SOCIALIZATION

OF JAPANESE

STUDENTS

/ NURSING

EDUCATION

RESEARCH

SOCIALIZATION o/Japanese Nursing Students

EILEEN CONDON AND NANCY SHARTS-HOPKO

ALUES, BEHAVIORS, AND ATTITUDES THAT INFLUENCE A NURSE'S

PROFESSIONAL

ROLE ARE AN IMPORTANT AREA

FOR STUDY.

This naturalistic, qualitative study examines the socialization

process experienced by Japanese nursing students at a large,
Christian, private college of nursing in Tokyo. Themes from
interviews conducted with eight students and two faculty
members are discussed. As an American nursing student
with a one-month fellowship for study in Tokyo following her
junior year, the first author was fascinated by the Japanese
approach to nursing education and the ways in which education in Japan differed from nursing education in the United
States. With an internationally diverse workforce and the
growing trend toward international study, an understanding
of how nurses from diverse cultures are educated can have a
profound effect on global health care and broaden one's own
perspectives about the socialization of nurses.
RESEARCH

ABSTRACT

An important focus of nursing education research is the acquisition of values, behaviors, and

attitudes that v^ill influence a nurse's professional role. In this qualitative study, the process of professional socialization among Japanese nursing students was investigated. Interviews with nursing students and faculty members
in Tokyo revealed that socialization of nursing students is a multidimensional process, with classroom experiences, clinical practice, and extracurricular elements all having an influence. Six themes emerged from the data:
openness to others, communication, team building, reflection, extracurricular networking, and focused education.
Although communication and clinical experiences are limited by cultural norms, students become socialized to
the nursing profession through various other means.

May

/ J u n e ZOIO

Vol.3]

No.3 1 6 7

S O C I A L I Z A T I O N

O F JAPANESE

S T U D E N T S

Review of the Literature Aspects of Japanese culture that

impact health care and nursing education have been described in
the American nursing literature (Sharts-Hopko, 2003).
Significant differences in the course of study for baccalaureate
nursing students in the United States and Japan have been
described. In Japan, for example, there is strong value on group
harmony and deference to others of greater age or status.
According to Lambert, Lambert, and Petrini (2004), increasing numbers of students from Asian countries are entering nursing graduate programs in the United States. In such situations,
contrasts in education often lead to challenges for Japanese students and their American educators. Lambert et al. described
clinical experience in Japan as a "short-term, low-tension observational study that fosters the development of inadequate clinical
skills" (p. 261). Because of restrictions posed by Japanese laws,
clinical experiences for nursing students are largely observational. Students may not administer medications or participate in
any invasive procedures; their responsibilities are limited to
tasks such as taking vitals signs and giving bed baths. With lecture the predominant method of teaching and the Japanese culture discouraging speaking freely and asking questions, Lambert
et al. stated that students do not question professors about content that is presented to them.
A study by Takahashi (1995) designed to identify factors that
influence the professional socialization of baccalaureate nursing
students in Japan found that faculty play a significant role in the
socialization process. Faculty with higher academic degrees were
viewed as having a positive relationship to the professional
socialization of students. The study also found that student
knowledge level at entrance to the program was another indicator
that promoted socialization.
Aside from Takahashi (1995), little research has been conducted on the process of professional socialization among
Japanese nursing students. The development of professional values in American nursing students has been studied more thoroughly. Leners, Roehrs, and Piccone (2006) identified values
possessed by undergraduate nursing students, including patient
advocacy, providing care without prejudice, and assuming
responsibility and accountability for practice. Secrest, Norwood,
and Keatley (2003) described socialization of nursing students
as having three components: belonging, knowing, and affirmation. According to Secrest et al., nursing students believe that to
become a professional is to become a valued part of the nursing
team with the knowledge to provide information to patients and
families, and to affirm these abilities through interaction with
others. A study by Day, Field, Campbell, and Reutter (2005)
evaluated the process by which American nursing students attain
their value systems. By participating in nursing care, rather than
simply observing it, students "began to critically observe regis-

168

Nursing Education

Perspectives

/ N U R S I N G

E D U C A T I O N

R E S E A R C H

tered nurses and to make decisions about whether they wanted to

nurse in similar ways" (p. 642). Faculty reassurance and peer
support were found to reinforce the students' beliefs and values.
According to the Day et al. study, experiences and interactions
with professionals and other peers allowed the nursing students
to think critically about their own beliefs and thus develop a personal value system.
Method Participants in this study were recruited by faculty
members and through social networking. All of the participants
were female, had completed at least two years of the nursing program, and were proficient in English. Participants were asked to
participate in one interview and were given the option to add
additional comments by email.
Questions were developed in advance regarding the socialization process; students and faculty members were asked different
questions. Interviews were tape recorded, and a journal of observations was kept by the interviewer during each session. The study
had been approved by the institutional review board of the investigator's institution. Informed consent was obtained from each
participant, and all data collected were kept confidential. The
interview recordings were transcribed, and constant comparative
content analysis was performed to identify common themes. The
investigator's independent study adviser audited the data trail.
Emerging Themes After analyzing the interview data, a number of unique but interdependent tbemes emerged. Most of these
reflect positive contributions to the socialization process: openness to others, communication, team building, reflection, and
extracurricular networking. One theme, focused education, represents a barrier to the development of professional values and
behaviors and successful socialization.
OPENNESS TO OTHERS The Japanese nursing students
believed it is important to understand other people, not only on
a physical level, but on a mental and emotional level as well: "To
not only see the patient's body, [but] to understand the patient's
feelings or pain is a very important step to become a professional nurse." In order to care for their patients, the nursing students
expressed a desire to not only understand their patients on a
deeper level, but to put aside their personal biases and opinions
and be open to the patient's beliefs. One student stated: "There
[are] many kinds of people, and they have their own life, and they
have their own thoughts and way to live...so first of all I should
think about the health, and how they want to live." Another student agreed: "Don't push your ideas or thoughts to the patient,
because each patient has their own values or thoughts. There is
no good ways or bad ways, but think of their dignity."
According to one student, students must interact with a
diverse patient population in order to achieve a deep level of

S O C I A L I Z A T I O N

O F JAPANESE

S T U D E N T S

understanding and become open to others: "To meet healthy people and also handicapped people and psychiatric people...so
many kinds of people makes me learn [their] way of thinking, so
I think it's important to meet not only students or the same generation, but also like elderly people and children." A nurse faculty
member supported this idea: "It is better for students if they can
[have] a lot of experience to communicate with people as much as
they can, especially older and younger people." She believed
openness to others is an essential step in achieving the values of
a professional nurse: "The person-to-person relationship is very
important in nursing; respecting yourself and respecting others is
the same thing."
COMMUNICATION Communication is another skill that students saw as a requirement for becoming socialized. Many students attributed their best learning experiences to interaction with
nurees and patients and considered hospital experience as crucial:
"The training at the hospital taught me how to communicate with
the patients." A student stated: "It's different when I go to the hospital to study because real nurses teach us the way of thinking."
Communicating with nurses not only helped students learn
technical skills, but also helped them discover the values and
beliefs that nurses have as they fulfill their professional role. One
student explained: "I could see the real professional nurse at the
hospital, so I could figure out how they work, how they move, so
I could see the real world, to see what is the professional world."
According to students as well as faculty, learning communication skills is very important for Japanese nursing students,
because for many, these skills do not come naturally. One student
stated: "Recently in Japan, people, especially young people, don't
have [effective] communication skills, and it's a problem [that
stems from] the family or community." A faculty member also
addressed this issue: "There are many shy Japanese students, and
some of them are not good at communicating with people, even
senior students." Because communication was seen as important
skill for a professional nurse to have and a crucial element for
socialization, faculty saw helping students with their communication skills as an important part of their role.
TEAM BUILDINC In Japan, nurses, doctors and other health
care professionals work closely with each other to provide patient
care. Dubbed by one student as "the team spirit," this approach
is evident in many different facets of Japanese health care. One
Japanese nursing student told of her work at a palliative care center: "I learned that the nursing is not individual, and the nursing
care is not done on the individual, it's done by team." Both faculty members spoke of the importance of team building, and one
stated the following: "They learn how to act for one of the team
members, or how to take a load for the leader, so I think that is
important for the social skill." Students accomplish this skill, she
went on, through communication with their peers.

/ N U R S I N G

E D U C A T I O N

R E S E A R C H

Both faculty told of instances where students were required to

work together, share information, and solve problems as a team:
"They gather information, discuss about the client, and at last
they can solve the problem about the client, and it's their cooperative work." Because Japanese nursing students and faculty
believe that a team approach can have a more positive impact on
the patient than an individual effort, the development of teambuilding skills is reinforced throughout the nursing curriculum.
EXTRACUKRICULAR NETWORKING Japanese nursing students and faculty members also attribute their professional
socialization to activities and experiences that take place outside
the college setting. For example, several students mentioned volunteer opportunities, but none had participated in such programs
personally. Both faculty members described volunteering as "a
very good chance to learn about socialization," but admitted that
the college did not currently have programs in place to facilitate
volunteering. They also considered part-time jobs to be helpful
for the socialization process, but students needed to initiate
employment on their own.
Students are widely exposed to interactions with other nursing students. Some were sent to the most recent International
Council of Nursing conference, and the school regularly hosts
nursing students from Thailand, Korea, and the United States.
Interaction with international nursing students provides valuable networking and learning experiences, facilitating a more
global understanding of the nursing role and process and greatly
enhancing socialization. Students come to understand nursing
in other cultures.
REFLECTION Many students identified reflection as an effective means of understanding and retaining information. Whether
the experience was positive or negative, reflection proved to be
helpful for the students. One student stated: "I think the most
important time is after the clinical training when I go home or
back to school. I should think about what I get, the information 1
get from the patient. What does it mean? What does it mean for
the patient? I should connect to it."
Making connections is an important skill for the professional
nurse, and reflection can be an effective educational tool. Nursing
professors facilitate this process by asking questions of their students and requiring them to think at a deeper level. One student
described her clinical instructor: "She keeps a distance, and
sometimes asks 'what are you doing?' This is a good time to think
about what I'm doing and what this means to the patients."
Although Japanese nursing students may not have a hands-on
role in the clinical setting, they develop nursing skills by analyzing situations and thinking critically. It is the responsibility of the
instructors and other nurses to ensure that students are reflecting
on what they have seen and heard so that they may gain a deeper
understanding of their role as a nurse.

May / June ZOIO

Vol.31

N o . ? 1 6 9

SOCIALIZATION

OF JAPANESE

STUDENTS

FOCUSED EDUCATION Several of the Japanese nursing students acknowledged the need for a variety of experiences and a
broad view of tbe world, but some felt that their education did not
meet this need. One student explained: "They only teach you
things you need to become a nurse here, they don't teach you anything else." Another saw this as a matter of great concern: "I think
nurses should have broad views, because when we graduate we
are going to meet lots of patients with lots of different backgrounds, so it is very important for us to have different values and
different views." Still another student said: "The teachers, students, or patients [that we encounter] are very highly socialized
people. But the world is so wide. There are poor people, not educated people, many kinds of people; so we shouldn't think like
this is the world."
To improve upon this narrowly focused education, instructors
need to work hard to provide their students with a wide range of
experiences and allow them to think for themselves about complex issues. Speaking about her professors, one student stated:
"They teach us according to their experience, so I feel that we are
taught their values...they're teaching us to become the nurses
that they want us to become, but I feel we have no variations."
Students stated that in addition to working with a diverse
patient population, there should be more opportunities for communication with others. One student explained: "I think there
should be more opportunities for students to socialize with other
students and teachers from nursing schools, and students that
don't study nursing." But another stated: "In Japan, sometimes it
is better not to communicate with the people, I just think about it
and think maybe [the patient] thinks this way."
Such hesitancy to communicate, although a cultural norm, can
be detrimental to the development of professional values, especially if it prevents nursing students from communicating with
their nurses, teachers, or one another. Not only do Japanese nursing students need an education that fosters diversity of curriculum and personal interactions, but also one that develops communication skills so that students can benefit from their education as
much as possible.

References
Day, R., Field, P., Campbell, I., & Reutter, L (2005).
Students' evolving beliefs about nursing: From
entry to graduation in a four-year baccalaureate

/ NURSING

EDUCATION

RESEARCH

Conclusion The purpose of this study was to examine the socialization process of Japanese nursing students. After interviews of
eight Japanese nursing students and two faculty members, the following themes emerged: openness to others, communication,
team building, reflection, extracurricular networking, and
focused education. These findings align with previous analyses of
Japanese nursing education (Lambert et al., 2004). Barriers to
free communication are reflected in the Japanese culture and,
because clinical experience is not interactive, Japanese students
are socialized into nursing by other means, such as observing
nurses, working with peers, and participating in team-building
activities.
In contrast with Takahashi's findings (1995), faculty influence seems to have little direct impact on the socialization
of Japanese nursing students. Although faculty can help facilitate the process by encouraging communication and self-reflection, they do not have a direct personal influence on students'
socialization.
As nurses continue to migrate across borders, cultural competency is increasingly important for nurses. It is essential to
understand the different socialization processes characteristic of
nursing education from country to country. By understanding the
diversity of nursing education, we can, in turn, better understand
the cultural differences of nurses in the workforce.
About the Authors Eileen Condon, RN, a .student at the
College of Nursing, Villanova University, Villanova, Pennsylvania,
when this article was written, is now a nurse in the newborn special
care unit at Yale-New Haven Hospital, New Haven, Connecticut.
She is also pursuing her master's degree at Yale University in the
Family Nurse Practitioner Program. Nancy C. Sharts-Hopko,
PhD, RN, FAAN, is a professor and director of the doctoral program. College of Nursing, Villanova University. Contact Ms.
Condon at Eileen.condon@yale.edu.
Key Words

Nursing Education - Socialization - International Nursing

-Japanese Nursing Students

Leners, D., Roehrs, C. & Piccone, A. (2006).

Sharts-Hopko, N. C. (2003). People of Japanese

Tracking the development of professional values

heritage. In L D. Purnell & B.J. Paulanka (Eds.),

in undergraduate nursing students.Journo/ of

Transcultural health careiA clinically competent

Nursing Education, 45( 12), 504-511.

approach (2nd ed., pp. 218-233). Philadephia: FA.

Davis.

programme. Nurse Education Today, 25(8),

Secrest, J. Norv^ood, B. & Keatley,V. (2003). "I was

636-643.

actually a nurse":The meaning of professionalism

Takahashi,T. (1995). Profss/onol socialization of

for baccalaureate nursing students. Journo/ of

baccalaureate nursing students in Japan. Doctoral

Nursing Education, 42(2), 77-82.

dissertation. University of Illinois at Chicago,

Lambert,V, Umbert, C. & Petrini, M. (2004). East

meets west:A comparison between undergraduate nursing education in Japan and the United
States. Journo/ of Nursing Education, 43(6), 260-269.

I 70

Nursing Education

Perspectives

Health Sciences Center, / 75. (UMI No.

PUZ9544351

Copyright of Nursing Education Perspectives is the property of National League for Nursing and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.