Features of Women’s Leadership and Nursing in Japanese Culture

Abstract

Mutual respect and harmonious relationships between people can be viewed as the fundamental spirit of Japanese culture. Japanese leaders try to keep the peace in human relations, rather than to achieve a goal. They become leaders due to internal and external conditions, rather than their own abilities. Japanese society has been basically male-dominated though the ratio of women leaders has increased recently. Higher education and development of academic societies in nursing have been very successful during the last two decades and nursing is one of the most trusted professions in Japan. However, some Japanese people still think a nurse is just an assistant to doctors. The purpose of this paper is to clarify features of women’s leadership in Japan from the nursing point of view. In Japanese culture, leaders need to possess human resource leadership as an indispensable element, while good leaders may have advantages in all four frames of leadership including structural, human resource, political, and symbolic frames. Japanese organizations are also supported by excellent followership which might be influenced by the structure of Japanese society which is called “the vertical society” where leaders are fostered from among followers. What is important in Japanese leadership is to have a vision that leadership leads to the happiness of all people in a shareable form.

Introduction

The ways of leadership are influenced by so many factors, such as gender, culture, and occupational area, which produce diversity. Different settings would require different approaches to leadership based on the different features of the societies and cultures where individual leaders live.

In this article, women’s leadership in Japanese culture is discussed with the leadership framework of Bolman and Deal (2008), based on literature and my experience. First, background information related to Japanese culture and leadership is described with a focus on women’s leadership. Second, how these cultural heritages could influence nursing in Japan is discussed. Third, my personal experience and encounters with women leaders in Japan are illustrated as exemplars. Finally, the best theoretical frame for woman leaders in Japan are proposed based on the leadership frames of Bolman and Deal (2008).

Background Information: Japan and its Culture

The Fundamental Spirit of Japanese Culture

Harmony is to be valued (Article 1, Seventeen-article constitution)

The phrase above is quoted from Japan’s oldest constitution, thought to date back to the seventh century. Harmony (“wa” in Japanese) here means mutual respect and harmonious relationships between people, which can be viewed as the fundamental spirit of Japanese culture (Tokoro, 2007). Japanese culture can also be characterized by such concepts as “patience (gaman),” “modesty (kenson)” and “hospitality (omotenashi).” These concepts have served as the wisdom of people living in a small, resource-poor island country. Japan is a small island country, with a total area of 377,800 km², which is about one-twenty-fifth of that of the United States, and with a population density of 337 people/km², approximately 10 times as high as the United States.

Japanese people have rather unique attitudes toward religion. Many Japanese visit a Shinto shrine each New Year; celebrate their wedding in a church; and have their funeral at a Buddhist temple. This suggests that, although most Japanese participate in what can be called religious rituals, they neither have a strong sense of belonging to any particular religion nor an intense awareness of religion. Incidentally, Shinto has the wording of yaoyorozu-no-kami (lit.: “eight million deities”), which indicates the belief that all things, including organisms, are inhabited by deities (Kojiki, 710).

Characteristics of Japanese Culture and Leadership

The Japanese sociologist Nakane uses the term “vertical society” to indicate a society, such as Japan, where greater stress is placed on “frames” (“ba” in Japanese, which include the community, organization, and guild to which each individual belongs) in contrast with a “horizontal society,” represented by European and Indian societies, where a heavier emphasis is placed on “attributes” (each individual’s social attributes, including the class into which he/she was born, and his/her academic and other qualifications) (Nakane, 1967). In a vertical society, which is assumed to be nearly homogeneous in people’s abilities, an importance is placed on ranks rather than abilities, which has led to the development of seniority and lifetime employment systems in Japan. Many companies position themselves as a kind of “family,” led by a father-like elderly president, with their employees continuing to perform their duties, with the hope of becoming the company’s president in the end. This has traditionally been a typical Japanese form of success. Belonging to an organization is based on its members’ affection for and loyalty to the organization, rather than their contract with it.

Nakane (1967) argues that the raison d’être of the Japanese type of leader is to keep the peace in human relations, rather than to achieve a goal. She also points out that leaders in Japan are not individuals who can lead a group using their own abilities, but relatively competent individuals who have been recommended to be leaders thanks to good timing. This means that, in Japan, people become leaders due to internal and external conditions, rather than their own abilities. A peculiarity of Japan is that incompetent elderly individuals (or elderly individuals with decreased competence) are often selected as leaders, not because of people’s respect for the elderly, but rather because of their social influence in the organization, embodied in the number of competent subordinates they have working under them (Nakane, 1967). Although the decline in the Japanese economy has caused ongoing changes in seniority and lifetime employment systems, these characteristics of Japanese-type leadership still provides the basis for organizations in Japan, and as well is exemplified by universities.

Active Participation of Women in Japanese Society

Although there have been some women rulers and corporate managers in Japanese history, Japanese society has been basically male-dominated. While Japanese women were given their rights to vote in 1945, many believe that the 1997 revision of the Gender-Equal Employment Opportunity Act triggered more active participation of women in Japanese society. With the Act on Promotion of Women’s Participation and Advancement in the Workplace enacted in 2015, Japanese government has striven to encourage working women and foster woman leaders. A governmental target is to increase the rate of the woman who occupies to a leadership post to about 30% by 2020 (Prime Minister of Japan and His Cabinet, 2013). Some new projects which empowers Japanese women to become leaders have been launched such as Japanese Women’s Leadership Initiative (JWLI, 2017), “Women Begin to Shine” by the government of Japan (The Government of Japan, 2014), and so on. In my view, these trends can be understood within the contexts of (1) the difficulty for a family to live in comfort with only the husband/father’s income, (2) the decrease of the working population due to a declining birth rate combined with an increasing aging population, and (3) the growth of service industries, in which many women can show their abilities. The ratio of woman presidents to all company presidents (7.7%) becomes high in the fields that originate from daily life services (10.3%) such as child rearing (44.7%), beauty and cosmetics (34.3–36.5%), elderly care (30.1%), and education (28.8%) (Teikoku Databank, 2017).

Nursing in Japan and its Influences on Patient Outcomes

Development of Nursing in Japan

The enactment of the Nurse Regulations in 1915 resulted in a greater public recognition of the Japanese term “kangofu,” literally meaning “nursing women,” for nurses. After being defeated in World War II, Japan established a new nursing system under the guidance of the United States. The Act on Public Health Nurses, Midwives, and Nurses, enacted in 1948, provides that working as a nurse requires a national nurse license, and unifies the education of public nurses, midwives, and nurses. Japanese Nursing Association (JNA) membership has increased year by year, reaching 718,187 nurses in 2016 (JNA, 2017).

In 2001, to reflect the needs of an era when male nurses were naturally accepted, the term “kangofu (nursing woman)” was replaced with “kangoshi (nurse),” a term without gender connotation. Male nurses accounted for about 6% of the total number of nurses (about 1.634 million) in 2015, but are growing in number. In 1994 and later, the systems of Certified Nurse Specialist and Certified Nurse were introduced, accelerating the specialization of nurse duties.

The first four-year undergraduate nursing course in Japan was established in 1952. However, university-level nursing education was developed slowly after that, with only 11 four-year universities having established undergraduate nursing courses or programs by 1990. The enactment of the Act on Promotion of the Maintenance of Human Resources for Nurses, etc. in 1992 rapidly accelerated the development of higher nursing education, resulting in 248 undergraduate courses, 151 masters courses, and 73 doctoral courses providing education in nursing in 2016 (Ministry of Education, Culture, Sports, Science and Technology Japan, 2017a). Academic society activities in nursing in Japan started with the foundation of the Japan Nursing Academy by the JNA in 1974. Currently, the Japan Association of Nursing Academies (JANA) has 44 nursing-related academic societies registered in 2017 (JANA, 2017).

The Public Image of Nurses

An opinion poll on the public image of nurses conducted by the Cabinet Office (N = 2,244) revealed that 79.5% of the respondents viewed nurses as kind and considerate, 72.5% as executing solemn duties relating to life, and 62.3% as living irregular lives due to their work, including night work (Cabinet Office, Government of Japan, 1993). Opinion polls on the most trusted professions in Japan rate nurses at the top (GfK Verein, 2016), indicating that the public image of nurses is generally positive. However, the feeling of the Japanese general public may in fact be somewhat different. When I decided to become a nurse, a relative told me that a nurse was just an assistant to doctors, so it was meaningless for a person who had graduated from a university to work as a nurse. I still sometimes hear comments like that. Not a few elderly people in Japan, in particular, rate nurses low in social status. While nursing is very popular with young people as a promising profession, nursing is expected to be increasingly in demand against the background of prolonged recession. Yet, while searching for survey results on the public image of nurse leaders in Japan, I could not find a single one. It maybe because nurse leaders are hardly reported in the mass media and still many people think nurses take all their orders from physicians.

Nurses’ Impact on Patient Outcome

Many studies in Japan have shown that the interventions of nurses contribute to better outcomes of nursing care. Examples of effective interventions might include: an intervention based on a care package designed to relieve the depression of cancer patients (Nozue et al., 2016), or a self-care program for patients with breast cancer treatment-related lymphedema (Arinaga, Sato, Sato, & Kashiwagura, 2015). However, many of these studies were conducted on a small scale. In addition, the outcome of studies on the effects of nursing management are often assessed based on nursing turnover rates or nursing staffs’ perceptions, and seldom on nurses’ impact on patients until now.

My Personal Experience and Encounters with Woman Leaders in Japan

Models of Nursing Leaders

The College of Nursing Art and Science Hyogo was founded in 1993 as the first public nursing college in Japan. Its first President was Professor Hiroko Minami, who later served as the President of the Japanese Nursing Association (JNA) from 1999 to 2005 and the International Council of Nurses (ICN) from 2005 to 2009. If asked to name nurse leaders in Japan, I would without hesitation cite her in the first place. She completed a masters’ program at the Hebrew University of Jerusalem, Israel, and obtained a Ph.D. at the University of California, San Francisco (UCSF). Strategically considering the development of nursing profession throughout the entire Japanese society, she established the system of Certified Nurse Specialists and Certified Nurses and introduced psychiatric liaison nursing. After experiencing the Great Hanshin and Awaji Earthquake in 1995, she also established the Japan Society of Disaster Nursing in 1998 and the World Society of Disaster Nursing in 2008. Serving as the President of ICN, she devoted her efforts to enhance the quality of nursing in the world. She is a great leader with a well-balanced combination of the four frames of leadership advocated by Bolman and Deal (2008). She seemed to me distinguished in all four frames: the structural frame relating to analyzing data and setting a clear goal; the human resource frame concerning respect for people; the political frame regarding political power and how it is used; and the symbolic frame regarding her charismatic images. Her commanding presence as the woman JNA President amid a male-dominated society earned her great respect from the Governor of Hyogo Prefecture and others.

A former Dean of the college, Noriko Katada, also provides a role model for nurse leaders. She earned a Ph.D. at UCSF, and has contributed immensely to enhancing the quality of nursing in Japan, by cooperating with Dr. Minami in establishing the system of Certified Nurse Specialists and Certified Nurses. The leadership of these two precursors has allowed the College of Nursing Art and Science, University of Hyogo, to maintain its top-class quality of education and research in Japan. In 2016, the college was ranked fifth or higher in the percentage of adopted applications for grants-in-aid for scientific research in four fields, including the clinical nursing research field, where the college was ranked high (Ministry of Education, Culture, Sports, Science and Technology, Japan, 2017b). Professor Katada, with her clear vision constantly paid attention to the development of faculty members and can be viewed as a remarkable leader in terms of the human resource frame, from the theoretical framework (Bolman & Deal, 2008). In 2005, I had the opportunity to study in residence at the University of Pennsylvania, thanks to her active encouragement for conducting research overseas.

The former Dean Afaf Meleis at the University of Pennsylvania is also a great model for nursing leadership, and has shown that a leader can bring considerable changes to the world around her/him. She has contributed immensely to raising the University of Pennsylvania School of Nursing to the top-level status in the United States, and I was astonished to learn that the School of Nursing ran a day-care service called Living Independently for Elders (LIFE program). Undergraduate schools of nursing in Japan were generally placed under the umbrella of schools of medicine, so they were seldom associated with business activities. By contrast, LIFE realized the productive cycle of clinical care, education, and research, and offered me a future vision of unconventional universities leading the cycle to profits and their own development. The former Dean Meleis said that the School of Nursing was leading other schools at the University of Pennsylvania, and I was truly able to feel that vision.

My Leadership Challenges

In 2014, I launched the Clinical Nursing Research Support Center at the University of Hyogo aiming to support nurses working at hospitals or in local communities in conducting research. In Japan, nurses had long conducted so-called “nursing research” following the policies of the nursing sections of their hospitals. A study subsidized with a grant-in-aid for scientific research in 2009 revealed that such nurses were only conducting limited research activities without adequate knowledge, techniques, guides, or a favorable environment, including a literature retrieval system (Sakashita et al., 2013). Usually, without Ph.D.-prepared nurses in hospitals, nurses and hospitals did not properly understand what research activities were, and embraced a kind of myth that “research” of any kind should lead to the enhancement of quality. Meanwhile, nurses’ enthusiasm for better patient outcome was a precious treasure. Therefore, this Center was launched with the aim of creating new practice-based wisdoms from the cycle of practice, research, and education, through collaboration between clinical nurses, who had questions (seeds) to be solved in clinical settings, and universities with research expertise. In this initiative, we placed a priority on the establishment of knowledge from on-site phenomena. The practice of nurses certainly contains the wisdom of nursing, but this wisdom may differ from what nurses recognize as wisdom, or they may not even be aware of their wisdom. Thus, importance has been placed on the creation of knowledge from practices partly because our university has devoted its efforts to educating Certified Nurse Specialists. The construction of knowledge of nursing now requires the clarification of concepts and theories hidden in phenomena and the development of clear models and processes of intervention. For this purpose, the journal of “Phenomena in Nursing” was created aimed at visualizing the processes of nursing practices focusing on the descriptions and explanations of nursing phenomena.

Over thousands of years of Chinese history, the practice of Chinese medicine was simply called “yi (healing),” and relied only on intuition and experience. However, the Ming dynasty saw the systematization of Chinese-style healing practices based on the construction of theories, and the wider use of the term “yixue (medicine as science).” This means the experience-based wisdom of yi as practice-based tacit knowledge has been theorized for innumerable years to systematize explicit knowledge. I believe that a large amount of tacit knowledge remains unnoticed and undocumented in nursing practice, which have not yet been integrated into the knowledge of nursing which everyone can share.

The reasons why I have been able to overcome a number of challenges include the following: my fondness of writing proposals and applications has enabled me to obtain initial funds; I have a strong desire to help other people, just like many other nurses, and the desire brings me various ideas; and people I work with feel grateful for our activities and have come together to devote their energies to creating the next activity. Another reason, is the spread of the Internet has allowed us to engage in research support activities and information sharing at a low cost. I have never found that being a woman has worked as a barrier against me (though this may be due to my insensitivity). Although the entire academic world is still male-dominated, most professors of the nursing department are women and the management of the university has treated women faculty with respect. Since the national government has striven to increase the number of women managerial staff members under the slogan of improving women’s statuses, women professors are respected, and are often asked to become members of various governmental committees.

Theoretical Framework for Women Leaders

Bolman and Deal (2008) advocate the four frames useful for considering leadership: the structural, human resource, political, and symbolic frames. While good leaders may have advantages in all of these frames, it is suggested from the models shown above that leaders in Japanese society need to possess human resource leadership as an indispensable element. There is a credo: “Every individual member shining most brilliantly and demonstrating her/his ability will lead to the development of nursing.” To fulfill the credo, various methods were tried while analyzing the current situation in structural terms. Academics cannot accomplish any achievements by only working for a certain designated time; they are required to create new things. Each member is not just a worker but a creator, so our organization could not develop without the demonstration of each member’s ability.

Furthermore, there is a limit to what an individual can do. Japanese organizations are also supported by excellent followership (Kohguchi, Sakata, & Fujimoto, 2007). Followers play important individual, relational, and collective roles in organizational failures and successes (Kelley, 1988). Crucial followership might be influenced by the structure of Japanese society which is called “the vertical society,” where leaders are fostered among followers. For example, most deans at Japanese universities are elected every two years from among professors; the deans are usually elected with a priority on age or the length of service at the organization, rather than their ability as a leader. As every new young comer has a possibility to become a leader of the organization, they usually have a strong sense of belonging and ownership. Thus, people tend to serve their company with all their hearts. These remind me of the thoughtful advice from ancient philosopher, Aristotle, “He who cannot be a good follower cannot be a leader” (Lipman-Blumen, 2014). Transformative leadership, with which a leader can play as a follower according to situations might be the feature of Japanese leadership.

Implications for Future Leaders

With the enactment of the Act on Promotion of Women’s Participation and Advancement in the Workplace, Japan may come to have women leaders who readily assume structural leadership typically found in success stories in Western male-dominated society. There are so many books and seminars about structural leadership, which may not be difficult to describe (Bass, 2008). However, I hope that many women will consider whether we really desire to live in such a world where efficiency and rationality would be prioritized.

There is a poem that portrays a feminine worldview: “A pot, a rice cooker and a burning flame in front of me” composed by the Japanese poetess Rin Ishigaki (1959). The poem describes kitchenware, such as a pot, which has been placed in front of women throughout history, to represent love and sincerity shown by women and their devotion to ordinary everyday lives created through such love and sincerity. She conveys that she would be content to be left behind in knowledge and social status, if necessary, to protect such peaceful everyday lives. She concludes the poem as follows:

As if cooking potatoes and meat

With profound affection

Let’s study politics, economics, and literature

Not for puffed-up pride or higher status, but

To have all these offered for the sake of human beings

For all of us to devote ourselves to our duties for the sake of our beloved ones

It seems to me that this is a form of Japanese women leadership. The leader herself is also a member of an organization, which is supported by many followers. What is important, is probing which goals will lead to the happiness of all people, and clearly showing the goals in a shareable form.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest concerning the research, authorship, or publication of this article.