Numbers of international students attending U.S. nursing colleges and universities continue to rise (Alexander & Shaw, 1991; Colling & Wilson, 1998; Gay, Edgil, & Stullenbarger, 1993; McCloskey & Grace, 1993; Shearer, 1989). Although a vast literature now exists concerning international students (Paige, 1990), the literature pertaining to international nursing students focuses primarily on descriptions of undergraduate exchanges (Beeman, 1991; Carty et al., 1998; Colling & Wilson, 1998; Duffy, Harju, Huittinen, & Trayner, 1999; Ryan, Markowski, Ura, & Liu-Chiang, 1998). Many of these papers describe the value and challenges of, or successful models for, short-term undergraduate international nursing education exchanges.
Within the nursing profession, there have been calls for increased diversity and multiculturalism for years (Beeman, 1991; Colling & Wilson, 1998; Furuta & Lipson, 1990; Loustau, 1986; Meléis, 1987; Uhi, 1993). Undergraduate exchange programs are one way to sensitize nursing students' and faculties' awareness across our national and cultural boundaries. Yet at the graduate level, international nurses often apply individually and are admitted without the formality of an exchange program. Grace (1990) and Alexander and Shaw (1991) found that when educators understand the life world of international nursing students, successful and relevant education experiences are more likely. The author conducted an interpretive study that investigated the lived experiences of Japanese graduate nurses in the U.S. This paper presents some of the common themes and shared meanings of Japanese nurse scholars' experiences, both during their study in the U.S. and when they returned to Japan. A concluding section offers suggestions for U.S. faculty that arise from these common themes.
DESIGN AND METHODS
Based on Heideggerian phenomenology, the study explores the lived and reflected experiences of Japanese nurses who obtained master and/or doctoral degrees in nursing from schools of higher education in the United States. The purpose of interpretive or hermeneutic research is not to produce rules or theory but to uncover life worlds to enhance understanding. The hope is that faculty with deeper understanding of the lived experiences of the Japanese students will incorporate this awareness into tactful, caring education practices. No behavioral prescriptions are intended.
Primarily in Japan, 42 one- to three-hour interviews with 25 nurse scholars (20 women, 5 men) were conducted over a ten-month period. Master or doctoral degrees from schools of higher education in the United States had been received or were in the process of being received by 22 of the participants. Most had returned to practices in Japan- many in teaching positions- 3 to 20 years before being interviewed. In addition, interviews with 3 Japanese consultants who aided in specific explication of themes and early analysis, were transcribed and treated as data. All participants gave written informed consent. Consent was conceptualized as a process (Munhall, 1988). Confidentiality was not assured because of the small number of possible participants, but consistent with the conceptualization of consent as a process, the nurse scholare were offered the option of withdrawing interviews or specific episodes at any time prior to publication.
Interviews were tape-recorded and transcribed verbatim, then sent back to participants for "member check" validation (Lincoln & Guba, 1985). They were conducted in English for several reasons. First, the author is not fluent in Japanese, while all participants were fluent in English after their international educational experiences. (The three Japanese consultants had also spent time in the U.S. and were fluent in English.) Second, participants stated they were able to speak about issues, concerns, and problems more precisely in English than in Japanese- a language of ambiguity (Hall, 1983), in which meaning often depends as much on the context of the message as on the words it contains.
It was thought that repeated contact with individual participants would create greater comfort and therefore more disclosure, which generally proved to be true. Up to three interviews were conducted with each participant. Initially, rather than proceeding with particular questions or specific probes, the interviews for this study, like other hermeneutic interviews, usually involved listening to episodes from everyday life (Diekelmann, 1991). Participants were asked to describe incidents they recalled about their adjustment to the U.S. They were asked about problems and requested to describe times when they were surprised, shocked, or embarrassed by what they encountered in their everyday H ves. They were also asked "how things had been going" since returning to Japan. During follow-up interviews, participants were asked about interpretations and themes were, at times, openly discussed. For example, "Some participants have talked about mental health changes. Did you have any experience with this?"
Interpretive analysis requires a deep understanding of background meanings, and meaning depends upon text. At times the interpretation hinges on specific word usage and language. In Japanese, several complex concepts and their relationships may be illustrated by kanji, the Japanese written characters based on Chinese ideographs. Explanation of certain kanji can deepen the interpretation. For example, according to Japanese colleagues, the kanji depicting "phenomenology" contains three characters. Alone, one may be translated, "appearing" or "being at present." The second may be translated as "elephant," "shape," or "figure." And the third refers to "the study of. . . ." When the three characters are used together to make phenomenology, they may be translated as "the study of the revealing of the essence" or as one participant put it "the whole picture." There is interpretive richness available through explanation of the characters. When difficulty in cross-cultural understanding was apparent, participants were often asked to describe the kanji they might use to portray the concept in question.
Analysis occurred in several iterative phases and began in Japan with the first interviews. Transcriptions of early interviews were sent to a group of doctoral and postdoctoral students and two faculty from the Oregon Health Sciences University School of Nursing, knowledgeable about qualitative, and specifically, hermeneutic methods of analysis. Three Japanese doctoral students, participants themselves, aided interpretation particularly in areas of confusion. The hermeneutic analytic process used overlapping strategies. Even during the early interviews interpretation occurred. Early reflective interpretation of the transcripts involved reading a single transcribed transcript, then reading several transcripts together, and identifying areas for further exploration in later interviews. Coding for data retrieval were carried out according to a plan devised by the analytic team. Analysis also included identification of principal themes and interpretive writing based on exemplars and paradigm cases illustrative of these themes. This analysis drew on the participants' narrative accounts and their subsequent reflections on their educational experiences, both positive and negative, that the nurses themselves judged transformative of their professional lives.
RESULTS AND IMPLICATIONS
Quotes from participants are used liberally in this paper. As is often the case in Heideggerian studies of this type, each example presented is representative of many reflections of a particular theme or concept.
Sense of Self and Self-Disclosure
During acculturation, Japanese international students may be undergoing a change in their deepest core, a change in the sense of self. Especially poignant are the words of one participant:
My self-esteem gradually went down. Six months is peak. My sadness is peak. After six months my sadness is peak. I can't speak English well. Fm sad to say so. Fm not happy. At night in my apartment, I'm alone. Sometimes I weep. I don't want my Japanese friend to know because she sometimes advises me. She told me people always felt depression. And I know. But now I feel.
This changing sense of self stems not only from acculturation stress but also from the different definitions of self in the U.S. and Japan. Hiroko Minami, DNSc, RN, (one of the three consultants), described the Japanese self and touched on the changes that occur during acculturation:
The way we think is always thinking of the other person's feelings and thinking. If I cannot predict what you think, what you feel, I am lost completely. I dont know how I feel and nobody is really thinking about what I feel, what I think. . . . But Japanese, because we have less ego boundaries, we don't have "I" or "you" or that kind of thing.
The flow of concern from the other is a foundation of self-definition in Japan. When the student is away from this grounding flow, s/he may experience a loss of self (jibun ga nai). This can be compounded by the differences in cultural expectations concerning self-disclosure (Barnland, 1987). U.S. Americans use self-disclosure to become closer to others. In Japan, there is less enthusiasm for verbal expression. Moreover, self-disclosure may be considered bragging or setting oneself off from the group, and it is not congruent with the restraint and humility valued in Japan. Consequently, for the recently arrived Japanese student, self-disclosure may increase the feeling of loss of self. Dr. Minami stated:
You are expected to disclose yourself in your country. If you don't you are isolated. But for a Japanese it is very difficult to do that because actually this is the ego boundary and so you feel like your self is going away. Or if you cannot do that [self-disclose] you feel you are a failure.
The importance of the advisor to international students was a strong theme in this study and has been reported elsewhere (Kayser-Jones & Abu-Saad, 1982; Tien, 1982). For Japanese international scholars, the decision to study in the U.S. implies a tremendous commitment. Likewise, the students infer a high level of commitment from faculty agreeing to work with them. The crucial position of the advisor to the international student is summed up by the following excerpt:
If you find a kind advisor, there is no problem I would say. She will help in your personal life or academic life. But otherwise, I would have been miserable.
The time of initial acculturation can be difficult. Early communication with faculty may be compromised by a lack of English fluency and acculturation stress. In addition, cultural differences, such as the difference between the hierarchical Japanese student-teacher relationship and less formal U.S. practices, may lead to misunderstanding. The high tolerance for ambiguity and discomfort with expression of personal preference characteristic of Japanese communication patterns means that students are unlikely to initiate clarification. Early miscommunications tend to be compounded by the fact that polite listening behavior in Japan includes nodding and repeating "hai" the Japanese word for "yes." When Japanese students repeated this automatic behavior in English, faculty assumed they were agreeing. In fact, the students were only conveying that they were listening to the conversation, though not necessarily understanding it. A participant describes a first advisor meeting and his almost total lack of understanding during it:
It was the first time for me to fly on an airplane, so when I left Japan- my first experience out was so strong that I was not able to remember the name of my advisor. Her name was Catherine, a common name for an American. She said her name, but I was not able to understand what she was saying at all. I was just smiling and didn't say anything. That was the first experience that I can remember. I felt totally strange.
During acculturation, faculty may wish to honor the autonomy of the international student, showing respect for independence and freedom of choice. Thus, although faculty may sense a problem, they may wait until a crisis or until assistance is requested, a response that reflects U.S. cultural values. Similarly, faculty may gently offer help by saying, "Let me know if there is anything I can do." Participants indicated two reasons this approach often failed. First, when participants were in the most serious trouble, they were not always aware of their situations. Or, they knew they needed help, but could not articulate what kind. One participant described this phenomenon:
They need help but they just believe they can manage. . . . And it's so painful because they wouldn't need help if they are in Japan. For some, partially they know they need help; but they think this is a kind of language problem or just try to deny the problem.
Second, Japanese international students must often overcome enryo or hesitancy to contact faculty. Enryo is a complex concept that in this study was tied to unwillingness to "bother" faculty or anyone higher in the professional hierarchy, such as physicians. Even when students had been invited to call on faculty, they often hesitated to do so. Below a participant describes feelings of enryo:
Sometimes faculty offer, "Why don't you come, because your English is not good enough? Maybe if we spend some time, it might be helpful for you". . .but students cannot take that advice because there is so much hesitating. Students think that maybe it's a burden on faculty so then the student doesn't visit the faculty's office. The faculty is angry because the student never shows up. It's a missed communication.
This reluctance tended to fade as students became aware of the lesser hierarchical separations between U.S. faculty and graduate students.
Participants were grateful to faculty who extended themselves in personal ways, for instance inviting students to their homes. The following excerpt is from a participant who recalled several years later the kindness of his dean.
The dean- he was very supportive to me. One reason is I was very poor in English so he was very worried about my academic advancement. He corrected my English and he was emotionally also very supportive. He invited me to dinner sometimes.
Japanese people are less likely than U.S. Americans to entertain in their homes and typically, student-teacher relationships in Japan are more formal. Participants reported how much they appreciated the more informal and less hierarchical U.S. relationships. For example:
The teachers say "we respect your opinion" and that kind of thing, so I don't need to think much about teacher-student relationships or age differences or gender differences or position differences. How to speak is different but I can say whatever I want. That's really a nice feeling for me.
Teachers were described as "being there" for their students and "students were the main guests" in the classroom. Even the idea of faculty holding office hours was enthusiastically embraced as evidence of a "kind of student rights."
In Japan we can visit any time but sometimes the professor is away or the professor has a meeting. So we hesitate to visit. But in America, we can. We can see the professor's open hours in the class schedule.
Mental Health Changes
Some participants in this study experienced mental health problems for the first time in their lives while studying abroad. Depression was the most common mental health complaint reported by participants, but paranoia was said to be common also. Some participants even said they had suicidal feelings. However, the suggestion to "seek counseling" has strong meaning for the Japanese international student. For example,
So [in this case] the faculty asked, "Why don't you get student counseling?" And the student's situation was getting worse and worse. The suggestion to get counseling at first really upset her. We don't need counseling. The concept of counseling or therapy is quite different. We think of that as a kind of the final alarm.
This participant had been asked to "help with language mediation" in a conference with another Japanese student and a U.S. faculty member who were having a difficult time communicating. The participant stated this was not because of language but was from lack of understanding each other's perspective. Therapy and counseling are based on Western ideas that verbal discourse can lead to insight and emotional relief. In Japan, verbalization and the ability to articulate a problem are less valued. In fact, speaking about something may lead to increased shame about it. The following comments illustrate this pouit:
And I don't want to express my weakness. I don't want to say so much. Sometimes I feel depression or sadness and when I tell someone, I regret it. Therefore sometimes I say to myself, "You can do so!" "You can do it!" It's my coping behavior. Or I call Japan. I can relax then. And when I felt sad, I go to bed.
Multiple mental health disturbances may accompany the process of acculturation (Paige, 1990). It is important to note that mental status changes, sometimes including those associated with psychotic processes, like hallucinations and paranoia, did not prevent these participants from successfully completing graduate programs in the U.S. Moreover, some participants reported that their mental health problems and associated experiences made them more empathetic and understanding.
Differences and Transformations
Differences in the nursing context between the U.S. and Japan emerged as profound and powerful themes in this study. Japanese international students may experience cultural dissonance and confusion when required to adopt U.S. views of nursing. Differences between the U.S. and Japanese contexts of nursing delineated by this study included, but were not limited to, differences in: role and power, patient expectations, the conceptualization of aspects of nursing, and caring practices. For example, the notion of the nurse as a patient advocate, assertively questioning physicians' decisions or orders, was said to be uncommon in Japanese nursing. Yet in the U.S., the nurse is expected to be a change agent, an assertive advocate for the patient, and a "truth telling" patient educator. Truth telling and informed consent are based in part on U.S. notions valuing autonomy and individualism, and in part, perhaps, on the lack of trust many U.S. Americans feel for their physicians. In Japan, other values are primary and in practice, the notions of truth telling and informed consent are often enormously conflicted, especially for the U.S.-educated Japanese nurse. Moreover, patient expectations concerning other aspects of health and nursing care may also be quite different. One participant described how, after practicing many years in the U.S., she had difficulty readapting her caring practices to fit Japanese patient expectations on her return. She gave patients choices about their care rather than providing for their unspoken needs.
So I said, "What would you like? You have five choices. Which choice would you like to have?" And they'd look at me. They'd stare at me sometimes for three or four minutes. For a long time for me but not for them because they are just seeking what I want them to choose.
In the U.S. people tend to appreciate choices, and caring includes asking those patients who can to specify preferences, but in Japan the unspoken caring connection is more valued. For a more extensive discussion of caring practice differences see Doutrich (1993).
Participants also encountered cultural differences in the academic environment. Becoming opinionated and verbal in classes, as well as expressing preferences and personal thoughts, was identified by participants as requiring a loosening of cultural proscriptions. One participant was initially amazed by students speaking out:
Even though it was a huge class, students talked a lot. In the beginning I could not understand much English and I was thinking, "Wow! They know a lot!" And after the quarter was halfway over I was getting so I could follow what was going on. And then I realized- many students are not relating their comments to any content in the class and I said, "What? This is not only the clever person questioning and challenging the faculty." . . .Later on I realized if I didn't speak up they [the faculty] would think I cannot understand, or I'm not interested in the class. Either way is a negative thing.
The participants in this study reported that the two most difficult aspects of U.S. graduate education were learning to speak out in class and learning to function in U.S. group situations. These were difficult in part because expected behavior was found to be so different. For example, in Japan, wa, harmony within the group, takes precedence. In the U.S., this value perhaps has less importance and usually does not conflict with group members' free expression of diverse opinions. Many participants learned to speak out directly and assertively, abilities that they perceived as necessary for success in U.S. classes.
Participants also found writing in the U.S. style, with points laid out explicitly and made in a linear, logical fashion, troublesome at first. Japanese writing tends to be more circumscribed and arguments are implied. There is a circular or spiraling sense to the reasoning, rather than a linear logic. A participant alludes to these differences below.
Japanese students are taught how to read between the lines. That's very important. . -One of my American friends said, "There is nothing between the Unes!" That's funny.
In 1982, Abu-Saad and Kayser-Jones reported that international nursing students in their study found "different patterns in personal and professional socialization" from those in their home countries- aspects of student life that were unexpected and required adaptation. As they came to appreciate the collaborative aspects of the patient-advocate role and learned these new ways of being, the Japanese participants in this study changed. These changes set them apart from their nursing colleagues at home in Japan, and sometimes resulted in intense experiences of personal loss and alienation at reentry.
Returning to Japan
A strong theme emerged in this study related to the Japanese nurses' re-entry: the overwhelming sense of loss expressed by many of the participants. While for some the loss was associated with an easier life style and more leisure time in the U.S., others mourned the loss of an independent personal life. Caught in the obligations and responsibilities inherent in faculty or leadership positions in Japanese nursing, participants reported suffering and feeling childish for complaining about it.
In Japan, in Japanese culture, if you are mature, you have to accept. You have to deal with the system. So to complain about the system or to complain about the situation- it is childish.
The time spent in school in the U.S. was often thought of as personal time. Long hours of study and short sleep were common, but there was a sense of freedom from other responsibility. "I was free! To study." The return to Japan, for many of the participants, consequently marked the beginning or the resumption of obligation. No personal life and little free time were universal complaints, and for those participants who came back relatively young, to midlevel positions in the seniority-driven hierarchy, overwhelming responsibilities were coupled with a lack of power and authority within the institution.
In contrast to other international students, re-entry may be especially difficult for Japanese returnees because of current ambivalent attitudes in Japan toward the U.S. and because of the conflicted Japanese response toward anyone who has left the group and tries to return. A Japanese children's chant that accompanies a playground circle game translates, "Leaving is good, but it's frightening to return" (White, 1988, p. 1). Tb play, children unclasp their hands and raise their arms to signal that the one who is "it" may leave freely. Then they quickly grab hands and move together to prevent the child from getting back inside the circle. White (1988) claims this is a metaphoric symbol of the exclusion that is often felt by persons returning to Japan.
Concerns about re-entry often preoccupied the students before returning. While in the U.S., participants talked with each other about difficulties they expected on return, but once back, the proscriptions on self-disclosure and the staggered arrivals of international students often precluded open discussion. One participant described it this way:
They can talk about it when they are in the United States and they can anticipate it. But when they come back, because of the culture, people don't speak. They don't discuss it.
Strategies for Faculty
Recognizing the motivating factors for Japanese international students, such as the desire to work closely with faculty knowledgeable in a specific area, can sensitize U.S. faculty to the international student's perspective on the level of commitment implied in the mentoring relationship. Although it is unlikely that Japanese international students will assume amae relationships with U.S. faculty, knowledge of the concept of amae, the Japanese cultural value that not only allows adult interdependency but idealizes the "sweet" relationship (Doi, 1973), could aid faculty understanding. It may be helpful to define what the agreement to "work together" means both to the student and faculty. For instance, one participant suggested if the faculty knows he or she will be gone on sabbatical during the student's expected program of study, it is important to explain this as soon as possible. Sabbaticals are unusual among Japanese nursing faculty and are not an expected aspect of graduate life there.
On arrival, many Japanese international scholars have better reading/writing skills in English than their listening/speaking abilities. Many participants recommended that faculty write down or type out important meetings, dates, or other kinds of information. However, Gay et al. (1993) suggested that faculty and administration need to be prepared to offer international students assistance with writing, and this notion was supported by participants of this study.
If faculty fear that an international student is having difficulty adjusting, caring responses could include social invitations to the symphony, viewing a parade, or other activities not requiring high verbal skills, but which show attention. On the other hand, active professional intervention may he required and to assume that the student will just get better with time, or to avoid suggesting professional help, might turn out to be irresponsible or tragic. Participants recommended that each student's situation be judged on a case-by-case basis. Offering the student a referral to a native Japanese-speaking professional counselor, though, makes sense. In the face of alienation and acculturation stress, participants cautioned, the international student may find that verbalizing thoughts and feelings or describing his or her situation in English is overwhelming or simply impossible. Moreover, a Japanese professional may have more culturally appropriate interventions to offer than U.S. American counseling and/or pharmaceutical treatment.
To enhance the possibility of caring educational practice, it helps if faculty attempt to become familiar with at least some aspects of contextual differences. In their efforts to understand the life worlds of the international student, faculty need to keep in mind that U.S. American nursing values reflect only one perspective on nursing. One way of accessing alternative perspectives that several participants found useful was to ask them- as recently arrived international students- to stay 15 to 20 minutes after class, so the U.S. educator could discuss class content with them. This not only allowed the student a second chance to discuss content in English, but it also provided the faculty with some sense of the student's level of understanding, strengthening possibilities for effective communications and relationships. Moreover, such interactions can provide a time for faculty to get information about the student's practice in a one-to-one or very small group setting where students might be more able and willing to speak up. International students are uniquely valuable as resources to point out other ways of thinking and other ways of practicing.
Grace (1990) claims that it is important for U.S. faculty to understand where international students come from and where they will go. Many of the participants in this study were sent by their colleges, or, if self-selected, were ambitious and curious, seeking higher education. At the time of this study, there were many fewer opportunities for graduate education in Japan than now. Many participants were faculty from prestigious schools of nursing and many came back to Japan to mid- and high-level academic positions. It is easy to imagine that for people accustomed to being "in charge," sent by their college or university because of their stature and academic ability, confronting the possibility of failure would be personally devastating. Most of the Japanese international scholars in this study experienced ontologica! transformation, fundamental changes in their ways of being, in the process of graduate education. They experienced a change hi the sense of self. They became more verbal, more direct, more able to acknowledge and state their personal preferences. They also experienced many "toughening" times: periods of intense personal distress or feeling alienated and outcast on their returns. Through understanding the Ufe worlds of these international scholars, U.S. faculty may be able to identify actions and ways of being that will enhance these students' graduate education. In this way, faculty can honor the commitment and ultimately the enormous contribution many of these nurses make.
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