The first nurse practitioner graduate programme in Japan.

AIM: This paper describes the establishment of the first Japanese nurse practitioner graduate programme and legislative activities to institutionalize nurse practitioners in Japan.
BACKGROUND: To address the super-ageing population, Oita University of Nursing and Health Sciences initiated the first academic graduate level nurse practitioner programme in Japan, based upon the global standard defined by the International Council of Nurses.
CONCLUSION: In 2010, Oita University of Nursing and Health Sciences graduated the first nurse practitioner. We believe that nurse practitioners will be highly valued in Japan for thoughtful nursing care to the fragile elders living in rural and urban Japan.

Introduction: development of nurse practitioners – the first attempt in Japan

Oita University of Nursing and Health Sciences (OUNHS), a vigorous and innovative nursing university located in a rural prefecture in southwest Japan, established the first nurse practitioner (NP) graduate programme in 2008. This initiative represents the first academic attempt in Japan to establish a graduate level NP programme. In fact, this development has provided the momentum to move the government to amend the nurse practice laws. In 2010, OUNHS produced the first NP graduate. This paper tells the story about the establishment of the first Japanese NP graduate programme and legislative activities to institutionalize NPs in Japan.

Background

The population in Japan is expected to shrink from 128 million in 2005 to 95 million in 2050 partially due to a decreasing birth rate, and the proportion of people aged 65 years or older will rise from 23% in 2005 to 40% in 2050 (Statistics Bureau, Ministry of Internal Affairs and Communications 2010). With the shrinking birth rate, the number of younger and middle-aged people in the workforce will decrease over time, leaving a smaller segment of the population to provide for the older population that is rapidly growing in number and vulnerability.

Oita Prefecture, one of the 47 prefectures in Japan, has a total population of about 1 180 000. The proportion of population aged 65 or more in Oita is 26.8% as of October 1, 2011; the predicted increase is 30% by 2015 and nearly 35% by 2030 (National Institute of Population and Social Security Research 2014). Thus, Oita has already exceeded the national average rate of the aged population and the prefecture must begin to address the increasingly serious problems of health care for the local residents earlier than the national government itself may begin to take measures.

There are 38 residential areas spread throughout the prefecture areas; many areas have no medical doctors to serve a large number of elderly people. Municipal and private clinics are located far away from these non-physician areas, making it difficult for the elderly patients to commute to the medical facilities by themselves. Further, this distance would require considerable time for the medical staff to reach patients in those areas in an emergency and would likely lead to worsening of the patients' medical or emergent condition. In this respect, a compelling need exists to improve the current situation of healthcare delivery system in the non-physician residential regions in Oita.

NP Project: Oita University of Nursing and Health Sciences begins to move

To address healthcare problems in these ageing conditions, Dr. Tomoko Kusama, then president of OUNHS, called for faculty members of the university to take action. She organized an academic project team to develop the NP Project in 2005. OUNHS was the first Japanese university to conceive of a programme to prepare NPs for practice in Japan.

Adopting the education and practice model for NPs in the USA as our guide, 12 nursing professors of the project team were sent to the USA for about 1 month and surveyed the current education and practice of American NPs. Meeting with American experts, they strove to understand the current and intended practice of NPs and envision this future role for nurses in Japan.

Results: introducing NP education at OUNHS

In 2008, OUNHS opened a clinical master degree course for NP development in its graduate school, based upon the global standard defined by the International Council of Nurses. In the curriculum for the gerontological NP course, students with 5 years or more of clinical experience are required to obtain at least 55 academic credits and over 540 h of clinical practice to graduate. Incorporating nursing theory and nursing philosophy as a basic premise, we emphasize the significance of the ‘3 Ps’ in our NP education, that is, physical assessment, pharmacology and pathophysiology.

As a result of their education, it is expected that the graduates will have acquired seven competencies as NPs in Japan, specifically: (1) advanced physical and environment assessment, (2) advanced clinical management, (3) expert clinical practice, (4) administration, (5) collaboration with other professionals, (6) consultation, and (7) ethical decision making. However, in order for the future graduates to perform their acquired advanced nursing practice independently in clinical settings, the current Japanese nursing service legislation must be ameliorated.

Institutionalization of NPs and standardization of the NP education

As soon as OUNHS initiated the NP course, the university project team also submitted an application, in collaboration with Oita Oka Hospital, to set up a designated special administration district system. In this system, NP students and graduates would be allowed to perform some of the designated medical treatments to hospitalized patients in need under the supervision of, and with comprehensive orders by, physicians in charge. The aim of this application was to institutionalize NPs in the Japanese nursing practice system.

Following these movements, the Ministry of Health, Labour and Welfare decided to introduce a new training system in March 2013. As of February 2014, legislative discussions began that will hopefully lead to needed legal changes. A bill for the amendment of the nursing service law, which has remained unchanged for 66 years, is now under discussion in the Japanese Diet, including the introduction of the training system for NPs.

In the forthcoming legislation, the following three items will be stipulated to guarantee the position and performance of NPs who finish their education and training at the level of master's degree for entry: (a) nurses should be educated and trained under the government-designating curriculum as NPs at facilities or institutions designated by the Japanese Government, (b) after finishing the authorized education/training programme, the NPs are allowed to perform the designated items of specific invasive medical practice under comprehensive orders instructed by physicians, along with using the protocols designed for each of the specific practice items, and (c) NPs who finish the above items will be enrolled as such in the list, which is kept by the Ministry of Health, Labour and Welfare.

Outcomes produced by NPs

In 2010, OUNHS Graduate School produced the first NP and has produced 14 graduates of the gerontological major and 3 paediatric graduates. These nurses are practising as NPs in hospitals, nursing homes and homecare nursing. All of the graduates are strong contributing members of healthcare teams at their medical facilities and are also collaborating with OUNHS and supporting NP academic initiatives and graduate education.

Evaluation data show evidence that these graduate NPs provide advanced practice to patients and families including but not limited to health promotion, prevention of illnesses, healthcare education and symptom management and treatment. In addition, they have written reports (in Japanese publications) about the effects of their clinical practice. The papers further showed that NPs established caring relationships with patients and families, and provided not only healthcare information but also emotional support. These reports demonstrated that the patients and families cared for by the NPs highly appreciated the NPs' care, citing the quality and availability of care. Patients further expressed a high degree of satisfaction with the NPs' care. While this research is in early stages, strong evidence exists for the positive process and outcomes of the emerging NP role in Japan.

Discussion

As previously described, due to a rapidly ageing population, Japanese society is now facing new societal challenges in terms of healthcare provision. Accordingly, the Ministry of Health, Labour and Welfare announced an emphasis shift from acute care to care for persons with chronic diseases and homecare, by changing the national reimbursement scheme (Ministry of Health, Labour and Welfare 2014). The impetus for this movement is not only the ageing of the society but also the current maldistribution of physicians (Matsumoto et al. 2011). It is argued, citing earlier research (Murata et al. 2010), that the lack of a sufficient primary care delivery system is likely to increase the health disparities that progressively appear in Japan (Ban & Fetters 2011). The risk is particularly serious for the elderly because they do not have enough income to receive proper health care; however, by developing an appropriate primary care delivery system, they can be relieved from such inequalities (Starfield et al. 2005).

Further supporting the need for this advanced practice nursing role, no effective system or measures have yet been developed to increase the number of physicians with general practice for primary care as their subspecialty (Ban & Fetters 2011). It is also reported that, due to the absence of standard guidelines and training in general practice in Japan, quality of care for persons with chronic diseases remains poor (Hashimoto et al. 2011).

To cope with the current clinical situation in Japan, it seems essential to introduce NPs, with gerontological nursing expertise to the healthcare system. Firstly, general practice as a subspecialty is not popular among physician candidates (Ban & Fetters 2011), whereas numerous experienced nurses are interested in primary care advanced practice nursing, as evidenced by a high number of NP programme applicants. Secondly, NPs are expected to work as effectively as physicians, similar to NPs in the USA (Pinkerton & Bush 2000), resulting in cost containment for national medical expenditures while promoting provision of high quality care. Finally, the Japanese Government has shifted its emphasis, recognizing the importance of improving the care provided to persons with chronic diseases at home. In this respect, NPs could play a crucial role in care at nursing homes and homecare nursing.

Implications for nursing

Advanced practice nursing is emerging worldwide as a nursing solution to global issues of lack of access to primary healthcare and acute care services. Numerous reasons exist for the lack of access, not limited to physician workforce and geographic distribution of healthcare providers. In Japan, the case has been made for improved healthcare services to the older population, a practice area where nurses excel. The establishment of this first NP graduate programme in Japan serves as a model for how this type of advanced practice nursing can be developed, evaluated and expanded nationally. The nurse–patient relationship between NPs and patients has been very high, increasing the potential for successful dissemination of this practice role. As more older persons reside in community-based settings as well as a smaller number in nursing homes, these are excellent settings to employ NPs who can promote provision of high quality care to the expanding Japanese older population. Nursing as a practice discipline is looking to a future of care delivery that is of the highest quality and safety. The NP movement in Japan represents the advent of a new nursing era.

Implications for health policy

To address the new era of nursing and to improve access and quality of health care to Japanese citizens, the legal and policy infrastructure of nursing practice in Japan must be changed to allow for this new practice role of NP. Therefore, the introduction of the NP graduate programme has become the momentum to move the government to amend the nurse practice laws. Policy and legal changes in the practice laws must include delineating the scope of practice for advanced practice nursing as well as providing the foundation for NP education. Once the policy is changed, NPs can contribute to maintaining the Japanese universal healthcare system by containing healthcare costs and avoiding social division.

Author contributions

All authors contributed to making this manuscript: HF contributed to writing, data collection and literature research; S. Miyauchi contributed to writing including language translation from Japanese into English and literature research; MT contributed to data collection and literature research; MO contributed to data collection and literature research; JKM contributed to language editing, some writing and interpretation; and S. Murashima contributed to study design and literature research. All authors contributed to the discussion and have seen and approved the final version of the study.

Conflicts of interests

We declare that we have no conflicts of interest.