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Pathways to Progress in Nursing: Understanding Career Patterns in Japan, Taiwan and Thailand

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Lenny Chiang-Hanisko, RN, PhD
Ratchneewan Ross, RN, PhD
Puangrat Boonyanurak, RN, PhD
Mieko Ozawa, RN, PHN, PhD
Ling-Chun Chiang, RN, MSN

Abstract

Nursing’s recent progress in fostering better health around the world has been impressive. This progress is due, at least in part, to the higher levels of education nurses are receiving today. However, the goal of developing a stable nursing workforce remains elusive worldwide, due to career progression challenges related to nurse recruitment, education, retention, and promotion. This article provides an overview of existing career pathways in nursing in three Asian countries: Japan, Taiwan, and Thailand. For each country, a brief presentation of the development of nursing is followed by a review of admission requirements for education programs, and a description of available career pathways, including the routes and types of licensure for general and advanced nursing practice. The article concludes with a discussion of issues and challenges common to all three countries, specifically the identity of the nursing profession, limited faculty resources, English language barriers, transitioning of nursing education, and the provision of culturally competent care.

Citation: Chiang-Hanisko, L., Ross., R., Boonyanurak., P., Ozawa, M., Chiang., L., (Sept. 30, 2008) "Pathways to Progress in Nursing: Understanding Career Patterns in Japan, Taiwan, and Thailand" OJIN: The Online Journal of Issues in Nursing; Vol 13 No 3 Manuscript 4.

DOI: 10.3912/OJIN.Vol13No03Man04

Key words: Career pathways, career patterns, international, issues and challenges, Japan, nursing education, Taiwan, Thailand

Nursing’s recent progress in fostering better health around the world has been impressive. This progress is due, at least in part, to the higher levels of education nurses are receiving today. Nursing’s recent progress in fostering better health around the world has been impressive. This progress is due, at least in part, to the higher levels of education nurses are receiving today. Despite this progress, the goal of developing a stable nursing workforce remains elusive worldwide. As nursing shortages persist in most counties (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aitken, Suchan, Sochalski, Nicholas, & Powell, 2004; Buchan, & Calman, 2004; International Council of Nurses [ICN], 2004), serious challenges remain in nurse recruitment, education, retention, and promotion.

This article will provide an overview of existing career pathways in nursing in Japan, Taiwan, and Thailand. For each country, a brief presentation of the development of nursing will be followed by a review of admission requirements for education programs and a description of available career pathways, including the routes and types of licensure for general and advanced nursing practice. The article will conclude with a discussion of issues and challenges common to all three countries, specifically the identity of the nursing profession, limited faculty resources, English language barriers, transitioning of nursing education, and culturally competent care.

These three countries share strong economic and political ties and are growing nursing education programs at similarly rapid rates. Although distinct cultural differences exist among the three countries, the focus of this article is not on cultural differences between these countries, but rather on identifying common issues and challenges related to the preparation and development of nurses. Providing a synopsis of the career patterns in each of these countries may help to identify our global workforce problems and challenges in nursing as well as provide insight into the unique approaches taken in the individual country to cultivate nursing as a national resource.

Nursing in Japan

This section will provide a brief presentation of the development of nursing in Japan, followed by a review of admission requirements for education programs and a description of the career pathways, including the routes and types of licensure available for general and advanced nursing practice.

Background and Development

Japan, which consists of four major islands as well as thousands of smaller islands, has a population of over 127 million. The use of the term “Kangofu,” meaning nurse, was first used in 1876 (Japanese Nurses Association, 2006). In 1885 the first training institute for nursing was established. A formal licensing system for nursing professionals was created in 1899 with the enactment of the “Midwifes Ordinance,” followed by the Registered Nurses Ordinance in 1915, and the Public Health Nurse Ordinance in 1941. In 1946, after World War II, the Japanese Association of Midwives, Registered Nurses, and Public Health Nurses was established and became the Japanese Nursing Association (JNA). The JNA is a professional nursing organization that represents public health nurses, midwives, professional nurses, and assistant nurses (JNA, 2006). The Public Health Nurse, Midwife and Nurse Law introduced in 1948 was designed to raise the standards of professionalism for nurses through regulation of practice, education, and examination. Japan established the first nursing university in 1952. As of April, 2006, Japan had 146 universities and colleges offering the bachelor’s degree in nursing with 87 of these programs providing postgraduate nursing education, 37 of which offer doctorate level courses (JNA, 2008a).

Nursing Programs Admission Requirements

After completing junior high school, students interested in nursing have various options to become a Registered Nurse (RN). They can attend a “Nursing High School” (5 year program), or attend a traditional senior high school and upon graduation, attend (a) a four-year nursing college or university, (b) a three-year junior nursing college, or c) a three-year hospital or medical affiliated training school for nurses (see Figure 1).

National educational policies allow universities, colleges, junior colleges, nursing schools, and nursing high schools to conduct their own recruitment process. Admission standards are varied with each school setting its own requirements, such as individual-school-based exams, essays, interviews, participation in social activities, high school grade point average, letters of recommendation, and scores on the National Center Test conducted by the National Center for University Entrance Examinations (NCUEE). This test examines students in the areas of mathematics, science, Japanese language, foreign language, geography, history, and civics (NCUEE, 2008). Universities, colleges, and junior colleges can use these test results as well as their own admission criteria to evaluate an examinees’ capabilities (Lambert, Lambert, & Petrini, 2004). For master and doctoral programs, each university has established its own set of criteria for admittance.

Career Pathways

General Nursing Licensure

There are several levels of “generalist nursing qualifications” in Japan, including Licensed Practical Nurse (LPN), Registered Nurse (RN), Public Health Nurse (PHN), and Midwife (Ministry of Health, Labor and Welfare [MHLW], 2003). Table 1 shows the various nursing programs in Japan.

Licensed practical nurse (LPN). LPNs are also known as practical, assistant, or associate nurses. Junior high school students who seek to become an LPN usually attend a high school nursing program or an assistant nursing school and are required to pass a prefectural (state) assistant nursing examination. LPNs are permitted by law to carry out many of the same duties as an RN under the direction of a doctor, dentist, or RN.

Registered nurse (RN). Senior high school graduates have several options available to become an RN. The basic route is to study at a university in a four-year nursing program to obtain a bachelor’s degree. Students can also attend a junior college nursing program for three years or a specialized nursing school for three years. Students who complete any of these programs are entitled to take the national examination to become a registered nurse. LPNs who desire to become an RN are required to attend a junior college or specialized nursing school for two additional years before taking the national examination.

Registered public health nurses (PHN). Nursing graduates from universities are qualified to take the PHN National Board Examination. Nursing graduates from junior colleges or specialized nursing schools are required to complete an additional year of public health nurse training in order to take the national PHN exam. After passing the examination, nurses with the PHN license can provide public health guidance in community, school, and workplace settings.

Registered nurse-midwives (Midwife) Only female RNs are eligible to become a midwife. The law prohibits males from taking midwifery education or taking the examination. Nursing graduates of four-year universities are qualified to sit for the Midwifery National Board Examination. Nursing graduates from junior colleges or specialized nursing schools are required to complete an additional year of midwifery training to become eligible to take the national Midwifery examination. With Midwifery licensure, nurses can enter into their own practice or work in cooperation with a doctor at a maternity clinic.

Advanced Specialization and Post-Licensure

For advanced specialized licensure, certification standards are developed by various nursing organizations and academic societies such as the JNA, since national qualifications have not been standardized by the government for these exams. There are three types of advanced specialized licensure: Certified Nurse (CN), Certified Nurse Specialist (CNS), and Certified Nurse Administrator (CNA). The JNA certifications are renewable every five years.

Certified nurse (CN). Nurses must have at least five years of clinical practice (three years in the specialty area) to be eligible to enter a CN-regulated curriculum. CN educational programs usually take six months to one year to complete. The certification examination is offered by JNA. Certified nurses provide advanced nursing practice, leadership, and consultation in 19 specific areas. Specialty areas include emergency, wound/ostomy/continence, intensive care, palliative care, cancer chemotherapy, cancer pain management, visiting nursing, infection control, diabetes, infertility, neonatal intensive, dialysis, perioperative, breast cancer, dysphagia, pediatric emergency, and dementia nursing.

Certified nurse specialist (CNS). Nurses must have at least five years of clinical practice (three years are in the specialty area of which one year is practice after graduation) and graduate with a master’s degree to be eligible to take the CNS examination offered by JNA. Certified Nurse Specialists are advanced practice nurses with expertise in one of ten specialized areas including: cancer, psychiatric mental health, community health, gerontology, child health, women’s health, chronic care, critical care, and infection control nursing. CNSs can positively influence care by providing advanced patient assessment and expert consultation to patients in their area of specialty. They may also take on a higher level of clinical and professional leadership as well as participate in research activity.

Certified nurse administrator (CNA). Nurses who have over five years of clinical practice and management experience, as well as a master’s degree with a major in nursing management, are eligible to take the CNA examination offered by JNA. Certified nurse administrators are involved in issues of nurse management, organizational development, and cost-effectiveness programs.

Career Development Opportunity

A specific career advancement opportunity for nurses in Japan is...the area of gerontology. A specific career advancement opportunity for nurses in Japan is that of specializing in the area of gerontology. Japan will have the world’s oldest population by 2020 with over 31% of the population over 60 years of age (Ogawa & Matsukura, 2005). Nurses with specialized knowledge and training will increasingly be needed in order to plan and deliver quality care to meet the needs of older adult populations. This continues be a critical nursing workforce issue considering the current shortage of nurses as well as the lack of advanced practice nurses trained in gerontological nursing.

Nursing in Taiwan

This section will provide a brief presentation of the development of nursing in Taiwan, followed by a review of admission requirements for education programs and a description of the career pathways, including the routes and types of licensure available for general and advanced nursing practice.

Background and Development

Taiwan is an island in the western Pacific Ocean with a population of approximately 23 million people. It was influenced during the 16th and 17th centuries by European settlers, such as the Portuguese, Spanish, and Dutch, and more recently by the Japanese who controlled the island for a period of 50 years ending in 1945 (Chiang-Hanisko, 2003). Historically, the first nurse-training program in Taiwan was initiated by the Japanese government in 1897 during the Japanese occupation. Nurses were called “Kan-Hu-Fu,” which means “the woman who looks after the sick people” (Chen & Tsai, 2001). During the occupation, nurses were trained and educated both by the Japanese and by missionaries from western countries such as Belgium, Canada, Switzerland, and the United States. After the occupation, the first official nursing program was founded in 1947 by the Taiwanese government (Chen, 2005; Shiau & Chen, 1997). As the demand for nurses increased, academic programs in nursing were established at the vocational level in high schools, as well as in institutes, colleges, and universities. The first graduate nursing program offering a master’s degree was started in 1979, and the first doctoral program began in 1997 (Department of Health, 2000). By 2008, educational programs to meet the demands for nursing professionals had expanded to 39 schools, including 14 associate, 25 undergraduate, 16 master’s, and 11 doctoral programs (Department of Statistics, 2008). The Nurses Association of the Republic of China was first founded in 1914 and later renamed the Taiwan Nurses Association (TWNA) in 1999. The TWNA works to promote the standards for professional nursing practice, education, and research on both the national and international levels (TNA, 2008).

Nursing Programs Admission Requirements

The minimum requirement to practice nursing at a professional level in Taiwan is that of being a registered nurse (RN). Hospitals and other healthcare institutions offer various programs to train nursing assistants. However, nursing assistants are not licensed as professional nurses and usually work under the guidance of RNs performing basic nursing tasks.

There are two systems of educational programs available to students to become a registered nurse, the Technical and Vocational Education system and the General University Education system (see Figure 2). The Technical and Vocational Education (TVE) system includes two types of entry-level nursing programs. After completing junior high school, students can select a program of study for three to four years in a nursing high school or enter a five-year junior college nursing program. Upon completion of either entry-level program, students can continue their nursing education by attending a two-year nursing college or a four-year institute of technology. The second system, the General University Education (GUE) system, accepts students from traditional senior high schools and provides four years of nursing education at a university level (Yu et al., 2005). Acceptance into either system is based upon scores on a national exam, high school grade point average, and participation in school activities. Entrance to both systems is highly competitive and high scores on the national exam are a prerequisite to acceptance. Mathematics, general science, biology, social sciences, English, and Chinese literature are subjects generally tested on the national exam. For master’s and doctoral programs, entrance criteria and requirements are set by each individual university. Normally, both written and oral evaluations are involved in the selection process.

Career Pathways

General Nursing Practice

There are 2 types of licenses recognized in Taiwan to practice nursing: registered nurse (RN) and registered professional nurse (RPN). The Ministry of Examination in Taiwan offers both RN and RPN license examinations. Both exams are comprehensive in scope and cover subjects in basic medicine, pathophysiology, pharmacology, medical-surgical nursing, pediatric nursing, maternal-child nursing, and psychosocial nursing. The RPN examination is considered more difficult since it tests more theoretical and conceptual nursing knowledge as well as advanced medical knowledge.

Generally, students who graduate from the nursing high school program in the TVE system are eligible only for RN licensure, and not for the RPN licensure. Graduates from all other programs, whether within the TVE or GUE systems, are eligible to take the RN and/or the RPN national license examination (see Table 2). In practice, RNs and RPNs have the same responsibilities for implementing nursing care. However, nurses with an RPN license may have more opportunities for advancement. Presently, the Taiwanese government is in the process of raising the educational requirement for RPN licensure to a bachelor’s degree.

Advanced Nursing Practice

In 2000, Taiwan began the development of a nurse practitioner (NP) system to improve collaboration between physicians and nurses and to provide continuous and comprehensive patient care. Before the development of this system, nurses in many hospitals and some clinics who were acting in advanced roles were often viewed as "physician assistants." In recognition of the expanding role of nurses in the healthcare system, the Department of Health established national standards for training and licensure for NPs to ensure a high level of competency as advanced practice nurses.

Currently, the NP system offers two specialty areas, medical and surgical. To be qualified as an NP, nurses must have an RPN license, at least five years of clinical practice in a specialty area, and the endorsement of their hospital management (Department of Health, 2008). Generally, those nurses recommended by the hospital for the NP examination are functioning at an advanced level as advanced clinical specialists. Once identified as a qualified candidate, they are eligible to take the NP examination which is both written and oral. Upon successful completion of the examination, they enter into a concentrated, hospital-based training program lasting for at least six months. The training is largely guided by physicians and includes 160 hours of coursework in advanced pharmacology, advanced pathophysiology, advanced health assessment, clinical judgment, health promotion and disease prevention, and medical law and ethics. In addition, candidates must complete a clinical practicum under a physician’s supervision with at least 30 medical or surgical patients and at least 10 acute and critical patients. After successful completion of the practicum, candidates are awarded an NP license which is renewable every six years.

Career Development Opportunity

Chronic diseases present an important area for career development in Taiwan, where eight out of ten leading causes of death are due to chronic diseases. Chronic diseases present an important area for career development in Taiwan, where eight out of ten leading causes of death are due to chronic diseases (Taiwan Government Information Office, 2008). For patients with chronic diseases and their family the provision, by healthcare professionals, of terminal care support to deal with death and dying has been insufficient. Although Dr. Co-Shi Chao (known as the “Mother of Hospice Care”) has been promoting the need for hospice and palliative care since 1993 (Chao, 2005), cultural acceptance of the hospice concept, the living will and the DNR directive has faced some resistance in general society. Recently, with the support of government, religious, and medical leaders, the need for hospice and palliative care services have become more widely accepted in Taiwanese society. To address these needs, even more nurses need to be prepared at the advanced practice level to offer palliative treatment and support in acute care hospitals, home care settings, and hospice centers.

Nursing in Thailand

This section will provide a brief presentation of the development of nursing in Thailand, followed by a review of admission requirements for education programs and a description of the career pathways, including the routes and types of licensure available for general and advanced nursing practice.

Background and Development

...with the support of government, religious, and medical leaders, the need for hospice and palliative care services have become more widely accepted in Taiwanese society. Thailand, formerly known as Siam, is located in Southeast Asia and has a population of over 65 million people (Ministry of Public Health, 2007). The country has never been colonized which is a point of great pride for the people of Thailand. This history and spirit of independence led to a change in the name of the country from Siam to Thailand, meaning the land of the free (Ross & Ross, 2008). The first school of nursing and midwifery in Thailand was established at Siriraj Hospital in 1896 in Bangkok. It was founded under the patronage of Queen Sripacharintra who was the Queen of King Rama V (Anders & Kunavikikul, 1999; Ministry of Public Health, 1976).

The father of the King of Thailand, Prince Mahidol Songkhla, received his medical education as a physician from Harvard University. In 1926, he initiated a relationship with and received help from the Rockefeller foundation to improve medical and nursing education in Thailand (Anders & Kunavikikul, 1999). The first four-year program leading to a Bachelor of Nursing Science degree was established in 1956. The first master’s program was started in 1973, and the first doctoral program in 1984 (Anders & Kunavikikul). During the past ten years, the number of nursing schools has increased significantly under the leadership of governmental and private institutions. At present, there are at least 60 undergraduate, 45 master, and 12 doctoral programs in Thailand. In 1985 the Nursing Council of Thailand was established to promote education and research and monitor the professional conduct of nurses and midwives. As with Japanese and Taiwanese nurses associations, the Thailand Nursing Council is expanding its interest and activities beyond the national level (Thailand Nursing Council, n.d. a), such as active participation in the International Council of Nurses and hosting international nursing conferences (Vonderheid et al., n.d.).

Nursing Programs Admission Requirements

To date, a baccalaureate degree in nursing is the entry-level requirement for working as a professional nurse in Thailand (Ministry of Education, 2008). There are different educational systems that students may attend after high school to become a professional nurse. The first route is to attend an established, four-year nursing program at a university that is within the Ministry of Education system. To enter these programs, high school graduates must take a rigorous national entrance examination that includes subjects such as biology, chemistry, English, Thai language, social studies, and mathematics. A high grade point average from high school and acceptable performance on an additional entrance examination administered by the particular institution may also be required. In most circumstances, available seats for nursing students are very limited at the university level compared to those in the United States. The second route is to enroll in a nursing program sponsored by the Ministry of Public Health, the military, a police department, a metropolitan school, the Red Cross, or a private university (Anders & Kunavikikul, 1999). An entrance examination is also required by each institution for admission into master’s and doctoral programs and available seats are very limited.

Career Pathways

General Nursing Practice

To obtain a registered nursing license, students who have earned a BSN degree are eligible to take the national licensing examination. Students who may have attended a two-year technical nursing program, popular in the 1980s, and received an associate degree in nursing (ADN), are eligible to pursue two additional years of nursing education to obtain a BSN (see Figure 3). The majority of nurses with ADN degrees have furthered their education towards a BSN degree since this is now the entry level degree needed to practice nursing in Thailand (Ministry of Public Health, Bureau of Policy and Strategy, 2006). The Thailand Nursing Council is responsible for the licensure examination for BSN graduates to become registered nurses. Subjects covered on the examination are similar to those in Japan and Taiwan and include medical-surgical, pediatric, maternity, midwifery, community health, gerontology, and psychosocial nursing, plus ethics and law (Thailand Nursing Council, n.d.b). Pharmacology and pathophysiology are not separated from but incorporated into these nursing subject areas.

By and large, BSN graduates have been employed by governmental and private healthcare institutions at all levels (primary, secondary, and tertiary care). All new BSN graduates are employed immediately upon graduation due to an increasing demand for nurses in Thailand. The Thailand Nursing Council has implemented programs for relicensing and continuing education to ensure nurses stay current with clinical and practice information.

Advanced Nursing Practice

As in Japan and Taiwan, advanced practice nurses (APNs) are needed due to the demand for increased specialization in patient care and health promotion. The Thailand Nursing Council has established national standards for licensure and examination of all APN programs. Candidates pursuing licensure as an APN, whether CNS or NP, must complete a master’s degree in nursing through the university-based system. CNS specialization areas include medical and surgical, pediatric, mental health and psychiatric, geriatric, and maternity nursing. NP specialization is currently focused on community health. Candidates must complete a clinical practicum under the supervision of a physician or an APN (one APN per two students). A thesis is also required for completion of the program. Licensure examination subjects include advanced pharmacology and pathophysiology, advanced health assessment, health promotion and disease prevention, law, and topics in their area of specialty (Thailand Nursing Council, n.d.b).

Career Development Opportunity

In Thailand, due to a lack of physicians, there is a crucial need for advanced practice nurses to work in primary care settings, especially those located in the rural parts of the country. In Thailand, due to a lack of physicians, there is a crucial need for advanced practice nurses to work in primary care settings, especially those located in the rural parts of the country. Nurses in rural practice must face many challenges, such as geographical isolation and limited resources which make it difficult to attract nursing professionals to work in rural healthcare delivery (Chinlumprasert, n.d.). To meet this need, the Nursing Council of Thailand, along with government assistance, must continue innovative initiatives to entice advanced practice nurses into the area of rural healthcare.

NOTE: Table 3 provides a summary comparison of nursing education in Japan, Taiwan, and Thailand including entry-level admission requirements, types of programs, and licensure.

Issues and Challenges

Five issues and challenges that Japan, Taiwan, and Thailand have in common and that impact the career pathways of nursing students and nurses in these countries have been identified. They include identity of the nursing profession, limited faculty resources, English language barriers, transitions of nursing education, and the provision of culturally competent care. These issues and challenges will be discussed below.

Identity of the Nursing Profession

Attaining a more established professional identity separate from physicians and unique to nursing is a goal toward which nurses in all three countries continue to strive.Although the role of nurses in the healthcare systems in Japan, Taiwan, and Thailand has unmistakably advanced in recent years, physicians continue to have a direct impact on the clinical practice and professional development of nursing. Traditionally, physicians regarded nurses as their "assistants" and closely controlled their scope of practice. More recently, nurse-physician relations have been improving, perhaps driven by serious nursing shortages and escalating healthcare costs. Many physicians have begun to realize that collaboration with nurses may result in improving nurse retention, reducing overall healthcare costs, and ultimately reaching more positive patient outcomes. This trend towards greater nurse-physician collaboration is encouraging; yet the traditional attitudes of “nurse as an assistant” and physician as “principal authority” in patient care decisions persist today. Lacking autonomy in practice, nurses feel their professional status is challenged. Attaining a more established professional identity separate from physicians and unique to nursing is a goal toward which nurses in all three countries continue to strive.

Limited Faculty Resources

Working in an academic position, such as that of a nursing faculty member, is associated with elevated status in most Asian countries, including Japan, Taiwan, and Thailand. This makes it relatively easier to attract nurses into academic positions in these countries than in some other countries. However, many nurses holding faculty positions have inadequate clinical experience. The lack of clinically qualified faculty to teach in both undergraduate and graduate programs has been a serious problem in nursing institutions in all three countries (Lu, 2004; Turale, Ito, & Nakao, 2008).

...many nurses holding faculty positions have inadequate clinical experience. Faculty who entered academia in the 1970s and 1980s, and who have often been promoted based on seniority and not merit, are still actively teaching in all three countries. Unfortunately, they may be out of touch with current practices. Newer, doctorally prepared faculty members, too, often have limited clinical exposure and do not understand the realities of nursing practice. This lack of current clinical experience brings about a disconnect between education and clinical practice (Chou et al., 2005).

Additionally, nursing programs in these countries depend too heavily on the use of non-nursing clinical faculty who teach nursing content from a non-nursing perspective. Students may be taught, both in the classroom and in the clinical setting, from a biomedical standpoint, rather than from a nursing perspective. The use of physicians to teach undergraduate and graduate nursing courses is still common today, especially in Japan and Taiwan. Many teaching hospitals and universities prefer that physicians teach nursing courses due to their perceived greater technical and clinical expertise. A shortage of qualified nursing faculty results in this continued reliance on physicians to teach in nursing programs. Qualified nursing faculty are needed to develop and guide nursing students to fulfill their role as professional nurses, thereby empowering nurses with greater autonomy and control over nursing practice.

English Language Barriers

Language barriers that may lead to errors may hinder the delivery of appropriate healthcare services and even result in life-threatening consequences for patients. Mastering English for medical and nursing purposes has become essential for career advancement in many Asian counties, including Japan, Taiwan, and Thailand. Patient documentation, doctor’s orders, medications, and progress notes are often written in English. Language barriers that may lead to errors may hinder the delivery of appropriate healthcare services and even result in life-threatening consequences for patients. For example, when a diabetic patient’s diet order has been written as “sugar free,” a non-English speaking nurse may interpret this to mean the “free use of sugar.” Such an interpretation could result in the patient experiencing a dangerously high level of sugar in the blood.

Increased migration of nurses to other countries, increased international travel, and the increased mobility of global epidemics have made competency in English a necessity. In addition, nurses enrolled in CNS, NP, master’s, or doctoral programs rely mainly on English language textbooks and research databases to keep abreast of the growing international body of nursing knowledge. The need to be proficient in English is also necessary to participate in international nursing activities, such as international collaborative research and conferences (Chiang-Hanisko, Ross, Ludwick & Martsolf, 2006).

Another issue related to language barriers concerns the use of textbooks translated from English. The selection of translated textbooks is often arbitrary, and some translations do not capture the contextual meaning of the medical and nursing terminology used. Some nursing programs will therefore avoid the use of translated textbooks and attempt to use the original English language textbook. Yet, this can often be a burden to nursing students and faculty with limited English-language-proficiency skills. Opportunities for career growth may be restricted for nurses with limited English-language proficiency. A greater emphasis on helping nursing students master the English language is needed.

Transitions of Nursing Education

The continuation of nursing programs under the baccalaureate level delays the transition of nursing education into the university system and hinders a clear set of standards for examination and licensure. The healthcare systems in Japan, Taiwan, and Thailand are experiencing ongoing changes to increase healthcare accessibility and specialization, with an emphasis on multidisciplinary collaboration and accountability. Nursing education in the three countries is responding by restructuring and upgrading curricula, clinical competencies, and specialization to raise the professionalism of nursing practice.

Although there has been much progress in responding to these changes in healthcare delivery, disparate routes for entry-level nursing programs persist; and widely varying levels of licensing for general practice are common, as described above. While multiple entry points may attract more students into various nursing programs, the quality of care provided by graduates below the baccalaureate level is questionable and may be inadequate for today’s and tomorrow’s professional healthcare environment (Ozawa et al., 2006). The continuation of nursing programs under the baccalaureate level delays the transition of nursing education into the university system and hinders a clear set of standards for examination and licensure. Also, the complexity of the nursing education system and licensure process can be confusing to the public and negatively impact the image of nursing. Discontinuing nursing programs under the baccalaureate level can help to move the profession of nursing forward.

Provision of Culturally Competent Care

Greater emphasis on providing culturally competent care is needed to ensure that nurses are prepared to work in a multicultural world.Although the number of foreign workers, including professional and technical personnel as well as labor and unskilled workers, has increased in recent years in Japan, Taiwan, and Thailand (Executive Yuan, 2008; Ogawa, 2008; Ross & Ross, 2008), nurses remain  ill prepared to offer culturally competent care to patients from different cultural and ethnic backgrounds. The nursing curriculums in each of these counties provides only limited, if any, culturally specific content to guide nurses in caring for patients from cultures different from their own. Nurses’ overlooking of cultural implications of care can result in patients experiencing misunderstanding, mistreatment, or marginalization, all of which can impede their recovery. Greater emphasis on providing culturally competent care is needed to ensure that nurses are prepared to work in a multicultural world.

Conclusion

The nursing profiles for Japan, Taiwan, and Thailand point to a number of similarities in career pathways, issues, and concerns. Each country is faced with nursing challenges including workforce shortages, overly complex curriculum paths, a struggle for professional status, a scarcity of qualified faculty, English language barriers, a changing healthcare environment, and the demands of operating in a multicultural world. Although the goal of a stable nursing workforce remains elusive in Japan, Taiwan, and Thailand, the enormity of change already taking place in nursing in these countries, and indeed in all of Asia, should not go unnoticed. For example, as the debate continues whether multiple entry points for nursing education and licensing is compatible with today’s healthcare needs, more employers are showing a preference for BSN-prepared nurses. As universities expand nursing programs and increase the number and quality of nursing graduates, the BSN degree as a standard for entry-level nursing positions is gaining wider acceptance.

It is interesting to note the rapid expansion of APN, master's, and doctoral nursing programs in each country.It is interesting to note the rapid expansion of APN, master's, and doctoral nursing programs in each country. Such programs benefit the nursing profession by increasing the supply of advanced nursing specialists and faculty, generating research-related activity, and equipping nurses with higher levels of clinical expertise and leadership skills.

Differentiation in nursing practice based upon levels of education, experience, and competency helps to define the structure and roles of professional nurses (AACN, 1995). Differentiation criteria will continue to be established as the healthcare system demands higher levels of abilities and competencies from nurses. Future career pathways for nurses will occur as nurses more clearly define their identity, increase their skills, and adapt to new work environments. Developing new career pathways during times of nursing shortages and workforce instability is challenging. However, as Japan, Taiwan, and Thailand address these difficulties by establishing more consistent requirements for education, professionalism, licensure, English language ability, and culturally competent care, they will continue to develop new career opportunities for all nurses throughout Asia. Nurses have always been a resilient group...able to respond to challenges proactively...to create new and exciting opportunities.

It may be helpful to consider that the word "crisis" in the Chinese language is derived by merging the characters "danger" and "opportunity." The future of healthcare will show that change, which is constant, brings tremendous opportunities for new growth and advancement. Nurses have always been a resilient group and have been able to respond to challenges proactively in order to create new and   exciting opportunities. Avenues for opportunity and growth are many in Asia today. Japan, Taiwan, and Thailand are lights upon the path.

Authors

Lenny Chiang-Hanisko, RN, PhD
E-mail: lchiang@kent.edu

Dr. Chiang-Hanisko is an Assistant Professor at the Kent State University College of Nursing. Her research areas include immigrant health, with a focus on older adult populations, and transcultural nursing. She is currently Chair of the Research Awards Committee for the Transcultural Nursing Society and member of the University Research Council at Kent State University. She serves as a visiting scholar for several universities in Taiwan. She received her PhD from Boston College.

Ratchneewan Ross, RN, PhD
E-mail: rross1@kent.edu

Dr. Ratchneewan Ross is an Associate Professor at the Kent State University College of Nursing. She received her PhD from the Frances Payne Bolton School of Nursing, Case Western Reserve University. Her research areas include depression and self-esteem (among HIV-positive perinatal women and nursing students), sexual violence, and adolescents’ risk behavior and health promotion.

Puangrat Boonyanurak, RN, PhD
E-mail:puangrat@saintlouis.or.th

Dr. Puangrat Boonyanurak is an Associate Professor, Vice Rector for Special Projects, and Director of the Graduate Program in Nursing Administration at Saint Louis College, Bangkok, Thailand. She received her EdD from Teachers College, Columbia University. She is a World Health Organization scholar and visiting professor at the National College of Nursing, Tokyo, Japan. Her research areas include nursing care quality, nursing management, caring, HIV, and maternal-child health.

Mieko Ozawa, RN, PHN, PhD
E-mail: ozawam@adm.ncn.ac.jp

Dr. Mieko Ozawa is a Professor of Nursing Administration and Informatics, and Assistant Dean of the Graduate School of Nursing at the National College of Nursing, Japan. She completed her MSc and PhD degrees in health sciences at the Graduate School of Medicine, University of Tokyo. Her research interests are organizational commitment, leadership, and continuing education in nursing with a focus on work outcomes, such as improved job performance and high quality care.

Ling-Chun Chiang, RN, MSN
E-mail: l.chiang@cwru.edu

Ms. Ling-Chun Chiang is a lecturer at Hung Kuang University, Department of Nursing, in Taichung, Taiwan. She is a member of the Curriculum Advisory Committee and Chairperson of the Student Affairs Committees providing guidance to nursing students on course selection and careers. She obtained her master’s degree in nursing from Emory University, and is currently enrolled in the doctoral program at the Frances Payne Bolton School of Nursing, Case Western Reserve University. Her research focus is on pain management in end-of-life care.

References

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 Figure 1.

 

 Figure 2.

 

Figure 3 

 

Table 1. Nursing Programs and Licensure in Japan

Nursing Program in Japan

Educational System

Degree Granted

Registered Nurse (RN)

Student Capacity by each Year (1)

3-year Nursing High School *

Secondary education

-

No

1,070

2-year Assistant Nursing School *

TVE

-

No

12,193

5-year High School and advanced courses in Nursing High School

Secondary education

-

Yes

3,510

3-year Nursing School *

TVE

-

Yes

23,447

3-year Junior College

JCE

ADN

Yes

2,130

2-year Advanced courses in Nursing High School (2)

Secondary education

-

Yes

 

13,704

2-year Nursing School * (2)

TVE

-

Yes

2-year Junior College (2)

JCE

ADN

Yes

4-year University /College

GUE

BSN or BS

Yes

12,323

Notes: TVE = technical and vocational education; JCE = junior college education; GUE = general university education; ADN = associate degree in nursing; BSN = Bachelor of science in nursing.
School with * has a part-time course but the length extends for one more year.
(1) As of April 2007 (JNA, 2008c).
(2) Courses for assistant nurse (LPN) to become RN

Table 2. Nursing Programs and Licensure in Taiwan

Nursing Program in Taiwan

Educational System

Degree Granted

Registered Nurse (RN)

Registered Professional Nurse (RPN)

3 or 4-year Vocational Nursing High School (end 2005)

TVE

Diploma

Yes

No

5-year Junior College

TVE

ADN

Yes

Yes

2-year Nursing College

TVE

ADN

Yes

Yes

3-year Nursing College (end 1997)

TVE

ADN

Yes

Yes

4-year Institute of Technology

TVE

BSN

Yes

Yes

2-year University Nursing Program

GUE

BSN

Yes

Yes

4-year University Nursing Program

GUE

BSN

Yes

Yes

Note. TVE = technical and vocational education; GUE = general university education; AND = associate degree in nursing; BSN = Bachelor of science in nursing.

Table 3. Comparison of Nursing Education in Japan, Taiwan and Thailand

 

Japan

Taiwan

Thailand

Entry-level Admission Requirements

National exam

High school GPA

High school activities

References

National exam

High school GPA

High school activities

National exam

High school GPA

Types of Programs

Diploma

Associate

Baccalaureate

Master

Doctoral

 

2, 3 years

2, 3 years

4 years

2 years

3 years

 

Ended 2005

2, 3, 5 years

2, 4 years

2 – 4 years

5 – 8 years

 

Ended 1998

2 years

4 years

2 - 4 years

3 - 5 years

Licensure

Registered Nurse

Registered Professional Nurse

Public Health Nurse

Midwife

 

Yes

-

Yes

Yes

 

Yes

Yes

-

Yes

 

Yes

-

-

Yes

Post-graduate Licensure

Certified Nurse (CN)

Certified Nurse Administrator

(CNA)

Clinical Nurse Specialist (CNS)

Nurse Practitioner (NP)

 

Yes (19 areas)

Yes

 

Yes (10 areas)

No

 

No

No

 

No

Yes (2 areas)

 

No

No

 

Yes (5 areas)

Yes (1 area)


© 2008 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2008


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