The impact and support for nurses in Japan under Covid-19. 

The impact for nurses in Japan under COVID-19

World Health Day, held on April 7th, 2020, was a day to celebrate the work of “nurses and midwives”, and to remind world leaders of the critical role they play in keeping the world healthy. This day has aimed to create awareness of a specific health theme to highlight a priority area of concern for the year (1).The COVID-19 pandemic has created unprecedented levels of stress for health care workers, including nurses, who are at the frontlines of COVID-19 response while putting their own health at risk. In this short note, I would like to focus on the situation of nurses and describe some of the support for them in Japan.

1. The number of nursing personnel in Japan

In 2025, when the baby boom generation retires, there will be an estimated demand of 1.96 to 2.06 million nurses, which may cause a shortage of 0.3 to 1.3 million nurses (2). In consideration of future demands due to a super-aged society, a law was established to increase the number of highly educated nurses, and the number of these schools for nursing in Japan, especially universities, has jumped since 1992 (3). The number of universities in 2020 was 272, which is approximately 25 times the number from 1991, and in the last 5 years, almost 55,000 people per year have passed the national nurses certification exam(4), which is basic requirements to for nursing personals including registered nurses, public health nurses and midwives . The majority of nurses works at health care facilities such as hospitals, long-term care facilities and home care stations. Meanwhile, public health nurses accounts for only approximately 3.3% and midwives account for approximately only 2.3% of nursing personnel in Japan (5).
The number of nurses in Japan per 1,000 inhabitants is relatively higher than that of other countries (11.3 in Japan versus an average of 8.8 for OECD countries) (6), due to this long term measure to increase nursing personnel. However, many health care facilities still struggle to fulfill the standardized staffing level of nurses. One of the reasons is that the number of hospital beds is quite high in Japan compared to other countries (13.1 beds per 1,000 inhabitants in Japan versus an average of 4.7 for OECD countries) (6).

2. Serious cases of COVID-19 require more nurses for intensive care

Most of the people who are infected with COVID-19 are able to recover, but severe cases of COVID-19 require care in Intensive Care Units (ICU), where the Ministry of Health, Labor and Welfare (MHLW) standardizes the patient and nurse ratio (2:1 or more) (7). In Japan, medical ventilation care may be provided not only by ICUs, but also by High Care Units (HCU), which require moderate patient and nurse ratios (4:1). As a result, HCUs also accept patients with severe COVID-19 symptoms. These high demands for nurses in ICUs and HCUs lead to burdens for other treatments, such as the postponement of non-urgent surgeries or limits for accepting outpatients.
MHLW decided to give approval for temporarily increasing medical charge fees for ICUs and HCUs when accepting COVID-19 patients under the National Health Insurance system as of April 18th, 2020 (8), in order to compensate for the financial burden on hospitals.
Moreover, when Extracorporeal Membrane Oxygenation (ECMO) is used, the demand for health workers, including expert nurses, is quite high. According to a survey via CRoss Icu Searchable Information System in Japan, the number of COVID-19 patients treated with ECMO began with 2 patients on February 15th, reached a peak of 63 on April 27th, and there were still 18 patients as of May 25th, 2020 (9). Japan seems to have relatively sufficient resources for ECMO (2,667) and medical ventilation (35,691) as of March 9th (10). However, hospitals would still need to prepare trained health workers, especially expert nurses who can work in ICUs and HCUs, not only for countermeasures against COVID-19, but also for maintaining daily medical treatments.

3. Support for nurses under COVID-19

The Japan Nursing Association, which is the largest nursing organization in Japan, has approximately 740,000 registered nursing personnel, including registered nurses, public health nurses, midwives, and licensed practical nurses. The association has been submitting several formal requests to the Prime Minister and MHLW, including those for special additional fees for nursing care using medical ventilation or ECMO (11).
MHLW have already decided to subsidize half of the costs for sending alternative doctors or nurses and their activity fees to hospitals forced to quarantine health workers due to outbreaks of COVID-19. Various prefectures have been attempting some form of original support for health workers, including nurses who have worked in hospitals responding to COVID-19. For example, Osaka prefecture established official funding to collect donations from individual or private companies in order to give a special allowance for health workers who are caring for COVID-19 patients, and the collected funding reached 2.16 billion yen as of May 26th (12). These supports should provide a certain level of empowerment for clinical health workers, including nursing personnel, who deal with COVID-19 and maintain health care for all patients.
The COVID-19 pandemic imposes a great deal of pressure for the health workforce. While this is an unanticipated situation, the theme of World Health Day happens to be “Support for nurses and midwives”, and highlights their work internationally. Health care organizations, including hospitals, long-term facilities, and home nursing stations, face many difficulties in balancing considerations of how they can protect their workforces and how they can maintain the health of patients or people in their communities under the pandemic. Japan prevented the collapse of the medical care system in the first wave of COVID-19, but we need to prepare for the next wave by considering health workers’ health, providing allowances for them, and implementing appropriate training.
 

1. WHO, World Health Day 2020 (Accessed on 25th May, 2020)
https://www.who.int/southeastasia/news/events/world-health-day
2. MHLW. Countermeasures to increase nursing personals (Accessed on 25th May, 2020)
https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000095525.html
厚生労働省.「看護職員確保対策」（Written in Japanese）
3. MHLW. The law regarding to increase nursing personals (Accessed on 25th May, 2020)
https://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000103786.pdf
厚生労働省．「看護師等の人材確保の促進に関する法律」（Written in Japanese）
4．MEXT. Data regarding nursing school in 2019 (Accessed on 25th May, 2020)
https://www.mext.go.jp/b_menu/shingi/chousa/koutou/098/gijiroku/__icsFiles/afieldfile/2019/05/27/1417062_4_1.pdf
文部科学省.「2019年度看護系大学にかかる基礎データ」（Written in Japanese）
5．MHLW. The number of working public health nurse, midwifes, nurses. Licensed practical nurse. (Accessed 25th May, 2020)
https://www.mhlw.go.jp/toukei/saikin/hw/eisei/18/dl/kekka1.pdf
厚生労働省. 「平成30年衛生行政報告例の概要―就業保健師・看護師・准看護師」(Written in Japanese)
6. OECD, Health at glance 2019 (Accessed on 1st June, 2020).
https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance_19991312
7. MHLW The report for safety management in ICU (Accessed on 25th May, 2020)
https://www.mhlw.go.jp/topics/bukyoku/isei/i-anzen/hourei/dl/070330-5.pdf
厚生労働省. 「集中治療室における安全管理について」（Written in Japanese）
8. MHLW. The comparison of the number of ICU (Accessed on 25th May, 2020)
https://www.mhlw.go.jp/content/10900000/000627782.pdf
厚生労働省. 「ICU等の病床に関する国際比較について」（Written in Japanese）
9. Japanese ECMO net for COVID-19 provided by The Japanese society of intensive care medicine, Japanese Association for Acute Medicine, Japan Society of Respiratory Care Medicine, The situation of saver COVID-19 patients (Accessed 25th May, 2020)
https://covid19.jsicm.org/
三学会合同（日本呼吸療法医学会、日本救急医学会、日本集中治療医学会）日本COVID-19対策ECMOnet. 「COVID-19重症患者状況」(Written in Japanese)
10.　Japan Society of Respiratory Care Medicine＆Japan Association for Clinical Engineers, Survey for the number of medical ventilation and ECMO
https://www.jaam.jp/info/2020/files/info-20200306.pdf
日本呼吸療法医学会、日本臨床工学技士会. 「人工呼吸器およびECMO装置の取扱台数等に関する緊急調査」
11. Japan Nursing Association, formal requests for governments regarding COVID-19 (Accessed 25th May, 2020)
https://www.nurse.or.jp/nursing/practice/covid_19/request/index.html
日本看護士協会.「新型コロナウイルス感染症関連情報の各種要望」(Written in Japanese)
12. Osaka Prefectural Government, Official funding for COVID-19 （Accessed 25th May, 2020）
http://www.pref.osaka.lg.jp/kenisomu/coronakikin/index.html
大阪府庁. 「新型コロナウイルス助け合い基金について」（Written in Japanese）

Masashi Suzuki Healthcare Global Unit Manager
Mitsuyo Morikawa Healthcare Global Unit Senior Staff
Mami Wakabayashi Healthcare Global Unit Staff