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U.S. Licensed School Nurses Working in an International Setting

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Julie Hudson, MSN, RN, NCSN
Nancy Smith Tsurumaki, MSN, RN, NCSN

Abstract

There are many similarities between school nursing abroad and school nursing in the United States. However, there are also some major differences in school governance, parents, students, school dynamics, and school personnel. This article offers insights from two nurses working overseas in Japan as school nurses, one at a Department of Defense Education Activity (DoDEA) school in Okinawa and one in an international school in Tokyo. The authors offer an overview comparison of these types of overseas schools in areas such as history; funding and governance; and families. They present student challenges and experiences encountered while providing school nursing overseas. Implications for practice are offered in the context of working with Third Culture Kids, or those students who return to schools in the United States after an international experience that, even if positive, may affect their reintegration into American culture.

Citation: Hudson, J., Tsurumaki, N.S., (September 30, 2017) "U.S. Licensed School Nurses Working in an International Setting" OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 3, Manuscript 5.

DOI: 10.3912/OJIN.Vol22No03Man05

Key Words:

Working overseas... as a school nurse is one way to combine a love of working with children and living in another country. Working overseas for a United States Department of Defense Education Activity (U.S. DoDEA) or an international school as a school nurse is one way to combine a love of working with children and living in another country. This article is based on the experiences of two American school nurses who currently work in Japan. Julie Hudson is employed by the DoDEA on the island of Okinawa; Nancy Smith Tsurumaki works at an international school in Tokyo. We offer an overview comparison of these two types of overseas schools in areas such as history; funding and governance; and families. We also present student challenges and experiences encountered while providing school nursing overseas. Implications for practice are offered in the context of working with Third Culture Kids (TCK), or those students who return to schools in the United States after an international experience that, even if positive, may affect their reintegration into American culture.

Two Types of International Schools: An Overview

One might ask how the experiences of a school nurse on a U.S. military base overseas differs from that of a school nurse in an international school and then, a school nurse in the United States. There are some similarities, but also major differences. In this section, we compare and contrast these two different types of overseas schools in several similar areas. Our discussion also considers the differences between the Department of Defense (DoD) military and civilian population in relation to living and working on an overseas base.

Department of Defense Educational Activity Schools

Following World War II, the military found it necessary to provide English speaking schools on military bases in the Pacific and Europe for children of military members stationed overseas. History and location. Following World War II, the military found it necessary to provide English speaking schools on military bases in the Pacific and Europe for children of military members stationed overseas. The military was already well versed in educating children of service members on military bases in the United States, dating back to 1819 (U.S. DoDEA, n.d.c). Over the years, governance of the schools had many changes, to include transfer to civilian leadership. Today the federally operated Department of Defense Education Activity (DoDEA), headquartered in Alexandria, VA, oversees schools in eleven different countries, seven states, and two territories, Guam and Puerto Rico (U.S. DoDEA, n.d.a).

The sole mission of DoDEA is to provide accredited educational programs from prekindergarten to twelfth grade students. The majority of these schools, about 110, are located across Europe and the Pacific and serve approximately 50,000 students (U.S. DoDEA, n.d.e). A large majority of students belong to active duty military families. The rest of the student population is comprised of children from DoD civilian families or those who are otherwise employed by the DoD.

Funding, governance, and accreditation. Unlike most schools in the U.S., DoDEA is not governed by the Department of Education, but rather the DoD. All DoDEA schools are accredited by an independent accrediting agency based in the U.S. (U.S. DoDEA, n.d.a).

Parent demographics of students who attend DoDEA schools differ from those enrolled in U.S. schools in many subtle ways. DoDEA school families. Parent demographics of students who attend DoDEA schools differ from those enrolled in U.S. schools in many subtle ways. With few exceptions, active duty military parents must have earned at least the equivalent of a high school diploma and some have completed college degrees (Military OneSource, 2014). Many DoD civilian employees hired from the United States hold positions that require a degree. Another difference is the significantly smaller percentage of single parents in the military, as compared to many families of school children in the states (Military OneSource, 2014).

Changes in military demographics and deployments (i.e., unaccompanied assignments and/or assignments to a combat zone) affect traditional roles of parents. These changes leave a significant impact on their children. While the vast majority of service members remain male, with more women now serving in the military; the notion of the mother being the primary caregiver has been altered (Military OneSource, 2014).

Military spouses, whether male or female, face challenges when the service member is deployed, which ultimately affects the family. Several studies have cited the negative impact these changes have had on military children (Cozza & Lerner, 2013; Fitzsimons & Karuse-Parello, 2009; Trenton & Countryman, 2012). The military is very clear that the mission comes first, but ensuring family unit stability allows the active duty member to stay focused on the mission at hand. Taking this into consideration, a greater emphasis has been placed on increasing availability of mental health services exclusively for military families. This initiative has resulted in beneficial programs, such as placing Military Family Life Consultants (MHN Military Services, 2017) in the schools, and providing a program known as “Families Overcoming Under Stress” (FOCUS) which emphasizes resiliency skills for the family (FOCUS, n.d.). However, individualized psychiatric services remain limited. Future studies are needed to better determine the efficacy of these programs.

DoDEA recognizes the challenges overseas students face with frequent moves, and the impact it has on education and graduation requirements. DoDEA recognizes the challenges overseas students face with frequent moves, and the impact it has on education and graduation requirements. In the summer of 2012, the DoDEA adopted the Common Core State Standards (CCSS) in all of their schools. This course of action was implemented as a way to provide consistent curriculum and standards, thereby minimizing the effects on students who move from school to school, not only within the DoDEA school system, but to some stateside schools as well (U.S. DoDEA, n.d.d).

Students who attend DoDEA schools overseas are the epitome of diversity in relation to birth origin, language, and culture. Some are U.S. citizens born in other countries while the family was assigned overseas; others were born in foreign countries with foreign passports. Many military spouses are foreign nationals or naturalized U.S. citizens. Some students possess limited English speaking skills, requiring English Second Language (ESL) services to aid them in their studies. School nurses become adept at utilizing charades and facial expressions when communicating with ESL students. Sometimes other adults or even parental assistance can be enlisted for support.

International Schools

International schools have been in existence since global travel and commerce began. History and location. International schools have been in existence since global travel and commerce began. For example, in Japan, a country where the host country language is not English, the American School in Japan was founded in 1902; the International School of the Sacred Heart in Tokyo was founded in 1908; and the Canadian Academy in Kobe was founded in 1913.

After World War II, an initiative was started to improve internationally based American schools to educate American dependents living overseas. Thus, the U.S. Department of State created the Office for Overseas Schools with a mission to “promote quality educational opportunities at the elementary and secondary level for dependents of American citizens carrying out our programs and interests of the U.S. Government abroad” (U.S. Department of State, n.d.c., para. 1)

The actual definition of an international school can vary. The actual definition of an international school can vary. In 2009 the International Association of School Librarianship (Nagrath, 2011) developed these defining criteria:

  • Transferability of the student's education across international schools
  • A moving population (higher than in state schools or public schools)
  • Multinational and multilingual student body
  • An international curriculum
  • International accreditation (e.g. Council of International Schools, International Baccalaureate; North Eastern Accrediting Commission for Schools; Western Association of Schools and Colleges)
  • A transient and multinational teacher population
  • Non-selective student enrollment
  • Usually English or French language of instruction, plus the obligation to take on at least one additional language

International schools are located worldwide, but the numbers are low in countries where English is the host language and public school curriculums can be easily accessed by students (e.g., the United States). On the “List of International Schools in the United States” (Wikipedia, 2017), the number is low and the majority follow a specific country’s curriculum, in a language other than English (e.g., German, French, Japanese, or the British system which has a different system of testing, as compared to the United States).

The ICEF Monitor website (2014), which lists a register of English speaking international schools, noted that number of these schools is increasing and there are “7,017 international schools around the world meeting the learning needs of over 3.5 million students, all using English as the language for learning” (para. 1). However, the website does not specify whether or not all schools are accredited.

International schools are usually private schools funded by student tuition. Funding, governance, and accreditation. International schools are usually private schools funded by student tuition. They can be divided into two principle groups: 1) not-for-profit, tax-exempt organizations that practice nondiscriminatory policies and are typically independently governed by boards of trustees; and 2) for-profit schools run by individual owners or companies. Depending on regulations of the country in which they are established, they may require a board for management.

The U.S. government has a list of 193 accredited international schools in various countries that offer continuing education opportunities to teachers in designated international schools, plus other types of support and safety recommendations (U.S. Department of State, n.d.a). Most well established schools are accredited through international accreditation agencies (e.g. Council of International Schools [CIS], International Baccalaureate Organization [IBO], North Eastern Accrediting Commission for Schools, Western Association of Schools and Colleges)

In addition to the children of expatriates, many schools also have local students from the host country. International school families. Parents of students in international schools are employees of international businesses, international organizations, foreign embassies, non-governmental organizations (NGOs), and missions or missionary programs. In addition to the children of expatriates, many schools also have local students from the host country.

Student Challenges

Students who attend school in an overseas setting experience unique challenges... Students who attend school in an overseas setting experience unique challenges, including health concerns, social adjustment, the environment, and dynamics upon return to the United States. Table 1 lists and compares factors and/or interventions that may impact common challenges for families and students in DoDEA and international schools, based on both the literature and the experiences of the authors. Where interventions are available to address these challenges, they are noted with an asterix. Table 2 briefly describes several similar family concerns for both types of schools, related to family cohesiveness, overseas assignments, trailing spouse (i.e., the spouse not on assignment), and legal considerations.

Table 1. Factors and/or Interventions in Typical Family and Student Challenges

Department of Defense Education Activity Schools

International Schools

Length of Stay

Military

- Varies from 1-3 years

Civilian

- Varies from 3-5 years or longer

- Varies; may be a citizen of the host country or could be based on contract/assignment with employer

(McLachlan, 2007)

Culture Shock

- Dependent on time spent on the military base

- Families new to overseas experience

- Lack of fluency and/or literacy in the local language

- Adaptation to new social customs and communication styles (Shibusawa & Norton, 1990)

Healthcare

Military

- Tricare insurance provided by military at no cost*

- Access to military health system on base (limited mental health)*

- Families screened for special medical needs which may affect career assignments (Military OneSource, 2017)*

Civilian

- Typical health insurance options*

- Host nation healthcare system

- Limitations include language and medical care offered

- Not medically screened for assignments

- Families usually screened by employer so any health condition is stable*; however, finding appropriate medical care depends on local providers, type of health insurance, language differences, and healthcare differences (medication availability)

- Local mental health resources may be difficult to access (U.S. Department of State, 2014; Hansson et al., 2012)

School and Childcare

- School tuition is free for military and civilian children*

- Before and after school programs available for cost*

- Some bring extended family members to assist with child care or hire a caregiver*

- Finding appropriate school with space available

- Entrance requirements can entail exam

- School tuition is expensive; often paid by employers

- Away from family support

- Utilizing an English speaking nanny for child care can alter family dynamics (Hansson et al., 2012)*

Working Conditions

Military

- Frequent deployments, which include war zones and military exercises

- Family is sent to the states without service member during disaster/war

Civilian

- Potential travel for work

- Civilian may be required to stay during disaster/war without family

- New job responsibilities for main visa holder (e.g., longer work hours, work-place dynamics, frequent traveling) (Shibusawa & Norton, 1990).

Student Challenges

Military

- Parental military rank consciousness by peers

- Frequent moves, up to 6-9 times per school career (DoD, 2016)

Civilian

- Move less frequent, but friends change often

Both

- School curriculum and graduation requirements may vary from one move to the next

- Difficult to maintain long term friendships

- Being different; possibly standing out in a crowd and being noticed (Shibusawa & Norton, 1990)

- Classmates may be of varying socio-economic status, with different expectations of behavior (Mclachlan, 2007)

- Grief from leaving behind friends and family, while needing to make new friend(s) (Mclachlan, 2007)

- School curriculum requirements may be a higher level leading to escalation of parental expectations for child’s achievement (McLachlan, 2007)

- Possibly must adapt to a new academic language (Baker, 1995; Hansson et al., 2012)

Future Educational Path

- School sanctioned sports offered only at high school level, limiting potential for scholarships

- Scholarships for graduating seniors in general are limited

- State discounts for lower tuition may not be available

- Difficult to decide future schooling location and career path

-State discounts for lower tuition may not be available

School Support Services

- Special education services are limited

- Required to follow Individuals with Disabilities Education Act (IDEA) and 504 laws

- Support services limited (U.S. Department of State; n.d.b)

- Since schools are private and not in the United States, there are no legal requirement to provide special education services

Environmental Concerns

- Air pollution and allergies (Otake, 2017; Perry, 2017)

- Weather related emergencies and natural disaster threats (Reuters, 2007b)

- Geo-political issues (e.g., war or government instability) (Fifield, 2017)

- Safety on the streets a possible be an issue of concern

- Communicable diseases may be more prevalent, or easily spread through air travel (World Health Organization, 2005)

- Drugs, alcohol, and cigarettes may be more readily available; country’s laws may be more or less strict than those in United States (Reuters, 2007a)

*Potential interventions to address selected challenges.

Table 2. Similar Family Considerations

Family Cohesiveness

Families are often a close unit due to frequent moves and social changes (McLachlan, 2007).

Overseas Assignments

Where a family chooses to live and when they have to move may not be negotiable (McLachlan, 2007).

Trailing Spouse

Career opportunities are limited, sometimes forcing spouse to place career on hold. Spouses may experience stress related to adaptation to new environment and new family roles and responsibilities (McLachlan, 2007; Shibusawa & Norton, 1990).

Legal considerations

Family is overseas at the invitation of the country’s government. Legal (i.e., Visa or Status of Forces Agreement) status for family may depend on individual behavior (Association of International Schools in Africa, 2014).

 
School Nursing Overseas

Holding a position as a school nurse in an overseas setting is both exciting and challenging. Table 3 compares the school nurse positions in each of these settings. We then further discuss some typical challenges in this nursing role.

Table 3. Comparison of the School Nurse Positions in an International Setting

Department of Defense Education Activity Schools

International Schools

Seeking a Position

- Majority of schools have a nurse

- Positions are advertised locally, then on USA Jobs if not filled

- Not all international schools have a school nurse, especially newer schools

- Recruitment may be through international school teacher fairs and job lists; however, the majority school nurses are hired locally (nurse is already in country for another reason)

Licensure / Education

- Maintain U.S. nursing license (finding continuing education offerings can be a challenge)

- Employment requirements include: Bachelor’s degree in Nursing; one year school nursing experience; 6 hours of undergraduate/graduate course work every 6 years

(U.S. DoDEA, Employment, n.d.e)

- Depends on country and regulations

- May require nurse to be licensed in the country of hire, so many schools hire English speaking, host-country nurses

- May alternatively allow school to hire most appropriate person for the school

- In general, nurse needs a license in home or host country and nursing experience

Contracts and Benefits

- Uniform contract signed every 1-2 years

- Living quarters allowance

- Airfare home every 1-2 years

- Post allowance to offset cost of living in foreign country

- Government retirement plan

Type of contract is variable:

- Teacher contract with health benefits, 190 day work year, and home leave

- Staff contract with fewer benefits, longer work year, lower salary scale

- Part time contract, with or without benefits

Policies / Procedures

- Developed by DoDEA Headquarters in Arlington, VA

- Some based on local military command

- Usually private or parochial schools, so variable

- Written and developed to meet accreditation regulations, country regulations, and school mission and values statements

Typical Duties (Duties are highly variable. Presented here are selected examples.)

- Everyday care of student injuries and illness, screenings, and record maintenance

- May include staff health, health teaching, curriculum writing, safety regulations, interpreting for families in a health setting, accessing care in emergencies

- Child protection and child abuse policies; local agencies may be difficult to utilize due to local county language differences

- Robust school policies and personnel training are vital for student protection

Challenges of a Department of Defense Education Activity School Nurse Position
DoDEA overseas-based school nurses are often either spouses of an active duty military member or DoD civilian, or they can be hired from the United States without any DoD affiliation. There are many challenges a DoDEA school nurse can face, such as familiarization with the military; frequent turnover of students, staff, and base personnel; and medical concerns that arise. DoDEA overseas-based school nurses are often either spouses of an active duty military member or DoD civilian, or they can be hired from the United States without any DoD affiliation. They have a unique set of circumstances to navigate when working both for the DoD and directly with the military. For those unfamiliar with military life, the prospect of working in a highly regimented, military-centric environment can be as daunting and foreign as the culture of the host nation where they serve.

Transfers and deployments of military and civilian personnel affect every aspect of a school nurse’s job, dealing with change is routine. As about one third of the student population moves each school year, the school nurse is required to constantly update files and reports. The same is true, but to a lesser extent, for teaching staff as typically several are trailing spouses and may be transferred. This frequent turnover of base personnel lends to reliance upon networking skills and keeps the school nurse busy throughout the school year, with little downtime.

...the prospect of working in a highly regimented, military-centric environment can be as daunting and foreign as the culture of the host nation where they serve. DoDEA school nursing acuity level, in relation to the student population on many bases, is greatly curtailed due to the screening process in place for military children. An exception to this can occur if a diagnosis that would normally have rendered the military family ineligible for a particular overseas assignment, such as epilepsy, may have been overlooked or not reported during the screening process. However, the most significant contributing factor to a school acuity level comes from children of civilians who, as discussed earlier, are not subject to the medical screening process. Behavioral and emotional issues related to frequent transfers and parental deployments are significant factors contributing to overall acuity as well.

Those who seek medical care from the host nation medical system, either due to unauthorized military health system access or unmet medical needs, may seek out the school nurse for assistance to locate appropriate medical care. Navigating a foreign healthcare system when English speaking personnel are limited can be quite concerning, not to mention differences in medical care provided. At minimum, orders, medication, and medical documentation must be interpreted accurately. Notwithstanding inconveniences and hardships, most DoDEA school nurses find that the benefits by far outweigh any unpleasantries.

Challenges of an International School Nurse Position
School nurses licensed outside of the host country are often local hires. They may be a trailing spouse of a school teacher; an expatriate who is part of the international community; or an immigrant. A host country nursing license may not be required, nor is it always necessary to speak the host country’s language, although it is convenient. However, licensure to practice as a nurse can be an issue. Some countries require that international school nurses hold licensure in the host country. However, since many countries do not closely regulate practices at international schools, the school is often allowed to hire personnel to fit the needs of their school.

Author Tsurumaki surveyed six other U.S. licensed school nurses who are members of the U.S. based National Association of School Nurses (NASN) and who are working at international schools, but not licensed to practice in the country of their school location. In general, there is a feeling of working in an ill-defined, grey zone. However, they noted that students for the most part are healthy and do not require extensive medical procedures.

Most school nurses consider themselves as acting in place of the parent in assisting the student (e.g., while providing diabetic care or administering medication per parent direction). Nurses follow policies and procedures which were developed for their private international school. They maintain licensing requirements and continuing education credits for their individual home state. They form professional networks in their respective area to share ideas.

...challenges in international schools present due to the wide variety of nationalities of students, with different languages and cultural norms. Other challenges in international schools present due to the wide variety of nationalities of students, with different languages and cultural norms. For example, Hansson et al. (2012) found that there were issues regarding advising students about sexuality and offering advice about contraception and sexually transmitted diseases (STDs) when the student’s family and the nurse observed different cultural norms. Laws of the country are also a consideration with regard to child abuse and student privacy reporting concerns.

Implications for Nurses: Third Culture Kids Dynamics

Children who attend school in another country have unique experiences that do not always easily translate to the U.S. school setting should they return. Children who attend school in another country have unique experiences that do not always easily translate to the U.S. school setting should they return. This section will define and discuss the concept of third culture kids (TCK) dynamics. We offer some implications for nurses who may work with students making this transition.

Smith (2013) wrote about the difficulty expatriate students have with defining where they are from and categorizing a cultural identity. Limberg and Lambie (2011) outlined David Pollock’s definition of TCKs as those who have spent a significant part of their childhood outside their parental culture. Therefore, a TCKs’ first culture is that of their parents, the second culture is where they were raised, and the third culture is an abstract one created from their shared experience with people who have lived the same lifestyle as they have.

The phenomenon of TCKs is not limited to American children attending school abroad. The phenomenon of TCKs is not limited to American children attending school abroad. Author Tsurumaki notes that Japanese government has a name for students who attended school overseas and then returned to Japan. It translates as 'returnee.' Some schools offer special provisions to support the students for exams. Author Tsurumaki works with quite a few returnees at her school because the Japanese language program is strong. At the school, students usually adapt quickly because the atmosphere is international, a difference from many American schools.

When a student is in an international school environment, they are surrounded by students who are TCKs. When they transition to their passport country (i.e., country of origin) or transition to another school or country, they may have difficulty with assimilation. Two subsets of TCKs are colloquially labeled military brats and missionary kids (MKs). These sub-groups may have additional unique experiences while living away from the United States. Mary Wertsch (2006) a self-proclaimed military brat, interviewed 80 similar children about their lives while growing up and their transitions into adulthood. Taylor Murray (2016), a self-proclaimed TCK, has written throughout her teenage years about her overseas experiences as a missionary kid.

...belonging both everywhere and nowhere can affect a person’s identity and can lead to struggles. In general, TCKs develop survival skills when forced to deal with frequent social and emotional changes, leading to adaptability. However, belonging both everywhere and nowhere can affect a person’s identity and can lead to struggles. TCKs may require additional emotional support or even intervention. Nonetheless, these students also develop significant cultural sensitivities and awareness based on their experiences while living in an overseas community and attending schools that promote internationalism.

For those students who have spent a substantial number of years living overseas, returning to the United States may be a somewhat frightening prospect. Owen (2015) offered the following suggestions to help TCKs integrate into the classroom and overall school life:

  1. Provide opportunities for TCKs to explore their identity and help them to develop their own sense of where they fit into the world.
  2. Make an effort to learn about them as a person and get to know their unique story.
  3. Help them connect to other students. They may fear making a cultural faux pas, since they may not know the cultural norms.
  4. Take care not to make assumptions or generalizations, or ignore their diversity.

Willingness by school nurses to listen and help TCKs integrate into a new environment, while acknowledging their unique experiences and lifestyles, can be helpful. The U.S. Department of State (2013) offers an extensive, but easy to read publication for parents of TCKs. This publication encourages them to create an environment of support, trust, and understanding in their family, where all members can feel free to discuss their feelings and problems. In general, many authors who write about the topic of Third Culture Kid dynamics have noted the necessity for parents of TCKs (e.g., Military Brats, MKs) to acknowledge that a mobile lifestyle is something that the parent has chosen, while TCKs have been born into it.

Conclusion

The practice of school nursing overseas sometimes takes into account similar factors considered by school nurses in the United States... The practice of school nursing overseas sometimes takes into account similar factors considered by school nurses in the United States, such as school governance, parents, students, and school dynamics. However, these factors often have unique characteristics in the setting of DoDEA and international schools. Comparing these two types of schools, as we have done in this article, will hopefully offer a greater understanding about their various similarities and differences. For example, one major difference is that the DoDEA provides a U.S. based centralized governing agency to oversee DoDEA schools, while governance for international schools is highly variable. Conversely, a comparison of student experiences suggests a common theme relating to the increased potential for frequent family moves, and thus exposure to more cultures. Another similarity identified is the typical day to day duties that make up the core foundation of school nursing.

Students attending schools overseas, when searching for their own sense of identity, may view themselves as a TCK. With knowledge about this unique phenomenon, U.S. based school nurses who are aware of the TCK dynamic can better understand and support students who are reintegrating, or perhaps even moving to the United States for the first time. Finally, overseas school nurses who work in a DoDEA or an international school have a genuine opportunity to share similarities and differences to support one another while living and working abroad.

Authors

Julie Hudson, MSN, RN, NCSN
Email: Julie.Hudson@pac.dodea.edu

Julie Hudson has worked as a registered nurse in a variety of settings for over 3 decades and is currently employed by the Department of Defense Educational Activity as a school nurse in Okinawa, Japan for the last 10 years. Utilizing her masters in nursing education from the Nebraska Methodist College she provides continuing education to fellow nurses and faculty. Julie is currently the president of the Overseas School Health Nurses Association and is a nationally certified school nurse. She also volunteers as an instructor and instructor trainer for the American Red Cross.

Nancy Smith Tsurumaki, MSN, RN, NCSN
Email: ntsurumaki@nishimachi.ac.jp

Nancy Smith Tsurumaki has a BSN from SUNY Plattsburgh, and a MSN from Rush University in Chicago, IL.  After serving as a Peace Corps volunteer in Honduras from 1979 to 1981, she has lived in Japan for over 30 years. She is one of the authors of the Japan Health Handbook (no longer in print; published original in 1995 and updated in 1998), a handbook for foreigners living in Japan. Working as a school nurse at an international school in Tokyo for the past 17 years, has been a challenging and fulfilling job, sharing the school with a large group of international students and teachers.

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© 2017 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2017


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