An investigation of the basic education of Japanese nurses: Comparison of competency with European nurses

Nurse Education Today 33 (2013) 552–557

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An investigation of the basic education of Japanese nurses: Comparison of competency with European nurses Kazuko Tateishi a,⁎, Taro Matsubayashi b, Keiichi Yoshimoto c, Takanobu Sakemi d a

Graduate School of Medical Science, Saga University, Saga, Japan Kouyoudai Hospital, Chitose, Japan Department of Education, Faculty of Human–Environment Studies, Kyushu University, Fukuoka, Japan d Centre for Comprehensive Community, Medicine, Saga Medical School, Saga University, Saga, Japan b c

a r t i c l e

i n f o

Article history: Accepted 17 August 2012 Keywords: Basic nursing education Competencies Nursing skills University education

s u m m a r y Background: A few studies have compared nursing education systems of Japan and Europe, particularly focusing on competency. Objective: We evaluated the competency of registered Japanese nurses by comparing it with that of European nurses; the implications of evaluation for the education of nurses are discussed. Design and participants: Subjects were 468 European graduate nurses and 100 Japanese nurses. Study used data from the Graduates in Knowledge Society (REFLEX) survey in Europe and the Japanese language version of REFLEX (2006) used in a survey of Japanese nurses. Methods: The questionnaire referred to the survey items of REFLEX modified for use in Japan. Items common to the Japanese and European surveys were (1) (2)

(3)

The importance placed on university course elements while at university Nineteen items of competency: for the abilities acquired in the present job (‘Acquired skills’) and those considered necessary to perform the job (‘Required abilities on the job’) Usefulness of subject matter taught at university to the current job

Results: (1) The important course elements in Europe were ‘Internship, work placement’ and ‘Lecture’ while those in Japan were ‘Theories and paradigms’ and ‘Lecture’. (2) The mean values for ‘Acquired skills’ were 5.06 for Europe and 3.73 for Japan and those for ‘Required abilities on the job’ were 4.86 for Europe and 5.16 for Japan. In Europe, no significant gap was observed between the above two scores, but in Japan, a big gap was found, particularly in relation to ‘Ability to assert your authority’. (3) In terms of the usefulness of university-learned nursing education, Japan scored significantly lower on all five items. Conclusions: The content of basic university education for nursing is directly linked to the workplace in Europe but not in Japan. A comparison of competencies shows that in Japan, self-evaluation scores are low and expectations are high. © 2012 Elsevier Ltd. All rights reserved.

Introduction The training of nurses in Japan after WWII began, as in many other fields, with a directive of the General Headquarters (GHQ) of the occupying US Forces. The GHQ urged Japanese that they should focus on the development of training facilities (Sakaki, 1998; Hirao, 1999; Yoshimoto, 1996). It was as late as in the latter half of the 1990s, universities came to play a central role in the basic education ⁎ Corresponding author. Tel.: +81 123 29 8051; fax: +81 123 34 0057. E-mail address: [email protected] (K. Tateishi). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.08.008

of nurses in Japan. The availability of nursing courses on the university level has grown in recent years in response to societal needs; in 1990, the country had only ten universities offering nursing-related programs, but in 2010, 190 universities were offering such courses. Aconcomitant shift took place in nurse training in post-war Japan, where Florence Nightingale's Memories of the Crimea had almost been regarded as sacrosanct, when The Nature of Nursing by Virginia Henderson from the US came to serve as the basic frame of reference in the education and training of nurses. The Henderson work deals with the realities of nursing in the US (OECD, 2004, 2005; Takahashi and Mikami, 2000; Murakami, 2002).

K. Tateishi et al. / Nurse Education Today 33 (2013) 552–557

In Europe a new system of mutual diploma accreditation was introduced in 2007 based on EU directives (at least 2005/36/EC): a diploma earned in an EU member state, regardless of the academic discipline, is to be treated as its equivalent in any other member state. This system, presupposing that a diploma requires at least three years of academic training provided on essentially the same level throughout the Union, is really one of mutual trust (Inoue, 2011; European Commission, 2005). Background Few studies have been conducted in which the nurse education system of Japan is compared with that of Europe. Part of the reason for this is that the Japanese system is modeled on the American system. Nor has there been research comparing Japan and Europe in terms of competency in nursing, though some studies have compared Japan with the US and Australia in this respect (Tateishi, 2008). Historically in Japan, competency in nursing has focused mainly on the management of nursing personnel, and it has been construed as an element in employee evaluation (Maruhashi, 2001; Hirai, 2002). Competency has been defined in Japan as ‘a nurse's capability that is measurable against a standard set on a selection of abilities and behavioral traits expected/required of a competent nurse which would routinely help her to achieve a high level of performance. Competency is meant to be a quantitative measure, and as such, it does not take into account her experience as a nurse, which is presumably reflected in her overall score in competency’ (Watanabe, 2003). As a measure of enhancement of nurses' competency, some research has attempted to relate it to the clinical ladder concept (Asakura, 2005). Sandar V. Dunn, e.g., analyzed competency qualitatively by participatory observations. Roger Watson and others compiled a report on the published results regarding competency, in which they concluded that, depending on the degree of clarity to which the competencies were defined and stated, they were able to measure the performance of the nurses (Watson et al., 2002). And Ritta Meretoja and her team developed a 72-point self-estimation scale to measure competency (Meretoja et al., 2004), and they investigated the capabilities required of nurses from the perspective of career development. The concept of competency as proposed by While in 1994 became widely known to Japanese nurses through Ibe's, 2002 translation: ‘knowledge, techniques and abilities’, which is in contrast to competence as ‘what people are able to do rather than what they know’ (While, 1994; Ibe, 1992, 2002). This study compares university-educated nurses in Japan and those in various European countries in terms of their basic education program in nursing and a certain number of competency elements. All nurses analyzed in the study, Japanese or European, were trained in essentially the same Western framework of nursing with negligible differences. (The reader is reminded of the mutual diploma accreditation system in the EU member states.) More specifically, we compared and tried to evaluate nurse education programs on the university level in Japan and Europe, and also how competent nurses are measured to be, as well as how competency is understood, in both regions. Also examined was whether differences found in some competency elements represented differences in the evaluation of university education. This study is directly tied to a major study called ‘The Flexible Professional in the Knowledge Society—New Demands on Higher Education in Europe’ (REFLEX) that was undertaken to compare Japanese and European university education and its relationship to their careers after graduation. This 2004 survey, led by Rolf van der Velden (Professor at Maastricht University in the Netherlands), explored the university education of 30,000 students who had graduated from high school in the year 2000 and its relevance to the first five years of their careers after graduation. A total of fifteen countries participated in this joint project: Austria, Belgium, the Czech Republic, Estonia,

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Finland, France, Germany, Italy, Japan, the Netherlands, Norway, Portugal, Spain, Switzerland and the UK. The survey was completed either by post or on the web, resulting in a sample of 33,587 persons. With the exception of Portugal and Switzerland, the breakdown in the thirteen remaining countries was 19,023 primary graduates and 14,564 master's graduates (Jim and Rolf, 2007). The Japanese Ministry of Education and Science used part of this REFLEX survey in Japanese Basic Research (A) ‘Japanese–European Joint Research in Relation to Spot Checks and Evaluation of the University Education by Corporations and Graduates’ (Research Representative, Keiichi Yoshimoto), a survey done between March 2006 and March 2007. The subjects of this research had graduated in March 2001 (the end of the Japanese academic year) from eighty-two departments and research labs in sixty universities across Japan. With the cooperation of the universities in question, the survey questionnaires were either completed and returned by post or completed on the web by 2501 persons (2279 primary graduates and 222 post-graduate respondents), representing a successful recovery sample of 18.1% (Yoshimoto, 2009). Methods This research uses data from three sources: REFLEX data from Europe, Japanese-version REFLEX data from Yoshimoto, and data from a new Japanese survey of university-trained nurses which Tateishi and others conducted at about the same time as Yoshimoto's. A comparison was made on the results of university education in Europe and Japan, its characteristics and the abilities acquired from it. Table 1 details nursing education systems in the countries with the five greatest numbers of participants in this analysis: the Netherlands, Norway, France, Italy and Japan (Nomura, 2008). The differences in the number of participants from the four European countries, which may be a potential weakness of this research, are ignored because we can assume that we are dealing with qualitatively homogeneous samples assured by the mutual diploma accreditation system mentioned above. Outline of the Data Used The European data from REFLEX included 19,023 graduates from thirteen countries (excluding Portugal and Switzerland) and 468 persons currently working as registered nurses in these countries, hereafter collectively referred to as EUNs (Table 2). Data on Japanese registered nurses was randomly selected from a survey conducted in February 2006 by Tateishi and others at 26 general hospitals with more than 300 beds in the Kanto and Kyushu regions of Japan; they consented to the authors' request to participate. The subjects were nursing graduates with at least five years of experience. Of the 345 respondents (recovery ratio of 58%), 100 individuals were used in this study as JPNs. Content of the Survey The content of the survey questionnaire referred to the survey items of REFLEX and was modified for use in Japan before implementation. We selected items of competency defined as ‘knowledge, techniques and abilities’ with modification of the original of Jim and Rolf (Jim et al, 2007). The common items in the Japanese and European surveys were as follows: 1. Evaluation of the university education program (refer to Table 3) 2. Nineteen items relating to competency (refer to Table 4): abilities acquired in the present job (Acquired skills) and those considered necessary to perform the present job (Required abilities on the job) 3. Usefulness of university subject matter in the current job (refer to Table 5)

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Table 1 Comparison of nursing education in five countries (Nomura, 2008). Professional nurses Licensing (population per head) qualification

Japan

1,292,593 (1:99) 2004 Netherlands 221,783 (1:73) 2003 Norway 68,000 (1:68) 2005 France 452,466 (1:142) 2005 Italy 350,000 (1:169) 2005

Length of license

School years Nursing education Basic (diploma course) general education

Duration of the degree course

Curriculum duration for three-year diploma in nursing

93 credits

After graduation from nursing school, applicants are required to take national exams Graduation from nursing school

Life long

12 years

3 years

146 h

Life long⁎1

10 years

4 years

12 h

Graduation from nursing school

13 years

3 years

31 h

Graduation from nursing school

Life long (till 75 years of age) Life long

17 years

3 years (practical nurse school)⁎2

332 h (practical 1400 h nurse school)

After graduation from nursing school, applicants are required to take national exams.

Requires renewal every year

13 years

3 years

3600 h

⁎1As of 2003, renewal is needed every 5 years, if this part of new legislation is to be operational. ⁎2Professional education: upon graduation from IFSI, national qualification can be obtained. IFSI is the training Institute for nurses.

4. Degree of satisfaction in the current job

Results

A seven-point grading scale was used for the nineteen items of competency, and a five-point grading scale was used for the other items.

Evaluation of the University Education Program

Data Analysis Methods The means and standard deviations derived from the data and the mean value (±standard deviation) were calculated. Thereafter, the difference between the two groups was subjected to the Mann–Whitney U‐test. SPSS13.0J was used in the data analysis and the significance level was set at 5%.

Logistical and Ethical Considerations Permission to use the REFLEX data in this research was obtained from the REFLEX representative in Japan. As for the Japanese registered nurses, written consent to let us take the survey was obtained from the management of the medical facilities concerned. The questionnaires were then sent to the subjects via the nursing section of each hospital; each respondent, after completion of the questionnaire, returned it by mail of her/his own volition. It was explained to the subjects in writing that the request for cooperation was solely for the purpose of research and that participation in the research was not obligatory. Also explained in writing was the significance of the research, its purposes and methods, guaranteed protection of personal information given in the questionnaire as stipulated by Research Ethics Committee, Kurume University, Kurume City, Fukuoka, Japan.

Evaluation of the university education programs involved eleven questions under various headings, such as ‘To what extent were the following emphasized in the faculty/department (subject/course) from which you graduated?’ Ratings ranged from ‘Not emphasized at all’ = 1 to ‘Emphasized very much’ = 5. This was designed to elicit the characteristics of the educational contents and methods of the nursing program (refer to Table 3). The mean value for all eleven items was 3.20 (±1.02) in Europe and 3.55 (± 1.00) in Japan. The item emphasized most in Europe was ‘Internship, work placement’ with a mean value of 4.11 (±1.02), while that in Japan was ‘Theories and paradigms’ at 4.33 (±0.75). On the other hand, the item least emphasized was ‘Multiple choice exams’ in both Europe (2.04 [± 1.34]) and Japan (2.81 [±1.04]). The mean values for ‘Facts and practical knowledge’ and ‘Internship, work placements’ were lower for JPNs (3.14 [±1.01] and 3.10 [±1.18], respectively) than for EUNs (3.77 [±0.95] and 4.11 [±1.02], respectively). A statistically significant difference was observed in the mean values of all these items between Japan and Europe.

Table 3 Evaluation of the university education program by graduates in Europe and Japan (on a scale of 1 to 5). EUNs (n = 466) Mean value (SD) Lectures Group assignments Participation in research projects Internship, work placement Facts and practical knowledge Theories and paradigms Teachers as the main source of information Project and/or problem-based learning Written assignments Oral presentations by students Multiple choice exams Mean

Table 2 Countries and numbers of subjects. Country

Subjects (%)

Italy France Austria Netherlands United Kingdom Finland Norway Belgium Total

41 (8.8) 47 (10.0) 2 (0.4) 100 (21.4) 2 (0.4) 15 (3.2) 259 (55.3) 2 (0.4) 468 (100)

+

4.02 3.40 2.08 4.11 3.77 3.34 3.03 2.94 3.55 2.92 2.04 3.20

(0.87) (0.98) (1.14) (1.02) (0.95) (0.99) (0.91) (1.15) (0.88) (1.01) (1.34) (1.02)

JPNs (n = 100) Mean value (SD) 4.22 4.00 2.98 3.10 3.14 4.33 3.24 3.72 4.05 3.47 2.81 3.55

(0.76)+ (0.88)⁎⁎⁎ (1.15)⁎⁎⁎ (1.18)⁎⁎⁎ (1.01)⁎⁎⁎ (0.75)⁎⁎⁎ (0.88)+ (0.92)⁎⁎⁎ (0.76)⁎⁎⁎ (1.00)⁎⁎⁎ (1.04)⁎⁎⁎ (1.00)

p b 0.05, **p b 0.01 ***p b 0.001. Note 1: EUNs are European University graduates working currently as registered nurses and JPNs are Japanese University graduates working currently as registered nurses. Note 2: On the scale, 5 implies very important and 1 implies unimportant.

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Table 4 Mean values for the registered nurses' ability to acquire skills and required abilities on the job. EUNs (n = 466),JPNs (n = 100) (A) Acquired skills

Mastery of own field or discipline Knowledge of other fields or disciplines Analytical thinking Ability to rapidly acquire new knowledge Ability to negotiate effectively Ability to perform well under pressure Alertness to new opportunities Ability to coordinate activities Ability to use time efficiently Ability to work productively with others Ability to mobilize the capacities of others Ability to make your meaning clear to others Ability to assert your authority Ability to use computers and the internet Ability to come up with new ideas and solutions Willingness to question your own and others' ideas Ability to present products, ideas or reports to an audience Ability to write reports, memos or documents Ability to write and speak in a foreign language Mean

Gap (B) − (A)

(B) Required abilities on the job

EUNs

JPNs

EUNs

JPNs

EUNs

JPNs

5.45 4.31 4.61 5.47 4.53 5.73 5.03 5.59 5.67 5.71 5.15 5.58 4.72 5.07 5.07 5.26 4.23 5.18 3.76 5.06

3.36⁎⁎⁎ 3.68⁎⁎⁎ 3.79⁎⁎⁎ 3.96⁎⁎⁎ 3.62⁎⁎⁎ 3.74⁎⁎⁎ 3.90⁎⁎⁎ 3.24⁎⁎⁎ 3.95⁎⁎⁎ 4.58⁎⁎⁎ 4.21⁎⁎⁎ 3.81⁎⁎⁎ 3.24⁎⁎⁎ 4.53⁎⁎⁎ 3.83⁎⁎⁎ 3.73⁎⁎⁎ 3.61⁎⁎⁎ 3.81⁎⁎⁎ 2.36⁎⁎⁎

5.62 4.13 4.38 5.14 4.27 5.79 4.81 5.49 5.77 5.73 5.22 5.58 4.61 4.60 4.80 4.78 3.90 4.95 2.82 4.86

4.82⁎⁎⁎ 5.21⁎⁎⁎ 5.57⁎⁎⁎ 5.66⁎⁎⁎ 5.11⁎⁎⁎

0.17 −0.17 −0.23 −0.33 −0.26 0.06 −0.22 −0.10 0.10 0.01 0.08 0.00 −0.11 −0.47 −0.27 −0.48 −0.33 −0.23 −0.94 −0.20

1.46 1.53 1.78 1.70 1.49 1.75 1.38 1.34 1.60 1.39 0.99 1.36 2.18 0.42 1.81 1.51 1.53 1.28 0.58 1.43

3.73

5.49+ 5.28⁎⁎⁎ 4.58⁎⁎⁎ 5.55 5.97+ 5.20 5.17+ 5.42⁎⁎⁎ 4.95+ 5.64⁎⁎⁎ 5.24+ 5.14⁎⁎⁎ 5.09 2.94 5.16

+p b 0.05, **p b 0.01 ***p b 0.001. Note 1: The gap represents the result of subtracting scores for ‘Acquired skills’ from ‘Required abilities on the job’. Note 2: EUNs are European University graduates currently working as registered nurses and JPNs are Japanese University graduated currently working as registered nurses. Note 3: On the scale of 1 to 7 for ‘Acquired skills’, 7 means that the subjects have sufficiently mastered it and 1 means that they have not; for the ‘Required abilities on the job’, 7 means very important and 1 means unimportant.

‘Acquired Skills’ Competency and ‘Required Abilities on the Job’ In regard to the nineteen items relating to competency, ‘Acquired skills’ were rated 1 for those not acquired and 7 for those acquired to a sufficient extent. ‘Required abilities on the job’ scores ranged from 1 for those not required to 7 for those considered essential by students. As shown in Table 4, ‘Acquired skills’ had a mean value of 5.06 (±1.45) in Europe, compared to 3.73 (±1.16) in Japan. In investigating the details, the highest mean values for the ‘Acquired skills’ items for EUNs were ‘Ability to perform well under pressure’ (5.73 [±1.01]) and ‘Ability to work productively with others’ (5.71 [±0.95]), while for JPNs, it was ‘Ability to work productively with others’ (4.58 [±1.16]) and ‘Ability to use computers and the internet’ (4.53 [± 1.33]). Characteristics rated low by both groups under this heading: ‘Ability to write and speak in a foreign language’ (EUNs = 3.76 [± 1.70], JPNs = 2.36 [±1.37]) and ‘Ability to present products, ideas or reports to an audience’ (EUNs = 4.23 [±1.53], JPNs = 3.61 [±1.06]). Next, in relation to ‘Required abilities on the job,’ the highest mean values in Europe were for ‘Ability to perform well under pressure’ (5.79 (±1.29)] and ‘Ability to use time effectively’ (5.77 [±1.22]), while in Japan, they were ‘Ability to work productively with others’ (5.97 [±1.01]) and ‘Ability to rapidly acquire new knowledge’ (5.66 [±1.08]). The lowest mean values for the European respondents were ‘Ability to present products, ideas or reports to an audience’ (3.90 [±1.69]) and ‘Ability to write and speak in a foreign language’ (2.82 [±1.73]), while the Japanese respondents chose ‘Ability to coordinate activities’ (4.58 [±1.24]) and ‘Ability to write and speak in a foreign language’ (2.94 [± 1.63]). Although not shown in the tables, the mean values for ‘Acquired skills’ in the overall REFLEX data were 5.06 for Europe and 4.24 for Japan, whereas those for ‘Required abilities on the job’ were 5.06 for Europe and 5.04 for Japan (Yoshimoto, 2009). Next, we defined the ‘gap’—the difference obtained by subtracting the scores for ‘Acquire skills’ from ‘Required abilities on the job’. The mean values for the gap in Europe across the nineteen items of competency was −0.20, while in Japan, it was 1.43.

In Europe, only the following five items showed positive gap values: ‘Mastery of own field or discipline’ at 0.17, ‘Ability to perform well under pressure’ at 0.06, ‘Ability to use time effectively’ at 0.10, ‘Ability to work productively with others’ at 0.01 and ‘Ability to mobilize the capacities of others’ at 0.08. By contrast, in Japan, all the items showed positive gap values. A significant difference was observed for every item in the ‘Acquired skills’ investigation. In relation to ‘Required abilities on the job’, no significant differences were found in respect to the four items ‘Ability to use time effectively’ (p= 0.099), ‘Ability to mobilize the capacities of others’ (p= 0.814), ‘Ability to write reports, memos or documents’ (p= 0.174) and ‘Ability to write and speak in a foreign language’ (p= 0.425). A significant difference was found at 5% confidence level for the five items ‘Ability to perform well under pressure’ (p=0.032), ‘Ability to work productively with others’ (p= 0.041), ‘Ability to make your meaning clear to others’ (p= 0.024), ‘Ability to use computers and the Internet’ (p= 0.011) and ‘Willingness to question your own and others’ ideas’ (p= 0.01). For the remaining ten items, a significant difference was found at the 1% confidence level (Table 4).

Table 5 Comparison between registered Japanese and European nurses regarding the usefulness of university education on the job.

Starting work Further learning on the job Performing current work tasks Future career Personal development

EUNs (n = 466)

JPNs (n = 100)

Mean value (SD)

Mean value (SD)

4.23 4.07 4.01 3.98 4.09

(0.97) (0.87) (1.00) (0.95) (0.86)

3.25 3.49 3.16 3.44 3.45

(0.98)⁎⁎⁎ (0.97)⁎⁎⁎ (0.99)⁎⁎⁎ (1.09)⁎⁎⁎ (1.10)⁎⁎⁎ ***p b 0.001

Note 1: EUNs are European university graduates working currently as registered nurses and JPNs are Japanese university graduates working currently as registered nurses. Note 2: Grading is on a scale of 1 to 5, with 5 indicating useful and 1 indicating not useful.

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Comparison Between Registered Nurses in Japan and Europe in use of University Education on the Job With respect to the usefulness of the knowledge gained at university, five questions were designed to elicit reflection on the participants’ university education and the extent to which it is utilized in their current profession. For example, ‘To what extent were the subjects studied at university useful?’ Scores ranged from ‘Completely useless’ = 1 to ‘Very useful’ = 5. Table 5 shows that the highest scorers for usefulness on the job were ‘Starting work’ at 4.23 (±0.97) for EUNs and ‘Further learning on the job’ at 3.49 (±0.97) for JPNs. In the case of Europe, the two least useful items were ‘Future career’ at 3.98 (±0.95) and ‘Performing your current work tasks’ at 4.01 (±1.00). Japan showed an overall tendency to low results, particularly in two items—‘Performing your current work tasks’ at 3.16 (±0.99) and ‘Starting work’ at 3.25 (±0.98)—which showed the lowest scores for usefulness on the job. A significant difference was found between Europe and Japan in all of the items, signifying that nurses in these two areas view the usefulness of their university education quite differently. Degree of Satisfaction with the Current Job The respondents were asked, ‘To what degree are you satisfied with your current job?’ Ratings spanned from ‘Completely dissatisfied’ = 1 to ‘Completely satisfied’ = 5. EUNs scored 3.95 while JPNs scored 3.05. The mean value for the eight European countries included in this investigation was 3.80 while that for Japan was 3.50. Japanese registered nurses not only scored lower than their European counterparts in ‘Degree of satisfaction with the occupation’, but they also scored lower than other Japanese graduate professionals. In contrast, the degree of satisfaction of European registered nurses is higher than that of other European graduate professionals. A significant difference (pb 0.001) was found between Japan and Europe in the ‘Degree of satisfaction with the occupation’ of registered nurses and also in relation to ‘Degree of job satisfaction’. Discussion This research has made it clear that EU and Japanese registered nurses take a serious view of different aspects of their professional training. EUNs scored high in ‘Internship, work placement’ and ‘Facts and practical knowledge’, whereas JPNs scored much lower in both of those items. And a parallel difference is recognized between the two groups in the result of the 19 competency-related items: mean value in ‘Acquired skills’ for EUNs was 5.06, which contrasted to JPNs’ mean of 3.73 (Table 4). This means that European university curricula in nursing stress the practical nature of the training of a professional nurse. In Japan, in contrast, as college- or university-level education came to be the core of nurse training, society expected nurses so trained to provide leadership in their profession. Accordingly, ‘Theories and paradigms’, not directly related to competency enhancement, was regarded important in their curricula. It is in a sense natural that JPNs did not score as high as EUNs in overall competency. An investigation using self-evaluation of ‘Acquired skills’ and ‘Required abilities on the job’ was conducted for all university graduates (not just nursing) on the basis of the same nineteen items of competency. First, examination of the REFLEX data and both sets of Japanese data showed the mean values for ‘Acquired skills’ with respect to competency were 5.06 for Europe and 4.24 for Japan. For ‘Required abilities on the job,’ the means were 5.06 for Europe and 5.04 for Japan (data not shown in the table) (Yoshimoto, 2009). In other words, university graduates in Europe, when evaluating their own ‘Acquired skills’, gave a high score, while those in Japan rated themselves low. This trend was also observed in the results for registered nurses. When ‘Required abilities on the job’ scores were compared, EUNs scored 4.86 and JPNs scored 5.16, showing

that Japanese registered nurses tended to rate themselves lower in this category as well. Almost no gaps were observed between the scores for ‘Required abilities on the job’ and ‘Acquired skills’ in Europe. In other words, regarding the ability and self-evaluation, EUNs found a closer match between their education and required job skills, than did JPNs, who demonstrated a considerable gap between ‘Required abilities on the job’ and ‘Acquired skills’. The gap was particularly marked in four items: ‘Ability to assert your authority’, ‘Ability to come up with new ideas and solutions’, ‘Analytical thinking’ and ‘Ability to perform well under pressure’. In addition, even in an overall evaluation of the nineteen items within ‘Required abilities on the job,’ Japanese registered nurses showed significantly high ratings. In other words, registered nurses seem to have set high standards for their nursing work in Japan. This mental outlook is also reflected in the results of the ‘Degree of Job Satisfaction’. One of the important factors related to the degree of job satisfaction among registered nurses is their belief that what they do is something worth doing. In particular, in their fourth through seventh years after graduation, ‘Meeting the requests and good evaluation by the patients’ is followed by ‘A feeling of achievement in the job’. Other factors are good communication which improves the working environment and teamwork, which is prerequisite to job satisfaction (Ozaki, 2003). Of the items of competency in this investigation, ‘Ability to make your meaning clear to others’ seems directly related to teamwork. A small but significant difference exists between the European score (4.86) and the Japanese score (5.16) in ‘Required abilities on the job’, and a highly significant difference is seen between the two groups in ‘Acquired skills’ (5.06 for Europe and 3.73for Japan). These lower scores may result in a low level of job satisfaction. The lower are one's self-evaluation scores, the less satisfied, it seems, one feels in the job. It can be asserted that self-evaluation and job satisfaction are linked. Japanese registered nurses can probably be said to have set high standards for their job, and this could be the reason for their relatively low self-evaluation scores and degree of satisfaction. Similar results for Japanese college or university graduates were reported in another study titled ‘Japanese and European Universities and Work Places’ (Japanese Representative: Keiichi Yoshimoto), in which the overall mean values for job satisfaction for Europeans was 3.72 (4.00 for French and 4.01 for Norwegians) and it was 3.3 for Japanese, while the score for Japanese Health Insurance-related Personnel was 3.50 (Akinaga, 2001). From a clinical perspective, ‘real’ nursing abilities that new registered nurses show are poorer than what they are expected to have acquired, and such ‘reduction’ in their technical abilities has been pointed out. A partial lack of technical skills has also been observed in all new graduates, not just university graduates (Masaki et al., 2000). In other words, nursing education in Japanese universities emphasizes theory more than practice. However, with a rapid transition of nursing education to universities, increasingly more universitygraduate registered nurses end up working in mid-scale hospitals. That makes it necessary to review and re-examine the practice of university nursing education. In that context, a reform of some nursing regulations and inclusion of integrated nursing have in fact affected the curriculum in some cases. With an aim to emphasize actual nursing abilities, the number of units related to the highest level of nursing, i.e. registered, has been increased and the new curriculum has been extensively promoted. Against a background of increasingly higher levels of education and of society's greater access to information, this new curriculum results in a re-emphasis of the practical aspects in nursing education. Most universities are being encouraged to further reform the integrated curriculum (which provides simultaneous acquisition of the qualifications of registered nurse and health-insurance officer) and to extend the basic RN education to four years. Finally, those of us engaging in nurse education in Japan can learn a lesson from a closer knowledge of how nurses have been educated

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in Europe. Japanese students in a nursing program on the university level are in fact receiving education where “participation in a research project” and “academic approach to theories and paradigms in nursing” are stressed. To reiterate, this is because universities take it for granted that they should provide society with nurses with leadership quality, future leaders in nursing profession. In Europe, in contrast, nurse training on the tertiary education level has traditionally emphasized its practical aspects; as a result, European registered nurses have consistently scored higher in competency-related items. Nurse training in Japan ought to undergo change so that it is more like the European style of RN education. Conclusions The following important conclusions can be drawn from this research: 1. University nursing education programs in Japan are not directly linked to the actual workplace competencies needed. 2. The content of basic nursing education at universities is directly linked to the workplace needs in Europe but not in Japan. 3. As a result of a comparison of competencies, the self-evaluated scores of nurses are low in Japan and expectations are clearly high. 4. In terms of job satisfaction, Japanese university graduates (all degrees) have low scores. These results clearly demonstrate that Japanese nursing education needs to learn from European education and extend the university program to a four-year course with improved practical applications. University nursing education also needs to include items relevant to later career development. An introduction of post-graduate internship programs also needs to be considered as a possible change to improve the future of nursing education and practice. Acknowledgements In writing this paper, the authors availed themselves not only of REFLEX data but also the data from the 2005–2007 Japanese Science Research Support Fund, Basic Research C (17592229, with Kazuko Tateishi as the representative of the research). The authors also jointly conducted their research with the following researchers: Etsuko Tanigishi (Kyorin University), Yukiko Maeda (Seinanjo Gakuin University), Setsuko Koga (Shuto University) and Michiko Maruta (Kurume University Affiliate Hospital). The authors would like to not only acknowledge the use of that data but also show their deepest appreciation of the support provided. The authors wish to give special thanks to emeritus professor Kensuke Tohkaichi of Saga Medical School, Saga, Japan for his help in the preparation of the English text. References Akinaga, Y., 2001. Japanese and European Universities and Workplaces: the Results of a Survey Comparison of Higher Education and Workplace across 12 Countries. Japan Labour Research Organization, Tokyo, pp. 103–113.

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