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Free Meeting
[Participants: symposium presenters (Dr. Tsuda, Dr. Ellis, and Dr. Ishigaki), faculty members and students from OPCN and other universities, one nurse and two graduate students at the Miyako satellite campus through tele-conference system]
Professor Kinjo: This is a free meeting session, so that I would like you to discuss freely certain themes. First of all, as a review of today’s symposium, I would like you to identify some keywords. What were the keywords presented today? [Answers from Participants: Islands, Nursing, Education, Advanced practice, Current Situation and Challenge]
I would like to ask some questions from the students at Miyako (the satellite campus) who have been participating in the symposium through our distance lecturing system. What about some questions about advanced practice? One student (on the screen) is our 4th year undergraduate student. The other is a nurse at the Prefectural Miyako Hospital as well as our graduate student.
[Topic: Flying Doctor Service]
Participant: I would like to ask Dr. Ellis. Which organizations pay for the Flying Doctor Service? In Okinawa, NPOs and the self-defense force are working for such service.
Professor Kinjo: In Okinawa, the Northern Okinawa Medical Association has been asking donations for MESH (Medical Evacuation Service with Helicopter).
Professor Ellis: In Australia, there are two funding sources. One is the Commonwealth of Australia. The other is donations from Australian citizens. We hold various events for fund raising. For example, “We will have a dance party, so that please buy the ticket.” There are many events where we donate money to support the Flying Doctor Service.
[Topic: Health Education]
Participant: When I visited (Tinian), I heard that the Public Health had to provide pregnancy guidance for teenagers because there are many cases of pregnancy among them. However, I also heard that the sex education is not easy there because their religion does not permit abortion or there is a custom that they are given a piece of land for a child birth. I would like to ask about their current efforts regarding the sex education for teenagers.
Professor Kamizato: The Public Health used to visit high schools for the sex education. However, due to lack of manpower, they had to discontinue the service. Then, cases of teenage pregnancy increased immediately.
President Noguchi: Effects of health education come immediately and are visible.
Professor Kamizato: They do not have enough people for house visits as well… The budget of Tinian was even worse last year. Therefore, there was no house visit as there was no human resource for the service. I heard from Ms. Long last year when I visited Tinian that a indigenous couple is given one piece of land when they get married. Even when the both used to have each land property, they have to lose one. They have long believed that they lose something for marriage. Ms. Long told me that about 80% are not married. Many become pregnant around 14 – 15 years old, but few get married. Therefore, if there is a wedding, everyone thinks “When will they divorce?”
Professor Kinjo: Is it the case only at Tinian?
Professor Ellis: We have an interesting situation in Australia to discourage young traditional aboriginal girls from getting pregnant too early. Aboriginal people, traditional people do not believe that babies are the result of intercourse between a man and a woman. They believe that a woman would breathe in the spirit of the baby, and the baby comes from the environment. It must be the spirit of bull frog or hummingbird, and when the time is right, the baby will grow inside the mother. Then, having intercourse is not related to pregnancy in their culture. To discourage girls from having early pregnancy, we do not talk about pregnancy, but we talk about sexually transmitted diseases. We do not mention pregnancy.
[Topic: Infection Control and Development of Next Leaders]
Participant: I am a certified Infection Control Nurse at the Miyako Hospital. I am not from Miyako, but Chatan-town in the Okinawa main island. This is my second year at this Hospital. At the symposium, in the talk about the development of island nurses and leaders, I was listening to it as if it was about my own situation. I think that my role is to train the next certified Infection Control Nurse at the Miyako Hospital. It would be great if one of my colleagues can eventually take over my position. However, nurses at prefectural hospitals are sometimes transferred. Therefore, my challenge is that how many colleagues I should train in a short time span to be an Infection Control Nurse, which can be costly. If anyone has a good idea, please give me a tip.
Professor Kinjo: I think that is a very good question. I assume that the tip can be drawn when we think of how a leader trains a next leader.
President Noguchi: There is a problem of money because if one wants to be licensed to be a certified nurse, he/she has to study at an institution in Tokyo or another place in Japanese mainland.
Professor Kinjo: First of all, she has to find and train someone who want to be a certified nurse…
President Noguchi: The Okinawa Prefectural College of Nursing has to establish a new program which can provide the certification in order to make it inexpensive (for the nurses in Okinawa). However, an Okinawa prefecture does not have an enough budget for that.
Professor Kinjo: The biggest difficulty you have is about opportunity to be a certified nurse, isn’t it? Or is it that there is opportunity, but still difficult because it is costly? Or is it difficult because you cannot find someone who wants to be a certified Infection Control Nurse? Do you want to train someone who can take over your role at the hospital?
Participant: Yes. In reality, I also need to level up myself who is already certified. I need to make efforts to participate in training programs outside Okinawa and learn something new. I wonder if someone can establish an educational system which allows nurses to learn from distance, just like the system we have between the main campus and the Miyako satellite.
Professor Kinjo: I see; the system that prevents you from rusting.
Participant: Yes.
Professor Tsuda: I guess the first thought that comes in my mind is; in order to be a leader, you need a follower. Yes? What would make people follow you? Tell her that I am not expecting an answer, but want her to think.
President Noguchi: Critical thinking
Professor Tsuda: Critical thinking; I want you to think critically.
Professor Kinjo: Maybe it is a good idea to remember when you decided to be a certified nurse.
Professor Tsuda: That is good; I want her to think such things.
Participant: I will think. Thank you.
Professor Tsuda: Tell the three (at Miyako) that the question is for all of them.
Professor Ellis: I have an answer for you. How do you make someone else be the leader? When you an island nurse, number one strategy that most leaders do is go off sick. So you must prepare everyone on your team to take up of leadership position in case you do go off sick. That is your responsibility as a leader is to make sure that there is always someone who can on that role when you are not there. So prepare for that right now.
Participant: I think I am thinking like that and trying my best everyday. I am trying to work without putting every duty on my shoulder. I asked about money because that is still a big problem.
Professor Kamizato: Are you talking about money to let your colleague take a certifying examination?
President Noguchi: I am not sure whether you are talking about money to implement infection control or to take a license. Is it important to get a license or to implement an appropriate job even without the certification?
Professor Kinjo: A leader is responsible to train a next leader. It was mentioned that she needs to make sure whether the next leader wants to be in charge of infection control. Then, the problem about money can be resolved somehow if the concern is the overall cost of license acquisition.
President Noguchi: Then, does it cost so much to do infection control? If you say “Please buy some materials” for the infection control, the hospital cannot afford it? Is there that sort of case?
Participant: Infection control is costly.
Professor Tsuda: Is it the cost for infection control? Or is it the cost for safety management of the hospital? Does it cost so much for infection control? Buying materials is part of overall risk management of the hospital. The hospital is not willing to cover the cost for that?
Participant: I saved about 3 million yen in order to take the course for certification. I spent the whole amount during the training because I did not have any income. I believe that someone with the license is able to do infection control as a specialist. Therefore, I would like to find and train someone who wants to be certified. Regardless of the license, a nurse who has sat in the infection control committee in each department has worked in infection prevention, so that he/she can handle the infection control. However, for infection control of the whole hospital, one needs specialized knowledge. Thus, someone with proper education is suitable for that position.
Professor Kinjo: Are nurses making enough effort to provide hospital managers with some evidenced processes that infection can be controlled? Do they use some data which can change the practice of infection control?
Participant: I am doing so little by little.
Professor Kinjo: Is it because you are at the Miyako Hospital located in an island environment?
Participant: No. I am going to make same effort wherever I work. Regarding the cost, talking about a cost-benefit performance, we tend to focus on lowering purchasing costs. From my experience of infection control, the cost-benefit performance can improve by reducing cases of infection among patients. We can reduce numbers of patients as well as days of hospitalization, and that can improve the cost-benefit performance.
President Noguchi: We also need to consider something besides an economic performance. A performance of a hospital is that patients get well or all citizens regard it as “our” hospital.
[Topic: Totality]
Professor Kinjo: I had to assume that many audiences were not exactly sure about the concept of “totality” presented by Dr. Ishigaki. When I heard it for the first time, I wondered what “totality” was. I wonder how clearly the audiences could grasp the concept.
President Noguchi: I wondered if there was an appropriate Japanese term for this concept.
Professor Ishigaki: Unfortunately, I could not find an appropriate term in Japanese.
Professor Kinjo: Dr. Ishigaki argued that “totality” comes to the fore in remote island settings. Doesn’t it have to come to the fore at urban settings?
Professor Ishigaki: It can easily come to the fore in remote island settings. It should so in other settings as well, but they tend to work on each specialized area and feel accomplished. However, there are many other small elements to be dealt with; for example, a discharged patient changes once he/she comes home, and it can be different from what medical and nursing individuals expect to the patient. As for activities of public health nurses, patients show us different aspects when we see them at house visits. I think it is very difficult to figure out what the most helpful service is for patients if we are not able to see and grasp a total figure. In island settings, it is easier to do so.
President Noguchi: “Holistic” indicates an individual approach and competition. What is involved in nursing is “sociality.”
Professor Kamizato: It is “sociality” when communities are concerned.
President Noguchi: That is basically right. However, in order to assure “totality” in a community, one needs to have mutual foundation or cultural understanding. In order to realize “totality” in a community, one needs to cross borders of specialization and keep making efforts. “Totality” cannot be realized if one says “This is a doctor’s role. This is his/her role, so that I cannot do this.” If there are only few members in one setting, “totality” can be realized.
Professor Kinjo: Professionals are at the same time members of the community, so that they have to cooperate with others in daily life settings. They also play multiple roles in the community. In urban settings, some roles are expected to be played only by some specialists. As a result, “totality” is not realized.
President Noguchi: There are some roles that one cannot play in urban settings. If one passes a particular duty onto another, the overall activity is not of “totality.” The question is whether in such a divided field, a nurse is able to provide patients with thorough service. From a perspective of nurses, what I explained is about “totality.” “Holistic” is about spiritual, social, cultural and all other factors for patients as well as nurses.
Professor Tsuda: As advanced practice, is “totality,” to be achieved by cooperation? Or by an individual playing multiple “total” roles?
Professor Ishigaki: It is both; it can be of an individual. Anyone who helps others is total.
Professor Tsuda: It can sound that specialization is not good. Is specialization a negative factor?
President Noguchi: Generally speaking, “advancement” means “specialization.” However, in island nursing, “totality” is what assures “advancement.” As an antithesis, we propose that “advancement” in islands is to assure “totality.”
Professor Tsuda: Then, it does not deny specialization.
President: No, it does not.
Professor Kinjo: Specialization is one form of advancement, and coordination is another form of advancement in one special field of nursing.
President Noguchi: Our hypothesis is that in a field of island nursing, “advancement” means “totality.”
Professor Ellis: We do not use the term “totality,” but I think that is a very good academic concept. Your explanations helped me understand the concept. For example, in an island setting, even if there are some specialists, it requires totality (or what can be defined as coordination or networking). That is a good concept, and it is easy to comprehend. It is not a mere concept, but it is backed-up and supported by research.
Participant: In an island, one has to be related to and cooperate with many people in order to work smoothly. I think that can mean advanced practice.
Professor Kinjo: In order to work and get along with others, one needs to understand many things. That is “totality.”
Professor Ishigaki: I would have wanted to define it in Japanese, but it was hard.
President Noguchi: “Totality” is about nursing embedded in community culture. It is not specialization, but “totality.”
Participant: One can be helped by others when it is needed. One can make such relationship in many occasions.
President Noguchi: “Totality” is different from medical service by a team. A medical team requires specialization (specialized members).
Professor Tsuda and Professor Ellis: We think that “totality” is a very new concept. As a next step, we need to think how to examine this concept. We are interested in finding out factors of this concept when it is applied and proved not only in one Japanese island, but also many places in the world. The question is how we examine validity of this concept. We want to expand this concept as a future theme. It will be great if we can keep thinking what to do with this concept.
Professor Kinjo: As a field of expanding this concept, where would you propose as a site to develop it into an academic concept? Cultural nursing or community nursing?
President Noguchi: Rural nursing cannot be implemented without factors of culture and community. Rural nursing consists of basic factors and concrete practice parts. Community nursing and cultural nursing are fundamental factors, and “rural” is a field of practice.
[Summaries and Propositions by the 3 Symposium Presenters]
Professor Ishigaki: I believe in Okinawa you have been trying to establish an academic field of island nursing. Making underlying theories that serves it is underway. The framework will be clearer in future. The symposium included many relevant and significant factors. I wanted to be small help for this process, so that I decided to present my research.
Such factors can be found in discussions by Ms. Long, Dr. Tsuda, and Dr. Ellis. I think that regarding these factors will help you come up with more generalized reality. I believe that theories of island and rural nursing come from there.
Professor Tsuda: It was a very interesting symposium for me. Besides whether I could inspire the audiences, I am content that I can go back with lots inspirations with me. This symposium stimulated me to ask myself many questions. I have to investigate many things in order to find the answers for the questions. Thanks for all of you who helped me come up with the questions.
Professor Ellis: I would like to express my appreciation for all who supported and worked for this symposium. I was inspired by many people who work in the field of nursing. I also learned new concepts. By keeping these concepts in my mind, I would like to investigate how to utilize and deepen the concepts in my practice. Thank you all students and other participants for paying attention to my talk.
I would like to propose to each one of you. You have worked or will work in the field of nursing. When you work, please think “What is culture?” I want you to think what culture means. Patients you treat may come through various cultural backgrounds. When you treat them, please remember what culture is and try various methods. Please learn how important it is to understand the patients and their cultures, and then use what you learn in practice. That is my wrap-up speech. Thank you.