Yearbook on Journal of the Japan Society of Nursing Research 2015

Change of Ideal and Practice on Patient Education in the Postwar Period
Kiyoka Niiya1)
Key Words :patient education
history of nursing
literature study

ABSTRACTThis research outlined how the nursing education of patients grew from the end of World War II to the 1980s,
and examined its various implications using documentary research methodologies centered on collecting,interpreting, and analyzing archives. From the standpoint of patient education, I aimed to establish a more
effective setup within continuing practice, emphasizing the basic principle of moving from a nurse-centered
to a patient-centered approach and incorporating an interdisciplinary methodology combined with practicalthinking centered on behavioral sciences and self-care. This is the process of moving from the provision of
abstract and generalized to specific and individualized information; teacher-taught to mutually supportive
relationship; unidirectional leadership to practice based on behavioral science; and issue resolution toclarification. By adapting to practical action in this way, patient education has grown methodologically bothfrom an interdisciplinary perspective and as an independent field of study.

Introduction

sphere of patient education through a critical examinationof conventional practice of patient education. For instance, it
was discussed from the perspective of learning support model(Yoshida, Kawaguchi, and Kawada 1992), the perspective ofproblem-solving learning (Miyasaka and Kawada 1984), andthe perspective of behavioral practice (Hinohara and others
1987: 179), and self-care perspective (Noguchi 1983: 46). At
first glance the practice of patient education appears to havespread since the 1980s but we must not forget that there wereattempts to construct “patient-centered” approach of nursing
by predecessors and the accumulation of practice aimed for“the support of self-reliance” before the 1980s.
This research is aimed to understand patient eduction
from a standpoint of nursing but it is insufficient to introduce“problem-solving methods” and “the method of support” forclarifying it. As long as it is taken for granted that the formulation of a problem as “patient education = nursing speciality”, avariety of things related to patient education such as the roleof nurses, their relationship with patients, how to practiceit, and how it is perceived remain to be seen. Therefore, it isnecessary to reexamine what was problematized and how
it went through changes by analyzing actual cases of patient
education. Some studies such as the works of Moriyama (2011)
and Yamaguchi (2008) which reviewed the historical transitionof patient education partly share the concerns of this study but
they do not examine how the meanings and theories attachedto nursing practice affected patient education.
Therefore, this research examines how patient eduction
for nurses had spread through the readings of a variety of
meaning attached to patient eduction by reviewing the transition of patient education for the postwar period from 1945
to the 1980s. For this purpose I focused on (1) the transition
from nurse-centered educational view to patient-centerededucational view, (2) the transition from teaching practice
to behavioral scientific practice, and (3) the transition fromproblem solving to problem clarification. Educational views
and practice are examined through these perspectives
for the following reasons: (1) “patient-centered” was notunderstood as a monolithic meaning on the transition fromnurse-centered- to patient-centered-educational views. The
meaning of “patient-centered” was evolved into the universal
value through the process of nursing practice. (2) On thetransition from teaching- to behavioral-practice nurses wereasked to get newly involved as study supporters when patient-Nursing in Japan was once not established as an independentwork. It was only sought as subsidiary work under doctor’s
guidance. Under this situation nursing reforms initiated bymembers of the American occupation forces after the Second
World War became a strong promoter of improving it. The
Occupation Administration reformed public health, nursing
service, and nursing education. It also made efforts to improve
patient education as a subset of nursing reform. Yet, medical
treatment was given priority over education in nursing at thattime, therefore, there were few nurses who recognized thenecessity of patient education.
The transformation from cure-centered medicine tocare-centered medicine in the 1970s, however, questioned
the practice of nursing education by making patient needs
involved deeply in medical care. The question to be asked
about nursing education was not about the enlargement ofnurse’s role awareness and area of interest on it but about
how nurses incorporated their own perspective of nursing
practice into helping for patients.
Patient education from the perspective of nursing wasintroduced from the United States into Japan’s nursing community in the 1970s and the 1980s. Following books were such
examples: Machiko Takeyama’s Kanjya kyouiku no purosesu(The Process of Patient Teaching in Nursing) (1971), Fumikazu
Sato’s, Seijin-byo kanjya kyouiku no jissai (The Actual Situationof Education for Patients of Adult Diseases) (1971), Hikaru
Horiuchi and others, Tounyoubyou kanjya kyouiku no riron tojissai (Theory and Practice of Education for Diabetic Patients)(1981), Misako Kojima’s Kanjya kyouiku no tame no jissenteki
apurouchi (Practical Approaches to Patient Education) (1986),
and Yuko Minami’s Mansei shikkan o ikiru (Chronic Illness and
the Quality of Life) (1987). These books which were publishedat the exact moment of the appearance of patient educationin Japan were highly conscious of the importance of patient
education on nursing.
Teruko Kawaguchi and Chieko Kawada were often mentioned
as representative scholars who conducted an essential studyof patient education. They delved into the new intellectual

1) Faculty of Nursing, Hiroshima International University

Corresponding author. Tel.: +81 823 73 8395; Fax: +81 823 73 8992.
E-mail address: k-akutag@ns.hirokoku-u.ac.jp

19This paper was published at “the Japan Society of Nursing Research” Vol.37 No.1 in 2014.

Yearbook on Journal of the Japan Society of Nursing Research 2015

centered patient education is conducted. This involvement
was based on behavioral scientific practice. It has been thecore of educational methods until now. (3) Problem solving
shows that the question of “which solution is good?” can be
answered only through educational practice from the nurses’
standpoint. On the other hand, problem clarification whichtries to answer the “why” questions such as “why do patientsmake questions?,” “why do patients think so,” addresses theway how patients become self-reliant. In other words, it canbe understood that it needs to clarify problems from thestandpoint of patients for thinking about patient educationfrom the perspective of nursing.
Based on these perspective it is examined what kinds ofeducational principles derived from practice and how they
were linked to nursing practice?

of (1) the transition from nurse-centered educational viewto patient-centered educational view, (2) the transition fromteaching practice to behavioral scientific practice, and (3) thetransition from problem solving to problem clarification.

1. The Transition from Nurse-centered Educational View toPatient-centered Educational View

Few nurses perceived the importance of patient educationfrom 1945 through the 1950s because medical care was a
primary intervention in patients. On nursing service Mizuno(1955) noted that “all nursing service were for doctors andnurses were primarily asked to serve doctors,” showing
doctors’ domination and nurses’ subordination during thisperiod. It is undeniable that his view is a rough generalization
because he ignored the cases of nurses who stood on the side ofpatients even against doctors or had more medical knowledge
and experience than average doctors. Yet, it is also undeniable
that hierarchy in medical community in the pre-war period
continued to exist after 1945. Nursing reform after 1945 aimed
for nursing service which tried to improve the health of patientswith a help of doctors and sought nurses who were good educators for attaining this goal (Inoue 1951).
Yet, as Kaneko (1959) notes, “nurses can provide care topatients but cannot educate them very much. This is because
they are not good at taking a leading role.” That is, it is pointed
out that the main problems of nursing education is the lackof knowledge and leadership on patient education. Patient
education was primarily conducted on tubercular patientsat the behavioral level such as the teaching of the knowledgeof tuberculosis and personal hygiene (Nakamichi 1951;
Tsukahara 1957). Nurses taught standard cautions on diet,sleep, and activities to patients. They might be helpful for
preventing expected complications and promoting medicalcare but its content was so abstract and general that it was
totally detached from individual lives and experience of
patients. The word information has been used widely sincethe 16th century. Its original meaning was the “teaching” by
those who have knowledge but it began to have the meaningof “inform” and “convey” information, notices, or reports(Terasawa 1997). Patient education also offers informationin the sense that it teaches the knowledge of diseases, informs
what a doctor says, and conveys the information of medical
treatment.
Educational relationship between a nurse and a patientis also based on the role relationship between the one whoteaches and the one who are taught, implying that it isdeliberate teaching relationship conducted between them.
The nurse must possess knowledge and technique necessary
for a patient and the patient must acquire it. Phrases such as“nurses teach...” and “patients are asked to do...” were often
found out in literature review, suggesting that nurses become
the central figures of patient education.
During the 1960s and 1970s the aging of population andthe increase of those who had chronic diseases enhanced therole of nurses on patient education. Ministry of Health andWelfare also noted in its examination of expanded role ofnurses that “medicine is not only the relationship between
doctors and patients but also the relationship between nurses
and patients. These human relationship is, so to speak, educational relationship and it is obvious that both doctors andnurses exist for patients” (1964). It was a major advance inpatient education because the autonomy and self-reliance of

I. Research Methods

This research collects, classifies, reads, and analyzes
relevant literature as a clue to know the practice of patient
education. The following literature was examined: Monographson health education, hygiene eduction, and patient education,
related legal documents on Ministry of Education, Culture,
Sports, Science and Technology (MEXT) and Ministry of Health,Labour and Welfare (MHLW), academic journals of medical careand nursing, and nursing journals: Kangogaku Zasshi (1946-),
Iryo (1947-), Byoin (1949-), Kango (1949-), Kango Gijyutsu(1955-), Kango Kyoiku (1960-), Sougou Kango (1966-), Kango
Kenkyu (1968-), Rinsho Kango (1975-), Kango Tenbo (1976),
Gekkan Nursing (1981-), and Kango MOOK (1982-).
Due to the shortage of papers and the GHQ’s control of
publication few nursing journals was published from 1945 to
the 1950s. The journals listed above are therefore characterized
as crucial historical materials for clues about nurses’ educational philosophy of patient education and their practice. The
investigation of historical facts were conducted by looking
through all nursing journals cited above and examined theauthenticity of historical documents and historical facts bycross-checking more than one articles. Kangogaku Zasshi wasespecially an important journal because it is the nursing journal
which was published first, and not only nurses but also officials
in the Ministry of Health and Welfare contributed articles tothis journal (Kaneko 1994). Members of the editorial board of
Kangogaku Zasshi was also writing articles in Koto Kangogaku
Koza, the first Japanese textbook of nursing, therefore, I referredto this journal many times for checking the authenticity ofhistorical facts.
According to Japan Academy of Nursing Science (2005),
patient education aims to help a patient to learn the knowledge, techniques, and attitudes for disease management andlife adjustment by himself/herself. In this research historicaltransition of patient education is examined, therefore, thewords - Eisei Kyoiku (hygiene education), Kenko Kyoiku(health education), and Hoken Kyoiku (preservation-of-healtheducation) which encompass the meaning of patient education
were treated as parts of patient education for making disease
management and life adjustment for patients.
II. The Transition of Educational Philosophy and Practiceof Patient Education

How did educational philosophy and practice of patient education evolve? This article examines it from the perspectives
20

This paper was published at “the Japan Society of Nursing Research” Vol.37 No.1 in 2014.

Yearbook on Journal of the Japan Society of Nursing Research 2015

by their own will. Ito (1987) viewed educational practice inwhich a patient learn by himself/herself with a focus on the
differences in learning style between adults and children. Miya
and Kawata (1985) also emphasized patient’s autonomy andself-reliance. They notes that “patient education is to help apatient to acquire necessary knowledge for cure for disease
and social rehabilitation, have an ability to use decision-making
skills for medical treatment and social rehabilitation, and topossess attitudes and energy to work actively for physicaland social recovery. In this way patient education had nochoice but to have “patient-centered” awareness by a criticalretrospection when patient education was grasped from the“learner-centered” perspective.
As a “patient-centered” approach the practice to promote
self-control by developing learning materials and methods
for encouraging patients’ participation, such as the teachingof insulin self-injection (Seto 1985) and the introduction of
educational hospitalization programs (Suenaga 1984) has
been conducted. New patient education of “patient-centered”
approach is also peculiar in that it tries to grasp psychology
and behavioral process of each individual. Noguchi (1983,p.50) noted that we need to provide psychological help topatients in order to make them have human relationshipthat can express their own feelings freely, become aware ofthemselves, and notice what they have to do by themselves,
so that they would become proactive about their own health.
Kadekaru (1983) notes that it is important to understand how
nursing involvement and practice contribute to the improvementof patient’s daily life activities through the analysis of the factsof their behavioral process in a logical way.
Nurses must change consciously from educational practitioners to learning supporters in patient-centered learning. It
is asked not only to tell necessary information to patients but
also to teach how to learn it, necessitating behavioral science
theory as a basis of this practice.

nurses was shown for the first time.
There was also a change of nurse’s perception on patient
education. It was originally recognized as a part of care but
it has become more important as a tool to support the livesof patients as a result of the increase of the aged who had
chronic diseases. For example, Yamagata, technical official
at Ministry of Health and Welfare, showed the importanceof patient education not only as the diffusion of knowledge
on adult disease prevention but only from the counseling forpatients with adult diseases (Yamagata 1961). Takahashi also
noted the necessity of patient education from the perspectiveof livelihood support (Takahashi 1963).
Subjects of patient education were also expanded fromtubercular patients to patients with adult diseases (Hinohara
1961; Hirayama, et al. 1967; Yajima 1967). The increase of
educational practice prompts us to revise the standardized“teaching” methods. The following statements that “inorder that each patient may understand and solve his/her
own health problem we must support him/her indirectly”(Matsumoto 1969) or “nurses must give guidance to patients
not with vague generalities of textbook knowledge but withspecific and concrete details” (Hinohara 1971) suggest that a
new method of patient education tailored to each individual
patient is sought after by nurses. During the 1950s “teaching”
was meant to tell patients general and abstract things but by
asking concrete practice as individuality nurses have begun to
notice a universalistic idea of “nurse-centered.” That is, they
have asked themselves a variety of “teaching” matters suchas “who do they teach?,” “where do they teach?,” “when dothey teach?,” and “how do they teach?” through the practiceof “teaching,” making it a trigger to ask the educational viewof “patient-centered.”Moreover, “l’education permanente” which Paul Lengrandpreached at UNESCO in 1965 affected many educational scenes
by prompting the study of adult development whose keyword
is “lifelong learning.” Its educational significance lies in thethoughts of “the power of self education” and the concept of“linkage” in which family education, school education, andsocial education should be conducted effectively (Lengrand1971). In Japan the policy report titled “About the Role ofSocial Education Dealing with the Changes of Rapid Social
Structure” which mentioned the role of the government
on lifelong learning and its importance was submitted bySocial Education Council in 1972 (the Ministry of Education
1971). The policy report of Central Council on Education
titled “About Lifelong Learning” (the Ministry of Education
1981) also claimed that “adult education and learning can be
matured only after each individual have enough motivation
and autonomy to enlighten and improve himself/herself,”
emphasizing the importance of self-reliance and autonomy
among each individual and of creating better educational
environment and teaching skills for supporting it.
Lifelong learning has been conducted in a variety ofplaces such as homes, schools, workplaces, and communities under the government’s promotion. There is a thoughtof “learner-centered” under the basis of these wide range oflearning activities. This transformation of educational views
contributed to develop a new strategy in the field of healthsociology and health education, making this principle a trend
to affect educational practice profoundly as “a new perspectiveof patient education” on nursing. For instance, Iwasaki (1985)
asserted that patients should not be regarded as subjects ofmedical cases but as human beings who engage in learning

2. The Conversion of Teaching Practice to Behavioral Scientific
Practice
In the 1970s and the 1980s the practice of health education
which analyzes observable phenomena became very popular
under the influence of the behavioral paradigm. For example,
Hinohara et al. (1987) promoted self-monitoring of bloodpressure and the 24-hour urine collection test toward local
residents. In this case doctors initiated to make them checktheir own blood pressure and urine collection by themselvesin order to induce them to form a good habit. A behavioral
science approach has shown that direct experience is more
effective as a new educational method than knowledge acquisition because it brings about high motivation and behavioral
transformation (Hinohara 1987: 203).
In this way educational practice of behavioral science
treats the questions of how health problems are solved as theprocess of “problem solving” between patients and healthcare
practitioner and “mutual cooperative ties between those
who help and those who are helped” (Munakata 1991). In“problem solving” approach patients are perceived as actors
who take actions to improve their own health, therefore,
medical experts are expected to help them in order to maketheir health behaviors effective. For that reason, there aremany reports which set the goal of patients’ behavioral
transformation and examined how to help them to solve theirown health problems by themselves in the practice of patient
21

This paper was published at “the Japan Society of Nursing Research” Vol.37 No.1 in 2014.

Yearbook on Journal of the Japan Society of Nursing Research 2015

education. Kumazoe, et al. (1987), for instance, reports that
their behavioral therapy for patients with anorexia nervosa
was effective in improving their eating habits. Kaneko (1987)
also carries out an exercise therapy program as a method of
problem solving for improving patients’ lifestyle. The main
goal of these practice is patient’s behavioral transformation,
so that they are expected to learn by themselves (e.g., “apatient can do something,” or “a patient did something.”).
Japan Nursing Association (1973) proclaimed that “relationship between a nurse and a subject is considered to be aninteractive process as a collaboration between them in order toachieve a particular goal.” This proposal contributed to change
the relationship between a nurse and a patient from “educational
relationship” to “relationship for mutual cooperation.” Iwata(1986) notes that nurse’s emotions and languages have great
effect on the construction of interactive relationship between
a patient and a nurse. Nakagawa and Nakashima (1987) also
state that nurses should listen to patients’ complaints patiently
and be sensitive to their emotions in order to construct mutual
cooperative ties with patients.
Relationship between a nurse and a patient had been
usually shaped vertically (those who teach → those who aretaught) but in mutual cooperative ties based on behavioral
science theory patients aspire to discuss and deal withproblems by themselves. Therefore, the terms “help” and“support” are more likely to be used than the term “educate”
in this practice. Fukase (1987) notes that it is “not patient
education but support or help. It is not taught from the top
but relies on horizontal relationship. That is, education nurses
conduct here is to help patients by constructing informal
relationship between them.” In this way she explained thesignificance of using the terms “help” or “support” theirstudy instead of the term “educate.” Some may think that theterms “help,” “support,” and “promote” which are used forexpressing educational activities would degrade the value of“education.” But in mutual cooperative relationship they areuseful for reexamining the importance and appropriate waysof “education” through the analysis of educational practice byusing these terms.
Reflection on the practice of patient education has beenpracticed on a variety of individual and organizational activities.
It has been influenced by learning and analytical views focusing
on behavioral science, questioning the practice of “those who
educate – those who are educated.” Asking this question has
contributed to situate the significance of behavioral science
approach on the field of patient education and clarify practicalmeanings of patient education.
Behavioral scientific practice has contributed to develop
patient education by bringing about a new approach but some
practice has been ineffective in causing behavioral changes ofpatients by just applying theoretical prescriptions to patients
without contextual considerations. There was a tendency toevaluate its utility by checking whether it can be useful asa means to contribute to behavioral changes, thereby theoretical foundations of behavioral scientific practice is rarely
problematized. Some people also raised questions about thebasis of behavioral science (Watabe 1985: 61).
Practical methods that focus on behavioral change in patientstend to focus more on their behaviors than on nonbehavioral
aspects of their livelihood, so that we tend to be unconsciousof the latter. Therefore, we failed to direct our attention onnurses’ limited understanding of the questions of “what ispatient education?” or “why do we have to engage in patient

education?”. In order to think about the meaning of an act ofpatient education we must look through the significance of
patient education from the standpoint of nursing. The purposeof patient education is deeply committed not only to the solving of health problems but to patient’s needs and self-reliance.
The important perspective on this point is patient education
captured from the perspective of self-care.
3. The Transformation from Problem Solving to Problem
Clarification

The concept of self-care has existed since the era of FlorenceNightingale and has been utilized in clinical nursing. Hildegard
E. Peplau also used the term “self-care” in the 1950s but oneof the most active promoter of “self-care” is Dorothea E. Orem.
She noted in her book titled Nursing: Concept of Practice(1971) that adults are independent and are expected to takeresponsibility for well-being of their own and of those who
depend on them and self-care is the practice which shouldbe pursued by their own initiative in order to maintain andpromote their own life, health, and well-being. She also talked
about teaching skills for assisting subject’s self-care behaviors.
Primary Health Care was declared (Declaration of Alma-Ata)in 1978 and self-care activities through one’s own efforts andresponsibility started to be pursued actively in Japan (Inada
1987). Health and Welfare Ministry announced in its The Mid
Term Report of General Task Force of National Health Service
that “it starts to put through reforms in a direction to focus
on the perspective of self-care that one’s own disease must
cure by himself/herself, hence contributing to enhance theinterests of self-care (Health and Welfare Ministry 1987). The
term - “self-care education” in place of patient education has
also been used. Lowell S. Leving made distinction between
them (1978):➀Patient education is aimed at patients but self-care education
does not presuppose their existence.
➁The goal of patient education is the treatment for disease
whereas the goal of self-care education is expected behavior
against risk.
➂Patient education is carried out by means medical experts
constructed whereas self-care education is conducted bylearner’s needs.
In other words, the most distinct element between themis that the former gives rise to dependence while the lattercreates self-reliance. If the purpose of self-care education is
to make a care receiver “independent”, a learner must decide
which action he/she should (or should not) take and get
responsible for his/her own actions.
Yet in Japan patient education from the perspective ofself-care has not been developed in a way that patients who
receive care are asked to bear a responsibility. Behavioral
scientific approach has tended to be educator-oriented andto lose sight of the essence of problems, therefore, we must
revisit patient education by contemplating the reasons “whywe conduct patient education.” Inaoka (1983) pointed outthat people’s health behavior is influenced not only by theirrational orientation but also mental and emotional ones but
conventional behavioral scientific approach tended to ignore
the latter. Sekito (1983) also noted that nurses tended tobe accustomed to patient’s passive behaviors, so that theyfailed to encourage their active participation, therefore, it isnecessary for them to realize the significance of self-care inpatient education.
22

This paper was published at “the Japan Society of Nursing Research” Vol.37 No.1 in 2014.

Yearbook on Journal of the Japan Society of Nursing Research 2015

Behavioral scientific approach was originally intended toreflect on one’s own life, notice the existence of its foundations,and attempt to engage in behavioral change but patient education
conscious of self-care put emphasis on the support of patient’s
self-reliance (Kimura 1982). “Self-reliance” here refers to thesituations in which a patient who has a disease attempts tocontrol his/her life again in a new way.
Support of self-reliance presupposes that patients acquirenecessary knowledge and techniques for their own livelihood
through learning. Directional approach is actually practiced
here, implying that it does not necessarily deny “teach-taught”
learning perspective. For instance, Narumi, et al. (1983)
reported that there was a stage of practicing directional
approach in the process of the development of self-carebehaviors among patients. Watabe also noted that it isimportant to support patients according to human views thatpatients observe their own existence deeply and have the will
to change in a good direction, therefore, it sometimes takes
the form of teaching and order for them (1985: 59).
Patient’s self-reliance is concerned with his/her individual
life, therefore, nurses could not prescribe its content. However,patients who do not have professional knowledge also cannot
prescribe it alone. Therefore, it is not appropriate for a patientto act just as he/she likes even if he/she wants to be self-reliant.
Nurses must judge what each patient needs from a professional
perspective and encourage him/her to deal with one’s own
learning needs and health problems by themselves. In this way
directional approach is used as educational practice.
Behavioral scientific approach tends to delay in taking
action because it tries to offer solution for achieving a goalof behavioral change after health problems occur. When aproblem is not solved, it tries to consider a new solution. In
other words, behavioral scientific approach tends to focus
only on a solution to problems without clarifying the natureof problems. Therefore, it is sought to answer the questions of“what is the best solution?,” “what purposes should we seek?”,and “what is the best means?” without problematizing thegoals of patients. On the other hand, practice of patient education from the perspective of self-care problematizes what
are problems for patients who try to be self-reliant. It tries
to answer functional questions such as “why does a patient
ask a question?” and “what does a patient think about?”.
Nurses should not presuppose the goals of patients in patient
education. Instead, they should aspire to help patients to be
self-reliant even if they are not healthy with a perspective of
how to understand patients. Seen in that light, it is a methodof practice not focusing on problem solving but on problem
clarification.

was functioned as the supplement of medical treatment.
Yet, vertical relationship between a nurse and a patient
has not need to be inevitable since the increase of lifestylerelated diseases and the transition from treatment-centeredto care-centered medical procedure. The pillar of educational
practice among patients was teaching skills of nurses whose
educational principle is patient-centered. It was influenced
by learner-centered lifelong learning and was started fromnurses’ practice of patient education, whose practice waspatient-centered. Patient education from the patient-centeredperspective emphasized the use of interdisciplinary methods
and practical thinking and verification of theory based on
behavioral science and self-care.
Practice based on behavioral science has redefined avariety of educational methods such as educational content,
educational materials, learning environment, individual study,
and group study for solving patients’ health problems. At thesame time, leadership qualities and abilities of nurses has
also been emphasized, necessitating the improvement of theirteaching skills as educators. In particular, nurses made efforts
to polish their teaching skills through enlarging educational
relationship between a nurse and a patient. To day this,patient education based on behavioral scientific approach isstill practiced as the core of educational methods.
Practice based on the assistance of patients’ self-reliance isaspired in the practice of patient education from the perspectiveof self-care. Whenever patients’ self-reliance becomes the maingoal, we face the problems of “how to think about a variety ofexperiences and difficulties,” “what kinds of care they expect
to receive,” and “how to engage in practice in accordance with
one’s needs.” In this case it is important to clarify the problemsof “what a patient wants,” and “what a patient expects.” Nurse’s
continuous attempts to ask patients about whether nurse’s
efforts really contribute to patient’s self-reliance can be called
the practice which is conscious of the clarification of problems
instead of the resolution of problems.
The validity of patient education has been proved by the
analysis of practice based on the patient-centered ideas which
had been conducted from 1945 through the 1980s. Researchon patient education accumulated its knowledge throughmethodological aspects in line with practical facts. This haschanged from the provision of abstract and general information to concrete and distinct content, from the relationshipbetween a teacher and a student to the mutually cooperative
ties, from unilateral guidance to behavioral scientific practice,and from the problem-solving to the clarification of problems.
Then, the meaning of “what is patient education?” has beenquestioned repeatedly through its practice. Nurses’ attempts
to question the practice of patient education have contributed
to rediscover the significance of patient education, opening
a new methodological possibility. In other words, patient
education has deepened its methodological approach andexpanded its interdisciplinary possibility as nursing researchthrough practice.
Yet, there have been few studies focusing on the essentials
of patient education (e.g., “what is patient’s self-reliance?”or “where is the possibility of patient education?”) although
there are many articles on the function and methodology ofpatient education. Researches on asking the essence of patient
education has focused on the understanding of adult learners
and informed consent since the 1990s.
Research on patient education has expanded and has
become more complex, whose goal is to make patients live aIII. Discussion

Human relationship between a nurse and a patient had
occurred only when medical treatment and procedure are
performed until the 1950s. Here a nurse plays a role as the aidof medical treatment but it is only a function “dependent” on
doctors in which he/she “carries out doctor’s order.” Therefore,
educational relationship between a nurse and a patient ismerely vertical relationship in which the former tells the latter
about knowledge under a doctor’s guidance. Knowledge offeredto patients was mainly the one for preventing complications
but it was merely the provision of abstract and generalized
information detached from patient’s living experience. This
relationship could be effective as long as patient education
23

This paper was published at “the Japan Society of Nursing Research” Vol.37 No.1 in 2014.

Yearbook on Journal of the Japan Society of Nursing Research 2015

humane life. Therefore, it is important to continue to answer
the question of how human beings live as human being andexamine human problems accompanied by becoming a patientin order to construct new patient education.

Japanese]. Nihon kango kenkyu gakkai zasshi, 8(3), 53.
Kadekaru, H. (1983). Research on the improvement of daily life
activities [in Japanese]. Nihon kango kagaku kaishi, 3(1), 39-51.
Kaneko, M. (1987). “Patient education” among patients with ischemic
heart disease [in Japanese]. Gekkan nursing, 7(1), 54-58.
Kaneko, H. (1959). Essay on curriculum [in Japanese]. Kango gijyutsu,
5(12), 20-26.
Kaneko, H. (1994). Hold the lamp of nursing high [in Japanese](pp.99-100). Igaku shoin, Tokyo.
Kimura, R. (1982). Patient education in a hospital [in Japanese].
Byouin, 41(11), 968-969.
Kouseisho (1964). The mid-term report of meetings hearing
comments from experts on nursing system [in Japanese]. Kango,
16(9), 2-8.
Kouseisho (1987). The mid-term report of general task force ofnational health service [in Japanese]. 34(8), 44-50.
Kumazoe, M., et al. (1987). “Patient education” for patients withanorexia nervosa aiming for stress control [in Japanese]. Gekkan
nursing, 7(1), 66-69.
Lengrand, P. (1971). An introduction to lifelong education (pp.44-55).
UNESCO Institute for Education, Switzerland:
Levin, L.S. (1978). Patient education and self-care: How do theydiffer?. Nursing Outlook, 26(3), 170-175.
Matsushita, K. (1969). The way to interact with outpatients [inJapanese]. Kangogaku zasshi, 33(8), 38-43.
Miyasaka T. and Kawada C. (1984). Health, medical care and healtheducation [in Japanese] (pp.82-83). Saishin hokengaku kouza,
Medical friend co., Tokyo.
Miyasaka T. and Kawada C. (1985). Theory of health education [inJapanese] (pp.21-22). Saishin hokengaku kouza (bekkan 1), Medical
friend co., Tokyo.
Mizuno, S. (1955). About nurses’ assistance to doctors [in Japanese].
Kangogaku zasshi, 18(6), 12-15.
Monbusho (1971). The report of council for social education [inJapanese]. Eidell.co., Tokyo.
Monbusho (1981). The report of a small committee on lifelong
learning in central council for education [in Japanese] (pp.19-20).
Monbusho, Tokyo.
Moriyama, M. (2011). History of patient education at the bedsidein Japan: From the down of modern nursing to the present [inJapanese]. Kango kyouiku kenkyu, 20(1), 30-43.
Munakata, T. (1991). Behavioral science of medical care [in Japanese].
In Hasegawa, H. and Munakata, T., eds., Koudou kagaku to iryo
(pp.7-36). Koubundo, Tokyo.
Nakagawa, Y. and Nakajima K. (1987). “Nursing education” in the
future [in Japanese]. Gekkan nursing, 7(1), 14-21.
Nakamichi, C. (1951). Tuberculosis and nursing [in Japanese]. Kango,
3(9), 2-4.
Narumi, K., et al. (1983). Development of patients’ therapeutic selfcare behavior [in Japanese]. Nihon kango kagakugaku kaishi, 3(2),46-47.
Nihon kango kagaku gakkai (2005). Classification of nursing practice[in Japanese] (p.209). Nihon kango kagaku gakkai shuppankai,Tokyo.
Nihon kango kagaku kyokai (1973). Basic attitudes on the
improvement of nursing institutions [in Japanese]. Kango, 25(13),52-57.
Noguchi, M. (1983). The promotion of self-care and nurses’ roles [inJapanese]. Kango gijyutsu, 29(6), 46-53.
Orem, D.E. (1971). Nursing: Concepts of practice. pp.103-104, Mosby,
Missouri.
Sekito, Y. (1983). Facts and prospects of self-care education [inJapanese]. Kango gijyutsu, 29(6), 69-75.
Seto, K., et al. (1985). The guidance of insulin self-injection [inJapanese]. In Baba, K., ed., Diabetes and nursing (pp.81-90).
Kanahara shuppan, Tokyo.
Shimazaki, R. and Oishi, S. (2003). Nursing reform in the postwar
Japan [in Japanese] (pp.19-22). Nihon kango kyoukai shuppankai,Tokyo.

Conclusion

Medical care in Japan was based on human relationshipbetween a doctor and a patient whereas nurses were merely
helpers to doctors and family members took care of patientsfor a long period of time. The postwar nursing reform
enlarged the roles of nurses and patient education was oneof them. But there was difficulties to pursue patient education
due to nurses’ long-term dependence on doctors. In spite ofthese difficulties, the role of nurse’s patient education was
enlarged from 1945 through the 1980s.
To be sure, the basis of patient eduction were mainly
inductive but there were attempts to establish the original
knowledge and techniques of nursing with the aid of theories
developed abroad and in other disciplines. It can also be
said that patient education has become a distinct disciplineby enlarging interdisciplinary field from a methodologicalaspect.
On the other hand, only the number of practical researchof patient education has increased due to the reduced lengthof stay and the promotion of streamlining in medical policy,
hampering the study of the essence of patient education.
When thinking about patient education it must be linked toits essential characteristics (e.g., “how do we see patientsas human beings?” and “how do we think about patients’
self-reliance?”). Practical aspects such as part of treatment
or behavioral transformation has been emphasized but what
is more important is how to see patients as persons who
possess rights and how to grasp self-reliant persons. Thesestandpoints would help us to rethink its methodology and theway to capture patient education.
In any case, researches on patient education is still developing.
I hope further studies on this field would be accumulated andthis study would contribute to it.
References

Fukase, K. (1987). How do we educate patients and their family
caregivers: “Patient education” starts from awareness that “nursing
is all education [in Japanese]. Gekkan nursing, 7(1), 22-27.
Hinohara, S. (1961). Health guidance of adult diseases [in Japanese].
Kangogaku zasshi, 14(12), 114-118.
Hinohara, S. (1971). Chronically ill patients’ way of life: From thestandpoint of doctors [in Japanese]. Kango, 23(8), 26-29.
Hinohara, S., et al. (1987). Health education [in Japanese]. Nihon
hyoronsha, Tokyo.
Hirayama, A., et al. (1967). Control receiving medical treatment
among outpatients with high-blood pressure and health education[in Japanese]. Sougou kango, 2(1), 34-55.
Inada, K. (1987). Theory of health education in Uzaki, H. ed., Economic
analysis of medical care [in Japanese]. Nihonhyoronsha, Tokyo.
Inaoka, F. (1983). Assessment of self-care ability and self-care
education [in Japanese]. Kango gijyutsu, 29(6), 54-60.
Inoue, S. (1951). Nurses and education [in Japanese]. Kango, 3(10),34-36.
Ito, R. (1987). How to enhance a motivation to “study” among patients[in Japanese]. Gekkan nursing, 7(1), 38-39.
Iwasaki, S. (1985). Lifelong learning [in Japanese]. Kangogaku zasshi,
49(7), 817-820.
Iwata, H., et al. (1986). The analysis of patient-nurse relationship [in24This paper was published at “the Japan Society of Nursing Research” Vol.37 No.1 in 2014.

Yearbook on Journal of the Japan Society of Nursing Research 2015
Suenaga, T. (1984). Patient education for diabetes [in Japanese].
Practice, 1(1), 36-40.
Takahashi, S. (1963). The role of nurses on adult diseases [inJapanese]. Kangogaku zasshi, 27(5), 17-21.
Terasawa, Y. (1997). The Kenkyusha dictionary of English etymology[in Japanese] (p.714). Kenkyusha, Tokyo.
Tokuno, Y. (1984). The guidance of diabetes patients from theperspective of life care [in Japanese]. Kangogaku zasshi, 48(4),399-404.
Tsukahara, K. (1957). On the guidance of home treatment for diabetes
patients [in Japanese]. Kangogaku zasshi, 21(9), 54-59.

Watanabe, J. (1985). Self-care and nursing [in Japanese]. In Baba, K.,ed., Diabetes and nursing (pp.56-61). Kanehara shuppan, Tokyo.
Yajima, M. (1967). Nursing for patients with colostomy [in Japanese].
Kangogaku zasshi, 31(2), 72-77.
Yamagata, S. (1961). Measures to deal with adult diseases [inJapanese]. Kango gijyutsu, 7(10), 29-35.
Yamaguchi, Y. (2008). The transition of patient education for diabetes
patients [in Japanese]. Nara-kenritsu ika-daigaku igaku-bu kangogakka kiyo, 4, 1-8.
Yoshida, T., et al. (1992). New thinking about patient education [inJapanese]. Practice, 9(1), 58-59.

25
This paper was published at “the Japan Society of Nursing Research” Vol.37 No.1 in 2014.