TOKYO -- Japan first started actively accepting nurses from other countries more than 11 years ago, when the Economic Partnership Agreement (EPA) with Indonesia went into effect in July 2008.
But even though the Japanese government is going ahead with plans to increase its number of foreign workers, a majority of the nurses accepted as part of the "first intake" in 2008 have already returned home.
I went to investigate why so many of these people couldn't put down roots in Japan, and consider what issues there are for foreign nationals to continue working here.
At the Kawakita general hospital in Tokyo's Suginami Ward, Mohamad Yusup, 38, an Indonesian nurse, moves briskly around the hospital ward. "I'm preparing your IV drip now," he says in fluent Japanese to an inpatient. His smile never falters.
He's now in his eighth year working at a mid-level position at the hospital, and also does work teaching young employees. But the road that led him to this point was not always easy.
He came to this country in 2008, after accumulating practical experience as a nurse in his home country of Indonesia, which has a good relationship with Japan. He thought he would be able to improve his career chances by coming here to learn about the latest developments in care.
But what awaited him was changing sheets and other duties usually fulfilled by a nursing assistant. He said he was shocked to realize he wasn't going to be using his nursing skills.
To work as a nurse in Japan, a person must have over two years of working experience in their home country, and within the four years of residency they are permitted in Japan, they must pass a national nursing test in Japanese. Yusup came to Japan with only an incomplete explanation of what it would be like.
He managed to pass the test in his fourth year. The issue was the Japanese language. At work, he used to keep a dictionary in his pocket for checking words he didn't understand. He would study for the test late at night, and his co-workers helped him too. Looking back on that time, he said, "The door (to a new life) opened little by little."
Even after he had memorized medical terminology in Japanese, there were still many words used in everyday life that he didn't know. When he was helping give meals to patients, they would ask him what it was, and he wouldn't be able to say the name of the food. As he was no longer treated as a "guest" at work, he refined his Japanese skills through teaching new employees and by helping to organize work parties.
His primary concern now is what to do about the education of his two sons, who are in elementary and junior high school. His younger son was born in Japan, and his family has now fit into Japanese society to the point that that they tell him they don't want to go back to Indonesia.
But he says that, in case they ever do return, he wants them to thoroughly understand their religion, Islam, and to be able to speak Indonesian. He says he thinks also about options where they are educated entirely in Indonesia.
Like Yusup, Lusy Fitriani, 40, is a member of the first intake. She works at Tobu Chiiki Hospital in the capital's Katsushika Ward. She describes herself as being fortunate in where she was placed. She too was simply told that she would be working as a nurse in Japan, and there were no detailed explanations before arriving here.
But she said that a hospital in Kanagawa Prefecture, just south of Tokyo, which was her first workplace in Japan as a nursing assistant, enthusiastically supported her efforts to get the qualifications. She was able to secure time in the hospital's library to study twice a week, and staff in charge of teaching educated her in Japanese and how to write official documents.
But the reality is that this kind of support is based entirely on the working environment people find themselves in. Reflecting on the three years before she passed the test, Fitriani said, "My nursing skills went back to zero." She added, "I want support systems to be established that help people pass those tests in a shorter time."
Between fiscal 2008 and fiscal 2018, up to 1,300 people from Indonesia, the Philippines and Vietnam, which all have EPAs with Japan, have come to work here as nurses. But current to the end of fiscal 2018, just 413 of them had passed the national tests. The highest passing rate was in fiscal 2017, when 17.7% of applicants were successful.
Overall figures including Japanese people show pass rates hovering around 90%, indicating a huge disparity between foreign nationals and residents. There are also people who have gone back to their home countries without taking the tests, showing how the potential of those who have made the effort to come to Japan is not being utilized.
Kazumi Murakumo, a PhD student at the University of Tsukuba, is researching the EPA between Japan and Indonesia after working at the Indonesian Embassy in Japan.
According to her findings, of the 104 nurses who came to Japan as part of the first intake, 90% of them have already left the country, and just six of them still work at the hospital where they were originally dispatched.
A group of nine second intake Indonesians who have returned home reportedly all said that they first found out they would start as nursing assistants upon arriving in Japan. Many of those who couldn't maintain their enthusiasm about working in Japan had their time here treated as a blank in their careers upon returning to work in their home countries. Part of this is down to the Japanese government, which doesn't issue documents such as certifications stating these people worked as nursing assistants.
There are also issues with the way the government is accepting foreign workers. Murakumo said, "Although these are agreements between national governments, the acceptance of these workers is left up to individual medical institutions, with no model for professional development.
Depending on the prefecture, some have hospitals that are engaged in Japanese education schemes and other support systems, but detailed plans are not set out by authorities.
When asked about a model case that has worked, Murakumo cited Iwasa Hospital in the central Japan city of Gifu, where first intake nurses still work. Among the special support the hospital provided, it helped with housing contracts, accompanied these nurses in training to obtain driving licenses, and extended all kinds of general living support.
Iwasa Hospital offers guidance on obtaining qualifications to practice as a nurse too by showing specific goals they should aim for, and providing them with time and a place to study. Junko Ikawa, 70, a former head nurse at the hospital who used to plan birthday parties and trips to local areas with the foreign nurses, said, "By getting involved in their lives outside of work, we wanted to prevent them from losing motivation."
(Japanese original by Go Kumagai, Lifestyle and Medical News Department)