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Warmly Received but Still Adjusting:
Filipino EPA Nurses in Japan
Cora A. AÑONUEVOa
Yoshichika KAWAGUCHIb
Michiyo YONENO-REYESc
Yuko O. HIRANOd
Abstract
This study reflects on the experiences of six Filipino nurses deployedto Japan under the Japan-Philippines Economic Partnership Agreement(JPEPA) and their employers.
It first presents the narratives of the interviewees on preparations for the
NBE. All of the six Filipino nurses acknowledge and appreciate the supportof the hospital. It also presents the thoughtful strategies and extraordinary
efforts of the hospital staff to help the Filipino nurses. The following
section is a discussion of their experiences after the NBE. The narratives
reveal that both the Filipino nurses and their coworkers are puzzled asthey face new challenges when the EPA nurses became licentiates. The
narratives also reveal that Filipino EPA nurses cannot have a clear career
path even after passing the NBE. This article also conveys the voices ofFilipino nurses how JPEPA program for nurses could be improved.
These narratives are reflected vis-à-vis theories on second-language
acquisition, scope of nursing, and migration policy. The article concludes
by proposing that Japanese language training be continued even after
passing the NBE, that qualified Filipino nurse candidates’ stay in Japan beextended for a few more years even after failing the NBEs, that retakingof the NBE by those who have returned to the Philippines be facilitated,
and that measures for brain circulation and brain gain be crafted.
Keywords: EPA, Filipino nurse migration, language barrier, career patha Former Professor and Director, National Graduate School of Health Sciences,

University of the Philippines Manilab Professor of Psychiatric Nursing, University of Occupational and Environmental Health, Japanc Visiting Fellow, University of Tokyod Professor, Graduate School of Biomedical Sciences, Nagasaki University

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Introduction
This paper reflects on the experiences of Filipino nurses from thefirst two batches of health workers deployed to Japan under the JapanPhilippines Economic Partnership Agreement (JPEPA) in 2009 and 2010,as narrated by themselves and their Japanese coworkers in semistructured
interviews. Specifically, this paper presents (1) the perceptions of Filipino
nurses of their status after passing the National Board Examination (NBE)
for nurses in Japan, particularly in comparison with that before they passed
the exam; (2) their personal and professional plans; and (3) their views of
JPEPA’s program for nurses and its implementation.
Previous transcultural nursing theories (Leininger 1978, 1991,
2002) have been for mulated from the standpoint of healthprofessionals—how they viewed their patients’ concept of illness, healthbeliefs, and health behaviors in a “different” culture. But when a nurse
moves to a foreign country and works in another cultural and social
setting, it is he/she who should adjust himself/herself to the newenvironment in accordance with the rules, customs, and habits of thehost country. This paper asks how this takes place when Filipino nurses,
who were educated in the Philippines, work in Japan under JPEPA andhow the gaps can be bridged.
The primary data for this paper are the narratives of six Filipino
economic partnership agreement (EPA) nurses gathered throughsemistructured interviews conducted in Japan in July 2012. Follow-up
interviews were conducted in April 2017 (see Ohno’s Acknowlegment),
with a Filipino nurse and a hospital staff, separately, using English,
Tagalog, and Japanese. All of them had passed the NBE for nurses given
in 2010, 2011, or 2012. The six interviewees were identified throughthe following process: All hospitals whose Filipino EPA nurse trainees
passed the NBE in 2010, 2011, or 2012 were contacted for possible
interviews of their respective Filipino nurse/s and other staff. Five of
the hospitals selected for this study replied positively and consented tothe interview. Seven questions guided the interview: namely, questions

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about (a) the NBE; (b) how they felt after successfully hurdling the exam;(c) changes in their jobs, salary, and benefits after passing the NBE; (d)human relationships at the workplace; (e) their personal and professional
plans; (f) their thoughts about JPEPA; and (g) their recommendations for
JPEPA. Interviews were conducted primarily in colloquial Filipino. Eachinterview lasted from one and a half hours to two hours. All of theinterviews were held in their respective hospital premises. Permission to
conduct the interview was given by the participants themselves, with theconsent of their employers. The interview was recorded and transcribed.
The script of each interview was sent to each interviewee for crosschecking and feedback. The present tense in the narrative is that of thetime of the interview. The names that appear in this report are not thenurses’ real names.
The six Filipino interviewees consisted of five females and one male.
The youngest was twenty-seven years old and the oldest was thirty-sevenat the time of the interview. In terms of civil status, one is married, one isseparated, and the rest are single. Two of them had worked abroad as
nurse before their stint in Japan. The rest had at least three years of work
experience in Philippine hospitals. One passed Japan’s NBE for nurses on
her first try, two on their second try, and the rest on their third try. Table 1
provides the profile of the six Filipino nurse interviewees.
Name

Age and
Gender

Civil
StatusYears of Work
Experience(before JPEPA)

Unit /Area of
Assignment at
the Time ofInterview

Elsa

37/F

Separated

13

Emergency

Fely

36/F

Married11

Obstetrics

Norma

30/F

Single3

Medicine

Jonas

28/M

Single à Married 3

Orthopedics à Rehabilitation

Lilia

27/F

Single3

Medicine

Carolina

31/F

Single3

Dementia

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To supplement the narratives of the Filipino nurses, their Japanesecoworkers were also interviewed separately. The Japanese interviewees
were three directors, three head nurses, three instructors, and seven staff
nurses who take care of Filipino nurses. They hold different positions
like director, head nurse, or staff nurse. The four questions that guided
the semistructured interviews were as follows: (a) how they support
Filipino nurses in their passing of the NBE; (b) current working conditionsof the Filipino nurses and the challenges they face; (c) their thoughts
about JPEPA; and (d) their recommendations for JPEPA. The interviews
were conducted primarily in Japanese.
The strength of this study lies in that both the Filipino nurses andtheir fellow hospital staff were interviewed, and that the Filipino nurses
were interviewed primarily in Filipino. Only a few Filipino or Filipinospeaking researchers have had access to Filipino EPA nurses who are working
in Japan for in-depth interviews until today. The study also introduces thevoices of the Japanese hospital staff, including their critical views of theJapanese government. It is also anticipated that the experiences, perspectives,and proposals this study presents will not only contribute to the improvementof JPEPA (and the Japan-Indonesia and Japan-Vietnam Economic
Partnership Agreements to a certain extent) but also enlighten those involvedin the preparations of mutual recognition agreements (MRAs) on
professional qualifications for the smoother movement of high-skilledworkers within member countries of the ASEAN Economic Community(AEC), as this study reveals the challenges experienced by professionalmigrant workers whose destination is not an English-speaking country.
In what follows, the article presents the narratives of the intervieweeson preparations for the NBE. All Filipino nurses acknowledge andappreciate the support of the hospital. We can also see the thoughtful
strategies and extraordinary efforts of the hospital staff to help the Filipino
nurses. The next section is a discussion of their experiences after the NBE.
The narratives reveal that both the Filipino nurses and their coworkers are
puzzled as they face new challenges when the EPA nurses became

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licentiates. The narratives also reveal that Filipino EPA nurses cannot havea clear career path even after passing the NBE. The Filipino nurses’
recommendations for JPEPA follow. These narratives are reflected vis-àvis theories on second-language acquisition, scope of nursing, andmigration policy. The article concludes by proposing that Japanese
language training be continued even after passing the NBE, that qualified
Filipino nurse candidates’ stay in Japan be extended for a few more years
even after failing the NBEs, that retaking of the NBE by those who havereturned to the Philippines be facilitated, and that measures for brain
circulation and brain gain be crafted.
Gearing Up for the NBE: Aspiration of Nurses
and Strategies of Hospitals
All nurses who were interviewed for this study belong to the batches
that were not provided predeparture language training but given a sixmonth intensive course after arriving in Japan. After that period, they began
to receive on-the-job training at the hospitals that employed them. To
prepare for the NBE, all of them were given at least three days in a week
for continuing language lessons and/or self-study with modules at theirrespective hospitals. Generally speaking, a six-month intensive Japanese
language training in a grammar-based syllabus with a writing systemcomponent—which is imperative for those aiming for professional work
using Japanese—is not enough for learners to be able to speak fluently orread all the questions of the NBE, even though they could be wellgrounded in grammar and are likely prepared to speak Japanese in daily
conversation settings (and potentially to improve thereafter) once they enter
Japan. The interviewees reported for hospital duty only twice a week. This
gave them enough time to study, especially to become familiar with theJapanese medical terms and to practice writing/reading kanji, Chinesecharacters applied in Japanese, which are confusing to every Japanese
language learner due to the arbitrary adaptation of letters developed for
Chinese language to the sounds of Japanese.

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Elsa and Fely, who have thirteen years and eleven years of work
experiences (in the Philippines and abroad) respectively, work for the same
hospital. Both of them acknowledged the enormous help provided by theirfellow hospital staff in facilitating their review for the NBE. They were given
ample time to study Japanese with their instructor, a hospital staff with agood command of English, who was specifically assigned to coach the nurse
candidates as “special instructor.” She gave Elsa and Fely a series of quizes
that drove them to study harder. In learning kanji, for example, the instructor
patiently taught them how to read every word correctly and the meaning
thereof, in one to two tutorial sessions held regularly. It is noted that not all
hospitals employing EPA nurses provided this kind of arrangement for
language study. As Hirano’s article in this special issue indicates, arrangements
for language study vary from one hospital to another, because JPEPA issilent on this matter and the Ministry of Health, Labour and Welfare (MHLW)
of Japan does not regulate measures with regard to preparations for the
NBE, including language study.
Elsa and Fely’s hospital is one of the most proactive hospitals among
those receiving Filipino nurses. In the interview,, the director of the hospitalthat employed Elsa and Fely shared with the authors of this article theirstrategies on how to make Filipino nurses pass the NBE. The planning
had started even before their entry to Japan. First, the director carefully
chose candidates by checking the profile of each nurse in the list of
applicants. The data provided in the list of applicants were gender, age,and previous work experience, among others. He carefully chose those
who were not too old but had sufficient work experience abroad. Being
too old may be an obstacle to learning a new language, while having
sufficient work experience abroad may indicate one’s flexible personality
to a foreign environment. Through this process, Elsa and another Filipino
nurse were chosen for the first batch (which entered Japan in 2009), andso was Fely for the second batch (which entered Japan in 2010). Second,he assigned a hospital staff who can speak English well as a special instructor
for the Filipino nurses. Third, the director visited Elsa and another Filipino
nurse candidate during weekends when they were taking an intensive

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language course at a training center of the Association for Overseas Technical
Scholarship (AOTS)1, after their entry to Japan as members of the firstbatch Filipino EPA nurse candidates. They were given instructions fromthe director in English, since they were not yet proficient enough in theJapanese language, to memorize kanji (Chinese characters) and technicalterms frequently used in NBE.
Fourth, after they were deployed to the hospital, Elsa and Fely were
offered ample study hours at the hospital under the supervision of thespecial instructor. The special instructor offered them mock examinations
using Japan’s NBE’s questions translated into English.2 They were also
advised to master kanji as much as possible to be able to understand what
is being asked in the NBE questions as well as what is being shown in theanswer choices for each question. The special instructor was very determined
to let the EPA nurses pass the NBE; therefore, memorizing kanji andtechnical terms—which are very often composed of kanji—was given moreemphasis than mastering grammar and sentence patterns. The special
instructor’s advice is reasonable. Experts in Japanese language education
report that highly specialized knowledge on vocabulary (and corresponding
kanji) is necessary for passing the NBE, whereas for grammar, only very
basic knowledge, with some specific knowledge on case-marking particles(kakujoshi), would do (Iwata 2014; Iwata and Iori 2012; Okuda 2011).3
Remarkably, Elsa passed the NBE on her first try in 2010. When Fely
arrived in Japan in 2010,4 a year after Elsa did, and was employed by thesame hospital, the same work/study conditions were applied to her. After
failing the NBE in her first try in early 2011, Fely was assigned to work in a
general ward while continuing her study, as recommended by the directorof the nursing service department so as for her to have on-site experiences
in a Japanese clinical setting.5 That was a strategy to let her pass the NBE, as
exam questions include situational questions that could be answered moreeasily by becoming familiar with the clinical settings in Japan.

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The six Filipino nurses interviewed for this article unanimously had
high motivation to pass the NBE, although some of them expressed thatworking and studying at the same time was physically and mentally tiring.
From the very start, said Elsa, her determination to pass the NBE was veryhigh. She set her mind to memorize ten kanji characters a day, as advisedby her special instructor. So it was a feat to learn a thousand kanji characters
before the examination. For Elsa, success in passing the examination is acombination of her personal effort and institutional support.
Norma, who applied for JPEPA’s program after a three-year work
experience, said that maintaining emotional and psychosocial stability isimportant for one to hold on to her dreams and life goals. Her employer
and her Japanese coworkers had been a source of support and stability
because they treat her as if she were a family member. Her employer’s
advice to her, “study hard for your own sake,” was a source of inspiration.
With regard to the exam questions, Filipino nurses generally consideredthose related to fundamentals of nursing and biostatistics as easy ones. The
difficult questions were those consisting of lengthy nursing situations andclinical scenarios written in long sentences, including numerous kanji. Also
considered difficult were the questions pertaining to Japan’s health-caresystem, nursing system, labor laws, and insurance systems. (See also
Kawaguchi’s article in this volume for details on this matter.)
Working as a R
egistered Nurse
RegisteregisteredTasks and Responsibilities
Until they pass the NBE, deployed Filipino nurses are called “nurse
candidates” or trainees. Before acquiring Japan’s nursing license, theparticipants in this study primarily performed the tasks of an assistant nurse,such as feeding, bathing, and assisting in the toilet needs of their patients.
In Japan, these activities are subscribed in the Act of Public Health Nurses,
Midwives and Nurses ([1948] 2014) to be handled by a registered nurse,
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activities they were tasked to perform included distributing tea to patients,changing diaper, dusting and mopping, cleaning toilets, and repairing
wheelchairs. The interviewees referred to these tasks as menial jobs or“non-nursing functions.” Filipino nurses (as nurse candidates) were
obviously embarrassed. However, it must be noted that in Japan thesetasks are usually rendered by both registered nurses and nurse aids.
Japanese hospital staff would never have thought that they were assigning“menial jobs” to Filipino nurses because these are considered nursing
tasks in Japan which, legally speaking, can also be rendered by nurse aids
who are yet to be licensed. The above-mentioned narrative by Filipino
interviewees manifests an instance of a gap in scope of nursing between
the two countries that must be addressed and bridged.6
The six Filipino nurses who passed the NBE expressed that there
had been major changes in their nursing responsibilities after passing the
NBE. They take and carry out doctor’s orders, give medications, and write
nurse’s notes. These are the tasks that they did not do when they weretrainees. Some of them perform blood extraction, maintain intravenouslines, conduct health teachings, and discharge instructions for patients.
One of them even handles trauma patients, administers emergency drugs,
and performs cardiopulmonary resuscitation when called for.
As a member of a team of interdisciplinary approach—which isoften practiced side-by-side with primary nursing, concurrently in many
medium- and large-scale hospitals in Japan today—Norma works withother health-care professionals, including doctors and pharmacists, intaking care of eight elderly patients, mostly bedridden. Her bedside-careduties include turning patients to sides, giving sponge bath and bedsore
care, suctioning, and drug administration. She says the work is very
demanding. But what is most challenging to Norma is understanding
doctor’s handwritten orders. She finds it quite stressful that she has to be
extra careful all the time so that she would not commit a mistake in taking
and interpreting doctors’ orders.7 Norma wishes her hospital would
introduce the electronic medical record.

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The nursing tasks peculiar to elderly care challenged Filipino nurses.
Jonas at first could hardly manage disimpaction when he was assigned to
do so as a registered nurse after passing the NBE. In the Philippines, he
had never had a chance to practice it. Today, he understands the significanceof dispimpaction in gerontology nursing since the elderly tends to sufferfrom constipation. Disimpaction is a means to make such patients feel
comfortable.
Jonas further disclosed that it was at first difficult for him to accept that
he had to assist transporting 45 patients twice a week for bathing, from bed
to bathroom and vice-versa when he was still a candidate (before passing
the NBE). Most of his patients are elderly, including those who are seriously
ill. He said “patayan sa trabaho dito; mahirap magbuhat ng pasyente” (Workhere is deadly grueling; lifting patients is tough enough). He was a memberof a team of ten or more medical staff who carry 45 patients one by one ona stretcher every bathing day. In 2017, Jonas views this experience slightly
differently. After passing the NBE, he came to have heavier responsibilities
as a registered nurse, particularly in primary nursing in which he is responsible
solely for an assigned patient from admission to discharge. Compared to his
present responsibilities, the task of transporting patients then was “easy.” In
his recollection, the days when he was a nurse candidate were his “happiestdays” (ichiban shiawase dattandesu). Today, after passing the NBE, Jonas is
no longer engaged in carrying patients for bathing, as his supervisor assigns
him to engage in more “professional work.”
Social Acceptance and Supportive Environment
The nurses interviewed for this study expressed their appreciation
for the support and assistance of their respective Japanese employers,
supervisors, and coworkers at large. Some shared that their superiors
were very helpful and accommodated their needs and requests. Lilia
said that, from the first day of her work, she did not encounter any
problems in the manner she was treated by her superior, who even said,“foreign nurses are like my daughters.” Similarly, Norma admitted thatASIAN STUDIES: Journal of Critical Perspectives on Asia

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she is happy with her relationships with her coworkers, “They treat me
nicely, and are supportive of me.” She also said that her employer
provided full support not only in preparing her for the NBE but also inaccepting and respecting her.8
Some of them said that passing the NBE made a difference in theirsocial environment. Fely said, “all my Japanese coworkers greet me, unlike
before when they regarded me quite inferiorly.” Another one shared that“whereas before, anyone in the ward would tell me what I should do, now
I can delegate some of the tasks to a Japanese caregiver.” Another said,“our supervisor is proud of us, telling others that Filipinos are intelligent.”
However, they knew that some of their batchmates who work for otherhospitals were not necessarily in a similar situation as they had to deal
with indifferent Japanese superiors.
Salary and Benefits
As nurse candidates, they received a monthly salary that ranged
from 120,000 yen to 230,000 yen (or PHP 54,000 to PHP 105,000).
Now as licensed professional nurses, they get 280,000 yen (PHP 128,000)
on average, plus a bonus and a three-day summer leave. Their monthly
net income amounts to an average of 280,000 yen (PHP 82,000) after
deductions of insurance, taxes, house rental, Internet, telephone andutility charges, and so on. They have eight to ten days off from duty
every month.
As Filipino nurses would like to visit to the Philippines from time totime, they request their hospitals for a leave of seven to ten consecutive
days. Granting employees more than a week of leave at a time is hardly
acceptable for Japanese hospitals because of difficulties in human resource
management due to manpower shortage. However, hospital managers
understand that Filipino nurses must go home for the ocassional family
reunion. Japanese staff nurses from two different hospitals claimed that
they, respectively, allowed foreign nurses a longer vacation leave than what
Japanese nurses received.9

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C. AÑONUEVO, Y. KAWAGUCHI, M. YONENO-REYES, & Y. HIRANOInterpersonal Relationships and Communication in Japanese
The Filipino nurses interviewed unanimously feel that they are wellreceived at their respective workplaces as licensed nurses after passing the
NBE. They also feel that they are liked by their patients. But they still
struggle with oral and written communication in Japanese. They feel thatthey need to continue studying Japanese, particularly technical and formal
expressions, as they regret that they are sometimes not perfectly confident
in taking doctors’ orders correctly and in rendering health teachings topatients accurately.
All of them said that Japanese patients like the Filipino nurses.
Lilia considers that she is well-liked by her coworkers and patients becauseof her “akarui” (cheerful) personality. Similarly, Jonas thinks that hispatients appreciate his way of caring, “Whatever I lack in verbal
communication, I make up for it by being sensitive to their needs throughfeelings and touch.” Carolina said, “my coworkers treat me well.”Japanese nurses politely and patiently respond to her questions thatconcern her work.
However, they continue to suffer from language gaps. Challenges
become greater as the tasks they handle require more sophisticatedlanguage skills. Jonas is still coping with his lack of proficiency in theJapanese language. He relies on a mentor who continuously guides him
in his work, especially in interpreting doctors’ orders correctly, instructs
him on how to write nurse’s notes using kanji, explains the work flow, andresponds to his questions. Carolina revealed, “I’m afraid of the doctors
whom I have difficulty communicating with.” According to her, she
continues to study Japanese to improve her oral communication. Elsa, theonly Filipino nurse then who had passed the NBE on the first try, also said
that she continues to experience language difficulties. Because her functions
have expanded, a good command of the language became a necessity.
This is where her insecurity comes in. “I feel bad when I don’t understandwhat others say in Japanese. For instance, when I take verbal order fromdoctors.” Fely added that she had difficulty explaining herself in Japanese

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especially when she gives health teachings. “I’m a bit frustrated because I
can’t give the best explanation to my patients. Health teaching is moredifficult than everyday conversations because health teaching has to bedone systematically and politely.” Jonas informs the authors of this article
that even after five years, he is facing difficulties in taking notes for his
committees even after five years, while appreciating that his hospital
introduced the electric medical record and has no problem in taking nursing
records.
Language barriers challenge hospital management, too. A Japanesehospital staff disclosed that the hospital cannot assign night shift to one of
the EPA nurses, due to insufficiency of language communication skills,
particularly in writing.10 With no night shift opportunity, the nurse has less
opportunities to earn extra honorarium. The hospital staff is evensympathetic to the situation. Writing records pertains to composition skills
that can be improved only through the personalized coaching of aprofessional language instructor. This situation confirms the need forcontinued support for Japanese language training for EPA nurses, evenafter passing the NBE.
Supporting the claims of the Filipino nurses, the Japanese hospital
staff are generally happy with the Filipino nurses. However, a Japanese
staff nurse who is working with a Filipino nurse, commented that whena Filipino nurse makes mistakes in using particles, even a single one in a
dialogue, patients and their families become anxious about the nurses’
competency in health teachings. Kanji is crucially important in theJapanese writing system, as are the particles in grammar. In Japanese, thewrong use of a particle could confuse listeners; moreover, the message
could not be conveyed as intended, or, in the worst case, it could be
totally misinterpreted. This manifests the need for continuing Japanese
language education. If mastering technical terms in kanji was the priority
in preparations for the NBE, improving accuracy in grammar (both oral
communication and written), including the use of particles, among others,
is vital for the post-NBE period.

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Personal and Professional Plans
All of the Filipino nurses are grateful for the support they received
from their respective hospitals, but none of them is determined to work inJapan for good.
Jonas said, “I’ll stay here for as long as I’m happy.” But he is notvery sure of his future prospects, “My feelings are unsure.” He is still
struggling with the Japanese language, especially in medical charting, which
affects his sense of confidence, a confidence needed by a good nurse.
Lilia assured that, in the next two years, she would fulfill her
commitment working in Japan, for as long as her body is able (“hanggang
kaya ng katawan ko”). She said that she appreciates the learning experienceobtained from her current job. For instance, simple as they are, there arehelpful bedside gadgets, like the bladder scan, which makes it easier forthe nurse to report the presence or absence of a patient’s urine output.
She finds that Japan is generally advanced in terms of medical technology,
even though the Philippines and Japan are on an equal footing in termsof nursing knowledge.
Similarly, Norma likes the new experiences she can obtain in Japan,
while facing a dilemma of whether to stay long in the country. The factorsthat pull her to stay are the proximity of Japan to the Philippines and theincessant support of her employer. “To return their kindness, I work seriously
and hard,” she said. She also appreciates the opportunity of learning new
trends in nursing, such as the interdisciplinary approach and preventive
care in the hospital setting. She is also attracted to the state-of-the-art medical
equipment in her work environment. However, the negative factors she
considers are the Japanese language and the high cost of living, which
depletes her personal budget and monthly remittance to her family.
As for Carolina, she disclosed that for some months she has been
self-reviewing for the National Council Licensure Examination (NCLEX)
for nurses in the United States.11 Should she pass the NCLEX, she is readyto set off to work there. If not, she sees herself continuously working inJapan.

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Fely’s dilemma poses a fundamental question on the nature of the“movement of natural persons” under JPEPA: either Japan accepts themas migrants or as temporary workers. She said that she could count five
more years in Japan if she could bring her family with her, “My family is
my priority.” Her hospital advised her not to invite her family to Japan.
The hospital director stuck to his position that Japanese society is not readyto accept foreigners in larger numbers at large—and in particular, inproviding English education for children and work opportunity for spouses.
Under JPEPA, a spouse of a nurse holding a visa “for Designated Activities(Nurses and Certified Care Worker under EPA)” is allowed to work only
up to twenty-eight hours a week.
Perceptions of JPEPA
Jonas finds that the Japan International Corporation of Welfare
Services (JICWELS) and other agencies of the Japanese government havegiven adequate support to JPEPA nurses in general. However, Carolina
suggested that the Philippine government has to be more proactive inmonitoring the condition of Filipino nurses in Japan, including theirwork conditions and the forms of support that hospitals provide them.
She said that Japanese hospitals participating in JPEPA should havestandard terms and conditions of work. Provisions of language training
should also be uniform among participating hospitals. JICWELS, on its
part, should work hand-in-hand with hospital employers to make surethat provisions in the contract are faithfully practiced. 12 For nurse
candidates who are not able to pass the NBE, Carolina says, there must
be a “safety net” so that they are not immediately sent home after failingfor the third time. Another chance should be given to those who reallylike to stay in Japan.13
Five of them said that it is important for the Philippine Overseas
Employment Agency (POEA) to ensure that the hiring hospitals haveserious and long-term plans about foreign nurses. JICWELS should
immediately address problems encountered by nurse candidates so thatthey would not be traumatized. For instance, the participants cited that

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some of their batchmates were not given free accommodations, which
they expected from their employers. They were also left to fend forthemselves during their adjustment period.
All participants to this study stated that hospitals should continue
providing support, especially with language education, even after the nurses
had passed the NBE. They believe that for as long as Japanese employers
need Filipino nurses and both governments are serious about the intentionsof JPEPA, it can have a bright prospect.
Discussion
a. Mastering the Japanese Language
In the Philippines the medium of instruction of nursing education
is predominantly English. Also, Filipino nurses complete the college degree
program.14 Previous studies cite these two practices as the primary reasons
why Filipino nurses are in great demand in the international labor market(Hawthorne 2001; Tan 2005; Lorenzo et al. 2007 cited in Cirujales 2012,5). Unquestionably, the American colonial legacy has facilitated theemigration of Filipino nurses to the United States and other Englishspeaking countries like Canada and the United Kingdom since the 1970s(Choy 2003, 1–3).15 In later decades, the emigration of Filipino nurses
has expanded to other English-speaking countries, such as those in the
Oceania and even the Middle East where modern medical services areoffered in English. Since the mid-2000s, the destination of Filipino nurse
migration has even expanded to some of the European language-speaking
countries where the knowledge of English in alphabetic writing system,
grammar, and vocabulary is applicable in mastering the medium ofcommunication. This trend is predicted to continue even further, owing to
the increasing demand for nurses today in a number of aging countries—
in Europe, the Americas, and Asia—that face a shortage of healthprofessionals (Lorenzo et al. 2011). In 2014, the Philippines sent 19,815
nurses overseas, a rapid increase from 16,404 in 2013 and a doublingfrom 9,178 in 2007 (POEA 2007-2011, POEA 2010-2014).

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It is reasonable that the special instructor of Elsa and Fely advised
them to focus on kanji and the technical terms for the sake of their passing
the NBE. Indeed, they did make it. But the narratives of the Filipino nurses
in this study make us aware that knowledge of Japanese language for passing
the NBE is not enough for Filipino nurses to work in a clinical setting, since
as a nurse, the tasks require them to have proficiency also in verbal
communication (with both medical staff and patients), reading (often badly)
handwritten notes, and writing nursing notes. In the case of Fely, she had a
one-year experience of working in a general ward while preparing for the
NBE, as recommended by the director of the nursing service department.
This was primarily intended to facilitate her preparations for the NBE throughon-site experiences in a Japanese clinical setting. But even with such
experience, Fely still found it necessary to continue studying Japanese. Other
interviewees shared the same view. No matter how hard Filipino nurses may
study Japanese, and how intensely hospitals may support them, the Japanese
language course provided in the framework of JPEPA is far from sufficientfor Filipino nurses to acquire enough competency in Japanese for work.
To date, few studies have been conducted on the second-language
acquisition of adult, professional migrants. Therefore, in this study, theoutcome of a research on the second-language acquisition of children isappropriated as a tentative measure to understand better the language
acquisition of Filipino EPA nurses in Japan.
Theories of second-language acquisition have been developed byexperts in heritage language education. They generally agree with the socalled Cummins’ theory that proficiency in one’s second language can bebetter analyzed by treating separately the language skills needed forcommunication in an everyday life setting and those for understanding
and expressing abstract and technical knowledge. The former is termed“conversational fluency” (CF) for oral conversational skills or “discrete
language skills” (DLS) for basic reading and writing. The latter is termed“academic language proficiency” (ALP) for understanding and expressing
abstract concepts (see Cummins and Nakajima 2011; Nakajima 1998).16
Based on her years of research in Canada among migrant children andVolume 52: 2 (2016)

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applying Cummins’ theory, Nakajima suggests that it takes two to three
years for child migrants to acquire a comfortable level of CF and DLS inthe second language (e.g., English in Canada) and five to eight years for
ALP (i.e., without handicap in exams, school assignments, or composition
in English like native speakers) when they attend an English-speaking local
school and receive due support (Cummins and Nakajima 2011).
It is emphasized that “language proficiency” does not pertain to amonolithic skill. Rather, it consists of different types of skills, each ofwhich must be measured separately and differently. To apply the logic of
the Cummins’ theory to EPA nurses in Japan as a tentative measure—
until new theories on language learning of adult, professional migrants
are developed—it is fair to estimate that they are likely able to acquire
only basic communication skills (in both oral communication and reading/writing Japanese letters including kanji, as equivalent to CF and DLS),
sufficient for everyday life within the period of three years of the JPEPA
program at most. It will take them a few more years to become proficientenough for professional work (as equivalent to ALP).
b. Difference in Scope of Nursing in the Two Countries
It is safe to assume from the interviews that not much attention wasgiven to the differences in the nature of nursing in Japan and the Philippines
in the process of crafting the provisions for JPEPA program, which contains
primarily the language training component (which itself has proved to be
insufficient as illustrated above). As a result, the different scope of nursing,such as the eminence of elderly care and difference in workplace culture
and personnel management system in Japan, disoriented both the Filipino
nurses and the Japanese hospital staff. The problem could have been
prevented if both were properly guided. Although the interviews revealthat both parties consider difficulties as learning opportunities in one way
or another, gaps in the scope of nursing practice between the Philippines
and Japan have to be filled for mutual benefits. Therefore, it is essentialthat a training program for EPA nurse candidates be designed by taking

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into consideration such variations in nursing practice in the Philippines
and Japan, which in turn arise from the medical needs, and socioculturalcontexts, in each country.
In addition to existing sociocultural differences, another cause of
the disorientation of Filipino nurses under JPEPA is attributed to a legal
restriction in Japan. Filipino nurses who are nurses in the Philippines are
not, legally speaking, nurses in Japan until they pass the NBE. They arecalled “nurse candidates” until such time. The narratives of the hospital
staff reveal that hospitals usually assign EPA nurse candidates the tasks
that are otherwise rendered by non-nurses due to legal restrictions andtheir linguistic limitations. Although hospitals deem this to be a logicalsolution, the Filipino nurses felt they were being deskilled by engaging“menial jobs,” as called by some Filipino nurses—such as distributing tea
and meals to patients, changing diapers, dusting, mopping, cleaning toilet,
and repairing wheelchairs. Filipino nurses were asked to do these tasks byJapanese registered nurses, especially before they pass the NBE. It is easy
to imagine the puzzlement of Filipino nurse candidates when they were
instructed to do these jobs.
Such situation leads us to the following points. First, by its nature,
nursing practice is influenced by the culture and social context of eachcountry—and by the human resources condition of each hospital in acountry. Second, for this reason, foreign nurses who are instructed toengage in such nursing practice in a country with different social, cultural,or human resource management contexts, may be bewildered, unlessthe sociocultural context of such nursing practices is properly understood.
Third, therefore, it is necessary for Japanese nurses to be able to explain
foreign nurses why a certain job is necessary and has to be handled byregistered nurses, with considerations of sociocultural as well as humanresource management perspectives. For this, it is imperative that Japanesenurses and hospital staff too become familiar with nursing practices of
the Philippines.

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c. Inconsistent Migration Policy
The narratives reveal that EPA nurses cannot have a clear vision of
their career path and future plans. On one level, they are not sure of their
physical and mental strengths to survive the challenging work environment.
On this, the previous three sections proposed that continuous support forJapanese language learning be rendered and that measures to bridge thedifferences in the scope of nursing between the two countries be crafted. On
another, as manifested by Fely’s predicament when she was advised not tobring her child/ren to Japan, EPA nurses are not sure how to manage theirfamily life should they continue to work in Japan after passing the NBE.
Some of them already have a family when they applied for the program,
while many shall be ready to have their own family sooner or later. If more
Filipino nurses enter Japan under JPEPA and they are expected to pass the
NBE and stay to work in Japan, it is imperative that the Japanese government
craft a system that allows the EPA nurses to stay legally longer (or even
eventually almost permanently) with their family members if they wish to
do so. Under the current system, EPA nurses may bring their spouses toJapan, but the spouses are allowed to work only up to twenty-eight hours aweek in Japan. Also, Japanese schools are far from ready to rendersophisticated multicultural education, as hinted by the director of the hospitalof Fely; therefore, EPA nurses (and their spouses) may not be able to raise
their children in Japan comfortably. In other words, even if the EPA programis designed for the enforcement of free trade, it cannot be run at the expenseof each nurse’s (and his/her family member’s) right to live a humane life as
an individual citizen.
In this respect, worth referring to is a recent newspaper article aboutan Indonesian couple who are both EPA nurses (Kimi and Miki 2016).
The article informs us that, as of September of 2016, 1,118 EPA nurse
candidates have entered Japan (from Indonesia, Philippines, and Vietnam)
and 191 passed the NBE. Among the 191 NBE passers, 62 have either left
Japan or changed their visa status (presumably no longer working as
nurse).17 The article leads to a story of an Indonesian couple planning to

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return to Indonesia—even though they can work in Japan as long as they
wish—since they found out that, per rules and regulations pertaining to
the Japan-Indonesia EPA, they cannot invite any of their parents to Japanto babysit their two children (grandchildren of their parents) because,against their expectations,, long-term visas shall not be given to the parents.
It is a common practice—almost a norm—in many Asian countries that
grandparents take care of their grandchildren (e.g., Ochiai 2014).18 The
couple has adjusted to Japan’s environment by raising children through achild-care facility (hoikuen), according to the news article, but they arehaving a hard time to find a babysitter when a child gets sick, as Japanese
hoikuens do not accept sick children. This is another flaw of the EPA. It
allows foreign nurses to stay and work in Japan but rules prevent themfrom sustaining their family life.
Conclusion
This study analyzed the interview narratives of the Filipino nurses
who had successfully passed Japan’s NBE, and of the Japanese staff of thehospitals that employed them. Since the passing rate remains about 10
percent, the nurse interviewees in this study do not necessarily represent
the entire Filipino nurse candidates under JPEPA and the hospitals that
employ them. Nevertheless, their narratives are significant as they convey
the foreign nurses’ view of what it is for them to work in Japan as a registerednurse, beyond the common narratives on EPA nurses in Japan such as
those on low passing rate and deskilling.
The interview narratives reveal that Filipino EPA nurses in Japan are
generally grateful for the generous support of their respective hospitals while
they were adjusting to the new environment and preparing for the NBE.
The type of support they received varies from one hospital to another,
depending on each hospital’s plan, strategy, and resources. Commonly, formsof support include close attention and supervision by the Japanese staff,
hiring a Japanese language instructor, and sending the candidates to training
courses provided by the government. However, the Filipino nurses are aware

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that not all of their fellow EPA nurses receive similar treatment from theirrespective hospitals. They therefore suggest that there be a unified rule interms of work conditions, particularly in work-study balance, aside fromsalaries and benefits (such as housing). As one of the nurses proposes, it
seems proper that the Philippine government screen the Japanese hospitals
more carefully, monitor the conditions of the Filipino nurses more closely,
and communicate with JICWELS should problems occur.
Moreover, although acknowledging the generous support they got,
especially in the NBE preparations, the EPA nurses still find it challenging tomaster the Japanese language. Even after they have passed the NBE, they stillneed to continue studying Japanese. Both the EPA nurses and the hospital
staff see the need for continuous support for language education so that foreign
nurses could use Japanese more freely and competently in a work setting andintegrate more fully into the Japanese hospital workforce. Whether they likeit or not, the Filipino nurses have to communicate with Japanese doctors,
nurses, and patients in Japanese. They have to be knowledgeable of medical
terms, and be able to comprehend handwritten instructions, read medicine
labels, and record information on Japanese forms. They have to communicate
with their patients and their family members too, including the elderly who
speak regional languages that are not found in Japanese language dictionaries.
While there is a need for more research on foreign language acquisition/
learning of adult professional migrants, existing studies on child migrants revealthat it takes migrant children eight to ten years to be able to catch up withpeers in school (in exams, etc.) in terms of academic language (Nakajima
1998). If we follow this logic, it is imperative that Filipino nurses be allowed
to stay a few more years—say, up to eight years—as long as they satisfy acertain criteria in their NBE performance. In connection to this, it could besaid that the Japanese government has allowed Filipino nurses to retake Japan’s
NBE even after they have returned to the Philippines once. However, as ofthis date, this mechanism heavily relies on concerned individuals and nonprofit
organizations. It is recommended that both governments formalize extended
support for the returnees retaking the NBE.

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Given the aging population in Japan, on the one hand, and thePhilippines’ competent educational system in nursing on the other, it will
be mutually beneficial for both countries if, under JPEPA, Filipino nurses
are accepted as a professional in Japan more comfortably and on equal
footing with the Japanese.
Under JPEPA, the Philippines’ role is framed as the producer ofhealth workers who are outsourced by Japan. The exodus of nurses
demonstrates an example of “brain drain,” or loss to sending countries.
However, more studies of migration today seek to find positive meaningin “brain gain” by facilitating the emigrants’ return to their home country
after working abroad (“brain circulation”). The training and experience
they would receive in Japan—exposure to an aging society, advanced
technology, preventive medicine, interdisciplinary approach, disaster risk
management, and so on—can be applied in the Philippines upon theirreturn (Itami et al. 2010, 81–82). Both Japan and the Philippines need tosee nurses as common valuable human resources in the labor market.
With this in mind, it is suggested that both Japan and the Philippines develop
a program that promotes brain circulation for their mutual benefit.
With this new development, it is hoped that the Philippines andJapan will continue to improve JPEPA so that it can bring expected benefits
to both source and destination countries.
Notes
1

2

3

4

Currently, AOTS has changed its name to Overseas Human Resources and Industry
Development Association (HIDA).
It is noted that using its own resources, Elsa’s hospital had the NBE questions in Japanesetranslated into English, using its own resources for her and other EPA nurse candidates. The
hospital’s support for them was extraordinarily generous. They were able to concentrate on
the review for the NBE in the first six months after deployment. In Japan, the NBE questions
are considered public document and made available in public each year.
Another important skill in taking the NBE is reading comprehension. No systematic studies onreading comprehension for foreign nurses have been conducted as of this date. See also note 5.
Unfortunately, another EPA nurse candidate of the same hospital who entered Japan with
Elsa did not pass the NBE.

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5

6
7

8

9

10
11
12

13

14

15
16

17

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Some Japanese head nurses interviewed for this study recognize the importance of offering
foreign nurses on-site training at a general ward to provide them opportunities not only
to brush up communication skills in Japanese but also to get familiar with Japaneseclinical settings, a major component of the situational questions in the NBE. This is areasonable strategy. See Kawaguchi’s article in this volume for his opinion regarding thenecessity of understanding the sociocultural background so that examinees can readbetween the lines of the NBE questions.
However, wheelchair repair and toilet cleaning are often outsourced.
In some hospitals in Japan where the digital medical chart has yet to be introduced,
doctors write the instructions by hand.
See Yuko O. Hirano’s article in this special issue for the cost a hospital may shoulder in
accepting an EPA nurse.
Each year, both Japanese and foreign nurses are entitled to the same number of days ofleave with pay.
This hospital assigns night shift to other foreign nurses who are considered qualified.
Since 2015, Canada has also adopted the NCLEX.
On this regard, JICWELS makes a yearly visit to every institution that has accepted EPA
nurse candidates. However, a hospital staff commented in the interview that this isseldom done. She says that hospitals also have a lot of concerns to inquire and discusswith JICWELS. She wishes that hospital staff can communicate with JICWLES more
frequently and closely.
As mentioned in the following part of this article, the Japanese government allows thenurses who achieved a certain cutoff point (i.e., 102 points out of 300 points) in the NBE
in their third try to extend their stay in Japan and retake the NBE the following year.
It is noted, however, that the batches before the implementation of the K-12 basic education
program (those who graduated from four-year secondary school or the 10th grade in 2014 or
earlier—that is, all EPA nurse candidates so far) had only fourteen years of formal education(against the international standard of sixteen years for a bachelor’s degree). In this connection,
the three-year work experience requirement for application for the JPEPA program may be
adjusted accordingly in the future by the time K-12 students become nurses.
See also Choy (2003, 197–98, note 10 to Introduction) for details.
CF and DLS used to be known as basic interpersonal communication skill (BICS) and
ALP as cognitive academic language proficiency (CALP) around the 1970s until the
2000s.
As of September 2017, total of 1,203 nurse candidates had entered Japan from Indonesia,
Philippines and Vietnam since 2008, and 266 passed the NBE (MHLW).
Ochiai does not cite specifically Indonesian cases in this article. She compares China,
Thailand, Singapore, Taiwan, South Korea, and Japan in this study. The data show thatin all of these countries, except for Japan, parents heavily depend on kin members forsupport in childcare. Authors of this article have empirical data from observations thatthe situation of the Philippines and Indonesia is akin to Ochiai’s study.

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