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Hindi Research Article, J Nurs Patient Care Vol: 1 Issue: 2
A Study on Preparations for Accepting Foreign Patients into Japanese Hospitals
| Mari Hirota1*, Misae Ito2 and Keiko Hattori3 | |
| 1RN, MSN, Department of Nursing Faculty of Health Science Hyogo University, Hyogo, Japan | |
| 2NMW, MSN, PhD, Professor, Department of Nursing, Faculty of Health and Welfare, Kawasaki University of Medical Welfare, 288 Matsushima, Kurashiki, Okayama, Japan | |
| 3RN, PhD, Department of Nursing, Gifu Shotoku Gakuen University, Japan | |
| Corresponding author : Mari Hirota RN, MSN, Department of Nursing Faculty of Health Science, Hyogo University, Institution and full postal address: 2301 Hiraokachoshinzaike, Kakogawa, Hyogo, 675-0195, Japan, ãÂÃ?Â?ÂÃ?Â? 675-0195 Hyogo Tel: +81-79-427-5111 Fax: +81-79-427-5112 E-mail: mari0812@hyogo-dai.ac.jp |
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| Received: July 28, 2016 Accepted: October 13, 2016 Published: October 20, 2016 | |
| Citation: Hirota M, Ito M, Hattori K (2016) A Study on Preparations for Accepting Foreign Patients into Japanese Hospitals. J Nurs Patient Care 1:2.doi:10.4172/2573-4571.1000105 |
Abstract
Aim: According to Immigration Bureau of Japan, the number of 2011 foreign residents were more than 2.07 million persons, and foreign nationals entering Japan including reentering in 2012 was approximately 9.17 million persons. The chances a foreigner will visit a medical institution, regardless of the disease or the reason for the visit, is thought to be high.The purpose of this study is to identify the actual accepting of foreign patients in hospitals throughout Japan.
Methods: A structured questionnaire was distributed to the person in charge of the nursing department in 1000 hospitals with 20 beds or more between July and October 2011, randomly selected and grouped by hospital bed size in Japan, except Miyagi, Iwate, and Ibaraki Prefectures.
Results: Responses from 223 individuals were valid for analysis:96 from small hospitals; 84 midsize; and 43 large from all 44 prefectures which received letters. The ratios of experience of foreign outpatients and inpatients were respectively over 83.9 and 57.4%. Of the respondents, 75.8% experienced confusion; the biggest problem was language differences. 29.1% of the hospitals had made some special preparations for accepting foreign patients. The large hospitals accepted more foreign patients than did the others.
Conclusion: Since nurses might need to personally cope with foreign patients, and ability or comfort level in this regard may vary by nurses and patient, it is necessary to consider ways to improve
integrated cultural care systematically.
Keywords: Foreign patients; Nurse Director; Hospital in Japan; International nursing
Keywords |
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| Foreign patients; Nurse Director; Hospital in Japan; International nursing | |
Introduction |
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| Prior to the mid 1980’s, most “alien residents” in Japan were people of South/North Korean nationalities [1]. However, since then, the number of foreigners newly moving to Japan, referred to as “newcomers”, has increased [2]. According to Immigration Bureau of Japan [3], the number of foreign residents peaked in 2008, and by 2011 more than 2.07 million persons, a slight decrease compared to 2008, were living in Japan. The number of foreign nationals entering Japan including reentering peaked in 2010, and the second largest number of it in 2012 was approximately 9.17 million persons. As a result, it is assumed that a greater number of foreign patients have access to Japan’s medical institutions. Consequently, problems experienced by foreign students when visiting medical institutions, conflicts in nursing related to different cultures held by foreigners, etc., [4-9]. However, the actual situation regarding receiving foreign patients and their nursing care at hospitals in Japan is hardly known. Since few hospitals provide systemized care for foreign patients, the medical staff on call at the time usually handles the foreign patient. Since the response by the medical staff is largely left to the discretion of each individual staff member, general services by the entire hospital which can provide health care to persons regardless of nationality, are needed. | |
| Therefore, the purpose of this study is to clearly identify actual conditions regarding the handling of foreign patients in hospitals throughout Japan. | |
Method of Study |
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| Survey targets | |
| According to Ministry of Health, Labor, and Welfare, there were 8670 hospitals with 20 beds or more in Japan at the time of October, 2010, and 37.3% small hospitals (99 beds or less), 44.8% mid-size hospitals (100-299 beds), 17.9% large hospitals (300 beds or more) [10]. | |
| Of 8,414 facilities throughout Japan (excluding Miyagi, Iwate, and Ibaraki prefectures), general hospitals were targeted after receiving consent from the WAMNET public website (www.wam.go.jp/iryo/ accessed in 10 March 2011). To maintain the size ratio of small hospitals (100 beds or less)/mid-size hospitals (101-300 beds)/large hospitals (301 beds or more) (4:4:2), 400 small hospitals, 400 mid-size hospitals and 200 large hospitals, for a total of 1000 hospitals, were randomly sampled. | |
| Survey period | |
| The survey was carried out from June to October 2011. | |
| Survey method | |
| A written request stating the purpose, method and ethical considerations of this study and a self-descriptive questionnaire were sent to the person in charge of the nursing department of each hospital. Initial collection rate was low, so a postcard was sent to the person in charge of the nursing department of these hospitals requesting a response to the survey, and then responses were collected. Regarding the questionnaire, three nurses were surveyed in advance in order to check and adjust the wording and format of the questionnaire. | |
| Survey content | |
| The questionnaire was originally created by the researchers of this study. The content of the survey included basic information, such as prefecture of the facilities, number of beds, type of hospital, establishment type of each medical institution, and survey items included conditions and readiness to receive foreign inpatients and outpatient visits, problems in nursing. | |
| Analysis method | |
| Statistical analysis software SPSS 18.0 version was used for the analysis method, and a simple summary, cross-tabulation and chisquare test were performed. | |
| Ethical considerations | |
| Approval was first obtained from the Kawasaki University of Medical Welfare Ethic Review Board. Then a request for participation and a questionnaire were sent to the person in charge of the nursing department of each hospital and written consent was obtained. | |
| The request for participation, which were sent to the person in charge of the nursing department of each hospital, specifically stated that the hospital or individual persons would not be identified, participation in the study was voluntary and no damage would occur as a result of nonparticipation, the information would not be used for purposes other than those stated in the study, sending a response would be considered as acceptance of cooperation, the collected surveys would be properly disposed of after study completion, and that the results of the study may be published in academic conferences, papers, etc. | |
Results |
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| Of 1,000 letters sent out, 227 (22.7%) were returned and collected, and the number of valid responses was 223(22.3%). | |
| Basic characteristics | |
| Hospitals from all 44 prefectures which received letters provided responses, the most responses were received from Hokkaido at 29 responses (13.0%), and the least responses were received from Gunma, Shiga, Nara and Saga at 1 response each (0.4%). 36 responses (16.1%) were received from prefectures where approximately half of the foreign resident population resides (Tokyo, Aichi, Osaka, Kanagawa, Saitama) and 187 responses (83.9%) were received from prefectures where less than half of the foreign population resides | |
| As shown in Table 1, responses from 96 small hospitals (70.0%), 84 mid-size hospitals (37.7%), and 43 large hospitals (19.3%) were received. 201 general hospitals (70.5%), 17 regional medical support hospitals (6.0%), 6 medical school hospitals (2.1%), 20 nursing and medical treatment support hospitals (7.0%), and 41 emergency medical service hospitals (14.4%) (multiple answers were accepted) were received. | |
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Table 1: Hospital characteristics (n=223). |
| Regarding establishment type and hospital scale, 156 hospitals were private (corporate associations) hospitals (70.0%), 63 were national or public hospitals (28.3%), and 4 were other types (1.8%). Regarding establishment type and hospital scale, among small/midsize hospitals, more than 70% were private hospitals and 20% or more were national and public hospitals. Among large hospitals, 50% were private hospitals and 40% or more were national and public. A significant difference was observed (P=0.040). | |
| Conditions and readiness to receive foreign inpatients and outpatients visits in 2010 (Table 2) | |
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Table 2: Conditions and readiness to receive foreign inpatients and outpatients visits in 2010 (n=223). |
| 187 hospitals received visits from foreign outpatients (83.9%), 27 did not (12.1%), and 9 were not sure (4.0%). Among those receiving visits, 122 hospitals had a maximum number of outpatient visits of 1-9 persons per year (65.2%), 35 received 10-29 persons (18.7%), 15 received 30-49 persons (8.0%), 6 received 50- 99 persons (3.2%) and 9 received 100 or more persons (4.8%). | |
| Among foreign patients who visited hospitals by nationality, Chinese were the most common at 123 persons (65.7%), followed by Filipino (92 persons, 49.2%), South/North Korean (72 persons, 38.5%), Brazilian (40 persons, 21.4%) and others (61 persons, 32.6%) (multiple answers were accepted). | |
| 128 hospitals accepted hospitalization of foreign patients (57.4%), 86 did not (38.6%), and 9 were not sure (4.0%). Of these, 104 hospitals received a maximum number of inpatients of 1-9 persons (81.2%), 10 received 10-29 persons (7.8%), 6 received 30-49 persons (4.7%), 4 received 50-99 persons (3.1%) and 4 received 100 or more (3.1%). By nationality, the Chinese was the most common at 79 persons (61.7%), followed by Filipino (45 persons, 32.8%), South/North Korean (36 persons, 28.1%), Brazilian (25 persons, 19.5%) and others (26 persons, 20.3%). | |
| In hospitals that accepted hospitalization of foreign patients, when categorized by department, the internal medicine department at 61 hospitals (47.6%), surgical department at 71 hospitals (55.5%), multiple departments at 14 hospitals (10.9%), obstetrics and gynecology department at 23 hospitals (18.0%), pediatric department at 9 hospitals (7.0%) and the psychiatric department at 3 hospitals (2.3%) were involved (multiple answers were accepted). | |
| More than 70% hospitals accepted outpatients regardless hospital size, while 18 small hospitals (18.9%), 5 mid-size hospitals (6.0%), and 4 large hospitals (9.3%), never accepted outpatients. A significant difference was observed (P=0.04). For both outpatients and inpatients, there was a higher rate for mid-size hospitals than small hospitals, for large hospitals than mid-size hospitals. The larger the hospital size, the higher the rate of acceptance, with more than 90% acceptance at large hospitals. In small and mid-size hospitals, the number of outpatients hospitalization was mainly 1-9 persons, while in large hospitals, the number of accepted patients varied, showing a significant difference according to hospital size. And for inpatients, as the size of the hospital increase, the number of 100 patients or more also increased (Table 2). | |
| When comparing establishment type, a difference was not seen in the number of outpatients and inpatients. The number of outpatients and inpatients was mainly 1-9, regardless of whether a private, or national or public hospital, followed by 10-29, 30-49, 100 or more, and then 50-99. A significant difference was not observed. Regarding the number of inpatients and hospital size, 1-9 persons was the most common, and no significant difference in rate was observed. | |
| Preparations to accept foreign patients (Table 3) | |
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Table 3: Preparations to accept foreign patients (Multiple answers) (n=128). |
| Sixty-five hospitals especially prepared for foreign patients in their hospital system or nursing department (29.1%), 156 did not (70.0%), and 2 were not sure (0.9%). Preparation mainly consisted of the “introduction of volunteer interpreters” (25 hospitals, 38.5%), “foreign language medical interview sheets” (24 hospitals, 36.9%), “conversation cards” (19 hospitals, 29.2%). Regarding displayed languages, 15 hospitals had displays in a foreign language (23.0%), 24 had foreign language medical interview sheets (36.9%), 19 had arrangements of had foreign language speaking nurses (29.2%), and languages offered were English, Chinese, Korean and Portuguese in this order. | |
| Systems which were newly required included the “introduction of volunteer interpreters” (85 hospitals, 15.8%), “conversation cards” (82 hospitals, 15.2%) and “manuals” (80 hospitals, 14.9%). | |
| Difficulties experienced in nursing administration in connection with the hospitalization of foreign patients (Table 4) | |
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Table 4: Difficulties experienced in nursing administration in connection with the hospitalization of foreign patients (n=128) (Multiple answers). |
| In connection with the hospitalization of foreign patients, 97 hospitals (75.8%) experienced difficulties in nursing administration, and 31 (24.2%) did not. The most common difficulty was “language” (91 hospitals, 93.8%), “lifestyle” (42 hospitals, 43.3%), followed by “insurance/welfare” and “culture” (24 hospitals, 24.7%). | |
| By number of inpatients, more than 90% of hospitals experienced difficulties in cases of 10 or more inpatients. A significant difference according to the number of patients was observed (P=0.007). | |
| Condition of trainings for foreign patient visits or hospitalization targeting nurses in 2010 | |
| Four hospitals conducted training (1.8%), and 219 did not (98.2%). | |
| Condition of health education and team teaching aimed at foreign patients and their families | |
| Two hospitals conducted health education and team teaching aimed at foreign patients and their families (0.9%), while 221 hospitals did not (99.1%). | |
| Condition of proposals from the hospital side encouraging foreign patients to utilize services offered by foreigner support associations, etc. | |
| Four hospitals encouraged services offered by foreigner support associations, etc. (2.9%), and 100 did not (72.5%), 34 were not sure (24.6%). | |
| Degree of interest in providing nursing care to foreigners | |
| Regarding the degree of interest in providing care to foreigners, 3 hospitals responded “none” (1.4%), 72 hospitals responded “not much” (32.3%), 140 hospitals responded “a little” (62.8%), and 8 hospitals responded “very interested” (3.6%). | |
| Preparation status to receive foreign patients by hospital size and establishment type (Table 5) | |
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Table 5: Preparation status to receive foreign patients by hospital size and establishment type (n=223). |
| According to hospital size and preparation status to receive foreign patients, the rate of preparation was higher at mid-size hospitals than at small hospitals (P<0.001), and higher at large hospitals than at mid-size hospitals (P=0.007). A significant difference was observed according to hospital size (P=0.001). | |
| More than 60% of hospitals were not carrying out preparations, regardless of establishment type. By establishment type, national and public hospitals (33.3%) tended to be more prepared than private hospitals (27.6%) (P=0.18). | |
Discussion |
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| Condition of foreign outpatient visits and hospitalization according to hospital size and establishment type | |
| In this study, 83.9% of the hospitals received foreign outpatient visits and 57.4% accepting hospitalization in 2010. According to the survey on the medical actions of foreign patients, more than 80% of foreigners visited hospitals in Japan [11]. A survey on Filipino workers residing in Japan reported that more than 50% of Filipino workers have visited hospitals in Japan over the past one year [12]. The chances a foreigner will visit a medical institution, regardless of the disease or the reason for the visit, is thought to be high. At this time, while the most common response for the number of outpatients and inpatients was 1-9 persons per year, some hospitals were receiving 100 or more persons, and Kunii & Nomiyama showed a monthly average of 1.3 persons, and Adachi et al. reported that approximately 50% hospitals were visited by more than 30 patients a year, showing an increase in the number of foreign patients who visit hospitals, although the targeted regions and facility type differed. However in this study, of a 1,000 surveys distributed, only 227 (22.7%) were collected, suggesting a low interest despite the hospitals having ample opportunities to see patients [13]. | |
| Within the “New Growth Strategy” approved in the Cabinet meeting on June 18, 2010, the “Medical Interaction (acceptance of foreign patients)” has been raised as the second most highly likely measure to contribute to the economic growth under the “National Strategic Projects by Life Innovation”. In order to ensure the quality of hospitals that accept foreign patients, “Japan Medical Service Accreditation for International Patients (JMIP)” has been developed and implemented by the Japan Medical Education Foundation based on “Support project of establishing accreditation system, for medical institutions accepting international patients”, which was implemented by the Ministry of Health Labour and Welfare in 2011 [10]. As of March 21, 2013, three medical institutions have been accredited by this accreditation system. It is useful to publicize the name of a hospital or the list of those that are accredited as a hospital accepting foreign patients toward global medical interaction countries for selecting medical institution by a foreign patient or an agent [14]. When a hospital is accredited, foreign medical insurance can be used, providing the advantage of responding to foreign patients, and indicates a further increase in the number of foreign patients in the future. At this time, it has been shown that the larger the hospital, the more outpatients and inpatients there are, and that acceptance varies depending on the size of the hospital. From this background, the larger the hospital, the more easily it will be recognized by foreign patients. Furthermore, large hospitals are more likely to serve as prefecturelevel core hospitals in emergency systems, regional medicine support hospitals, etc. | |
| This study did not observe a difference in foreign outpatients and inpatients between private hospitals and national and public hospitals. However, regarding establishment type nationwide, the proportion of official hospitals, such as national and public hospitals are reported to be 14.6% and private hospitals 66.7% (private clinics 5.4%) [10] and in this survey, national and public hospitals are 30% and private hospitals are 70%, and no difference in the acceptance of outpatients and inpatients was observed. Also, in the survey of national and private hospitals, more than 70% have been reported as providing some kind of service to foreign patients [4]. | |
| In consideration that there are many official hospitals such as national and public among large hospitals, a difference in foreign outpatients and inpatients and accepting systems may result according to establishment type. | |
| Difficulties in nursing when accepting foreign patients | |
| Regarding difficulties in nursing management of foreign patients, more than 70% of hospitals reported difficulties, with the main reason being “language”. In items other than language, the percentage tended to increase as the number of inpatients increased. Also few hospitals had a system or readiness to handle foreign patients with a low rate of 30%. Yet about half of all the hospitals which accept more than 30 inpatients have made arrangements. As the number of inpatients increases, the more preparation the hospital carries out. The description of preparation made by hospitals that responded included “foreign language medical interview sheets”, “conversation cards”, “medical interview sheets in foreign languages” etc. There has been much support for “language”, and due to experiencing difficulties, matters related to “language” were mainly focused on. | |
| This is similar to the survey results by Adachi et al. and Hasegawa, Takeda, & Tsukita which pointed out nurses were most anxious about “language” when caring for foreign patients [4,15]. From the foreign patient side, the report listed “no interpreters”, “not understanding the explanation of the doctor”, “unable to explain my symptoms”, “no time to come to the hospitals”, “high cost of treatment”, “not understanding how to pay” and “do not know how to take medicines” as difficulties [16] showing that foreign patients also had “language” problems. | |
| When performing medical procedures without interpretation, miscommunication can result in medical error. Introducing a medical interpreter with high level training in the medical field would help avoid these risks. In order to respond to the expected increase in the number of foreign patients [17], there is an urgent need to establish a medical interpretation system. | |
| In line with this, training of medical interpreters and volunteer interpreters is desired. | |
| Regarding “language”, hardware is also needed, it is desirable that hospital nursing departments make preparations to be able to support foreign patients and nurses, and large hospitals with many departments which treat foreign patients are especially encouraged to adjust their system. | |
| As suggested by this survey, due to the inability to communicate by “language”, medical workers are not able to understand the customs of the patient [5] and the care provided to such foreigners does not sufficiently consider their culture. Now is the time to learn different cultural perspectives. As professional health care providers, nurses will be asked to take the lead in ensuring that all people have equal access to high quality, culturally appropriate, and culturally competent health care. Cultural assessment can give meaning to behaviors that might otherwise be judged negatively. If cultural behaviors are not properly identified, their significance may be confusing to the nursing staff [18]. In the patient-nurse relationship, nurses are in the position to see the response of patients and judge areas of difficulty in nursing and to take action to solve these difficulties. When nurses do not consider the culture that influences the “human response” such as attitude and actions, health (nursing) issues may be misread. Hence, it is important to properly understand the culture and provide care in consideration of the culture. To do this, nurses must assess the cultural background of the patient, as well as properly understand their own culture. In order to understand the characteristics of the Japanese, training in properly understanding one’s own culture and culture other than “language”, and how to perform an assessment according to the patient’s culture is needed. By such a system and making adjustments, providing care that considers the culture and takes advantage of the characteristics of Japanese. | |
| Another area recognized as highly problematic is “insurance/ welfare”, and issues such as unpaid medical fees and visiting a hospital without understanding payment procedures [19] were considered. On the other hand, in a survey targeting foreigners residing in Japan, difficulty in communication and concerns regarding payment of medical fees were also pointed out as obstacles in visiting hospitals [20,21]. A study in the West observed that the issue of medical fees kept foreign workers from visiting a hospital [22]. Costly medical fees was shown to be an obstacle in visiting hospitals and concerns due to a lack of understanding of the entire insurance system itself were also mentioned [1]. The existence or absence of an information support network most strongly influenced visits to hospitals, and information support was listed as a practical support network [23]. This shows the need to create pamphlets which help foreigners understand the insurance system and provision of information on the insurance system through workshops and other means. For the information to be effectively provided, cooperation with hospitals and official institutions is also desired. | |
| In order for foreign patients to easily access such information, disclosing data over the Internet in multiple languages and displaying the information in areas where foreigners gather would be helpful. | |
| At this time, half of the persons in charge of the nursing departments of hospitals expressed an interest in the care of foreigners [24]. This is considered to be influenced by the actual interest in accepting foreigners at hospitals and the recent implementation of “international nursing” in the curriculum of nursing colleges. With more opportunities to study “international nursing science” in the future and contents are expected to be enhanced, and as more medical personnel are given the opportunity to attend such educational programs, higher ability in cultural care can be developed and greater interest in the care of foreign patients can be expected. According to this survey, few hospitals have postgraduate training, demonstrating the need for education and seminars which can deepen the understanding of international nursing by the nurses. | |
Acknowledgments |
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| The authors would like to thank all nurse directors participating in this study. | |
Disclosure |
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| No conflicting interests and relationships exist for any authors. | |
Authors’ contributions |
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| MH and MI contributed to the conception and design of this study. KH critically reviewed the manuscript. All authors read and approved the final manuscript. | |
References |
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