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Development of emergency nursing specialists in Japan
Development in Japan
of emergency
nursing specialists
A. Takahashi and M. Ohta
During the past 10 years, improvements and higher standards in emergency nursing and medical care have been pursued throughout the world. In Japan, the modern emergency medical care system has been evolving since 1976, and is now based on the philosophy that severe acute illness or injury is a specialist field. It is recognised as such by both the Japanese medical world and the ordinary Japanese citizen. In line with this philosophy, the development of specialist training for emergency nurses has been given careful consideration. This paper describes the factors involved and the resulting conclusion.
CURRENT SITUATION In Japan, a vast amount of money is spent on medical care-more than 150 billion US dollars per year. There is an excellent medical insurance system which ensures that even the most advanced medical treatment can be obtained by anyone, without financial hardship. Despite this, the average Japaneseis not satisfied with the medical care they receive. The main reason for this appears to be becausethe standard of care received is not as high as the rate of cure. The unsatisfactory standard of care is due chiefly to the shortage of nurses, the result of 40 years’economy on training nurses in order Akiko Takahashi, RN, EISN, Critical Care Medical Centre, An abstract of this paper was September 1992. Manuscript
to keep medical costs down. Currently there are approximately 700 000 nurses working in Japan; in hospitals the national average is 1 for every 4 patients. However, the need for more nurses increases dramatically year-by-year, due to rapid advances in medicine and also to the increased number of elderly patients in hospital, who require far more nursing care than younger patients. The relationship between these developments and the social and professional status of nurses must now be addressed. Socially, the nurse is usually compared to a school teacher. However, in Japan the nurse’s income and hours of work compare
Director of Nursing Services and Muneo Ohia, MD, Director, Osaka Prefectural Senri Suita City, Osaka, Japan read at the Second Pan Pacific Emergency Nurses’ Conference in Singapore, accepted 18 December 1992
162 ACCIDENT & EMERGENCY NURSING unfavourably with those of the teacher, despite the fact of decreasing numbers of children and the increasing need for nurses. Even though many high school students wish to be nurses, there are not enough nursing schools and not enough places in the existing ones. In the past few years these contradictions and imbalances have been pointed out repeatedly, and though the government has laid plans to establish more nursing schools this cannot be done in a short time. About 5% of nurses leave the profession each year; graduate numbers do not keep up with this rate and so nursing numbers reduce. Reasons for young nurses leaving the profession are many-for example: low income, night duty and too much responsibility. The government has recently become sufficiently aware of this serious situation to make an effort to improve it, but this will take a long time because the circumstances are complicated.
POSTGRADUATE EDUCATION FOR NURSES Although it is usual for senior nurses to teach junior nurses and thereby help them to develop professionally, senior nurses do not have time to prepare an education programme as such. In most hospitals, it is therefore the responsibility of the director of nursing to issue an education programme for new employees and especially for the newly qualified nurses. This is unsatisfactory for several reasons. The postgraduate education varies from hospital to hospital and depends on the enthusiasm and commitment of the senior nurses. There is a wide range of methods and standards; students are attracted to the hospitals where the quality of postgraduate training is known to be high and prefer to stay there rather than move elsewhere. These hospitals make a point of trying to attract the graduates.
BASIC EDUCATION FOR NURSES Nursing education in Japan is based on a 1948 Act of Parliament. Accordingly, in order to register, the nurse undergoes 3 years’ training which can be modified in various ways for convenience to the student. The curricuhun is based on the American system. During the past 10 years, many junior nursing colleges have been established, but nurse training in Japan still rests largely with the nursing schools. The first of these was established in 1952 and today there are only ten. 30 more are planned for the next few years, but even this will not compare with numbers of nursing schools in other developed countries. The theory taught is revised every 10 years or so and more time allocated to it, whilst the time spent on clinical practice is reduced. If this trend continues, the trainees’ clinical practice will decrease in both quality and quantity and there will be more emphasis on in-service training after graduation.
In-service training This method is convenient and clinically efficient. The nursing department of each hospital issues a schedule to ensure that new graduates understand the aim and philosophy of the hospital, as well as aspects of the nursing manual such as orientation, special&d and technical knowledge and leadership.
Education plans made by the Japanese Association of Nurses
(JAW This is a national professional association for nurses, with headquarters in Tokyo and branches throughout the country. About 70% of working nurses belong to it. JAN’s main educational activities are annual meetings and seminars at both national and branch level, plus advanced courses run at the seminar school for nurses throughout the country.
ACCIDENT & EMERGENCY NURSING
Education by the Professional Association of Nurses This training is aimed at general nursing and not at any kind of specialisation. So each nurse also belongs to another professional association for her own field-surgical nursing, paediatric nursing etc. These associations each have their own meetings and seminars, and supply special&d training. Most are run by physicians, since most were founded by physicians. This illustrates the relationship between nurses and physicians in Japan, namely that nurses depend on physicians for their professional and financial status. This applies equally to emergency nurses in spite of the responsibilities they carry in their work and the spirit of independence that motivates them in attempting to change the system.
Nurses’ department of Japanese Association for Acute Medicine Before this is discussed, the Emergency Medical Services System (EMSS) in Japan should be explained: The Japanese Ministry of Health and Welfare has instituted several new systems in emergency medicine. The present EMSS was established in 1977 and is based on the classification of patients and facilities into three levels of need, linked by an information network:
Level 1 These patients require simple treatment or some medication, and can then return home. They are treated at practitioners’ clinics and/or hospital outpatient clinics designated by the governor of each prefecture. Each city has night/holiday emergency clinics.
Level 2 These patients need more treatment and should be admitted or held for observation. Most of them are treated at designated hospitals or at hosuitals on a rota svstem. , 1
163
Level 3 These patients are in a severe stage of an illness or disease, or have received serious injury, and need intensive care, special treatment e.g. respiratory care, circulatory care, hemodialysis, plasma exchange, hyperbaric oxygen therapy etc. They are treated at the 106 critical care medical centres, most of which belong to general hospitals or medical colleges and serve, on average, 1.5 million people. There are also three independent critical care medical centres; one of these is the writer’s place of work. The information networks, both at prefecture and city level, respond to 119 (UK equivalent 999) calls from the public. Their main role is to assessthe severity of the emergency, and to coordinate the emergency and ambulance services and the availability of beds in the various critical care centres. 99% of the population has access to the ambulance telephone call service (119 system), which responds in less than 10 minutes. Even so, the recovery ratio of cardio-pulmonary arrest patients is still lower than in other developed countries. Very few Japanese have any knowledge of First Aid to be applied before the ambulance team arrives. Ambulance team personnel are not trained in advanced life-support techniques such as endotracheal intubation, because these are legally medical procedures and are limited to physicians. The result is that Japan has a large number of so-called ‘vegetative patients’, bringing many problems to families, medical workers and the health service. One attempt to overcome this problem is the doctor’s car system, in which a car is sent to pick up a doctor and take him to the scene of the accident/emergency. This is being run as a pilot scheme in several areas, but is not functioning well. During the past few years there have been major citizens’ campaigns, organised by the mass media, to raise the ratio of recovery from cardiopuImonary arrests. These campaigns have pressed for rescue personnel to be trained in advanced life-support skills. In 1991 the Registered Emergency Technician law was passed, and from May 1992 these
164 ACCIDENT & EMERGENCY NURSING
new Registered Emergency Technicians began to work in the Emergency field. However, this development is not expected to influence the situation significantly since the ordinary citizen still has no education in basic life-support skills for cardiopulmonary arrest.
-To give sympathetic and understanding emotional support to families.
The basic nurse training includes little emergency nursing in its curriculum, and so the emergency nurse needs organised postgraduate education as much as nurses in other specialist areas, such as paediatrics and psychiatry. Nurses’ Section of the Japanese Once a nurse is qualified, there is no legal Association for Acute Medicine requirement for her to update her knowledge, (JAAM) and so postgraduate education depends on JAAM was established in 1973 by physicians the individual hospital. In the emergency deworking at critical care medical centres, and partment it is in the interests of the physicians has contributed to the development of emer- to ensure the nurses are trained in the necesgency medicine to its present form. However, sary skills to assist them. There is no doubt until 10 years ago, nurses working in Inten- that this has benefitted emergency nurses, but sive Care Units (ICUs) and emergency depart- until the JAAM Nurses’ Section was estabments were not trained adequately in the use lished in 1981 and began to grapple with the of the rapidly-advancing technology. In addi- problem, training content and methods were tion, they were regarded by general nurses as not standardised. a separate group closely allied to the physiciOnly recently has the Japanese Associaans. tion for Nurses issued guidelines on trainThe Nurses’ Section of JAAM was estab- ing in certain specialities-circulatory disease, lished in 1981 by a few nurses working at cancer, psychiatry, acute medicine, paediatric, tertiary nursing facilities, and has since con- gerontology and emergency medicine. The tributed to the development of emergency training plan for emergency nurse specialists nursing in Japan. There is a membership of has been under consideration for some time about 2000; the steering group is elected from and therefore leads the field. The basic conactive critical care medical centres. There is cept is as follows: an annual meeting attended by an average Each critical care facility now uses a schedof 1000 members, where new techniques and ule which was compiled after discussions at experiences are shared. The quality of emer- the meetings and seminars, as follows: gency nursing has consequently improved. Once a year, 200 or so junior and intermediate nurses participate in an emergency nursing Training of beginners-10 days” seminar. A journal of emergency nursing also -Philosophy of the hospital and/or unit disseminates information and experience. -Concept of emergency medicine, including emergency nursing and EMSS -Basic skills in intensive care Postgraduate training -Respiratory care -Circulatory care The role of the emergency nurse increases and -Fluid balance becomes more complicated year-by-year, due -Use of medical instruments to the advances in technology and the under-Basic knowledge of common traumas standing of disease. The role can be defined and diseases. as: -To observe patients in the light of accurate knowledge of various diseases. -To assist physicians in their treatment, using one’s knowledge and experience.
* It seems a strange custom to me that some nurses whom I met in Canada and the USA change to a different unit every day. In Japan, because each hospital and each unit has its
ACCIDENT & EMERGENCY NURSING
own nursing manual, new employees take more than a month to learn the manual, and in the early days every nurse receives orientation training about every aspect of the work. Advanced training (2 hours every 2 weeks for 6 months) After 6 months, nurses receive specialised training in emergency medicine and nursing. This involves lectures on diseases and treatment such as myocardial infarction, cardiac insufficiency, cerebrovascular accident, acute abdomen, burns, trauma, organ failure and special&d medical procedure such as haemodyalisis and plasma exchange etc. Training of leaders (1 week) As many hospitals are adopting team nursing, the role of leader becomes more important. Nurses who have more than 3 years experience in the field of emergency nursing are able to take the leaders’ course and become a leader nurse. After working for 2 years as a leader nurse, they can attend the second training course. This training is based on discussions about leadership, education of junior nurses, nursing study, management etc. Guidelines for professional education After 3 years experience, nurses begin to report on their postgraduate studies, to meetings at both local and national level. Some of these are published in professional journals, some of the nurses are given the opportunity to attend meetings and seminars sponsored by JAAM and other organisations. In this way their education continues and they become potential specialists in emergency nursing. Training for emergency nurse specialists The roles of emergency nurse specialists in Japan are classified as follows: First Aid -Correct -Triage.
observation and assessment.
165
-To assist physicians at CPR and other special procedures. -To prepare the room with necessary equipment. -To provide emotional support to patients and their families. These aspects of the role are similar to those of the nurse in the admitting room of an emergency clinic. KU cure -Patient care using high-technology medical instruments. -Management of patients in intensive care, especially respiratory care, circulatory care and fluid balance. -Advanced and close observation of emergency patients whose previous history is unknown.
Post ICU -To help patients and families to come to terms with their illness or injury. -To plan and execute suitable rehabilitation in cooperation with other medical personnel. -To care for dying patients and their families.
Emergencyprocedures -Setting venous lines -Defibrillation -Oxygen therapy -Hemostasis etc. Training in emergency procedures is still not sufficient because the quality varies from hospital to hospital. Therefore it cannot always be said to reach the standard required for emergency nurse specialists. Because of the shortage of nursing schools in Japan, the nurse specialist does not yet require a Master’s degree. The Nurses Section of JAAM requires emergency specialists to have
166 ACCIDENT & EMERGENCY NURSING at least 5 years experience in the field, and to have gained credits through examinations, reports and attending classes and seminars. These specialists are needed not only to help improve the quality of emergency nursing, but also to emphasise the stimulus and pleasure to be gamed from working in emergency nursing. Those nurses who are working towards becoming specialists will hopefully stimulate and encourage their colleagues in the department. So much in emergency nursing currently depends on experience. With the introduction of the nurse specialist system, the Nurses Sec-
tion of JAAM hopes to encourage these experienced nurses to provide high quality, systematic training for the less experienced. So far, 4000 nurses have qualified as Registered Rescue Personnel, even though there is doubt about the merit of this qualification. This alone indicates that emergency nurses are keen to learn and to assume more responsibility. Finally 1 emphasise that there is still a long way to go before emergency nurse specialists in Japan are properly trained. The international opportunities for exchange of ideas must be increased and extended.
of emergency
nursing specialists
A. Takahashi and M. Ohta
During the past 10 years, improvements and higher standards in emergency nursing and medical care have been pursued throughout the world. In Japan, the modern emergency medical care system has been evolving since 1976, and is now based on the philosophy that severe acute illness or injury is a specialist field. It is recognised as such by both the Japanese medical world and the ordinary Japanese citizen. In line with this philosophy, the development of specialist training for emergency nurses has been given careful consideration. This paper describes the factors involved and the resulting conclusion.
CURRENT SITUATION In Japan, a vast amount of money is spent on medical care-more than 150 billion US dollars per year. There is an excellent medical insurance system which ensures that even the most advanced medical treatment can be obtained by anyone, without financial hardship. Despite this, the average Japaneseis not satisfied with the medical care they receive. The main reason for this appears to be becausethe standard of care received is not as high as the rate of cure. The unsatisfactory standard of care is due chiefly to the shortage of nurses, the result of 40 years’economy on training nurses in order Akiko Takahashi, RN, EISN, Critical Care Medical Centre, An abstract of this paper was September 1992. Manuscript
to keep medical costs down. Currently there are approximately 700 000 nurses working in Japan; in hospitals the national average is 1 for every 4 patients. However, the need for more nurses increases dramatically year-by-year, due to rapid advances in medicine and also to the increased number of elderly patients in hospital, who require far more nursing care than younger patients. The relationship between these developments and the social and professional status of nurses must now be addressed. Socially, the nurse is usually compared to a school teacher. However, in Japan the nurse’s income and hours of work compare
Director of Nursing Services and Muneo Ohia, MD, Director, Osaka Prefectural Senri Suita City, Osaka, Japan read at the Second Pan Pacific Emergency Nurses’ Conference in Singapore, accepted 18 December 1992
162 ACCIDENT & EMERGENCY NURSING unfavourably with those of the teacher, despite the fact of decreasing numbers of children and the increasing need for nurses. Even though many high school students wish to be nurses, there are not enough nursing schools and not enough places in the existing ones. In the past few years these contradictions and imbalances have been pointed out repeatedly, and though the government has laid plans to establish more nursing schools this cannot be done in a short time. About 5% of nurses leave the profession each year; graduate numbers do not keep up with this rate and so nursing numbers reduce. Reasons for young nurses leaving the profession are many-for example: low income, night duty and too much responsibility. The government has recently become sufficiently aware of this serious situation to make an effort to improve it, but this will take a long time because the circumstances are complicated.
POSTGRADUATE EDUCATION FOR NURSES Although it is usual for senior nurses to teach junior nurses and thereby help them to develop professionally, senior nurses do not have time to prepare an education programme as such. In most hospitals, it is therefore the responsibility of the director of nursing to issue an education programme for new employees and especially for the newly qualified nurses. This is unsatisfactory for several reasons. The postgraduate education varies from hospital to hospital and depends on the enthusiasm and commitment of the senior nurses. There is a wide range of methods and standards; students are attracted to the hospitals where the quality of postgraduate training is known to be high and prefer to stay there rather than move elsewhere. These hospitals make a point of trying to attract the graduates.
BASIC EDUCATION FOR NURSES Nursing education in Japan is based on a 1948 Act of Parliament. Accordingly, in order to register, the nurse undergoes 3 years’ training which can be modified in various ways for convenience to the student. The curricuhun is based on the American system. During the past 10 years, many junior nursing colleges have been established, but nurse training in Japan still rests largely with the nursing schools. The first of these was established in 1952 and today there are only ten. 30 more are planned for the next few years, but even this will not compare with numbers of nursing schools in other developed countries. The theory taught is revised every 10 years or so and more time allocated to it, whilst the time spent on clinical practice is reduced. If this trend continues, the trainees’ clinical practice will decrease in both quality and quantity and there will be more emphasis on in-service training after graduation.
In-service training This method is convenient and clinically efficient. The nursing department of each hospital issues a schedule to ensure that new graduates understand the aim and philosophy of the hospital, as well as aspects of the nursing manual such as orientation, special&d and technical knowledge and leadership.
Education plans made by the Japanese Association of Nurses
(JAW This is a national professional association for nurses, with headquarters in Tokyo and branches throughout the country. About 70% of working nurses belong to it. JAN’s main educational activities are annual meetings and seminars at both national and branch level, plus advanced courses run at the seminar school for nurses throughout the country.
ACCIDENT & EMERGENCY NURSING
Education by the Professional Association of Nurses This training is aimed at general nursing and not at any kind of specialisation. So each nurse also belongs to another professional association for her own field-surgical nursing, paediatric nursing etc. These associations each have their own meetings and seminars, and supply special&d training. Most are run by physicians, since most were founded by physicians. This illustrates the relationship between nurses and physicians in Japan, namely that nurses depend on physicians for their professional and financial status. This applies equally to emergency nurses in spite of the responsibilities they carry in their work and the spirit of independence that motivates them in attempting to change the system.
Nurses’ department of Japanese Association for Acute Medicine Before this is discussed, the Emergency Medical Services System (EMSS) in Japan should be explained: The Japanese Ministry of Health and Welfare has instituted several new systems in emergency medicine. The present EMSS was established in 1977 and is based on the classification of patients and facilities into three levels of need, linked by an information network:
Level 1 These patients require simple treatment or some medication, and can then return home. They are treated at practitioners’ clinics and/or hospital outpatient clinics designated by the governor of each prefecture. Each city has night/holiday emergency clinics.
Level 2 These patients need more treatment and should be admitted or held for observation. Most of them are treated at designated hospitals or at hosuitals on a rota svstem. , 1
163
Level 3 These patients are in a severe stage of an illness or disease, or have received serious injury, and need intensive care, special treatment e.g. respiratory care, circulatory care, hemodialysis, plasma exchange, hyperbaric oxygen therapy etc. They are treated at the 106 critical care medical centres, most of which belong to general hospitals or medical colleges and serve, on average, 1.5 million people. There are also three independent critical care medical centres; one of these is the writer’s place of work. The information networks, both at prefecture and city level, respond to 119 (UK equivalent 999) calls from the public. Their main role is to assessthe severity of the emergency, and to coordinate the emergency and ambulance services and the availability of beds in the various critical care centres. 99% of the population has access to the ambulance telephone call service (119 system), which responds in less than 10 minutes. Even so, the recovery ratio of cardio-pulmonary arrest patients is still lower than in other developed countries. Very few Japanese have any knowledge of First Aid to be applied before the ambulance team arrives. Ambulance team personnel are not trained in advanced life-support techniques such as endotracheal intubation, because these are legally medical procedures and are limited to physicians. The result is that Japan has a large number of so-called ‘vegetative patients’, bringing many problems to families, medical workers and the health service. One attempt to overcome this problem is the doctor’s car system, in which a car is sent to pick up a doctor and take him to the scene of the accident/emergency. This is being run as a pilot scheme in several areas, but is not functioning well. During the past few years there have been major citizens’ campaigns, organised by the mass media, to raise the ratio of recovery from cardiopuImonary arrests. These campaigns have pressed for rescue personnel to be trained in advanced life-support skills. In 1991 the Registered Emergency Technician law was passed, and from May 1992 these
164 ACCIDENT & EMERGENCY NURSING
new Registered Emergency Technicians began to work in the Emergency field. However, this development is not expected to influence the situation significantly since the ordinary citizen still has no education in basic life-support skills for cardiopulmonary arrest.
-To give sympathetic and understanding emotional support to families.
The basic nurse training includes little emergency nursing in its curriculum, and so the emergency nurse needs organised postgraduate education as much as nurses in other specialist areas, such as paediatrics and psychiatry. Nurses’ Section of the Japanese Once a nurse is qualified, there is no legal Association for Acute Medicine requirement for her to update her knowledge, (JAAM) and so postgraduate education depends on JAAM was established in 1973 by physicians the individual hospital. In the emergency deworking at critical care medical centres, and partment it is in the interests of the physicians has contributed to the development of emer- to ensure the nurses are trained in the necesgency medicine to its present form. However, sary skills to assist them. There is no doubt until 10 years ago, nurses working in Inten- that this has benefitted emergency nurses, but sive Care Units (ICUs) and emergency depart- until the JAAM Nurses’ Section was estabments were not trained adequately in the use lished in 1981 and began to grapple with the of the rapidly-advancing technology. In addi- problem, training content and methods were tion, they were regarded by general nurses as not standardised. a separate group closely allied to the physiciOnly recently has the Japanese Associaans. tion for Nurses issued guidelines on trainThe Nurses’ Section of JAAM was estab- ing in certain specialities-circulatory disease, lished in 1981 by a few nurses working at cancer, psychiatry, acute medicine, paediatric, tertiary nursing facilities, and has since con- gerontology and emergency medicine. The tributed to the development of emergency training plan for emergency nurse specialists nursing in Japan. There is a membership of has been under consideration for some time about 2000; the steering group is elected from and therefore leads the field. The basic conactive critical care medical centres. There is cept is as follows: an annual meeting attended by an average Each critical care facility now uses a schedof 1000 members, where new techniques and ule which was compiled after discussions at experiences are shared. The quality of emer- the meetings and seminars, as follows: gency nursing has consequently improved. Once a year, 200 or so junior and intermediate nurses participate in an emergency nursing Training of beginners-10 days” seminar. A journal of emergency nursing also -Philosophy of the hospital and/or unit disseminates information and experience. -Concept of emergency medicine, including emergency nursing and EMSS -Basic skills in intensive care Postgraduate training -Respiratory care -Circulatory care The role of the emergency nurse increases and -Fluid balance becomes more complicated year-by-year, due -Use of medical instruments to the advances in technology and the under-Basic knowledge of common traumas standing of disease. The role can be defined and diseases. as: -To observe patients in the light of accurate knowledge of various diseases. -To assist physicians in their treatment, using one’s knowledge and experience.
* It seems a strange custom to me that some nurses whom I met in Canada and the USA change to a different unit every day. In Japan, because each hospital and each unit has its
ACCIDENT & EMERGENCY NURSING
own nursing manual, new employees take more than a month to learn the manual, and in the early days every nurse receives orientation training about every aspect of the work. Advanced training (2 hours every 2 weeks for 6 months) After 6 months, nurses receive specialised training in emergency medicine and nursing. This involves lectures on diseases and treatment such as myocardial infarction, cardiac insufficiency, cerebrovascular accident, acute abdomen, burns, trauma, organ failure and special&d medical procedure such as haemodyalisis and plasma exchange etc. Training of leaders (1 week) As many hospitals are adopting team nursing, the role of leader becomes more important. Nurses who have more than 3 years experience in the field of emergency nursing are able to take the leaders’ course and become a leader nurse. After working for 2 years as a leader nurse, they can attend the second training course. This training is based on discussions about leadership, education of junior nurses, nursing study, management etc. Guidelines for professional education After 3 years experience, nurses begin to report on their postgraduate studies, to meetings at both local and national level. Some of these are published in professional journals, some of the nurses are given the opportunity to attend meetings and seminars sponsored by JAAM and other organisations. In this way their education continues and they become potential specialists in emergency nursing. Training for emergency nurse specialists The roles of emergency nurse specialists in Japan are classified as follows: First Aid -Correct -Triage.
observation and assessment.
165
-To assist physicians at CPR and other special procedures. -To prepare the room with necessary equipment. -To provide emotional support to patients and their families. These aspects of the role are similar to those of the nurse in the admitting room of an emergency clinic. KU cure -Patient care using high-technology medical instruments. -Management of patients in intensive care, especially respiratory care, circulatory care and fluid balance. -Advanced and close observation of emergency patients whose previous history is unknown.
Post ICU -To help patients and families to come to terms with their illness or injury. -To plan and execute suitable rehabilitation in cooperation with other medical personnel. -To care for dying patients and their families.
Emergencyprocedures -Setting venous lines -Defibrillation -Oxygen therapy -Hemostasis etc. Training in emergency procedures is still not sufficient because the quality varies from hospital to hospital. Therefore it cannot always be said to reach the standard required for emergency nurse specialists. Because of the shortage of nursing schools in Japan, the nurse specialist does not yet require a Master’s degree. The Nurses Section of JAAM requires emergency specialists to have
166 ACCIDENT & EMERGENCY NURSING at least 5 years experience in the field, and to have gained credits through examinations, reports and attending classes and seminars. These specialists are needed not only to help improve the quality of emergency nursing, but also to emphasise the stimulus and pleasure to be gamed from working in emergency nursing. Those nurses who are working towards becoming specialists will hopefully stimulate and encourage their colleagues in the department. So much in emergency nursing currently depends on experience. With the introduction of the nurse specialist system, the Nurses Sec-
tion of JAAM hopes to encourage these experienced nurses to provide high quality, systematic training for the less experienced. So far, 4000 nurses have qualified as Registered Rescue Personnel, even though there is doubt about the merit of this qualification. This alone indicates that emergency nurses are keen to learn and to assume more responsibility. Finally 1 emphasise that there is still a long way to go before emergency nurse specialists in Japan are properly trained. The international opportunities for exchange of ideas must be increased and extended.