh air, light, warmth,
cleanliness, quiet and the proper selection and administration of diet—all at the least expense of vital power to the patient.

For instance, in caring for a patient having an asthma attack,placing the patient in the sitting position is based on the idea of proper
nursing intervention that will make asthma patients feel more
comfortable.

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

75
81

Second, the results seem to indicate the career experiences of theexaminees. One can observe a competency gap, as reflected in the resultsof the Filipino EPA nurses. A nurse who has been working in a particulararea of nursing for years would become an expert therein. For example, a
psychiatric nurse could obtain higher competency in the area of PsychiatricNursing but might get a lower score in other areas (e.g., in the area of
Medical and Surgical Nursing) where he or she has had lesser opportunities
to perform nursing duties. Moreover, Filipino nurses who wish to apply
for the EPA program need to have at least three years of clinical work
experience. Therefore, at least three years must have passed since theexaminees graduated from nursing programs. It may also be taken into
consideration that Filipino EPA nurses may have experienced a stressful
life in Japan in adjusting to the new working and living environments(particularly upon entry to Japan). For these reasons, it is possible thatsome of the Filipino participants in this study were not able to perform
very well.
Third, the differences in the accuracy rate between the two groups
might be attributed to the differences in the educational system of the twocountries. The nursing education system is constructed to reflect thesociocultural context of nursing in each country, which may affect the course
content and their practicum. In Japan, nursing students are required to takeeight credits in the area of Gerontology Nursing, which is an independently
classified subject. In the Philippines, Gerontology Nursing is not a required
subject but a two-unit elective course in the undergraduate nursing
curriculum.13 Hence, some Filipino participants in this study may have had
limited training in the care of the elderly, even though the concepts and careof the elderly population may have been integrated in certain subjects(Ishikawa 2011; Kawaguchi 2009, 2010). This may explain the wide gap in
accuracy rate in Gerontology Nursing between Japanese and Filipino
examinees, as shown in Table 1. Therefore, the authors of this article argue
that it is important to pay attention to the differences in curricula between
the two countries when receiving foreign-educated nurses.

Volume 52: 2 (2016)

76
82

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

Fourth, in line with the previous point, differences in prevalentdiseases and health-related issues between the two countries also seem tohave resulted in differences in the accuracy rate, as observed, for example,
in Gerontology Nursing, which is given more emphasis in Japan than in
the Philippines. Because of the rapid increase of the elderly populationin Japan, the demand for competency in Gerontology Nursing in the country
is extremely high.14
Fifth, the Filipino EPA nurses were able to answer the Physiology
and Pharmacology questions in the English version of Japan’s NBE. It issafe to suggest that this is because the questions pertaining to these areas
are relatively universal and less culturally affected. However, a large numberof the questions of Japan’s NBE for nurses fall under the areas that are
more culturally varied. In other words, foreign EPA nurses could executea higher accuracy rate in Physiology and Pharmacology once they canmemorize the technical terms in Japanese. But in other areas, even if they
have mastered Japanese, answering the questions may not be very easy as
the correct answers are culturally determined.
Sixth, differences in the job description of nurses are reflected in
the practice test result. For example, the low accuracy rate by Filipino
examinees in knowing the procedures of blood collection or body puncture
may be attributed to differences in the job description of nurses. In Japan,
blood collection and body puncture are categorized under Fundamentalsof Nursing—in other words, these are considered essential work done bynurses. However, in the Philippines, these are performed by medical
technologists and are not considered part of nurses’ job description in aclinical setting. Such sociocultural differences in terms of job descriptionof nurses must be taken into consideration in supporting foreign nurses intheir preparation for the NBE.
In summary, an analysis of the result of a practice examination ofJapan’s NBE for nurses in English conducted among Filipino EPA nurses
in Japan reveals that Filipino nurses had lower accuracy rates in thequestions pertaining to sociocultural, curricular, and legal features particular

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

77
83

to Japan. While the universality of nursing is reflected in some of theresult and while Japanese language proficiency is unquestionably important,
it is suggested that sociocultural, curricular, and legal differences of nursing
between the two countries must also be taken into consideration in making
plans to improve the passing rates of Filipino and other foreign nurses
who enter Japan under EPAs.
This paper predominantly discussed Japan’s NBE for nurses as theprimary condition for them to work in Japan. Nevertheless, Lastly, the authorsof this article wish to emphasize that passing the NBE is not a goal but
merely the start of the career. As a Filipino who has passed the NBE said,
Daily conversation with patients and medical jargons used among the
medical staff are different from the language used in the NBE. I have tokeep studying my Japanese even after I have passed the NBE.15

EPA nurses have to build up their language skills in order to execute
their work without any problems. They must continue studying the Japanese
language and also continue learning the sociocultural norms of theJapanese workplace and those pertaining to the patients and healthprofessionals in particular. Therefore, the authors of this article also
recommend that support for EPA nurses after passing the NBE, especiallyof Japanese language, is be formalized and enhanced to make the program
more meaningful.
A cknowledgements
cknowledgements
This study is a part of “A Study on Support System for Foreign
Nurses Introduced by Economic Partnership Agreement” (Representative:
Yuko Hirano) funded by KAKENHI (Grant-in-Aid for Scientific Research[B], 21390166, 2009-12).

Volume 52: 2 (2016)

84
78

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO

Notes
1

2

3

4

5

6

7

8

9

10

11
12

The Japan Foundation, which has been providing Indonesian and Filipino nurse candidates
with Japanese language training, assesses their performance by using a similar schemeas that of the official JLPT.
Filipino nurses are required to have longer work experiences than Indonesians because
the number of years of their elementary and secondary education under the old curriculum
had been shorter by two years than the international standard of twelve years until the
introduction of K-12 education system in the Philippines in 2012.
The first and second batches of Indonesian and Filipino EPA nurses were allowed toextend their stay in Japan for another year and take the National Board Examination thefollowing year, considering that the duration of their Japanese training course before
deployment to hospitals was only six months. Also, some qualified nurse candidates areallowed to do so.
The passing rates in the NBE each year are as follows: 0 percent (2009), 1.2 percent(2010), 4.0 percent (2011), 11.3 percent (2012), 9.6 percent (2013), 10.4 percent (2014),
and 7.9 percent (2015) (MHLW 2015b).
The Ministry of Health, Labor and Welfare notes that the “EPA is a system to introduce
nurses to be trained and to study for passing the NBE for nurse, and to work in Japan”(http://www.mhlw.go.jp/stf/seisakunitsuit/bunya/koyou_roudou/koyou/gaikokujin/other22/index.html, accessed 2 April 2015).
Nursing education in the Philippines is provided in English, and the NBE for nurses in thePhilippines is also conducted in English.
Currently, AOTS has changed its name to Overseas Human Resources and Industry
Development Association (HIDA).
“Compulsory Question” is the official translation of hisshu mondai in Japanese. Thispart contains the questions that test the basic or the “must know” knowledge for nursesto-be. It is not that the questions on the other categories are elective or optional, but allquestions of the NBE have to be answered. Since the official translation is misleading,this article refers to it as “Compulsory Questions (Basics of Nursing)” hereafter.
Although the passing score for Compulsory Questions (Basics of Nursing) is fixed, thatof General Questions/Situational Questions are adjusted every year by the MHLW. The
passing score was 160 points for the 2013 examination, 167 points for the 2014
examination, and 159 points for the 2015 examination.
Tokyo Academy Co. Ltd. is a private tutorial institution providing practice examinations
for NBEs. Each year, after the NBE for nurses, Tokyo Academy announces the estimatedaccuracy rate of the examinees.
This act is a counterpart of Republic Act 9173 (Philippine Nursing Act of 2002).
In his previous study (Kawaguchi et al. 2012), Kawaguchi, one of the authors of thisstudy, mentioned that all Filipino EPA nurses answered correctly the questions on selfpay ratio for the population insured with the national health insurance.

ASIAN STUDIES: Journal of Critical Perspectives on Asia

An Analysis of the Performance of Filipino EPA Nurses in the
Practice National Board Examination of Japan Conducted in English

13

14

15

79
85

The scope of the BSN (Bachelor of Science in Nursing) curriculum in the Philippines covers
nursing care in the preventive, promotive, curative, and rehabilitative aspects throughout thelifespan. Thus, care of older persons is integrated in the different courses, in the classroom andin the practicum. The elective Gerontology Nursing is an attempt to enhance the competencies
in providing nursing care to older patients.
At any rate, we can assume that Filipino nurses’ learning more about Gerontology Nursing
while in Japan may be utilized effectively in the future in the Philippines, where alteration of age
distribution is expected. According to the CIA World Factbook, Filipinos between twenty-five tofifty-four
years
old
occupies
37
percentin2014(http://www.indexmundi.com/philippines/age_structure.html). See Wongboonsin and Wongboonsin(2013) for the demographic dividend of Asia, including the Philippines and Japan.
This narrative was given by a Filipino nurse who passed the NBE in her first trial(interviewed in 2011).

Ref
ences
efee rrences
CIA World Factbook. “Filipinos between 25 to 54 Years Old Occupies 37% in 2014.” Accessed
2 April 2015. http://www.indexmundi.com/philippines/age_structure.html.
Furukawa, Emi, Kanako Seto, Kunichika Matsumoto, and Tomonori Hasegawa. 2012.
“Keizairenkeikyotei ni motozuku gaikoku-jin kangoshi kouhosha ukeire shisetsu no genjou
to kadai” [A Questionnaire Survey of Economic Partnership Agreement (EPA) Host Facilities
for Foreign Nurses]. Journal of Japan Society for Health Care Management 12 (4): 255–60.
Ishikawa, Yoko. 2011. “Firipin no hoken iryou-kango kyoiku seido: Donna kuni kara kouhosha tachi
wa kiteiru noka?” [The Medical System and Nursing Education in the Philippines: The Report of
the Nurse Sending Countries 2]. Japanese Journal of Nursing Education 52 (9): 792–96.
Kawaguchi, Yoshichika. 2009. “Nihon, Firipin, Indoneshia no kango kyouiku karikyuramu
no hikaku” [A Comparative Study of the Curricula of Nursing Education in Japan, thePhilippines and Indonesia]. Kyushuu Daigaku Ajia Sougou Seisaku Sentaa Kiyou [Bulletinof Kyushu University Asia Center] 3: 91–104.
———. 2010. “Firipin-jin Indoneshia-jin kangoshi kouhosha no kyouiku to kadai” [Issues in the
Education and Training of Filipino and Indonesian Nurse Candidates]. Hoken Iryou Shakaigaku Ronshuu [The Japanese Journal of Health and Medical Sociology] 21 (2): 30–34.
Kawaguchi, Yoshichika, Yuko Ohara-Hirano, Reiko Ogawa, and Shun Ohno. 2012. “Exploring
Learning Problems of Filipino Nurse Candidates Working in Japan: Based on the Resultsof a Practice National Board Examination of Japan Given in English.” Southeast AsianStudies 49 (2): 643–51.
Ministry of Health, Labour and Welfare. 2009a. “Heisei 22-nendoban hokenshi josanshi
kangoshi kokkashiken shutsudai kijun ni tsuite: Kangoshi” [Question Standard of the
National Board Examinations for Healthworker, Midwife, and Nurse of Fiscal Year 1997:
Nurse]. http://www.mhlw.go.jp/topics/2009/04/dl/tp0413-1f.pdf.

Volume 52: 2 (2016)

80
86

Y. KAWAGUCHI, C. AÑONUEVO, & Y. HIRANO———. 2009b. “Dai 98-kai Kangoshi Kokka Shiken no mondai oyobi kaitou ni tsuite”[Questions in the 98th National Board Examination for Nurses and Correct Answers].
Accessed 2 April 2015. http://www.mhlw.go. jp/topics /2009/04/tp0422-3.html.
———. 2015a. “Dai 104-kai Kangoshi Kokka Shiken no goukakusha happyou”[Announcement of those who passed the 104th National Board Examination for nurses].
http://www.mhlw.go.jp/general/sikaku/successlist/siken0304 05/about.html.
———. 2015b. “Keizai Renkei Kyoutei (EPA) ni motozuku gaikokujin kangoshi kouhosha no
Kangoshi Kokka Shiken no kekka [The result of the National Board Examination for
nurses of foreign nurse candidates based on Economic Partnership Agreements EPAs].
http://www.mhlw.go.jp/file/04-Houdouhappyou-10805000-Iseikyoku-Kangoka/0000079084.pdf.
———. n.d. “Introducing Foreign Nurses from Indonesia, Philippines, and Vietnam.” Accessed
April 2015. http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/koyou_roudou/koyou/gaikokujin/other22/index.html.
Nakamura, Etsuko, and Fusako Ozaki. 2013. “Gaikoku-jinkangoshikouhosha noukeireshisetsu to kouhosha no seikatsu, shokuba, gakushuukankyoueno tekiou” [Studyon challenges of foreign nurse candidates and host institutions: Daily life, working andstudy environment]. Nihon Kango Gakkai Ronbun-shu: Kango Kanri 43: 219–22.
Nightingale, Florence. 1859. Notes on Nursing: What Is Good and What Is Not. New York:D. Appleton and Company.
Okuda, Naoki. 2011. “Kangoshikokkashiken no goi no shosou: Nihongo Nouryoku Shiken
Shutsudai kijun goi hyo tono hikaku kara” [The Vocabulary of the National Nurse’s
Examination: A Comparison with Test Content Specifications of the Japanese Language
Proficiency Test]. Journal of International Development and Cooperation 17 (2): 129–43.
Setyowati, Herni Susanti, Krisna Yetti, Yuko Ohara-Hirano, and Yoshichika Kawaguchi.
2010. “The Experiences of Indonesian Nurses in Japan Who Face the Job and Cultural
Stress in Their Work: A Qualitative Study.” Bulletin of Kyushu University Asia Center 5:
175–81.
———. 2012. “Indonesian Nurses’ Challenges for Passing the National Board Examination
for Registered Nurse in Japanese: Suggestions for Solutions.” Southeast Asian Studies 49(4): 629–41.
Tsubota, Kunio, Reiko Ogawa, Shun Ohno, and Yuko Ohara-Hirano. 2015. “A Study on the
Cost and Willingness to Recruit EPA Foreign Nurses and Care Workers in Japan: From theAngle of Hospitals and Care Facilities.” Health Science Research 27: 45–53.
Wongboonsin, Patcharawalai, and Kua Wongboonsin. 2010. “Demographic Dividend andthe Future of Asia.” In Transformation of the Intimate and the Public in Asian Modernity,
edited by Ochiai Emiko and Hosoya Leo Aoi, 91–115. Leiden: Brill.

ASIAN STUDIES: Journal of Critical Perspectives on Asia