Running head: NURSING THE JAPANESE CULTURE

Nursing Considerations in Investigating the Japanese Culture

Maggie M. Fabry
California State University, Stanislaus

NURSING THE JAPANESE CULTURE

Nursing Considerations in Exploring the Japanese Culture

A good nurse possesses an array of different skills and qualities. Empathy, responsibility,
a caring nature, good communication skills and an ability to think fast are just a few. An
additional skill that is becoming increasingly important is cultural competence. One of the five
components of cultural competence is cultural knowledge. Cultural knowledge includes both
formal and informal education about specific cultural values, worldviews, beliefs and
perceptions about wellbeing and sickness (Hockenberry & Wilson, 2013). Nurses can gather
cultural knowledge in many different ways including a personal interview, which is the method
that has been implemented to create this paper. Informant selection was based on an extreme
lack of knowledge of East Asian cultures. In addition, availability and convenience were factors
that proved to be influential. This paper is based on an interview conducted with Bruce
Kawabata who is a Japanese Buddhist (B. Kawabata, personal communication, March 31, 2014).
This interview was conducted on March 31st of 2014 in Mr. Kawabatas home. Verbal
permission to write about the information gathered during the interview was given prior to the
creation of this paper. The bulk of the paper will focus on the Japanese culture, but information
about the Buddhist religion will be included as well. Purnells 12 Domains Model, appropriate
nursing interventions based on my informants cultural needs, nursing standards of practice and
an analysis of the interview and writing experience will be utilized and included to help illustrate
this cultural experience.
Purnells 12 Domains
Overview of Heritage
The country of origin for the Japanese culture is Japan. Since the late 1800s, Japanese
immigrants have been migrating to the United States (Paulanka & Purnell, 2003). Mr. Kawabata

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was born in the United States and is a third generation Japanese American immigrant. His
mothers family originated in Hiroshima and his fathers in Tottori. Bruces ancestors came
here from Japan to seek better financial opportunities for themselves and for their children. The
three generations have all resided in California. Bruces father graduated from Cal Berkeley
with a degree in mechanical engineering and his mother stayed at home and cared for the
children. Bruce has a bachelors in business and is currently a technology manager. His wife
also graduated from college and is an office administrator. Getting a good education and having
a successful career is considered extremely important in the Japanese culture. According to
Paulanka and Purnell, Japanese immigrants, tend to be highly educated professionals
(Paulanka & Purnell, 2003, p. 219). During the interview, Bruce took his time when expressing
the importance of his childrens education to his wife and himself. His two children were not
given options when it came to their education and college degrees were expected from both of
them. Both have followed this path and are currently in college and working towards graduation.
Communication
The dominant language of the Japanese culture is Japanese. In addition to learning
Japanese, students graduating from high schools in Japan also take several years of English
lessons (Paulanka & Purnell, 2003). As a result, almost all Japanese immigrants can speak and
understand at least some English. For Bruce and his immediate family, Japanese is a second
language and English is the primary language. Bruce explained that his culture is traditionally
unanimated and does not use much body language during conversation. Body language is
typically subtler and involves things like pursing the lips and crossing the arms. Bruce went on
to say that individuals from the Japanese culture and also those who practice Buddhism tend to
be non-confrontational and to internalize their feelings. Through growing up in America, Bruce

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is much more animated than previous generations of his family. Throughout the interview,
Bruce was very enthusiastic and used hand gestures often to support his dialogue. In addition,
Bruce is also more affectionate than his ancestors typically were. Bruce often hugs and kisses
close friends and family, which is not a traditional practice. In Japan, close contact in public is
taboo (Paulanka & Purnell, 2003). The Japanese culture also values promptness. Bruce
communicated that tardiness is considered rude and is not tolerated well. This could possibly be
related to the fact that citizens in Japan rely heavily on public trains, which follow strict time
schedules. When it comes to naming their children, the Japanese are thoughtful. Bruce
explained that the name is usually handed down from some derivative of a family name.
Random assignment of names is traditionally not used. In Japan, last names or family names are
said first and their first name is stated second (Paulanka & Purnell, 2003).
Family Roles and Organization
Traditionally, women in Japan assumed most of the household decision-making
responsibilities. Japanese women were expected to manage the children, the house and the
finances while men worked long hours and earned the sole source of income for the family
(Paulanka & Purnell, 2003). For Bruce, however, his mother and father were equals in decision
making and parenting obligations. Although his father worked and earned the income, his
mother was not expected to make all of the decisions and do all of the parenting-related activities
on her own. In Bruces household today, things are the similar. Bruce acknowledged that this is
because his parents and himself are second and third generation Japanese Americans.
Spirituality, education, and well-being seem to encompass the Kawabata family
priorities. When it comes to religious practices, Bruce practices Buddhism and his wife is a
Christian. Bruce expressed the difficulties that his wife and he have faced while trying to find a

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Christian church that is accepting of a Buddhist belief system. Being Buddhist, Bruce was raised
to be open and accepting of everyone and agreed to raise his children in the Christian church
because it was important to his wife. Due to this nature of the Christian church, he often goes to
church separately from the rest of his family. Bruce is not bothered by this and is simply happy
that his family is attending church. The education and well-being of their children is a
overarching goal for Bruce and his wife. In addition to a college degree, the importance of
having hobbies and giving back to the community has been emphasized to his kids from a young
age. According to Bruce, having hobbies and being involved in community services contributes
to ones well-being just as much as a good education does. For this reason, his daughter was put
in girl scouts and his son was put in boy scouts during their childhood.
When it comes to alternative lifestyles, Bruce believes that his Buddhist background has
been most influential. Buddhists are non judgmental in nature and tend to focus on their own
journeys rather than on the lifestyles of others. For this reason Bruce does not have any stance
on alternative lifestyles. In traditional Japanese culture, prostitution and involvement in porn are
accepted lifestyles and are growing industries (Paulanka & Purnell, 2003). The open discussion
about these activities, however, is less standard. Gay and lesbian involvement as well as
extramarital sex are starting to be more accepted as well (Paulanka & Purnell, 2003).
Workforce Issues
There were not many workforce related issues that Bruce could identify during the
interview. Bruce did mention that typically, men work and earn the income while women stay
home and care for the children and the household. Second and third generation Japanese
Americans have started to become more westernized, however, and women often work outside

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of the home as well. In addition, the Japanese tend to work long hours and their salaries are
often low compared to the cost of living (Paulanka & Purnell, 2003).
The Japanese in the workforce tend to exhibit less autonomy and instead simply do what
the leader asks of them (Paulanka & Purnell, 2003). In addition, Japanese workers rarely refuse
to do a task and aim to please their colleagues and superiors. Japanese American workers may
only assert themselves if the law supports the decision to do so and it is within their legal rights.
Biocultural Ecology
Japanese individuals have some distinct physical features. Slanted eyes, yellow to tan
skin coloring and a shorter stature are a few of these (Paulanka & Purnell, 2003). Black, straight
hair and brown eyes are dominant features as well. Bruce has each of these features as does his
wife and his two children. Bruce was unaware of any prominent diseases or health conditions in
the Japanese culture. According to Paulanka and Purnell, the three leading causes of death in
Japan are cancer, heart disease and stroke (Paulanka & Purnell, 2003). Despite these health
issues, Japanese have the longest average lifespans of anyone in the world. When it comes to
drug metabolism, the main variance for the Japanese population is a lower average height. Their
smaller statures may have an influence on the effects of drugs and the speed at which they are
broken down in the body (Paulanka & Purnell, 2003).
High Risk Behaviors
Bruce and his wife are both non-smokers and drink only on occasion. Bruces parents are
non- smokers as well and drink even less often than Bruce does. However, Bruce did say that he
believes smoking tobacco was a popular high-risk behavior of past Japanese generations. In
reality, over 50% of men and almost 15% of women in Japan do smoke tobacco products
(Paulanka & Purnell, 2003). In Japan, excessive drinking is not a regular custom but is more

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often practiced by men than women. Working men sometimes indulge with sake and beer after
work and on Sundays. Drugs are not tolerated in Japan and the legal ramifications associated
with drug use are steep. One area of concern in Japan is the rise in obesity among children. The
recent trend towards eating Western foods may be to blame due to the high calorie, carbohydrate
and fat content (Paulanka & Purnell, 2003).
Nutrition
Food has played a significant role is Bruces faith and his culture. Bruce explained that
Buddhists believe that food plays a role in good fortune, a long life and money. Food dishes
such as ozone, umami, gobo and crab are all present at the New Years Day celebration and
during family gatherings. Bruce also stressed the importance of the presentation of food.
Buddhists only offer food that is presentable and physically appealing. To offer food that was
not presentable would be considered rude. In Bruces Japanese culture, rice is a highly respected
food and can be used in almost every meal of the day. Bruce explained that his mother would
prepare handmade sushi for the family regularly using seaweed, rice and different fishes.
Traditionally, the Japanese have been a very healthy people and food items such as fish,
seaweed rice and green tea have contributed to their overall health (Paulanka & Purnell, 2003).
Today, the Japanese have begun to eat many meals that are higher in fats as a result of Western
influence. As obesity rates rise, the creation of weight loss programs and health promotion
education has begun to surface (Paulanka & Purnell, 2003).
Peoples of Asian decent typically have a higher prevalence of lactose intolerance. In
some areas, more than 90 percent of the population has some degree of intolerance to dairy. This
is because East Asian countries have not historically had a dependence on milk products (U.S.
National Library of Medicine, 2010). Bruce, however, is not affected by lactose and is able to

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eat dairy products regularly. His wife consumes dairy minimally due to certain side effects that
her body experiences and both of their kids eat only minimal amounts as well. A nutritional
deficiency that tends to be seen in populations that consume high amounts of rice is a lack of
adequate amounts of Vitamin A (Bamji, 1983). The traditional Japanese diet typically lacks 20
percent of the recommended daily intake of Vitamin A and of riboflavin (Bamji, 1983).
Pregnancy and Childbearing Practices
Due to the fact that this informant is male, limited information will be presented here.
Bruce was unaware of any specific Japanese practices and views towards pregnancy. In regards
to fertility practices, neither his wifes nor his own religion has any specific guidelines relating to
contraception methods. Bruce was able to note that due to the fact that the Japanese are more
stoic in nature, it is probable that a women would be quiet and unanimated during labor. During
her labor experiences, his wife received epidurals and was almost completely free of pain.
Death Rituals
Issues surrounding death have been influenced more greatly by Bruces Buddhist
background than by his Japanese heritage. In Buddhism, death is viewed as a part of life. Bruce
explained that although there may be a short period of grieving, Buddhists view death as the
beginning of a new life or hopefully as the beginning of the journey to Nirvana. Nirvana is the
place in which all Buddhists eventually go after being reborn many times in different forms and
realms. Upon the death of a Buddhist, a minister will come to the house and do a sermon at the
bedside. That evening, a service will be held at the individuals house for immediate family
members. Typically, a seven-day service will follow and then an additional service on the 49th
day after the death will also be conducted. Bruce did explain that in Japan, the service can last
for 49 days because this is how long it takes to get to Nirvana. At the services, family and

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friends will get together and tell stories, reflect and honor the deceased. Bruce described these
services more as celebrations of life rather than times of mourning. In addition, Bruce explained
that Buddhists are always cremated and never buried.
Buddhists greatly value a peaceful death. In fact, the thought of not having this peaceful
death is an area of extreme worry for family members (Kongsuwan, Chaipetch, & Matchim,
2012). This may be due to the fact that a good death is said to lead to a better rebirth.
Involvement of family members in the care of the dying individual promotes a peaceful death
and is an important part of the dying process (Kongsuwan et al., 2012).
Spirituality
Buddhism is religion that has been passed down in Bruces family for generations.
Buddhism is seen in many areas of East Asia. In Japan, most households contain a Buddhist
altar where loved ones who have died can be honored (Paulanka and Purnell, 2003). Buddhists
use both meditation and regular prayer in their faith, according to Bruce. Bruce says that he
rarely finds the time to meditate and usually uses prayer as a form of worship. Buddhists and
most all other Japanese religions believe in reincarnation. For this reason, the goal is simply to
be reborn into a better form and, eventually, to get to Nirvana. Bruce explained that Buddhists
believe that the journey to Nirvana can only be attained when craving has been eliminated from
ones life. When one goes to Nirvana, the suffering that is present in each realm is eliminated
and one can truly be at peace. Bruce explained once again that Buddhists are an accepting
people who aim to self improve so that they can eventually have eternal peace.
Buddhists worship Buddha. According to Bruce, Buddha acts as a coach for Buddhists
and through following his teachings, one can finally end the suffering and have eternal peace in
Nirvana. Buddhists believe that they will continue to die and be reborn into one of the six realms

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until craving has been eliminated. Bruce also explained that Buddhists believe that the life you
lead now will determine which of the six realms you will be reborn into next. Buddhists refer to
this concept as Karma.
Bruce explained that when it comes to health care, his religion does not play a large role.
Like most of his Japanese friends and family members, Bruce is widely accepting of Western
medicine and health care practices. However, some traditional Japanese religions do play roles
in health-care practices (Paulanka & Purnell, 2003). Shrines and temples are sometimes used to
request bodily healing or to receive blessings. In addition, personal objects can be taken to these
areas to be cleansed and rid of evil. These rituals are important in some Japanese religions, but
seem to be used more for providing comfort than in making any true medical decisions
(Paulanka & Purnell, 2003).
Health- care Practices
In many ways, Japanese behaviors related to health-care differ from those of Americans.
Physical imperfection is a worry of many Japanese (Paulanka & Purnell, 2003). Birthmarks and
ear piercings can be concerns because they become flaws on the body. A tendency that is more
common in Japan is the termination of a pregnancy if health conditions of the fetus are
suspected. This can partly be attributed to the extreme competiveness of education in Japan, and
also to this importance placed on physical perfection (Paulanka & Purnell, 2003). Bruce
described his health- care practices to be in congruence with the typical American practices.
However, he did note that he tends to wait longer to see a doctor because his Buddhist heritage
has led him to wait for a natural resolution rather than involve a doctor for no reason.
One recognized folk practice used in Japan is Morita therapy (Paulanka & Purnell, 2003).
This strategy is used to treat individuals with sensitivities to social environments. Regular self

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reflection is considered harmful, and Morita therapy helps individuals to come to grips with
reality. Two other folk practices are Naikan and Shinryo Naika. These practices deal with
reflecting on the love in ones life and seeking connections between illness and emotion
(Paulanka & Purnell, 2003).
One cultural response to health and illness that Bruce conveyed more than once during
the interview was the stoic nature of the Japanese. This can be a result of the great importance
put on bearing ones pain in the Japanese culture (Paulanka & Purnell, 2003). In addition, pain
medications are used much less in the Japanese culture than in the American culture. Reliance
on pain medications or any narcotics is considered taboo in Japan. The Japanese culture has not
typically responded well to mental disabilities in their society. This has led to inhumane
treatment of mentally ill individuals in the past (Paulanka & Purnell, 2003).
Health- care Practitioners
According to Bruce, the Japanese do not have a preference when it comes to more
traditional or more biomedical practitioners, and that they simply want a doctor who is culturally
sensitive. Bruce explained that physicians are highly respected by the Japanese and their
influence over health related decisions is substantial. The Japanese believe that the doctors know
best. In Japan, physicians typically tell patients what to do and this authority is not to be
questioned (Paulanka & Purnell, 2003). Physicians are also typically in charge of the hospitals
in Japan. Nurses, on the other hand, on not as well regarded in Japan as they are in the United
States, which is in part due to the status of women (Paulanka & Purnell, 2003). Bruce conveyed
that physician and nurse roles are not viewed by Japanese Americans the same way that they are
viewed by the Japanese living in Japan. Nevertheless, physicians are highly respected by both
societies.

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Nursing Interventions
If Bruce Kawabata were a patient in an acute care setting, it would be important for any
nurse, to inquire as to the specific cultural practices of the patient. The information collected
should include religious practices, identified culture and dietary preferences. This is important
because every individual is different, and as Bruce has displayed throughout the interview, not
everyone follows his or her cultural norms as closely as the rest. Through gathering this
information, the nurse and the rest of the medical team can take steps to make sure that the
clients wishes are respected and that he remains comfortable during his stay. In this
questioning, it would also be important to ask Bruce if he is comfortable being cared for by a
female nurse or if he would prefer to be attended to by a male nurse. This question is one that
should be asked of each patient whose cultural values are not completely known. This
intervention would fall under Leiningers Culture Care Preservation or Maintenance because it
aims at preserving the values of the individual rather than attempting to augment them.
After learning more about Bruces background and learning the importance of family in
the Japanese and Buddhist cultures, an important nursing intervention would be to call his family
and ask them to accompany him in the hospital if Bruce so wished. Buddhists place great value
on the familys involvement in taking care of ill and dying loved ones. Involving the family in
the care process and promoting a family-centered care environment can greatly improve the
patients experience at the hospital. In addition, if Bruce were to suddenly have a steep decline
in health, his family could be there to support him in his last days. This intervention would also
fall under Leiningers Culture Care Preservation or Maintenance because it does not use
negotiation or restructuring and simply aids in preserving the values of the client.

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A third nursing intervention would be to ensure that Bruce was receiving adequate
amounts of Vitamin A in his diet. After learning that the majority of Japanese individuals do not
consume the recommended amounts of Vitamin A, is it clear that some instruction may be
necessary. It would be important to first inquire about Bruces knowledge of Vitamin A and the
deficiency associated with his culture. From there, supplements and/or an increase in dietary
Vitamin A can be recommended. Foods high in Vitamin A such as leafy vegetables and tropical
fruits can be recommended because they are also healthy and contain other important nutrients.
It would also be imperative to explain to Bruce the reasoning behind consuming the appropriate
amount of each of the Vitamins so that adherence may be improved. This intervention falls
under Leiningers Culture Care Accommodation or Negotiation because it aims to negotiate with
the patient to reach a beneficial goal.
Transcultural Nursing Standard of Practice
The Transcultural Nursing Standards of Practice standard three is knowledge of cultures.
This standard is both important and applicable to this interview with Bruce. This standard of
care reviews the importance of understanding the various areas of culture such as values and
family systems (Transcultural Nursing Society, 2010). It also demands that nurses gain
knowledge about the variables of a culture that affect an individuals attainment of good health
and well being. Nurses must have a knowledge base of information about different cultures of
people that they care for in order to provide culturally competent care. Standard three
acknowledges the importance of gaining knowledge of cultures in order to prevent
overgeneralizations and stereotyping (Transcultural Nursing Society, 2010). The entire
interview process involved gathering information about the Japanese culture through a series of

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questions. The knowledge gained included both specific details about the individual and broader
information about the Japanese culture as a whole.
Analysis of Cross Cultural Experience
This experience has been a huge learning process. Through completing this interview,
wisdom has been gained regarding what constitutes a good and a bad question and also about
how to better word some questions. Some of the questions that one has to ask while conducting
a medically related interview can be uncomfortable for both the interviewer and the interviewee.
Having practice in asking these difficult questions may make the process go a little bit smoother
each time. In addition, a great database of information about a culture that has grown larger in
number in the United States can really aid in ones ability to provide culturally competent care.
In retrospect, it would have been nice to gain a little bit of information about many cultures
instead of so much information about just one. However, this knowledge can be gained bit by
bit, and having the full information collection process experience is invaluable. One thing that
worked well during this process was looking up information about the culture ahead of time in
anticipation for the interview. This allowed the interview to go quicker and for questions to be
more specific and better thought out. In addition, choosing an individual who one is comfortable
with proved to make things slightly more relaxed, and was a good introductory step. Looking
back, it would have made things easier if the informant had been a first generation immigrant or
simply a more traditional one. Also, it would have most likely assisted in a gaining a better
overall picture of the culture. However, second and third generation Japanese immigrants seem
to be the generations that are beginning to age and will soon require more nursing care. Overall,
this was a fun and interesting way to learn a lot more about a culture.

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A plethora of knowledge was gained through conducting this interview with Bruce.
Information about both the Japanese and Buddhist cultures was acquired through this process
and it will certainly be applied to a future career in nursing. Out of everything that was learned,
the most important would have to be the cultural rituals surrounding death and dying. The
impending death of a patient is a situation that most new nurses would be unsuited to deal with
healthily. Through gaining knowledge about how certain cultures would like events surrounding
death to be handled, nurses can be better prepared to deal with the devastation. Whether its
calling the family, calling a minister or knowing which life saving maneuverers to avoid,
recognizing which actions to take when dealing with death and dying is essential for all nurses.

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