In many countries undergoing rapid social transition, there is high concern among nursing administrators regarding at least two basic problems in their profession. These problems are: ( 1 ) raising the standard of nursing in a situation of uneven social change, and (2) developing means of attracting optimal types of persons to nursing careers. Although a large body of information on nursing and on characteristics of nurses in Western countries is now available in reports, little systematic data of a comparable nature is available pertaining to non-Western settings. This lack of data limits the availability of models and closely relevant reference points to which nursing administration in countries with non- Western backgrounds can turn.
This article, which is a report on some characteristics of a population of Japanese student nurses at two distinguished schools of nursing in Japan, describes some of the influences that affect basic career decisions of student nurses in an industrialized, non-Western country and attempts to clarify some of the elements that may shape the subsequent careers of these nurses. Although the data are derived entirely from student nurses in two schools only, the empirical description may serve as a reference point for possible comparison with other student nurse populations in Japan and in other countries in relation to the traits, orientations, and goals of a group of women who will become professional nurses.
In particular, the following characteristics of the study population are examined: (1) age at time of decision to enter nursing, (2) age at time of choice of nursing school, (3) attitudes of parents toward the nursing career decision, (4) the influence of key persons upon the decision, (5) factors associated with the choice of specialty, and (6) related matters. To set the findings in their proper context, moreover, some basic social background characteristics of the study group are briefly reviewed.
The data in this report are perhaps of special interest because they are from a country involved in dynamic, wide-ranging social change. Since the days of the Allied occupation, when the status of the Japanese woman underwent abrupt legal change, the role of the Japanese woman has been evolving in a distinctive way. The nursing profession reflects this unusual evolution and itself represents an occupation in transition.1
The data were derived in 1959 from sociological questionnaires completed by the total student nurse populations of two schools of nursing in Tokyo. The two institutions, Tokyo University School of Nursing and St. Luke's International Hospital School of Nursing, have a three-year curriculum which leads to certification as a registered nurse. The main portions of the questionnaire, which the students completed in the Japanese language, concerned information on factors involved in choice of occupation and on aspects of social background and family characteristics. One hundred and thirteen students at Tokyo University and ninety-three at St. Luke's participated in the study.
Traits of the Study Population
Age and Class in Nursing School. The study population ranged in age from 18 to 23. Their mean age was 19.3 years. In terms of distribution by year of school, the study population was divided into segments similar in size: 32 percent were enrolled in the firstyear class at the time of the study, 32 percent in the second year, and the remaining 36 percent in the third year.
Social Status of Family of Orientation. A basic feature of the study population is that they come from families of relatively high socioeconomic status. Both parents were comparatively well-educated, as compared with the general Japanese population. Fifty-one percent of the fathers had completed the equivalent of at least one year of college; and twenty-three percent had completed from 17 to 19 years of education, an amount roughly equivalent to that completed by persons receiving postgraduate professional training in the United States. Less than one-fifth of the fathers had had the equivalent of a grade school education or less.
The occupation of the father indicated that the study population was largely from the upper level of the social status scale. Forty-five percent of the fathers were in professional occupations of various types. The proportion of manual laborers was relatively small, for only four percent were blue collar workers and eight percent were farmers. The remainder were engaged in white collar occupations, such as executive, managerial, and clerical jobs.
Religious Affiliation. Religious identification presented a striking picture. Seventy-four percent of the respondents were affiliated with the modal religion of Japan, Buddhism or a combination of Buddhism-Shintoism. Twenty-six percent identified themselves as Christians, the majority being Protestant. In Japan, members of the Christian faith number approximately 600,000 in a country of over 93 million persons. St. Luke's Hospital School of Nursing, which has an historical affiliation with Christianity, is responsible in large part for the relatively large proportion of Christian students in that institution. Among the total group of students of Christian faith, about 75 percent were enrolled in St. Luke's.
Focusing now upon this group of Japanese student nurses comprising the study population, what is the nature of their orientation toward nursing, and what factors contributed to their career decisions? These questions can be answered in part by examining their responses to the research questionnaire.
Age and Career Decisions. According to the students, their first considerations of nursing as an occupation came relatively late. Approximately 75 percent of them first thought about becoming a nurse after they had passed their sixteenth birthday, and 25 percent did not consider nursing until after they had passed their eighteenth birthday.
From these data, it is apparent that the possibility that nursing represents the fulfillment of childhood fantasy is relevant to only a small mumber of the students. Further, these data are in marked contrast to findings in American settings concerning age at decision in regard to medical and nursing occupations. 2"5 A study of the total student nurse population at Children's Hospital in Boston, Mass., for example, revealed that well over half the respondents had considered nursing as a potential occupation before age fourteen, and approximately 30 percent before age ten. 6
In the study population in Japan, the choice of the specific institution for training was also made comparatively late. Ninety-five percent of the students began planning for entry into their school of nursing after age sixteen. Of the total population, 40 percent undertook such planning after age eighteen. In American settings the young girl of high social status equivalent to that of these Japanese nurses is very often likely to begin fantasying at an early age about the school she will enter and about her experiences at college. This kind of planning and dreaming among the Japanese student nurses does not appear to be notably common.
Alternative Occupational Choices. In view of the fact that career decisions regarding nursing were arrived at relatively late in the adolescent life of the Japanese student nurses, it is not surprising that nursing was chosen from a set of competing alternatives. Indeed, about four-fifths of the study population had considered entering other occupations besides nursing. The nature of the other occupations indicates in part the pattern of interests of the young women who will eventually enter nursing careers, and illustrates the kinds of competition which nursing administrators engaged in recruitment in Japan must face.
The study population was asked an open-ended question concerning possible alternatives to nursing. The range of these alternative occupations indicates that the majority of the nursing students were oriented toward professional level occupations. The occupations most frequently cited were in the field of education, those of teacher or scholar. These alternatives were mentioned either singly or in combination by 40 percent of the respondents. Third in rank was "pharmacist," an occupation which is related to matters medical and which, like that of the nurse, represents a link in the process of patient care. Next in rank was an occupation differing from the others in that it is not on a professional level- that of secretary or office worker -cited by 1 1 percent of the students. The occupation ranking fifth was "doctor," listed by 10 percent of the nurses. Finally, "dietitian" was listed by about 8 percent. The remaining choices were distributed among such occupations as journalist, radio announcer, dress designer, and so forth.
In sum, the decision to enter nursing meant the selection of an occupation within a status and occupational range toward which the respondents were already directed. The most frequently cited occupations at the professional level reflect two types of patterns: (1) interest in occupations which in many ways involve skills and substantive areas of knowledge similar to those involved in nursing, and (2) particular interest in a traditional and respectable pursuit of young women, that of the teacher.
Parents in Medical and Paramedical Fields. The possibility that parents served through their own occupations as role models in guiding the students toward nursing is minimal. Only 10 percent of the fathers were in a medical or paramedical occupation. Included in this group is the 8 percent of all the fathers who are doctors. It appears that 5 percent of the mothers formerly had been employed in nursing. One mother was a physician. It might be suggested that at least some of the young women chose nursing by following the occupational example of their parents, but this explanation does not hold for a substantial majority of the students.
Nursing, Employment, and Future Way of Life. Although the choice of nursing as an occupation was made relatively late, the Japanese student nurses, on the whole, indicated intentions to maintain commitment and involvement in continued employment well after graduation. Most of them planned to continue nursing after marriage. Traditionally, in Japan, women of the higher social strata do not work after marriage. However, approximately 50 percent of the students indicated their intention to continue working after marriage; an additional 25 percent were undecided. Only 25 percent reported that they did not intend to continue working, possibly demonstrating thereby an adherence to a traditional social norm. These data reflect in part the changes in postwar Japan in the direction of "modernization" of the role of women, changes which make the employment of married women more socially acceptable.
The women who intended to continue working after marriage reported several types of plans. One-half indicated that they would work as nurses during the first year or first few years after marriage. The second half would continue working indefinitely, but within this group about one-half reported that they intended to maintain employment on a part-time basis.
Some indications of the kind of future life the students would prefer after graduation may be seen in their responses concerning the kind of occupation they would prefer their future husband to have. A majority of the students (161) listed professional level occupations, a preference which is consistent with the fact that these students are themselves preparing for a profession and that they come from families of relatively high social status. Within this group of 161 students, 36 percent designated a preference for a husband in a medical or paramedical occupation. In fact, 31 percent explicitly indicated that they would prefer to marry a doctor.
Bases for Occupational Choice. What factors led the study group to select the particular career of nursing? The motivations are complex, but some insight into the factors that influenced the student nurses can be obtained from their reports. In the interview schedule the students were asked in an openended question to list the three most significant factors that led them into nursing. The total pattern of responses revealed that these students fell into two major categories. One can be termed "humanitarian" reasons, the other "pragmatic" or "instrumental". The humanitarian -pragmatism dichotomy may be analyzed in terms of the kinds of ends which the nursing career is designed to serve, as it is conceived by the nurse. Essentially, the humanitarian orientation refers to service to others. The pragmatic orientation serves the needs and requirements of the student herself, thus constituting a means of fulfilling personal, practical goals.
Among the responses of a humanitarian nature most frequently cited were the following: (1) the desire to do something for others; to care for the sick and to thereby contribute to society; (2) a wish to be part of a worthy or noble profession; (3) the fact of having been motivated toward nursing as a result of having had a serious illness oneself or having had the experience of observing serious illness and/ or the death of a parent, relative, or friend.
Among the most frequently cited reasons of a pragmatic nature were the following: ( 1 ) obtaining a nursing education was less expensive than other types of education; (2) the desire to have a professional type of occupation; (3) the wish to have a job which could ensure economic security; (4) inability to attain an original goal of entry into another occupation or another type of school.
Examples of influences that did not clearly fit into either the humanitarianism or pragmatism categories were such responses as: (1) the persuasion or examples of family members and friends, and (2) the operation of chance or coincidental factors that seemed to make entrance into nursing school a reasonable decision at the time.
Each of the reasons underlying the career decision to enter nursing was coded, and the nurses were classified according to simple numerical dominance of "humanitarianism" or "pragmatism" as career decision factors. For example, if two or more responses were of the humanitarian type, the student nurse was classified in the humanitarian category. In a third residual category of "other" was included students who listed a majority of "other" responses or who had tie scores of humanitarianism-pragmatism. Fifty-four percent of the students gave predominantly pragmatic reasons for having chosen nursing. On the other hand, only 27 percent were influenced primarily by humanitarian reasons. Nineteen percent of the nurses gave responses in the residual "other" category.
One feature of the sets of factors influencing career decisions was associated with religious identification. Fifty-one percent of the girls who identified themselves as Christians tended to be humanitarian, and twenty-two percent were predominantly pragmatic. On the other hand, the students affiliated with religions traditional to their country, such as Buddhism-Shintoism, presented a somewhat different picture. Sixtyfour percent were predominantly pragmatic, and eighteen percent were humanitarian. In this Buddhist-Shinto group practical, rational contingencies concerning economics, practical planning for future security, and reduction of ambitions in the case of frustrated goals were dominant reasons for their entrance into nursing. Twenty-seven percent of the Christian nursing students and eighteen percent of the Buddhist-Shinto students were classified as being in categories such as "mixed" and "other."
Student nurses in the two religious groups differed significantly when patterns of responses regarding motivation were subjected to a statistical test. Moreover, within each religious group no association was found between humanitarianism-pragmatism and social status level of the family of orientation, rural-urban origins, and other variables. The basis for these differences between Christian and Buddhist-Shinto nurses may lie in the ethical systems and orientations of the two religions with which the students are identified. The Christian group may reflect idealism, altruism, and humanitarian interests, whereas the traditional Japanesereligion group may reflect the situational, particularistic ethic which has been described as characteristic of their culture. 7"10 Further empirical research into the basis for the differences is needed to determine the basis for the finding.
Parental Attitudes toward Career Selection. Among the contexts in which the decision to enter nursing is made, the family is a crucial setting. The attitudes of parents toward nursing, and their reasons for encouraging or opposing a daughter's decision, are significant from at least several standpoints. n"13 They reveal the extent to which the occupational choice by the student is consistent with parental and family goals. Secondly, the types of reasons for encouraging or opposing the choice provide data on the bases upon which nursing is evaluated as an occupation by a population of Japanese parents.
Although a number of parents were eventually favorably inclined toward their daughter's decision to enter nursing, in general the initial choice of this particular occupation did not constitute a fulfillment of parental expectations and hopes. Only 6 percent of the fathers and 4 percent of the mothers had specifically desired that their daughters become nurses. From these data it would appear that the daughter's decision to enter nursing was not the product of an extensive amount of parental channeling. One feature of the range of parental attitudes was that a considerable proportion of the students had chosen the occupation in opposition to the wishes of their parents. Fifty percent of the girls reported that their fathers had encouraged them; about 34 percent reported that he had opposed the decision; and the remainder, 16 percent, reported that the father was neutral, that he had left the decision up to them. A similar pattern is seen in the maternal attitudes reported. Fifty-four percent were encouraging, but thirty-nine percent were opposed. A somewhat smaller proportion of mothers, 7 percent, maintained a neutral position and left the decision up to the daughter.
To what extent was there consensus between parents in regard to the daughter's decision to enter nursing? It appears that a considerable proportion of the parents did not reach a consensus. In fact, many of the parents expressed unanimous opposition. Only one-third of the parents of the intact families encouraged their daughter's decision to enter nursing. On the other hand, approximately 20 percent of the parents were in consensus in their opposition. An additional 25 percent were in one type of conflict position, with one encouraging, the other opposing. In an additional 7 percent, one parent opposed while the other maintained a neutral position, leaving the decision up to the daughter. In sum, in about 53 percent of the families there was either united opposition, disagreement, or partial opposition to the decision.
The basis for the disagreement between parents or for direct opposition reflects in part one of the common images of nursing in Japan. The most common reason indicated was the "low status" of the occupation, and the second-ranking reason was that nursing involves work which is considered too strenuous for the daughter. The fathers were more concerned over the status issue than were the mothers, whereas the proportion of mothers opposing for reasons of the strenuous nature of the work was greater than that of fathers. A third basis for opposition was that preparing for a nursing career would delay marriage for the daughter, and here again a somewhat higher proportion of mothers expressed concern over this issue than did the fathers.
The bases for encouragement by parents were relatively simple, and they appeared to be consistent with the kinds of decision factors cited by the student The most frequently cited reason for parental encouragement was a pragmatic one. Forty-eight percent of the mothers and thirty-six percent of the fathers considered nursing a desirable occupation because of the security it offered. The nurse, according to their view, has a professional skill which will enable her to be economically secure and even financially independent. The second most frequently cited basis for encouragement was related to idealism and humanitarianism. Nursing was regarded as a worthy profession because it serves humanity, aids the sick and helpless, and promotes other humanitarian aims. A somewhat higher proportion of mothers than fathers encouraged their daughters for practical reasons of financial security, and the proportion of fathers who encouraged their daughters because of humanitarian aspects of nursing was even higher. The third most prominent basis for encouragement represents a more general appraisal of the occupation and includes some of the elements in the pragmatic and humanitarian reasons already cited. Similar proportions of parents encouraged their daughters because of a conception that nursing constitutes a suitable or "fit" occupation for a woman.
It should not be inferred that the attitudes representative of parents of student nurses in Japan as a whole are necessarily reflected here. These data indicate, however, the kinds of supports and obstacles which confronted the young women in the study group before they became students at these two schools of nursing. Furthermore, they may suggest the kinds of factors with which administrators engaged in the recruitment of nurses must deal in their efforts to attract young women of high social and/or economic status into nursing careers.
Influences in Selection of Nursing School. Once nursing has been selected from among the range of occupational possibilities, the choice of the specific nursing school constitutes a critical matter for decision. It involves selection from among a range of institutions diverse in quality, character, and availability. In the case of the study population, the primary influences upon their selection of a school were their parents.
The highest proportion of students ranked their fathers as being the most important influence in the decision, and the second highest percentage ranked the mother second. The distribution in intact families in regard to parental influence is of special interest. In these families both mother and father were present, but the proportion of student nurses who cited the father as chief influence was more than twice that of the students who cited their mothers. This finding is consistent with the traditional image of the Japanese family as one in which the father is the dominant figure, and it is contrary to a recent work which points up the role of mothers in determining the educational careers of their children. 14
Another key aspect is the relatively minor role of other relatives and of peer group influences upon the choice of nursing school. These, in fact, were ranked close to more remote "role models," persons whose example the respondent may wish to follow, such as distinguished figures in the nursing profession. At the bottom of the list in terms of significance as primary factors are the effects of influence stemming from mass media. Advertisements and brochures as well as books, plays, radio, and television were minimal influences in affecting the choice of school.
The data can be viewed from at least two standpoints. They indicate first of all the high importance of parental influences upon the key decision to enter a particular school, and they point up the relatively minor role of other factors, including peer group influences. From the standpoint of the nursing school, moreover, they demonstrate the key target toward which messages pertaining to recruitment may be aimed. Obviously, the use of mass media materials to attract students is less critical than the direct and indirect measures that may be used to influence parents about the merits of the school and about the desirability of sending their daughters to it.
This examination of responses from nursing students at two schools of nursing in Japan has centered primarily on various elements involved in occupational choice. From the wide range of data reviewed, several characteristics can be noted to present a brief survey portrait. As has been seen, the choice of nursing as a profession and the selection of a nursing school was made relatively late in the life of the girls, as compared with decisions made by student populations in professional training in the United States. Further, although norms in Japan traditionally may have militated against employment of married women in professional occupations, a considerable proportion of the students intend to carry on with nursing after marriage. This fact may be an expression of the changes in the role of women in Japan that have been occurring during the postwar period. If such intentions are carried out on a wide scale by students in other schools, the common problem of nursing, the loss of trained personnel because of marriage, may be reduced considerably.
In selecting nursing, an occupation with roots in the West, and bespeaking religious traditions of altruism, humanitarianism, and idealism, many students were actually primarily influenced by pragmatic concerns. Christian students in the study population, however, apparently were more likely to be influenced by a higher level of idealism and humanitarianism in their decisions than were nurses associated with the traditional Japanese religions of Buddhism-Shintoism. A primary feature of the study population was that substantial proportions of students were present in the school in the face of parental opposition or disagreement about their decision to enter nursing. In only a small proportion of the cases was there any indication that the occupational choice represented fulfillment of parental ambitions. The decision to enter a specific school of nursing was of another order, however. Once the girl had decided upon nursing, the chief sources of influence in selecting a school were her parents.
This article has been based on data from a highly selected population, insofar as it deals solely with students at two distinguished schools of nursing in Japan. Further, the student population itself derives from families of relatively high social status. Nevertheless, these findings fulfill at least two purposes. They constitute a body of empirical data on nursing populations which are only rarely studied by American students of nursing and the professions - those of ? on- Western settings. Hence, they provide at least a beginning basis for comparison with other student populations not only in other countries but in Japan itself, as well.
Secondly, they point to some of the issues with which nursing administrators and persons interested in recruitment in non-Western countries and in underdeveloped nations might well be concerned. For example, it would appear that attempts to attract qualified persons into nursing may not necessarily be lost if they are directed toward women in late adolescence, as well as in the younger age groups. Although parents may be opposed or at least nonencouraging regarding nursing as a profession, prospects are hopeful that even young women of high status can be attracted to nursing in the face of parental opposition. Finally, it would appear that although the status of nursing may in some senses constitute an obstacle to recruitment, the situation in countries such as Japan may be changing, and there is hope for attracting qualified young women into the profession from all levels of the social status scale.
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