This study identified a number of factors associated with the intention to recruit foreign nurses under the EPA in Japanese hospitals that have not previously done so. The strongest factor was the managers’ degree of interest in the government’s foreign nurse recruitment policy, followed by their perception of foreign nurses, and their opinion on the government policy to implement recruitment.
The findings indicate that reviewing the EPA regulation is essential to increase the number of hospitals that wish to employ foreign nurses. The number of hospitals interested in Japan’s policy to recruit foreign nurses under the EPA has decreased since 2008 (50% vs. 83%) , before foreign nurse recruitment started. This is due to the burden on hospitals that employ foreign nurses, and particularly, providing support to them [10, 11–17] (e.g. providing assistance with daily living and instruction for the NBE in Japanese) as well as the cost, which is estimated to be as much as 3.6 million yen per nurse, including 26% to cover the “extra” work of Japanese nurses to support foreign colleagues during the three-year contract . The respondents in this study had not employed foreign nurses, but they seem to be aware that supporting foreign nurses who are not fluent in Japanese is a burden for the hospital. This is consistent with the fact that, regardless of their intention to recruit foreign nurses in the future, 85.5% of the respondents said that the government should require foreign nurses to be proficient in Japanese before entering Japan, to ease the burden on the hospitals. This suggests that a fundamental review of the EPA is required, particularly in terms of language training.
Study participants may have been influenced by their negative perceptions of foreign nurses, including their low pass rate of the NBE. Shinohara’s study  on certified care workers who entered Japan under the EPA indicated that Japanese people were more likely to respond negatively to healthcare worker migration. Considering the mean image score in this study, this tendency may also be applicable to foreign nurses. However, there are some advantages to employing foreign nurses. Ogawa et al  reported that 75% of hospitals that employed the first batch of Indonesian nurses were satisfied or very satisfied with them, and that these nurses had a bright personality (92.9%), and an appropriate attitude towards patients (89.3%). This led hospitals to change their mindset, and encouraged Japanese staff to develop a better understanding of different cultures. This tendency has also been observed in other countries recruiting foreign nurses [21–23], and the process may even regenerate the workplace. We suggest that it may be helpful for the government to emphasize the advantages of employing foreign nurses to encourage their recruitment by hospitals.
The EPA is a government-led program, so it should explain the need to introduce foreign nurses into Japan in intelligible terms. Currently, the MHLW states that “introducing foreign nurses is not to combat the shortage of nurses in Japan, but to respond to the request of the partner countries to accept the nurses” . The statement is not helpful in persuading hospitals with nurse shortages, especially in rural regions . Its ambiguity also confuses Japanese taxpayers, who paid more than 380,000,000 yen per year  in 2016 towards the costs of EPA nurses. It is, therefore, necessary for the Japanese government to make clear that the main purpose of bringing foreign nurses to Japan is to address the shortage of nurses.
As a destination country for migrant nurses, the Japanese government is required to respond to both international and domestic communities by reviewing the EPA scheme to attract nurses who wish to learn the use of advanced technology in Japan  and to encourage hospitals to recruit qualified nurses from South-East Asian countries. To do so, shared recognition of nursing licenses between Japan and its partner countries is necessary. The Japan Nursing Association (JNA) opposes this idea . However, refusing to recognize nursing licenses might result in the stagnation of career development for migrant nurses who return to their countries of origin, or who wish to apply “points” or credits obtained in Japan in a partner country. Approving shared recognition would allow more flexibility between partner countries; Japan can then persuade partner countries to encourage nurses to obtain further qualification or “points” that can be used when they return from Japan to their home country.
This study is not immune to respondent bias. The majority of participants were from medical corporations (88.2%) and small institutions with fewer than 99 beds (70.6%). Recruiting foreign nurses will help to secure the nurse supply and reducing the risk of building an “inefficient medical service system” that was set out in the mid-term report published by the National Committee for Social Security in 2008 . The report called for changes in hospitals in Japan, the majority of which are small medical corporations, with too few medical staff. Further research, including public medical institutions and hospitals equipped with more beds, is therefore needed to confirm these results.