After reading this chapter, the nurse will be able to do the following:
Describe the influence of acculturation on Japanese Americans.
Develop sensitivity and understanding of the communication styles within and across the Japanese American culture to avoid stereotyping and to provide culturally appropriate care.
Describe the time orientation of some Japanese American people and its influence on wellness and illness behavior.
Discuss the spatial needs and implications for culturally appropriate care for the Japanese American client.
Discuss the influence of family and social organization on behavior.
Explain the health care beliefs, folk beliefs, and folk practices of Japanese Americans and their influence on health-seeking behaviors.
Recognize physical, biological, and psychological variances that exist within and across the Japanese American culture to provide culturally appropriate care.
Overview of Japan
Japan is a chain of islands that stretches in an arc more than 145,914 square miles (377,914 square km) long from the twenty-fourth parallel, off Taiwan, north to the forty-fifth parallel, just below Sakhalin Island ( ). Japan lies just east of the Asian mainland. The Ryukyu chain, which lies southwest, was once United States–occupied territory. Similarly, the Kuriles, which are northwest, are Russian occupied. The Tsushima Strait separates Japan from Korea.
Japan is composed of four large, closely grouped islands—Hokkaido, Honshu, Shikoku, and Kyushu—and 4000 smaller islands. In landmass, Japan is 145,898 square miles. The four main islands constitute approximately 98% of the total landmass of the country. By comparison, Japan is just slightly smaller than California ( ). The habitable and uninhabitable terrain of Japan roughly composes 0.3% of the world’s total landmass, yet the population of this country accounts for 3% of the world’s population. In 2014, Japan had the tenth largest population in the world, with 127,103,388 people ( ). Because the Japanese landscape is mountainous with angled slopes, only 15% of the total land area is habitable ( ), which accounts for the density of the population in certain regions of the country. In fact, the population of Japan is so dense that there are 873 people per square mile (320 square km). If the uninhabitable areas of Japan were excluded from this equation, a more realistic figure of 3885 people for every 1500 square yards (1760 yards equals a mile) would emerge ( ).
The population explosion of Japan is attributed to industrialization; the population reached 65 million by 1930. After World War II, the Japanese government initiated a population policy to lower the rate of increase. Since the mid-1950s, the population growth rate has corresponded to those in Western European countries ( ). In 2014, the birth rate for Japan was reported to be 6.07 per 1000, with the infant mortality at 2.13 per 1000 live births ( ). The average life expectancy at birth was 79.5 years for males and 86.3 years for females in 2010 ( ). A declining rate of population growth, coupled with an increased average life expectancy, has resulted in the Japanese population becoming the most rapidly aging population in the world ( ). This has prompted the Japanese government to develop long-term care insurance, to explore incentives for child-bearing, and to look carefully at current exclusionary immigration policies, a contentious political issue ( ; ).
The capital of Japan is Tokyo, and with a population of 8.946 million (Statistics Bureau, 2014) and 3.533 million in the urban surrounding areas, Tokyo is among the largest cities by population in the world ( ; ). Although Tokyo–Yokohama (often considered together) is a densely populated city, it sprawls over only 800 square miles (2000 square kilometers) ( ; ). Tokyo is largely industrial and is the home of the Tokyo Stock Exchange (the Nikkei counterpart to the New York Stock Exchange), which is a barometer for the economic climate throughout the world.
Hokkaido is the least populated island in Japan. It is an industrial site where agriculture, leisure activities, and brew-making dominate the economy. Honshu is the island on which approximately 80% of the Japanese people reside, with the majority concentrated in the plains of Kanto (Tokyo) and Kansai (Kyoto-Osaka). Honshu is known for its distinctive business culture, major ports, and multiple airports ( ). Shikoku is devoted primarily to agriculture. It is a subtropical island, and the people are reputedly the most outgoing of all Japanese. Kyushu, the third largest island of Japan, is located in the southwest and close to Korea and China. There are bullet train services to anywhere in Honshu and Kagoshima in Kyushu.
The Ryukyu chain of islands was occupied by the United States from World War II until 1972 and is perhaps the poorest of all the regions in Japan. Several of the islands in the Ryukyus are uninhabited. Okinawa is one of the major islands in the Ryukyus and a major staging base for the U.S. Air Force and Army, another political issue for many Japanese ( ).
In Japan, there are approximately 60 active volcanoes. In addition, Japan sustains approximately 1000 earthquakes a year, although most result only in minor damage ( ). Three significant exceptions are the Great Kanto Earthquake of 1923, which killed over 100,000 people in the Tokyo and Yokohama area; the Great Hanshin Earthquake of 1995, which killed 6000 and injured 415,000 people in the Kobe area (CIA, 2015; ); and the third, the Tōhoku earthquake (also called the Great East Japan Earthquake), which registered a 9.0-magnitude and hit Japan on March 11, 2011. It triggered a large tsunami. According to the Japanese , 15,889 people lost their lives due to the combined earthquake and 30-foot tsunami. The Tōhoku earthquake was the most powerful earthquake ever recorded to hit Japan, and the tsunami it triggered resulted in nuclear reactor core damage and meltdowns in the Fukushima prefecture, disasters taken together that shocked the world. Other than earthquakes and occasional typhoons, climatic conditions in the Japan archipelago are usually mild, with sufficient warmth and humidity in the summer for cultivation. Winters are cool and dry, unlike the subtropical and tropical winters of much of the rest of Asia. Significant seasonal changes vary with the direction of the prevailing wind, like much of monsoon Asia ( ).
Although more than 67% of the total land area of Japan is forested, not all forests have commercial value because soil erosion is a problem. The sea provides the major portion of protein in the Japanese diet. Both the Sea of Japan and the Pacific Ocean are rich fishing grounds. Japan’s fishing catch has been the world’s largest since 1972. Japan has few mineral resources and depends on imports of raw materials and fuel ( ).
Historically, Japan has primarily had an agriculture-based economy. The economy has changed rapidly since the late nineteenth century with industrialization, especially after World War II. Today, Japan is considered the most urbanized country in Asia.
The Ainu, whose name means “human,” are known to be the original inhabitants of Japan. contends that although official estimates place Ainu populations around 2% (23,000) of the Japanese, these are likely underestimates and there are more contemporary Ainu who chose not to self-identify because of fears of racism and discrimination. The ancestors of the Japanese are believed to have come from mainland Asia, crossing over from Korea. These early settlers moved eastward from Kyushu and settled in the Kansai Plain (Kyoto–Osaka regions). Eventually, they established an ordered society under chieftains who were dedicated to the cult of the sun. Buddhism was later introduced in the sixth century. The ethics of Confucianism were added to the practice of sun worship and animism ( Shinto ) ( ). The Ainu once maintained a culture and language that are different from the rest of the Japanese; however, the Ainu language is now almost extinct.
Except for the Ainu, the Japanese population tends to perceive itself as ethnically and linguistically homogeneous ( ). Yet there are significant numbers of long-term resident foreigners now living in Japan—over 2 million as of 2012 ( ). Included are Chinese (674,879), Koreans (545,879), Japanese-Brazilians (210,032), Filipinos (209,376), and 52,843 Peruvians in 2011 ( ). The foreign-born labor force in Japan is estimated at 686,000 in 2011 ( ). Although this is not a large percentage of the population, it does suggest the homogenous label may be misleading.
Today the ability of Japanese Americans to identify with Japanese culture depends largely on when they arrived, their historical trajectory, whether they were born in the United States, where they live, and how much acculturation and assimilation have occurred. The term Nikkei refers to all individuals of Japanese ancestry and includes Japanese Americans who have been in the United States for many generations and those who came recently ( ). Among the various ethnic groups in the United States, a clear generational distinction among Japanese American groups is not only unique but also meaningful ( ; ). This distinction highlights different characteristics of Japanese Americans, including values and beliefs the immigrants from Japan brought with them, what they retained and passed on to their offspring, and the impact of historical events and laws on their experience and acculturation.
Before the 1890s a few Japanese scholars and businessmen came to the United States and settled along the East Coast. Because of their small numbers and desire to be acculturated and assimilated into the mainstream society in the United States, they were more readily accepted than later immigrants. The large influx of Japanese immigrants between 1890 and 1924 settled primarily along the West Coast and in Hawaii. Because of the prejudice they experienced, their lack of knowledge about the new country, and the language barrier, they tended to keep to themselves and formed relatively self-sufficient communities where they were able to retain familiar cultural values. Nisei, second-generation Japanese Americans, were largely influenced by the values and norms of their parents. However, third- and fourth-generation Japanese Americans may be less familiar with the Japanese language and customs.
To recap, the Japanese American people are the only immigrant group to identify themselves by the generation in which they were born, and these generation groups are distinguishable by the individual’s age, experience, language, and values. The generation groups are the issei, the first generation to live in the United States; the nisei, the second generation; the sansei, the third generation; the yonsei, the fourth generation; the gosei, the fifth generation; and the rokusei, the sixth generation ( ). These generational categories provide a framework for understanding family-related cultural values. For the issei, the family provided the anchor for the values and traditions of Japan. Today the family remains one of the most important factors in the lives of the Japanese people. The issei withstood extreme hardships and made personal sacrifices for the benefit of their children. Before the 1890s, the majority of Japanese persons who immigrated to the United States were men. Generally speaking, it often took many years before a Japanese man was able to afford a wife or family. These men might have been 30 or 40 years of age before they looked back to Japan to find their brides through the exchange of photographs and letters. Thus these Japanese women were often 10 to 20 years younger than their husbands. For the issei descendants, there was a strong, stable family support system. The exclusion law of 1924 prevented some of the early Japanese male immigrants from finding a spouse, which resulted in a group of single elderly men; however, most of these are no longer living.
The nisei were born in the United States during the pre–World War II period. Although this generation tended to have a higher educational level and was more fluent in English than their parents, they still faced intense racial discrimination in housing and employment ( ). Hostile feelings on the part of many U.S. citizens intensified in 1942 with the declaration of the war with Japan. This sentiment climaxed with the evacuation and internment of Japanese Americans when President Roosevelt signed executive orders 9066 and 9102. Although restrictions applied to Japanese, German, and Italian aliens on the West Coast, only the Japanese, both alien and U.S.-born, were removed from their homes in California, Washington, Oregon, Arizona, and Hawaii and forcibly placed in internment camps ( ; ). More than 120,000 persons were imprisoned. The experiences of those who survived are well documented ( ; ; ). Missing, however, are the accounts by those who did not survive or whose lives were broken and warped by this experience. During the internment, 6485 Japanese Americans were born in the camps, and 1990 Japanese Americans died in the camps ( ).
The evacuation and internment of the Japanese in U.S. camps have been described as the most dehumanizing experience for Japanese Americans. It not only disrupted their families and way of life but also had enormous financial implications that were largely created from the loss of their homes and businesses. To prove their loyalty as Americans and combat the racism that confronted them, an overwhelming number of nisei volunteered for the all- nisei 100th Infantry Battalion and its larger unit of Japanese Americans, the 442nd Regimental Combat Team ( ; ). These volunteers, who came from Hawaii and mainland internment camps, emerged as the most decorated unit for its size and duration of service ( ).
After the war, the employment and cultural expectations of Japanese Americans from the nisei became more aligned with their American background. As this new generation became more acculturated, they began to rely less on the economic sanction of their issei fathers. These individuals sought a better way of life and upward mobility. The GI Bill offered many veterans a chance at a first-class education. Japanese Americans have been extremely successful in the assimilation process, particularly in certain states. In Hawaii, successful inroads have been made, particularly in the political arena ( ; ). Succeeding generations of Japanese Americans have benefited tremendously from the efforts of these earlier immigrants. Recognition of Japanese American rights and political power occurred, after a decade-long campaign, when the U.S. Congress passed the Civil Liberties Act of 1988 to make redress payments of $20,000 to each survivor who had been incarcerated during World War II ( ). Formal apologies occurred around this time. And, in 1993, then President Bill Clinton signed a presidential letter of apology that stated the “nation’s actions were rooted deeply in racial prejudice, wartime hysteria, and a lack of political leadership” ( , p. 230). In 2001, Congress appropriated funding to preserve ten of the detention sites, including Manzanar and Tule Lake. Besides lasting long-term psychological consequences like post-traumatic stress syndrome, health consequences of internment included increased cardiovascular disease and mortality. It is important to remember that the history of forced internment is a primary difference between early Japanese Americans and their descendants and recent Japanese immigrants
In 1965, with the lifting of the immigration restrictions based on race, creed, and nationality, Japanese immigrants were able to reestablish the continuity of family life ( ). Japanese Americans who immigrated after World War II may be called shin-issei, which means “new first generation.” Many shin-issei came for business reasons or as brides of servicemen after World War II, the Korean Conflict, or the Vietnam War. Others immigrated more recently and some married U.S. citizens. Since these individuals grew up in Japan, their lives, values, and beliefs tend to differ somewhat from those of the descendants of the original issei ( ; ).
Life in the United States
In 2010, 763,325 Japanese Americans (designated as Asian alone on the census) resided in the United States (U.S. Department of Commerce, Bureau of the Census, Asian Population, 2012). This number represents a 0.3% increase in the population of Japanese Americans since the 1990 census, currently the slowest growth among Asians in the United States. When Japanese and one other Asian group are reported, however, 1,304,286 people designated themselves in the 2010 census survey as Japanese. This number includes multiracial individuals. Japanese Americans are reported as having the highest proportion (41%) of inter-racial identity among all Asian Americans ( ). Overall, multiracial Japanese Americans represent 13.9% of the total Asian American population. Of the number of Japanese Americans residing in the United States, for the first time, geographic distribution has changed: 71% live in the West, 22.1% live in the South, 8% live in the Midwest, and 8.5% live in the Northeast. By state, the largest populations of Japanese Americans are found in California (33%), Hawaii (24%), New York (4%), and Washington (5.2%). They tend to live in the larger West Coast cities ( ; ).
Whereas the median age of Asian Americans is 36.8 years, it is approximately 38.2 years for Japanese Americans in 2008 ( ). In the United States, Japanese Americans are the oldest group of Asians by median age, and with one of the longest life expectancies of any American racial/ethnic group, “Japanese Americans constitute the country’s oldest racial/ethnic group with almost 22% age 65 and older compared to about 13% in the overall U.S. population” ( , p. 150). Of the number of Japanese Americans residing in the United States between 1980 and 2009, 20% were foreign born, compared with 12.4% of Japanese Americans living in the United States before 1975. These data suggest that immigration has played a major role in the increase in numbers of Japanese Americans in the United States (U.S. Department of Commerce, Bureau of the Census, Asian Population, 2012).
Japanese Americans, on the average, have 2.4 persons per family, compared with the national average of 2.6 persons per family. This number is in stark contrast to some other Asian groups whose family size may be considerably larger ( ).
In 2010, the median family income for Japanese Americans was $65,050 as compared with $49,800 ( ) for all other races/ethnicities. Likewise, Japanese Americans tend to be better educated than the U.S. population, with 46% of Japanese American adults 25 or older having earned a bachelor’s degree or higher, while only 28% of the U.S. population has obtained this ( ).
Asian Americans enjoy the longest life expectancy compared with other racial and ethnic groups residing in the United States. The life expectancy of Asian Americans regardless of gender is 83 years. By subpopulations, the life expectancy is 86 years for Chinese Americans, 85 years for Filipino Americans, and 85 years for Japanese Americans ( ).
Communication and Culture
The official language in Japan, which is spoken by some 190 million inhabitants, is Japanese. Three systems (glyphs) are used concurrently to communicate in writing in Japanese. In the Japanese language, one system includes the kanji, or honji, ideographic or pictographic characters borrowed from the Chinese and used to express chief meanings of words, such as substantive and root meanings of verbs and adjectives ( ). Kanji characters may have concepts embedded. For example, the kanji for human, hito, implies “an individual who is supported by another” ( , p. 316). The kanji is composed of two sticks leaning inward against each other; without one, the other falls, pictographically signifying the interconnectedness of the Japanese self. In addition to kanji, there are two syllabic scripts, hiragana and katakana ( ). Hirigana is the phonetic “alphabet” used to represent Japanese words, whereas katakana is used as the phonetic representation of foreign words ( ). The katakana are also used in official documents and advertisements. Today, Romaji, from the Latin alphabet, is often used in modern Japanese, particularly for such things as company names and advertising, and especially for inputting Japanese into the computer. Western-style Arabic numbers are more commonly used for numbers when used in a left-to-right writing style, whereas traditional Chinese and Japanese numberings are more commonplace in the verbal communication of 1 to 10 and an up-and-down writing style in Japanese language.
Of the number of Japanese Americans residing in the United States, 0.7% speak an Asian or a Pacific Islander language at home, 84.9% speak English “very well” or “well,” and 15.1% are linguistically isolated ( ).
Japanese characteristics in language and behavior reflect characteristics of some of the values inherent in this ethnic group. A side note about the citations included in the sections of this chapter concerning culture and values is included here. Many of the citations come from classic anthropological or intercultural communication studies. These are dated, yet culture and values tend to remain stable and constant with change occurring incrementally over generations. In particular, cultural consistency has tended to be valued by the Japanese. For these reasons, the classic findings should still be considered relevant. The Japanese culture is known as the “culture of anticipatory perception” or “culture of consideration” because of the importance of empathizing with the speaker ( ). A concept central to the issue of communication is “empathic identification.” The speaker identifies with and views the listener from the listener’s point of view. The expectation is that the listener will also empathize with the speaker. Thus, verbal communication can be held to a minimum. For some Japanese Americans, constant verbal communication is seen as unnecessary. Many Japanese Americans value communication that is implicit, nonverbal, and intuitive over explicit, verbal, and rational ( ). Therefore, communication may be seen by outsiders as less direct, somewhat vague, and somewhat concealing. A talkative person may be considered a “show-off” or insincere ( ). There is an underlying assumption that when true connected caring communication is happening, there is little need for words ( ).
Behavior and communication are defined by role expectancy and status and by an attempt to preassess the listener’s feelings or wishes. According to , the content of communication depends on the characteristics of the persons involved. Factors such as age, sex, education, social status, family background, and marital status often influence specific behaviors. Behaviors that may be seen as negative or resistive in Western culture may, in fact, be reflective of proper upbringing for some Japanese Americans. Openness may be construed as a sign of immaturity or lack of self-control, which may bring shame to the family.
In a high-context culture such as Japanese, implicit nonverbal messages are of central importance; in multiethnic low-context cultures, explicit verbal messages are emphasized ( ). Behaviors of individuals in a high-context culture tend to reflect the value of thinking before speaking, of modesty in acts and speech. In this sense, context is also viewed as intuitive. This concept is related to the context of empathy, with its value on sensitivity and responsiveness. It is essential for the speaker to avoid superficiality and poor subtleties of speech if intuitive understanding is to occur ( ). In addition, in a high-context culture, esthetic refinement and sophistication are evident in nonverbal, indirect, implicit, subtle messages. Thus, it is not surprising that some Japanese Americans may be threatened by or avoid ambiguous situations ( ).
The grammatical structure of a language frequently reflects the major theme of a culture ( ). Four themes relating to verbal behaviors in Japanese Americans govern interactions: (1) a strong sense of gender differences, (2) a concern for hierarchy and status that manifests itself as deference toward authority, (3) an emphasis on self-effacement, and (4) a focus on nonverbal communication. These themes can be seen in the primacy of hierarchical status in the Japanese culture, where themes of the Meiji era (post-1868) of Japan and Confucian doctrines still dominate social behavior among many Japanese Americans.
The Japanese culture stresses nonverbal communication, and for some Japanese Americans there may be a general mistrust of spoken words ( ). attributes this characteristic to a belief held by some Japanese Americans that indicates that the ma-gokoro (“true-heart,” thus the innermost self) is incapable of being adequately or sincerely expressed through an outer part of the body such as the mouth, which is inclined toward deception. Directly related to the ma-gokoro is the importance of personal self as the monitor of self-identity. Again, words are perceived as a poor substitute for the adequate expression of sincere feelings.
Self-abasement, modesty, and apology used by Japanese Americans when communicating are viewed by some health care professionals as self-effacing behaviors. Many health care professionals believe that this type of behavior is open to misunderstanding. Yet the complex meanings behind these attitudes and behaviors can be understood by the concept of enryo, which directs Japanese Americans to be modest, to defer to others, to play down personal accomplishments and achievements, and to direct attention away from oneself ( ; ). Enryo by near translation means “restraint,” “holding back,” or “hesitancy” ( ; ). It also may be thought of as “ritualized verbal self-deprecation used to maintain group harmony” ( , p. 29). For some Japanese Americans, self-praise or the acceptance of praise is considered poor manners, resulting in denying, ignoring, or negating another trait or behavior. To many Westerners, this behavior may be interpreted as lack of self-esteem or belittling ( ).
The concepts of hierarchy and status also dictate communication patterns. For some Japanese Americans, it is considered impolite to disagree publicly with a person of higher status for fear of making this individual lose face. In traditional Japanese society, gender differences are reflected by males tending to be more economical in speech, particularly in public situations, and more direct in their delivery of opinions or ideas than their female counterparts ( ). Oral expression is focused on increasing harmony and avoiding conflict ( ; ). Therefore, answering “yes” to questions may be a way of avoiding embarrassment or shame and does not necessarily imply that communication is agreed with, clear, or understood ( ). concluded that Asian Americans are more likely to avoid having to express themselves verbally.
In studying communication apprehension among individuals in Japan, Korea, and the United States, found that the Japanese frequently expressed feelings of nervousness and anxiousness. In some instances, these feelings made some of these individuals generally awkward and unsociable when communicating with strangers, particularly persons from different cultures. Furthermore, when some Japanese Americans become distressed, their communication may default to metaphors and idioms ( ).
Vocal qualifiers include intensity, volume, pitch, and rate or speed ( ). In general, Japanese speak in a high-pitched voice, which may relate to the love of traditional folk songs ( minyo ) and sentimental nostalgic songs ( enka ), which call for high-pitched voices. Gender differences are also manifested in the manner in which women are expected to speak.
The Japanese culture is a relatively non–eye contact culture, and this is quite noticeable in public speaking and in the communication process ( ). Most Asian Americans consider it disrespectful to look someone directly in the eyes, especially if that person is in a superior position ( ). In nonverbal communication, integral quality and explicitness of feelings are involved in the process itself and are communicated paraverbally rather than directly. High awareness of nonverbal gestures and facial mimetic nuances exist among Japanese Americans ( ). For some Japanese Americans, emotional expression of anger is unusual, and a stoic reaction is often manifested as a response to pain. Gaman is a Japanese concept that stems from the verb gamansuru, which translates as “to bear, to endure, to tolerate” and which has to do with self-control and endurance ( ; ). of Japanese American elders found that gaman had importance in help-seeking behaviors among nisei who tended to value enduring pain and discomfort with perseverance and dignity. Gaman is also considered a valuable social skill to be learned in childhood and used later in life when facing hardships, such as when in pain.
Related to the development of gaman, noted that nonverbal communication is an emphasized Japanese socialization pattern. Bearing up with quiet self-control is valued and expected to be learned at a young age. In a study of preschool Japanese children, Katada found that some Japanese as young as 4 years old could verbalize the need for gaman . In this study, one child was able to suggest strategies (e.g., adequate information about what to expect with surgery) that would have aided him in his struggle to achieve gaman. Thus, there is cultural value placed on “bearing up,” or doing gaman, which can be described as stoicism in the face of hardships such as pain and uncertainty. Japanese behavior patterns require that an individual be trained to recognize subtle cues of nonverbal communications and finely nuanced choices of words. Although cultural values for gaman and expectations for highly acute nonverbal perception are based upon traditional Japanese values, these values have meaning for many Japanese Americans.
estimates that, for Japanese Americans, communication of feelings and attitudes is 5% verbal, 38% vocal, and 55% facial expression. Thus, facial expression plays a crucial role in communicating emotions and attitudes. It is essential to remember that the traditional behavior of some Japanese Americans is to control emotions, especially in formal and public situations. This value is believed to have originated in heijo-shin (“ordinary state of mind”) in Zen Buddhism, which advocates controlling emotions and maintaining a neutral presence. An inappropriate smile may sometimes be seen as an unconscious and reflective attempt to avoid troubling others by showing one’s true feelings.
Japanese culture is viewed as a nontouch culture. A hug is rarely offered and hugging is not common practice. There is close contact with infants but less touch or physical contact among adults ( ). found that Japanese Americans touch family members less frequently than people in other cultures do. Physical contact may be perceived negatively and introduce tension into relationships ( ).
The ideal and ultimate pattern of communication in Japanese society is silent communication. Some Japanese Americans do not appreciate aggressive or spoken forms of communication and instead place a premium on intuitive understanding of what is being communicated ( ; ). Findings from several studies suggest that Japanese adults spend only half as much time in conversation per weekday as their U.S. counterparts ( ; ). The data further suggested that Japanese couples, especially those who had been married for some time and were happy in the relationship, usually remained silent with each other because they had developed sasshi (“guesswork” or “intuitive sensitivity”). In other words, they understand each other without speaking. Sasshi is also highly appreciated in other situations.
Implications for Nursing Care
Because it is impolite to think of personal needs, some Japanese Americans, when asked if they want something to eat or drink, may respond negatively. In such instances, if the nurse does not try to persuade the client to eat or drink, the nurse may be perceived as insensitive. The nurse should offer at least two to three times, even after receiving a negative reply the first time.
The nurse can learn to anticipate needs and accurately assess discomforts by relying on astute interpretation of the meaning of nonverbal expressions and behaviors. It is essential to remember that subtle facial expressions and gestures are expected to be understood. Japanese American clients may wait silently rather than ask questions because they believe health care providers know best and will meet their needs without being asked ( ). This relates to a high regard for “anticipatory care” and the concept of omakase ( ). Omakase refers to a coping style that allows the patient to place his or her trust in the physician or nurse; therefore, the health care provider carries the burden for the patient. For the Japanese, health professionals are authority figures and are to be trusted ( ), although there is recent evidence that this attitude has changed ( ). While identified concepts specific to Japan, there are values embedded in the concepts that have migrated with the Japanese Americans. These include a value for hierarchy and trusting authority, an expectation that one will be cared for, and an expectation that one will not have to ask verbally for what one needs but that it will be anticipated by a caring other ( ).
Because direct expression of negative feelings is an unusual behavior for some Japanese Americans, indirect messages should not be mistaken for agreement. For example, rather than verbalize to the staff discontent with the health care, the client may have the family request a unit change. Nurses who expect clients to express their feelings through direct action may be surprised when they encounter a Japanese American client who is withdrawn and silent. For the nurse who is unfamiliar with the cultural behaviors of the Japanese American, behaviors in ambiguous, embarrassing, or anxiety-producing situations may be difficult to understand, and the client may be labeled as passive or nonresponsive. For some Japanese Americans, it is extremely important to control expressions of anger or pain. The nurse should be aware of situations that may cause discomfort, such as the exclusion of the family from the plan of care. The nurse must also remember that some Japanese Americans consider it insulting to be addressed by their first names, especially the first generation, who tend to follow strict hierarchical rules of deference and respect.
Although there are variations in spatial requirements among individuals, Japanese Americans tend to have a higher tolerance for crowding in public spaces than other Americans ( ). Even in relative proximity, a personal space can be created. Time and attention are given to the organization of their living space and perception by the senses ( ). Privacy is generally maintained by family members by limiting self-disclosure to persons in binding or trusting relationships ( ). For some Japanese Americans, well-manicured gardens can provide a degree of tranquility and peace that tends to expand personal spatial boundaries.
Japanese Americans, like other Asian Americans, tend to use less physical contact when interacting. They may also appear reserved and formal in new situations as they maintain their social zones. However, a contemporary study found that while Asian Americans compared with White Americans differ in the way they perceive crowding, all suffer similar negative psychological distress at high-density housing, independent of household income ( ).
Implications for Nursing Care
Nurses should not misinterpret the reserved and formal behavior manifested by some Japanese Americans as a dysfunctional sign. The nurse should remember that these clients need to establish a caring, trusting relationship before they engage in self-disclosure. Japanese Americans may feel uncomfortable with the overuse of physical contact or the invasion of personal space when interacting. When some Japanese Americans are hospitalized, the nurse can help the client by identifying territorial boundaries within the room. Identification of these territorial boundaries may reduce conflicts created from the invasion of privacy of others, particularly when more than one client shares a room.
Effect of Immigration on Social Organization
Most early Japanese immigrants who remained in the United States, the issei, eventually brought their future families to the United States. As their numbers increased, many Japanese immigrants experienced increased racial prejudice. Their fairly self-sufficient subcommunities often served as a buffer and provided for their needs and social support. The traditional Japanese value system places emphasis on the family, group orientation, harmony, and mutual aid ( ; ; ). This value system has allowed the families and communities to survive, particularly during and after World War II. Japanese behaviors and values, such as not imposing on others or standing out, preserving harmony, controlling emotions, persevering, and respecting authority, have allowed them to acculturate rapidly ( ). For many Japanese Americans, interdependence and dependence on each other are perceived as very important ( ).
As increasing numbers of the nisei generation entered adulthood, they sought ways to overcome the personal, economic, and legal barriers that their parents endured. For example, at one point in American history, Japanese Americans were prevented from buying homes in desirable parts of town, using public swimming pools, and entering many professions ( ). The early nisei, some of them recent college graduates but most still teenagers, wanted to prove their loyalty as Americans and thus combat anti-Japanese sentiment. Citizen organizations sprang up in various West Coast cities in the early 1920s. In 1930, the Japanese-American Citizens League became a national organization ( ). Some of the political clout of these organizations can be seen in the successful enactment of an amendment to the Cable Act to permit nisei girls who married alien Japanese to regain their citizenship. In addition, a bill was passed to allow foreign-born Asian men who served in the U.S. armed forces in World War I to be granted citizenship. The passage of this bill enabled 700 issei to become naturalized citizens ( ). And, as mentioned previously, the U.S. Congress has passed laws that specifically address reparations of Japanese Americans interned during World War II.
Ethnic community organizations, such as long-term care services established and expanded by the nisei and maintained by the sansei, are examples of ways that traditional Japanese values and culture are expressed ( ). Japanese American descendants of the issei continue to emphasize the importance of caring for their elderly parents. Interestingly, it is important to note that the issei generation rarely experienced caring for their own parents because in most cases their parents were in Japan. Increased intermarriage among Japanese Americans and dispersed residency suggest that it might be difficult to pass on aspects of Japanese tradition and ethnicity to future generations. Yet in a recent comparative study of social service environments for elders, 230 Japanese American baby boomers preferred a mixed service environment that included both Japanese-specific and nonethnic-specific activities, preferences that suggest a value related to maintaining elements of Japanese culture ( ).
Intergenerational relations are close among most Japanese Americans. There continues to be a flow of goods, money, and services among the generations. The general pattern of the Japanese family is the vertical family structure, with the father and other male members in the topmost position. “Vertical” social structure means that relationships are clearly defined to those above or below, a clearly determined line of social status ( ). In contrast, social structures in the United States have been described as more “horizontal,” implying less differentiation among social classes. The phrase kodomo no tame ni (“for the sake of the children”) reflects the sacrifices and hardships families would endure to ensure the success of the next generation. Many of the activities in the Japanese family occur in both the nuclear family and the extended family. Problems are handled within this structure, and the achievement or accomplishment of the individual member is a reflection on the entire family ( ; ; ).
The younger generation continues to be willing to assist and give more than what is requested and expected by the older generation ( ; ). Yet despite a long-standing tradition of family connection and caregiving, Japanese American families face challenges similar to those of other populations—aging parents, fewer available caregivers, more women in the workforce, and geographic mobility ( ; ; ).
studied the psychological needs of Japanese American elders. Among other things, they found that there was heterogeneity among this group and that the elders tended to want contact and connection with family but did not want to be burdensome. Many hesitated to directly verbalize need and valued family and social networks. A newer study of community-dwelling Japanese American elders living alone in “Chicagoland” was conducted by . This in-depth qualitative study added a more detailed explanation about aspects of support for this population. The authors found the elders relied on family for homemaking and health management but hesitated to lean on family for other types of support. This was primarily due to concerns of being burdensome, worries that there could not be reciprocation of support, and a sense of self-reliance on the part of the elder. Other perceived barriers included family-related interpersonal circumstances like poor communication, distance, and intergenerational differences. The elders relied on partners for emotional and emergency support, on friends for transportation assistance and emotional support, and on neighbors for emergency support. But they also described issues with friend and neighbor interpersonal situations, including difficulty in making “real” friends, relocation, health declines, and the death of friends and neighbors. The authors stated the formal support system (e.g., adult day care and cultural programs) was used by the elders for socializing and learning, and the in-home care formal support was used by the elders “for personal/homemaking assistance and companionship” (p. 149).
For some Japanese Americans, the self is viewed as part of a set of interpersonal relationships, of which the family system is the central core ( ). In this sense, the self is subordinate to the family social unit, and consequently most Japanese Americans find it difficult to stand out publicly as individuals. This difficulty is evidenced by the reluctance of some Japanese Americans to give speeches, talk about themselves in casual conversations, or engage in self-serving behaviors.
Fostering of amae, or “interdependency,” is also seen as a method of enhancing group solidarity and social relationships. This concept is also based on preservation of harmony and the suppression of conflict ( ; ). Amae (“passive love”), as defined by , means “to depend and presume upon the benevolence of others” and is often associated with the Japanese word for “sweet” ( amai ). This relationship may also exist between two people. Some data indicate that this concept is significant for Japanese American families living in the United States ( ; ; ; ). In traditional U.S. society, assertiveness is seen by Americans as a characteristic of well-behaved children. For some Japanese-American parents, assertiveness is interpreted instead as a characteristic of the poorly behaved child ( ). On (a sense of obligation within the Japanese hierarchy) forms the basis of reciprocal relationships among peers and within social networks ( ).
While intervention and assistance are taken for granted within the family, the in-depth qualitative study of Japanese American elders mentioned previously revealed that a sense of reciprocity is an important component for elder Japanese Americans related to their willingness to receive family support ( ). Casual help from outsiders is usually avoided because of the concern of becoming entwined in reciprocal relationships with them. The reluctance to accept help from social service agencies may reflect this concern as well as values of stoicism, privacy, and frugality ( ). According to , Japanese families traditionally value authoritarian styles of leadership, where the father makes unilateral family decisions. described the family lifestyle of Chinese and Japanese Americans as patriarchal, with authority and communication exercised from the top down. also noted that within these families there is a need for interdependent roles, strict adherence to traditional norms, and minimization of conflict by suppression of overt emotion. In a study comparing Japanese and White American couples, Japanese American couples tended to make more unilateral decisions and showed more restraint and less self-disclosure ( ). The concepts or values related to guilt and shame may be used to control family members.
Japanese American individuals tend to exhibit close contact among the generations. For some Japanese American families, family obligations take precedence over individual desires. Problems are generally handled within the family, and negative behaviors, such as delinquency, school failure, unemployment, or mental illness, are considered family failures that disrupt the desired harmony of family life and reflect badly on the family. The care of the elderly is generally the responsibility of the oldest son or an unmarried child. Yet there is a rapidly changing context for elderly care in Japan based on the changing demographics and the economic requirement that women work outside the home. Similarly, in the United States, according to a study by , changes are taking place in the context and to some degree in the underlying core values related to caretaking among generations of Japanese Americans.
Active discouragement of verbal communication, avoidance of discussion of personal problems, and limited expression of emotion have also been noted as common patterns in the traditional Japanese family ( ; ). However, a number of other studies ( ; ) have found that a process of cultural change in family norms has become more prevalent across generations of Japanese Americans. There is a tendency to adopt more White American family norms and behaviors. This may be especially due to the higher rate of inter-racial marriages.
This tendency may not be true among elderly Japanese Americans, however. An elders study ( ) in New York City with a sample size of 25 and a mean age of 70 found that study participants endorsed traditional values such as respect and obedience (76%). Decision-making authority continues to primarily rest with the eldest son (96%), the concept of on is still important, and approval of their children’s mate (96%) and avoidance of divorce for family reasons (92%) are also important. They also viewed generational differences in traditional values as minimal (86.4%).
Among Japanese Americans, there is evidence that participation in U.S. culture may shift personality dimensions toward those endorsed by monocultural U.S. Euro-Americans. A recent study ( ) indicates that first-generation Japanese American immigrants tend to score in between U.S. Euro-Americans and Japanese nationals on several personality dimensions, including openness to experience, extraversion, conscientiousness, agreeableness, and neuroticism. The Japanese American participants report becoming more “American” and less “Japanese” in their personalities as they participate more with the U.S. culture ( ). While the study explores personality dimensions and the first-generation Japanese American immigrant experience, paper, “‘I’m not Japanese, I’m American!’: The Struggle for Racial Citizenship among Later-Generation Japanese Americans,” analyzes the experience of third- and fourth-generation Japanese Americans. Tsuda states that the third and fourth generation are still seen by “mainstream Americans” as “perpetual foreigners” (p. 406). Their Asian phenotype causes them to be challenged and marginalized and threatens their identity as they struggle for national inclusion. Clearly, stereotyping, generalizations, and discrimination by the majority culture continue to be a concern to some Japanese Americans.
Methods of child care are inextricably linked not only to the tradition and customs of a culture but also to its systems of values. These methods appear to persist from generation to generation despite the acculturation process. For both the issei and the nisei , parent–child relationships tended to be intense, with few open expressions of emotion displayed. For these generational groups, there was much tolerance and permissiveness for the child until 5 or 6 years of age, at which time parents began to place emphasis on having the child learn emotional reserve and control.
In a classic study, compared the maternal and child care habits of Japanese Americans with those of Japanese nationals and White Americans to determine the effect on infant behavior. Findings from the study suggest that Japanese American mothers have a closer behavioral style to other Americans than to their Japanese national counterparts. The data also indicate that certain patterns of behavior from their Japanese cultural heritage were retained by these Japanese American mothers and babies. Nonetheless, in contrast to their Japanese counterparts, Japanese American mothers tended to play with their babies for longer times, held their babies more often, and sang to their babies more often ( ). Further findings from this study also suggested that Japanese American babies did less finger sucking than White American babies and spent less time playing alone ( ).
In another classic study, in interviews conducted with Japanese Americans in California, found that the sansei were more likely to have a sense of closer family ties; a greater sense of duty, obligation, and deference; less need to dominate; a greater tendency to affiliate; less aggressiveness; a greater need for succor and order; and a greater fear of failure in social role performance than other Americans. These individuals also valued the importance of family and the preservation of the ie, which, translated, literally, means “household.” However, it can also imply a continuum from past to future members (including the present generation, the dead, and the unborn, as well as a hierarchical structure with the father as head). Notable differences were found in childrearing practices between Japanese and American parents ( ). The respondents in this study were Japanese businessmen who lived in Houston. Findings from the study suggested that Japanese parents were less likely than their American counterparts to report the use of external types of punishments, such as time-out or physically and socially punishing the child. A plausible explanation for these differences is the assimilation of American cultural values that place emphasis on independence and individuality. It is believed that insistence on individuality makes it necessary to use powerful, external techniques to ensure compliance in some situations ( ). In a summary of the literature on the grandparent caregiving role in ethnically diverse families, reviewed grandparents as caregivers in three broad ethnic categories: African-American, Hispanic, and Asian American. They summarized results from 22 articles and three chapters published from 1980 to 2003 and stated that approximately 6 million grandparents are living with their grandchildren. While clearly this role is on the rise in many populations, information on Asian grandparents giving care was limited. In a comparative study of Asian grandparenting, found younger, U.S.-born, householding grandparents were more likely than to be responsible for their grandchildren, and Asian Indians are less likely than Japanese grandparents to take on this responsibility. Research specifically on Japanese American grandparent caregivers was notable for its absence.
note that, among Japanese Americans, abortion is not generally condoned but may not be uncommon for numerous reasons. First, some Japanese believe that an unwed mother brings great shame to the family. Second, adoption has become more common in recent times, and often some Japanese Americans will adopt a boy to carry on the family name ( ).
Family Role in Education Attainment
The model-minority thesis surfaced in the mid-1960s because of publicity regarding high educational attainment levels, high median family incomes, low crime rates, and absence of juvenile delinquency and mental health problems among Asian Americans ( ). Asian Americans have been portrayed as extraordinary achievers. Mordkowitz and Ginsberg (1987) found that Japanese Americans often reported that their families emphasized educational accomplishment, and this is borne out by the fact that 46% of Japanese Americans 25 or older have at least a bachelor’s degree ( ). Many Asian immigrants are willing to sacrifice their own socioeconomic standing in exchange for giving the next generation a better chance to be successful in the world ( ). As a result, these students held high expectations of themselves. More importantly, they were able to control their behavior because of the direct relationship between appropriate behavior and personal achievement.
found that Asian American responses were not significantly different from those of other groups regarding the value of working hard, parental pressures for academic achievement, need for students to make their parents proud, and, most important, avoiding embarrassment to the family. Significant group differences were noted in only one area. Asian Americans were more likely to believe that success in life depends on what is studied in school, which was directly related to the grades they received in high school. According to , a plausible explanation for this behavior is the belief held by some Asian Americans that educational attainment provides opportunities for upward mobility. To the extent that upward mobility is limited in noneducational avenues, education becomes increasingly important as a means for advancement. In addition, education is perceived by some Japanese Americans as a feasible means for mobility in view of limitations for success in other areas. concluded that the effects of culture have been confused with the consequences of society.
Some of the ingrained cultural values evident in Japanese Americans are derived from Zen Buddhism, Confucianism, and Shintoism. Today, these values are seemingly manifested in Japanese Americans whether they practice Catholicism, Buddhism, Protestantism, or another religion. From the earliest immigrants, who came from mostly Buddhist backgrounds, the Japanese tended to adopt the religion of the area in which they lived, which resulted in divergent religious beliefs and practices among Japanese Americans in different locales. Religion and the church have both played an important role in acculturating the Japanese within their communities ( ; ).
Shintoism and Buddhism are subscribed to by more than 80% of the Japanese culture in Japan. Christianity is also well established in Japan. In the United States, a great number of Japanese Americans are Christians. Nonetheless, funerals for some Japanese Americans, despite this Christian orientation, are likely to be Buddhist, particularly for the issei and the nisei. Obon, an important Buddhist observance honoring the ancestors, is celebrated by many Japanese American communities and has spiritual, cultural, and community significance ( ). In addition, for some Japanese Americans, births and marriages are colored by Shinto rituals but to a lesser extent for yonsei and gosei ( ).
Implications for Nursing Care
Because many Japanese Americans place a high value on the family system, the nurse should be aware of the significant role the family plays in providing support, interdependence, and the fulfillment of duties. Respect is also greatly valued, and the linear relationship apparent in families and in casual relationships should be maintained and supported when providing care for the Japanese-American client and family support system. Although these values are the strength of the Japanese-American family, they can create stress and disharmony not only for the client but also for the family unit, especially with inter-racially married offspring. For example, the son- or daughter-in-law may not understand Japanese family values and beliefs well ( ). It is essential for the nurse to remember that some Japanese American families may want to provide support to the hospitalized family member by keeping a bedside vigil, especially if the individual is elderly and doing poorly. Married men, especially issei and nisei Japanese Americans, may expect their wives to serve in the traditional caretaker role. Therefore, the wife (or daughter) may be expected to be available at the bedside so that the client does not have to bother the nurses, especially with intimate care or requests for assistance. The nurse must be alert to the overextension and lack of self-care of family members in providing for the client. The nurse should make every effort to assist the family to identify resources, both financial and human, to reduce the stress created when a family member is ill. In addition, the family should be assured that they are not alone. The nurse should not be discouraged if the family initially refuses outside help but rather realize that timing is important. In a study of attitudes toward community-based services among Japanese American families, found that timing and pacing of the resource information were facilitating factors for Japanese Americans in considering services. Moreover, they found that health care providers could play a more active role in assisting families with service identification, information, and evaluation. Because family name and honor are important for this group, the nurse should be especially cognizant of the issue of confidentiality and respect. Information should not be shared with outsiders, even with extended family members who may appear close to the client. Information concerning illness is often kept within the immediate family.
In a classic 1962 study, Caudill and Scarr examined Kluckhohn’s value orientations in Tokyo-area high schools and concluded that time orientations differed by context, with a future focus in technology and a present focus in social relations. The greatest number of generational changes in these values occurred in political considerations, whereas the smallest number occurred in the religious area. In contrast, believed that this future orientation originated from a religious, philosophical view of life. Buddhism teaches that death in all living things is inevitable. People are instructed not to make plans in this world without reckoning with death. According to , time is considered valuable and must be used wisely. Hard work in the present is seen as important for future successes ( ). For Japanese Americans, the time-person perspective with regard to past, present, and future is perceived in terms of generational distance from Japan. This is reflected in the geo-generational grouping of issei, nisei, and so forth ( ). noted that in the United States, monochronic time predominates, which places emphasis on meeting deadlines, making plans, and being prompt. Polychronic time is associated with doing many things at once and is concerned with relationship rather than task completion. They suggest that the Japanese tend to use monochronic time when dealing with outsiders but polychronic time in their interpersonal relations.
Decisions are not necessarily made in relation to individual needs or benefits. state that the issei perception of time was related to death, in which death is seen as continuous and suprapersonal. This view is in stark contrast to the Western view of death as personal and discontinuous. Depending on the degree of acculturation, the nisei also accept death more readily than the sansei and the yonsei , who are more like Americans in their attitudes toward death and time.
Implications for Nursing Care
Because Japanese Americans are both present and future oriented, the nurse must consider the context of the current situation. The Japanese American client is usually prompt and adheres to fixed schedules. However, Japanese American clients tend to be more prompt with persons they hold in high regard such as physicians than with persons not held in high regard. They generally follow directions concerning medications and treatments. Because of future orientation regarding their children, care must be taken with the children’s diet and health. Japanese Americans will work hard with little regard for their health in the hope that future generations will have a better life.
Locus of Control
Locus of control refers to the extent to which persons ascribe their successes or failures to internal or external causes. Japanese Americans tend to place more importance on relationships and familial commitments. As such, they tend to also be more externally influenced than persons from Western cultures ( ). noted that the concept of the individual is culturally bound and needs to be understood from an emic or cultural insider’s perspective. In the classic work of , cultural interpretations using distinct dichotomies such as “individualism-collectivism” and perhaps the internal/external dichotomies of locus of control may assume a Western concept of individualism (consisting of autonomous individuals) as the starting point for the self. observed that the Japanese are often portrayed in the greater society as “soldier ants” or “worker bees” who will willingly sacrifice their interests as individuals to contribute to the group. cautions against interpreting culture based on false dichotomies, and quotes who notes that the concept of the “individual” is not universal. The Japanese self is defined in relation to nature and other persons. In this sense, the Japanese culture is contextual, situational, and relational, rather than collectivistic ( ). In Japanese, the word for “individualism” ( kojin-shugi ) is an ambivalent word, one “suggesting selfishness rather than personal responsibility” (Reischauer, 1977). Noting these fundamental differences in the concept of the self is important when exploring locus of control. compared Japanese, Japanese Americans, and European Americans in health attitudes and behaviors. They found that both American groups (Japanese Americans and European Americans) were similar but the Japanese respondents placed less priority on health, had less belief in the efficacy of health screening tests, had lower levels of internal health locus of control (HLOC), and had higher levels of “chance” and “powerful-other” HLOC. The difference in the sense of self to a more individualistic one may in part explain the differences in HLOC.
Illness and Wellness Behaviors and Folk Medicine
Major beliefs that have contributed to medicine in Japan influence the Japanese-American person’s view of health and illness. In the Shinto religion, people are seen as inherently good. Evil is caused by outside spirits that cause humans to succumb to temptation and harm, which can be alleviated through purification rites. Disease is believed to be caused by contact with polluting agents, such as blood, corpses, and skin diseases, which accounts for the emphasis on cleanliness ( ; ).
Another important belief held by some Japanese Americans is based on the traditional Chinese concept of harmony and balance among oneself, society, and the universe. Some Japanese Americans believe disharmony (with society or family) or imbalance (as from lack of sleep or exercise or because of poor diet) can cause disease. Therefore, restoration of balance should be the major focus of treatment. In addition, some Japanese Americans believe that illness may cause energy to slow or stop along the meridians of the body. Thus acupuncture, acupressure, massage, or moxibustion may be used to restore the flow of energy ( ).
The kampo (“Chinese medicine”) medical system was developed around the belief that forces of the universe affect an individual’s body processes and activities. Health depends on maintaining a harmonious relationship with the universe. Kampo practitioners believe that dietary precautions and preventive measures help resist illness ( ; ).
Certain foods have special symbolic meaning for Japanese Americans. Special foods, such as soft boiled rice and miso soup (a soup made with fermented soybean paste), may be eaten during illness as well as to promote good health. Traditionally, on their most important holiday, New Year’s Day, most Japanese Americans eat special foods that have symbolic meaning for good health, prosperity, and happiness. Such foods include kazu-no-ko (dried herring roe) for fertility, mochi (steamed rice cake) for longevity and prosperity, soba (buckwheat noodles) served in clear broth for longevity and prosperity, and kuromame (black beans) for good health ( ; ). Other symbolic foods include ozoni (a soup with mochi, vegetables, and/or meats) for prosperity, gobo (burdock root) symbolic of deep family roots, and tai (sea bream, a large red fish served whole) for happy occasions.
Although Asian medical traditions recently have regained popularity with the holistic and preventive health movement, most Japanese Americans tend to rely on Western medicine. Some use both Asian and Western medicine, depending on the illness and the efficacy of Western medicine. Yet for those who still subscribe to the Old World traditional health care practices brought with them from Japan, the basis for health practices may include a mixture of traditional medical practices ( kampo ) brought to Japan from China, Shinto beliefs, and Western medical practices ( ). explored sociodemographic and ethnic differences in Hawaii and California for taking dietary supplements. The authors reported the main reasons Japanese Americans take dietary supplements were (1) to maintain a healthy life, (2) because of recommendations by a health professional, and (3) to prevent a disease or medical problem. Japanese Americans participating in the study also believed dietary supplements were as important as prescription medications.
When considering wellness, it is also useful to consider health risk behaviors. analyzed health risk behaviors among five Asian American groups (age over 18) in California. Using data from the California Health Interview Survey, they estimated about 80% of Japanese American men had body mass indices (BMIs) of “increased/high risk” by Asian-specific BMI categories, and Japanese American women had one of the highest smoking and binge drinking prevalences among the five Asian American groups. These are concerning findings and can be helpful to inform priority setting for health promotion.
Death, Dying, Death Rituals, and Customs Observed
Meaning of Death and the Afterlife.
Many Asian Americans believe death is a natural part of the life cycle; thus, death cannot be overcome through human intervention ( ; ). This is a fundamental Buddhist belief. According to , traditionally the Japanese have an animistic reverence; nature, shizen, means “a force that transcends human control and follows its own course of changes or processes.” In this sense, for many Japanese, mechanical interventions to prolong life may be difficult to accept. Likewise the acceptance, or recognition, of brain death without an arrested heart may be problematic. In Japan, unlike in the United States, cardiopulmonary resuscitation is not commonly performed out of the hospital or by laypersons. Some Japanese make pilgrimages to Buddhist temples, which are associated with the belief that prayers made at the specific temples will assist the pilgrim in procuring a sudden death. The Japanese preference for a quick death is desired not only because there is less suffering involved but also because a prolonged illness may be a burden to the family ( meiwaku ), whether financially, physically, or psychologically ( ).
The concepts of karma and reincarnation are based on the premise that one’s conduct in a previous life affects the condition of the present life. This is also a part of the belief system of some Asian Americans ( ). For Japanese Americans, an individual’s identity and the interpretation of the meaning of life are closely tied to their belief in their ancestors’ spirit ( ). Therefore, because death is viewed as a natural phenomenon, some Japanese Americans may be better able to accept it when it comes. The Samurai ethos expects one to maintain an attitude of indifference to the minutiae of daily life. Thus, bravery and silent endurance are typical Japanese virtues ( ). Coupled with this is the notion that the bereaved should understand the dying person’s last true wishes without there being verbal expression. Because of a strong feeling of connection to offspring consistent with an interdependent self, implicit rather than explicit expression has more weight and value. A strong interrelated society makes it possible to let the dying go without explicitly knowing his or her wishes. Moreover, the Japanese American family may accept the challenge of understanding the wishes of a dying person without explicit discussion since it is viewed as evidence of the closeness of their relationship. Ishin denshin (mind-to-mind communication or thought transference) is then put into practice.
Traditionally, the Japanese are willing to discuss death and dying while they are healthy. However, once someone becomes seriously ill, such discussion is difficult. In addition, anything relating to the number four (which has the same pronunciation, shi, as the Japanese word for death) and the number nine (pronounced ku, which also means suffering) should be avoided. Although fresh flowers are acceptable to give to the dying or the bereaved, a plant gift is considered taboo and is associated with long-term illness. This may be so because for the Japanese, the word for rooting, ne-zuku, is similar to the word that means “bedridden.” Visiting of the sick by a religious leader is accepted in the United States but may indicate bad luck for some Buddhist Japanese because Buddhist monks are associated with death or funeral rituals. Whether Japanese Americans know their illness and prognosis depends greatly on their own and their family’s acculturation level ( ; ).
and , in a qualitative study of 16 Japanese Americans, found that although most Japanese Americans preferred family decision making, the older family members tended to share implicit understanding with the ill patient about his or her end-of-life wishes. In contrast, the younger members tended to discuss end-of-life wishes explicitly. Further findings from this study suggest that there are times when the Japanese American patients kept their diagnosis or poor prognosis from their family to protect the family members from psychological burden. , in their qualitative study of elderly Japanese American beliefs about death, found that their participants ( n = 18), Japanese Americans in Hawaii, highly valued not being a burden to family. Although they expected certain support from family and friends, the participants tried to prepare their living arrangements and finances to avoid being a burden at the time of death. This avoidance of burdening others was a large component of what they considered “a good death.”
Japanese Americans on the West Coast now have options for culturally sensitive long-term care and assisted living facilities (with Japanese language and culturally sensitive providers), and there has been an increased use of these types of care among the Japanese American population. Today, more hospice care is being used among this population ( ; ) although they had a shorter length of stay than other groups of patients (21 days, compared with 32 days for Filipino Americans and 26 days for Whites ( ). These researchers indicated that reasons for this were likely related to culture and included a lack of, or delayed, informed consent and a family willingness or sense of obligation to provide care. A possible issue for Japanese and Japanese American families is the practice of diagnostic disclosure, the discussion of a terminal diagnosis or poor prognosis with the patient. In the United States, diagnostic truth-telling is based on a concept wherein the patient is considered an autonomous individual, which is a key aspect of informed consent. Diagnostic disclosure is not the norm in all cultures and until recently was not common in Japan where typically the family would be informed first of a terminal diagnosis and they would decide how, when, and whether to inform the patient ( ). In a Hawaiian study, surveyed 112 Japanese Americans (mean age 74.7 years, 71% women) and found that the preferred place to receive end-of-life care by their participants was hospice (40%) and home (39%), and more than half (53%) had discussed end-of-life issues with their physician and/or family. Clearly, these patients were aware of their diagnoses and diagnostic disclosure was not an issue.
For traditional Japanese in the prefuneral period just after death, the body is bathed, dressed, and laid out with the deceased’s head pointed toward the North without a pillow. A monk recites sutras (Buddhist prayers) at the bedside and gives the deceased a posthumous Buddhist name. This name is later inscribed on the tombstone and on the family’s memorial tablet, which is kept in the home in a Buddhist altar. An overnight vigil is held at the home or a funeral site. During the vigil, it is important to keep incense burning, and visitors reminisce about the deceased. Acquaintances visit the site with “incense money” and offer incense during the vigil and/or funeral. Usually, a funeral lasts 2 hours. Cremation occurs right after the funeral, and a reception is held during the cremation. Then immediate family members go back to the crematorium to collect pieces of bones, which are placed into a small jar (urn) and are put under the tombstone or kept on an altar. Weekly ceremonies occur up to the seventh week, and an annual ceremony takes place up to the fiftieth year (not every year). The celebrations occur on the death date, equinox days, and the summer Obon festival. The extent to which Japanese Americans follow the traditional rituals depends on their level of religious practice and connections with traditional Japanese culture.
Implications for Nursing Care
Because some Japanese Americans hold traditional value orientations regarding fatalism, they often are perceived as having an external locus of control. The nurse must also remember that some Japanese Americans value self-control, particularly in areas they believe may reflect weakness or inadequacy. The loss of “face” and dignity should be especially considered in procedures and treatment. The desire to gaman may affect the Japanese American’s willingness to request pain medications. Nurses can offer their time and practice attentive listening skills. Nurses also can make sure the patients and their families understand that it is expected that they express concerns and feelings. One approach from the nurse (particularly to offer pain medications) may not be enough for the patients and their families. Instead it is important to be particularly sensitive with these patients and multiple approaches to offer medications and care are recommended.
The nurse should inquire about treatments the client is using at home and what measures are most helpful. Special foods, tea, or herbal decoctions may be important for the client to have if there are no contraindications. It is very common for family or friends to bring fruit or special Japanese food when visiting. The client and family are likely to show hospitality by offering food to the nurse and visitors. Although it is unusual for the family and the client to hold special religious ceremonies at the bedside, privacy will be needed if such ceremonies are held.
found that there was difficulty in bringing up a sensitive topic such as the internment experience between nisei and sansei . The results suggested that it could be difficult to talk about end-of-life issues. Health care providers may need to initiate such a discussion with a gentle suggestion.