Culturally Sensitive Medical Care and Nursing Support : A Study of the Concerns of Foreign Visitors to Japan

Background: Considering the development of international transportation in modern societies, nursing care needs to be sensitive to the cultures and customs of patients from other countries. The purpose of this study is to determine, from the perspective of culturally sensitive nursing support, the cultural practices that foreigners consider important when they visit a Japanese hospital for check-ups or hospitalization. Methods: A survey was completed by 110 foreign participants at a shrine in Kyoto City. The purpose of the survey was to evaluate the concerns of foreign visitors regarding Japanese medical providers, caused by cultural differences such as customs of daily life. The statistical analyses were performed using descriptive statistics as well as cross-tabulation, chi-square, and Fisher’s exact tests. Results: After grouping participants by continent, the top concerns observed in all groups about visiting a Japanese hospital were accessibility to and cost of medical care. First, as for medical facilities, participants from North and South America (North and South American) and Europe (Europeans) were significantly more concerned than those in Asia (Asians) (P < 0.01). Second, North and South American and Oceanians were more concerned about accessibility of medical care than Asians (P < 0.05), and Europeans more than Asians (P < 0.01). Third, North and South American, European, and Oceanian participants were more concerned about the duration of hospitalization than Asian participants (P < 0.01). Finally, Asian participants showed more concern regarding the gender of medical staff than European participants (P < 0.05). Conclusion: Nurses need opportunities to learn and understand differences in cultures. If nurses have opportunities to learn cultural differences as well as to experience caring for foreign patients, their competencies in culturally sensiHow to cite this paper: Murase, Y. and Yamamoto, M. (2019) Culturally Sensitive Medical Care and Nursing Support: A Study of the Concerns of Foreign Visitors to Japan. Open Journal of Nursing, 9, 329-346. https://doi.org/10.4236/ojn.2019.93031 Received: February 8, 2019 Accepted: March 26, 2019 Published: March 29, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access Y. Murase, M. Yamamoto DOI: 10.4236/ojn.2019.93031 330 Open Journal of Nursing tive nursing support will improve over time. It can be said that this is an issue not only in Japan but also in all other countries.


Introduction
In 2003, Japan launched the "Visit Japan Campaign" with the aim of increasing the number of foreign visitors.Another strategy to increase inbound tourism, in preparation for the Tokyo Olympic and Paralympic Games, focuses on investments to make the environment more welcoming for international visitors.This includes making the environment more multilingual, familiar with the needs of Muslims, and easy for foreigners to find accommodation [1].In 2017, the number of foreign visitors in Japan exceeded 28,691,000 and it continues to increase yearly.These visitors come from many different countries and cultures.Although most come from Asia (mainly South Korea and China), there are also many visitors from Europe (mainly the United Kingdom and France), North America (mainly the United States, Canada, and Mexico), South America (mainly Brazil), and Oceania (mainly Australia and New Zealand) [2].Due to this increase in foreign visitors, the percentage of foreigners using Japanese medical care is increasing [3].The Ministry of Health, Labor and Welfare has adopted a set of policy measures that allows foreign patients to receive Japanese medical services safely and securely [4].However, before accepting foreign patients, Japanese hospitals must overcome certain barriers [3].Understanding and responding to multilingual correspondence and cultural practices is a big challenge [3].Regarding multilingual correspondence, interpreters are dispatched to hospitals and other medical institutions.However, there are problems with interpreter burden and interpretation training with medical knowledge.This causes occasional misunderstanding, difficulty in providing treatment in another language, and problems concerning cultural differences.Consequently, some medical providers are not interested in treating foreigners unless they have to.Therefore, certain medical institutions are reluctant concerning medical care of foreigners.
Meanwhile, it is not easy for foreigners to receive care from medical institutions in Japan.Most Japanese citizens are covered by public insurance and receive partial coverage for medical treatment.However, foreign tourists who do not belong to the public insurance system will need to bear the entire burden of cost for medical care received in Japan.Investigation by the Tourism Agency revealed the following [5]: 6% respondents in the survey experienced unexpected injuries and illnesses while traveling to Japan, and 26% felt that they needed to visit medical institutions.Additionally, 30% people from foreign countries visit-Open Journal of Nursing ing Japan did not buy travel insurance.The concerns of respondents who did not visit outpatient were "language problems", "no time to go", "there is no medical institution in a convenient place", "Information regarding medical institutions is unreliable", and "cost was high".Thus, it is conceivable that visiting a medical institution in Japan involves many hurdles for foreign patients.To overcome these problems, we need to be familiar with foreign patients' beliefs, cultures, and customs.Nurses are in direct contact with patients through conversations and care.Therefore, nurses who understand culture and custom can be helpful to foreign patients.This idea is reflected in the theory of transcultural nursing, which was first proposed by Leininger [6].In the 1970s, she explained that "Our rapidly growing multicultural world makes it imperative that nurses understand different cultures to work and function effectively with people having different values, beliefs, and ideas about nursing, health, care, wellness, illness, death, and disabilities".Although more than 40 years have passed since Leininger proposed the concept, transcultural nursing is a field of research that is still new because it is intricately connected with matters related to nursing and anthropology, comparative culture, health, and other disciplines.According to Murphy [7], "Transcultural nursing is both a specialty and a general practice area".However, there are still few studies of foreign patients in Japan.Nakata et al. [8] and Mochizuki et al. [9] suggested that there were too few medical care providers capable of treating foreign patients.In addition, Kubo et al. [10] reported that nurses have difficulty nursing foreign patients due to differences in language and culture.Chiba et al. [11] also suggest that Japanese nurses need to have international experience.Likewise, Nakagawa et al. [12] suggested the need for providing care in languages other than Japanese.Further, Takaku et al. [13] and Hamai et al. [14] indicated the importance of medical translation.In addition, studies of Adachi et al. [15] and Nonaka et al. [16] on nursing care for foreign patients, and of Utagawa et al. [17] and Teraoka et al. [18] on transcultural stress have found that foreigners suffer from transcultural stress when they are stricken with an illness in Japan, suggesting the need for culturally sensitive care.According to previous research by the author, it is suggested that nurses create opportunities for understanding cultures; not only communication in other languages, but also cultivate cultural care ability.In other words, there is a need for nursing care that takes into account differences in culture and customs [19].
Most of the studies about foreign patients were designed and conducted from medical care support or nursing care perspectives of Japanese researchers and clinicians.Although Japanese nurses are aware of the need for cultural competency in the treatment of foreign patients, they are uncertain about how to deal with diversity, that is, with different cultures and customs, including patients' concerns about potential differences in the accessibility of medical care.Therefore, the purpose of this study is to determine, from the perspective of culturally sensitive nursing support, the cultural practices that foreigners consider important when they visit a Japanese hospital for check-ups or hospitalization.By determining cultural and custom differences that should be addressed when for-eign patients visit medical providers, this study may help provide culturally sensitive nursing care.

Participants
Participants included 110 foreigners above 20 years old who were visiting Japan for various purposes, including sightseeing, school, or work.Given that the purpose of the study was to examine cultural differences with participants' native countries, we excluded special permanent residents of Japan who were Korean, Chinese, or Taiwanese.A special permanent resident refers to a person from the Taiwan-Korean peninsula residing in Japan or that person's descendants who have lived in Japan since the Second World War, and who have stayed in Japan even after withdrawing Japanese citizenship under the San Francisco Peace Treaty (1952).Permanent residency status is recognized by a special immigration control law.Because the sample was too small to permit analysis by nationality, we grouped participants by continent, resulting in four "geocultural groups": Asians, North and South American from North and South America, Europeans, and Oceanians.There were no respondents from Africa or the Middle East.In addition, we identified invalid answers as those with no nationality and gender reported.

Materials
For this study, we used an anonymous questionnaire created by the researchers, wherein the responses were assessed on nominal and ordinal scales.The questionnaire was composed in English, Chinese, and Korean.The questions focused on the participant's nationality, age, gender, problems or concerns they had about using Japanese medical providers, and cultural differences such as customs of daily life.The participants could submit multiple answers for a question.
Answers were recorded on the nominal scale.There are three gestures Japanese nurses often use to communicate with foreign patients: pointing at one's own nose to indicate "I", making a circle with the thumb and forefinger to indicate "OK", and pointing upward with the thumb to indicate "Good".For example, in outpatient treatment, when a nurse wants to measure a patient's vital signs, s/he may use the gesture for "I" to communicate "I am going to measure your blood pressure".Depending on the result of the measurement, s/he may use the gesture communicating "Good".To respond to a patient's request, s/he may use the gesture for "OK".In order to be conscious of communication, we set up frequently used gestures as question items.

Procedure
The study period was from July through August, 2017.The survey was conducted at a shrine in Kyoto City.This study was approved by the Tottori University Ethical Review Board (approval No. 1707A078) following the principles of the Helsinki Declaration.The purpose of the research was explained to the participants and they gave informed consent.

Analyses
Participants' nationality, age, gender, medical history, geocultural group, and their medical history in Japan were demographic variables.The other survey items were divided into groups to analyze participants' concerns about visiting a Japanese hospital with different cultural practices.
For the statistical analyses, we used the Japanese statistical package BellCurve for Excel 2.0 in Windows.Descriptive statistics were calculated for each questionnaire item, and chi-square and Fisher's exact tests were used to identify significant pairwise differences in response frequencies between the geocultural groups.

Results
Of the 149 questionnaires distributed, 118 (79.2%) were returned completed.We excluded those in which nationality had not been disclosed, after which we considered 110 (73.8%) as valid responses (the responses of 8 people were excluded as invalid).To avoid further elimination of questionnaires and reduction of sample size, we used full information maximum likelihood estimation.

Participant Characteristics
The mean age of the respondents was 33.32 ± 12.86 years, the youngest and oldest respondents being 20 and 75 years, respectively.Fifty-three participants (48.2%) were male and 57 (51.8%) female.In their home countries, 22 participants (20.0%) had received outpatient care only, 66 (60.0%) had been hospitalized, 21 (19.1%) had never visited a hospital (neither outpatient nor inpatient care), and 1 participant (0.9%) did not answer the question.In Japan, 7 participants (6.4%) had received outpatient care only, no participant had been hospitalized, 100 (90.9%) had never visited a hospital, and 3 (2.7%) did not answer the question.

Concerns about Visiting a Japanese Hospital
Table 2 shows the aspects that participants indicated as concerns about visiting a Japanese hospital.Table 3 shows the results of chi-square tests on these responses by geocultural group.

Medical Facilities
Table 2 shows that the Europeans, North and South American, Oceanians, and Asians were concerned about Japanese medical facilities.Chi-square tests in

Medical Accessibility
Oceanians, Europeans, North and South American, and Asians were concerned about accessibility to medical care (Table 2).Chi-square tests further showed that Europeans, North and South American, and Oceanians were more concerned than Asians in this regard (Table 3).

Treatment Period
Oceanians, Europeans, and Asians were concerned about the duration of hospitalization (Table 2).Chi-square tests further showed that North and South American and Europeans were more concerned than Asians.A combination of chi-square and Fisher's exact tests also showed that Oceanians were more concerned than Asians in this regard (Table 3).

Medical Staff's Gender
Asians, North and South American, and Europeans were concerned about the gender of medical staff (Table 2).Chi-square and Fisher's exact tests revealed that Asians were more concerned in this regard than Europeans (Table 3).While Table 2 shows that most respondents did not care about medical staffs' gender, their responses changed when the question was asked specifically referring to the person who would be attending to them (Table 4).Both men and women indicated they would refuse service from the opposite gender without receiving sufficient explanation.There were no significant differences between men and women for this answer.

Cost
Oceanians, North and South American, Europeans, and Asians were concerned about medical costs (Table 2).Results showed that more than half of the respondents had concerns about costs.Tests for independence found no significant differences between geocultural groups (Table 3).

Language Barriers
Europeans, Oceanians, Asians, and North and South American were concerned about language barriers (Table 2).Tests for independence found no significant differences between geocultural groups (Table 3).The top mother tongues of people who were concerned included English, Chinese, and Spanish (Table 5).

Gestures to Facilitate Communication
We observed the participants' interpretations of these gestures (Table 6) and compared response frequency by geocultural group (Table 7).
3.9.1.Pointing to One's Nose with a Forefinger Asians, North and South American, an Oceanian, and Europeans correctly selected "I" (Table 6).Chi-square tests showed that Asians and North and South American perceived this gesture more correctly than Europeans (Table 7).
However, some Oceanians, North and South American, Europeans, and Asians incorrectly selected "Nose", and some Europeans and an Asian incorrectly selected "Other" (Table 6).There were no significant differences between geocultural groups in the choice for "Nose" and "Other" (Table 7).

Making a Circle with a Thumb and a Forefinger
All Asians, North and South American, and Oceanians, and some Europeans correctly selected "OK" (Table 6).Chi-square and Fisher's exact tests showed that Asians perceived this gesture more correctly than Europeans (Table 7).
Since multiple answers were allowed, some Asians also selected "Money" while some Oceanians, Europeans, Asians, and an North and South American selected "Zero" (Table 6).Chi-square and Fisher's exact tests showed that Europeans perceived this gesture more correctly than North and South American.
An North and South American and another Asian participant selected "Other" (Table 6), but there were no significant differences between geocultural groups for this response (Table 7).
Table 5. Mother tongue of respondents who chose the language barrier (n = 71).

Pointing Upwards with a Thumb
All the participants selected "Good".However, because multiple answers were allowed, one North and South American also selected "Insult a person".In addition, some Europeans, an North and South American, and an Asian also selected "Other" (Table 6).No significant differences between geocultural groups were found for these responses (Table 7).

Taboos
In medical care, mutual trust is important.When nurses interact with non-Japanese patients, they need to know what taboos there may be in the patient's native country.In this study, we asked about behaviors that might be considered taboo (Table 8) and compared responses between the geocultural groups (Table 9).

Touching Superiors' Head and Shoulders
Asians, North and South American, Europeans, and Oceanians indicated that "Touching superiors' head and shoulders" was taboo (Table 8).Chi-square tests showed that Asians considered this behavior as taboo more than North and South American and Europeans (Table 9).

Crossing One's Arms before Superiors
Oceanians, North and South American, Asians, and a European indicated that "Crossing one's arms before superiors" was taboo (Table 8).Chi-square and Fisher's exact tests showed that Asians, Oceanians, and North and South American considered this behavior as taboo more than Europeans (Table 9).

Sniffling
Oceanians, Europeans, North and South American, and an Asian indicated that "Sniffling" was taboo (Table 8).Chi-square and Fisher's exact tests showed that while Oceanians and North and South American considered this behavior as  taboo more than Europeans, Asians considered it more so than Europeans, Oceanians, and North and South American (Table 9).

An Unmarried Man and Woman Being in the Same Space
Asians, an Oceanian, another North and South American indicated that "An unmarried man and woman being in the same space" was taboo (Table 8).
Chi-square and Fisher's exact tests showed that Asians considered this behavior as taboo more than Europeans (Table 9).

Touching Another's Body
North and South American, Asians, Oceanians, and Europeans indicated that "Touching another's body" was taboo (Table 8).However, tests for independence found no significant differences between geocultural groups for this response (Table 9).

Touching the Head
Asians, North and South American, and Europeans indicated that "Touching the head" was taboo (Table 8).However, tests for independence found no significant differences between geocultural groups for this response (Table 9).

Passing Things over Someone's Head
Asians, North and South American, and Europeans indicated that "Passing things over someone's head" was taboo (Table 8).However, tests for independence found no significant differences between geocultural groups for this response (Table 9).

Stepping over Another's Legs
North and South American, Europeans, Asians, and an Oceanian indicated that "Stepping over another's legs" was taboo (Table 8).However, tests for independence found no significant differences between geocultural groups for this response (Table 9).

Other Person's Feet Touching You
North and South American, Europeans, Oceanians, and Asians indicated that "Other person's feet touching you" was taboo (Table 8).However, tests for independence found no significant differences between geocultural groups for this response (Table 9).

Receiving Things with One Hand
Only few Asians indicated that "Receiving things with one hand" was taboo (Table 8).However, tests for independence found no significant differences between geocultural groups for this response (Table 9).

Passing Things and Eating with the Left Hand
Only one Asian participant indicated that "Passing things and eating with the left hand" was taboo (Table 8).However, tests for independence found no significant differences between geocultural groups for this response (Table 9).

Discussion
Most of the respondents had never received treatment at a Japanese hospital, which suggests that their responses regarding Japanese medical facilities and the accessibility to Japanese medical care could have been influenced by assumptions they have of Japanese hospitals.Many participants were concerned about the duration of the hospital treatment.These responses may have been influenced by concerns that receiving medical treatment abroad might impact the limited time participants have in Japan and they may have been concerned that the longer the treatment lasts, the higher the cost will be for them.According to OECD Health Statistics 2016 [20], Japan has invested more in medical equipment, such as CT and MRI machines, compared to Western countries.Moreover, Japan has fewer physicians; therefore, the quality of medical care is maintained by investing in medical facilities and hiring more nursing and pharmacy staff.This means that costs are inevitably high given the need for more medical tests to support diagnosis and treatment by a smaller number of doctors.Consequently, it is important, when possible, to obtain the patient's consent before performing medical tests.
While the mother tongues of respondents who indicated concerns about the language barrier included English, these respondents were also native speakers of many other languages including Chinese, Korean, and Spanish.Some of these respondents were from Asia and Europe, where multiple languages are spoken, and from South America, where Spanish is the official language in most countries.Concerns about language barriers are likely due to respondents being conscious of the fact that, in Japan, it can be difficult to communicate in not only English but also in other foreign languages.To address this concern, Japanese hospitals need to invest in providing signage, documentation, and medical interpreters in other languages.Moreover, Japanese hospitals should also provide staff who can speak languages other than Japanese.
It was clear from the results that more respondents from Asia, followed by those from Oceania, cared about the gender of the medical staff members attending to them, than respondents from the other regions.It was observed that women indicated that being treated by a staff member of the other gender would be problematic.However, few men also indicated that they would refuse treatment or that they needed adequate explanation to accept treatment from a staff member of the other gender.These results suggest that, since the number of male nurses has been increasing and gender bias has an impact on treatment, hospitals need to be able to provide the patient with a medical staff member of the same gender.
Regarding the gestures nurses frequently use for communication, 70% -80% of the respondents thought that pointing to one's nose with the index finger meant "Nose".According to Morris [21], this gesture is only used in Japan while in the West a speaker commonly points to her/his chest to indicate the self.Assuming that foreign visitors to Japan are interested in Japanese culture and media, with the variety of information that can be accessed with the technology available today, one might think that respondents would know this gesture means "I/me".However, most of the foreigners believed that pointing to one's own nose meant "Nose", suggesting that to indicate "I/me", nurses should point to one's own chest and not the nose.
Almost all respondents from every region seemed to be aware that making a circle with the thumb and forefinger meant "OK".However, depending on the situation, misunderstandings could still easily occur with this gesture given that some Asian participants thought it could sometimes mean "Money" and some Europeans thought it could mean "Zero".Again, according to Morris [21], in Arab countries, it represents the evil eye and, as such, can indicate a threat or a curse.Although there were no respondents in this study from the Arab region, care should be taken when using this gesture with Arab patients.
With respect to the gesture of pointing a thumb upward, the results showed that care may be needed when using this gesture.Some of the respondents thought it could be used to insult another person or mean something else, although, in general, respondents from every region were aware that it meant "Good".Thus, the results reiterated that gestures do not necessarily have only one meaning in different regions and cultures and can be interpreted in a variety of ways.Consequently, to prevent a misunderstanding or misconception of their intentions, Japanese nurses need to be careful and confirm that patients have correctly understood their meaning.
Regarding the taboos studied, more respondents from Asia, Oceania, and North and South America, than those from Europe, tended to consider crossing one's arms before superiors as taboo.Therefore, as is the case in Japan, while people may cross their arms when they are pondering something, it may be best to avoid this gesture.Regarding touching another's body, in Asia it is considered taboo to touch anyone older or of higher status on the head or shoulder, which is not the case in other cultures; therefore, special care needs to be taken with Asian patients.Since touching someone on the head or shoulder is only something older people do to younger people, it is important to avoid touching them in this way, if possible, or to warn them before doing so.
Results showed that sniffling is considered taboo in other regions besides Asia.
To give a concrete example, in Japan, while it is strongly considered shameful to blow one's nose in public, nurses should try not to make foreign patients feel bad about it when they are suffering from allergies or a cold and should be considerate of the possibility that they may be feeling ashamed and, for example, quietly hand them tissues.
In Asian cultures, it can be considered taboo for single men and women to be alone together.Since the respondents who indicated this was taboo were from South Korea and China, which are Confucian cultures, it is something nurses need to keep in mind during examinations or other interactions.This could also be applicable to Muslim patients.Thus, for smooth communication with foreign patients, nurses need to know and keep in mind the things that different cultures consider taboo.These are not only related to culture and customs but are also significantly influenced by religious values, suggesting that nurses must exercise special care when interacting with foreigners.
It could be said that the concerns studied in this paper are not issues that occur solely in Japan; given how developed international transportation has become in modern societies, it could be an issue in every country.Amiri R. et al. [22] have said that "Necessary facilities must be provided to people from different cultures.The rights of all patients should be respected equally, and necessary information is given to them".In addition, Ahn [23] explains that "Nurses cultural competence can be developed by offering multicultural nursing education, increasing direct/indirect multicultural experience, and sharing problem-solving experience to promote the coping ability of nurses".

Conclusion
In this survey, we found that communication based on culture, religion, etc. was important for foreigners and that it was necessary to provide nursing care taking these considerations into account.However, it may be difficult for nurses to learn about the culture and customs of every patient to provide culturally sensitive care.This suggests the need to prepare cultural correspondence manuals for foreign patients.One of the goals of nursing and medical care is that all patients should feel safe and secure when receiving treatment.To that end, nurses' cultural competency should be developed through perpetual learning and experience.Regardless of nationality and culture, we can build a relationship of trust between nurses and patients and provide safe and secure nursing.

Limitations
This study examined only a small sample of foreigners; therefore, further studies are needed to include foreigners of several other nationalities and cultural regions.In addition, this survey suggests procedures for nursing care with respect to foreign visitors serving as outpatients in Japanese medical institutions.Finally, future research needs to consider cultural considerations for foreign patients who have been hospitalized.

Table 3 .
Concerns about visiting a Japanese hospital.

Table 4 .
If the nurse's gender is not the same as you, will you decline that offer?(n = 110).

Table 6 .
Please let me know what gestures mean.

Table 7 .
Please let me know what gestures mean.

Table 8 .
What is taboo in your country?

Table 9 .
What is taboo in your country?