Although the respondents had not employed EPA nurses previously, they offered several insights to identify the problems with and improve the policies on EPA nurses. The EPA nurse policies are not widely known, and hospitals in Japan are not adequately informed of them. Only 20% of the respondents answered that they wish to recruit EPA nurses. However, this does not necessarily mean that the rest are not interested in EPA nurses at all, as half (50%) of the respondents answered that they are interested in the government’s policy on EPA nurse recruitment. Given that over 80% of the respondents found it very hard/hard to recruit Japanese nurses, it may be interpreted that half of the respondents carefully monitor EPA policies, wondering if the current system would help fill the shortage of nurses. As such attitudes toward EPA nurses were observed regardless of type and size of the hospitals, or the managerial position of the respondents, and it seems that this perception is widely shared by hospitals in Japan.
One of the strongest factors associated with hesitation toward EPA nurses is their image. The image score mirrors a conviction of hospital staff that EPA nurses would encounter various difficulties arising from their limited Japanese language proficiency, which is crucial for their daily hospital work and for passing the NBE. We assume that there are some prejudices against EPA nurses. The respondents seem to be unaware of the many EPA nurses that had acquired a good reputation among patients and families. In fact, 75% of the hospitals that employed the first batch of Indonesian nurses in 2008 were satisfied or very satisfied with them because they had a bright personality (92.9%) and an appropriate attitude toward patients (89.3%) . We assume that biases against EPA nurses are not the EPA nurses’ responsibility, but of the EPA system. The low Japanese language proficiency of EPA nurses may be due to an inadequate time period set for pre-departure Japanese language training. This is particularly true among nurses of the first, second, and third batches of nurses from Indonesia and the first and second batches from the Philippines, who were not given any pre-departure Japanese language training. It may be that the image scores of this study reflect the shortcomings of the EPA in the early stages. Vietnamese nurses, who have 12 months of pre-departure Japanese language training, have higher language proficiency. Therefore, they have fewer language problems than Indonesian or Filipino nurses. In this light, the governments of Japan and the sending countries are recommended to employ returning EPA nurses to teach the Japanese language and provide information on Japan’s unique nursing practices to the incoming EPA nurses, so that they will be well prepared to work and train in Japan. This may lessen the economic and psychological burden of hospitals.
This study also revealed the crucial conditions of hospitals that were struggling with a shortage of nurses. Twenty percent of the hospitals answered that they wished to recruit EPA nurses because they found it very hard/hard to recruit Japanese nurses. We assume that the hospitals attempted to employ EPA nurses to alleviate the shortage of Japanese nurses. A mid-term report released by MHLW  indicated that nursing shortages are especially severe in rural Japan. Hospitals in rural regions are assumed to be more likely to substitute EPA nurses for Japanese nurses than those in big cities, such as the Tokyo area. Regional differences cannot be proved by our survey because, due to the anonymity of the questionnaire, we could not identify the location of the hospitals. However, we take the excerpt from the narrative of a doctor respondent, who called the researchers to add comments on the survey, to strengthen the hypothesis. The respondent was the owner of a small private hospital but unfortunately was not successful in recruiting EPA nurses because nurses prefer to work in hospitals in the big cities. He expressed his opinion to the first author (HY) as follows: “I think the Japanese government should invite more EPA nurses to Japan. Please tell the government that there are some small-sized hospitals, especially in rural areas, that badly needs nurses. Even those who are from abroad will do to maintain our hospital to secure the health of people in this region.”
However, the current EPA system does not seem to be effective in solving the imminent problems of hospitals. The EPA sets a quota of 200 nurses per country per year, which falls well short of the deficit of nurses. The country needs at least 30,000 nurses by the year 2025 . Nurses are needed in Japan, especially in rural areas, although EPA regulations seem not to secure them effectively. Therefore, a fundamental solution must be implemented.
Recently, hospitals in Japan interested in recruiting EPA nurses have noticed a higher number of Chinese nurses being hired through private agencies. The actual number of Chinese nurses is unclear, as the Japanese government does not disclose the nationality of persons who obtain “medical visas,” although the number of visas issued has been increasing. This phenomenon assumes that many Japanese hospitals are not satisfied with the system of recruiting nurses under the EPA and are thereby seeking other means of recruiting foreign nurses. Nearly 60% of the respondents of this study agreed to invite private agencies to the EPA under the supervision of the government to stimulate the principle of market mechanism, regardless of their intention of recruiting EPA nurses. The idea of implementing other means to address the manpower shortage seems to be widely accepted by hospitals nationwide. This is exemplified by the fact that the Japan Hospital Association, one of the biggest associations of hospitals in Japan, introduced the International Medical Human Resource Foundation in its website , a recruitment agency of Chinese nurses for member hospitals that claims to “provide a better service than the EPA.” According to the foundation , they recruit eligible Chinese nursing students to be educated in the Japanese language for 1 to 3 years prior to entering Japan. After entry, the Chinese nurses will enroll in Japanese language schools to improve their language skills to pass the N1 level (the ability to understand Japanese used in a variety of circumstances ) of the Japanese Language Proficiency Test to be eligible to take the NBE. After they pass the NBE, they can work in Japanese hospitals as registered nurses. Contrary to JICWELS, who clearly stated the recruitment costs and previous NBE passing rates of EPA nurses, these private agencies did not disclose such key information. Therefore, the authors are careful not to judge this business model prematurely, as many counties reported problems caused by improper nurse recruitment [41,42]. Nonetheless, these recruitment agencies seem to be attracting more hospitals because Chinese nurses can read Chinese characters in the NBE, thereby presenting higher passing rates than EPA nurses. The new business model also attracts nurses. Since they are not entering Japan under the EPA, Chinese nurses are offered a “medical visa.” The visa is unlimited and allows nurses to work more flexibly than the “Special Activities, Registered Nurse” visa issued to EPA nurses. This flexibility is an advantage of the business.
Given these conditions, it is understandable that hospitals in Japan would be attracted to this model because, as shown in this study, 82.2% of the hospitals, regardless of their intention of recruiting EPA nurses, agreed with the statement “The Japanese government should require EPA nurses who pass the NBE to stay for several years.” This represents the severe need of the hospitals suffering from the shortfall of nurses. They wish for nurses to work for as long as possible. If nurses are given visas that permit more flexible work, they would spend more time working in Japan. If Japan wishes to employ more EPA nurses, attracting more hospitals by reviewing the EPA scheme so that it would satisfy the needs of the hospitals is key. As the logistic regression model indicates, the more hospitals that are interested in the EPA, the more chances they take to recruit EPA nurses.
However, the Japanese government does not seem keen to fill the nursing job vacancies with EPA nurses. We assume that the MHLW, who is in charge of monitoring the EPA nurses’ recruitment, cannot articulate the need to introduce EPA nurses to secure the nurse labor force, even though they know that there is a nursing labor shortage, as per their estimation .
Yeats et al. underscored that bilateral agreements offer governments more control and regulatory discretion . As long as the government of Japan denies the recruitment of foreign labor in the name of immigration policy , it can only explain the significance of the present EPA as follows: “introducing EPA 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” . However, the statement is not helpful in assisting 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 toward the costs of EPA nurses. It is, therefore, necessary for the Japanese government to make clear that the main purpose of bringing EPA nurses to Japan is to address the shortage of nurses.
This study is not immune to respondent bias. The majority of participants were from privately-owned hospitals (88.2%) and small institutions with fewer than 99 beds (70.6%). Recruiting foreign nurses will help to secure the nurse supply and reduce 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 privately-owned hospitals with too few medical staff. Further research, including publicly-owned hospitals equipped with more beds, is therefore needed to confirm these results.