As we’ve previously explored, some of the core themes that run through Kogado Studio’s visual novel Nurse Love Syndrome include the ideas that people are fallible, that first impressions aren’t always correct — and that becoming overly dependent on someone is usually a bad idea.

The narrative route for Yasuko Yamanouchi explores these concepts from a slightly different angle. Protagonist Kaori Sawai once again finds herself struggling in her early days as a nurse, but this time around the ways she finds herself having to cope — and the things she has to cope with — are a little different from that which we witness if we pursue the route focusing on her senpai Nagisa.

Like much of Nurse Love Syndrome, Yamanouchi’s route is emotionally charged and, at times, a challenging read. Sounds ripe for a bit of deeper reading, no?

A quick recap for now. Nurse Love Syndrome is the story of Kaori Sawai, a nurse who is fresh out of nursing school and about to start her first job in a relatively small local hospital. On her arrival at her new workplace, she discovers that she will be working alongside her senpai from school Nagisa, along with the rather stern Chief Hatsumi, and, of course, Yamanouchi.

Yamanouchi is the most senior nurse of the main cast besides Chief Hatsumi, and thus she is someone that Kaori looks up to and defers to. The relationship between them is different from that which she and Nagisa share, however; the slight age difference plus the fact that they didn’t grow up together means that Kaori doesn’t view Yamanouchi as a senpai, but an outright superior with considerably more experience and talent than she, as a complete rookie, will ever have.

In the original release of Nurse Love Syndrome for PSP, Yamanouchi didn’t have her own route, despite being present for much of the other narrative paths. Indeed, the poor girl didn’t even get to appear on the cover — but the RE:Therapy expanded release, on which the novel’s English localisation is based, provided her with plenty more to do. And it’s a good thing, too; even if you’re not directly following her narrative path, Yamanouchi comes across as a thoroughly likeable character — and someone who perhaps has a few things in her past that might be interesting to explore.

Kaori isn’t sure what to make of Yamanouchi when they first encounter one another, however. Understandably terrified at starting her first day in a new workplace, she is mortified when the intimidatingly pretty Yamanouchi picks up on her stumbling over her words and being visibly nervous when introducing herself to her new colleagues. But it’s not long before Yamanouchi shows that this is just her own way of lightening the atmosphere in what can sometimes be a rather grim profession — and she absolutely seems to have the best interests of the team as a whole at heart.

In Kaori’s early days on the job, Nagisa is assigned as her “preceptor” to help her learn the ropes, despite Nagisa only having a year’s head start. Yamanouchi acts as a source of support for both of them, encouraging Kaori to rely on everyone in the ward to help her out rather than either trying to take on too much herself — or overburden her senpai by coming to her, and her alone, any time she has a problem.

“We’ve all been there,” she says. “Ya realise there’s so much ya can’t do, and you start to hate yourself… feelin’ all pathetic, wondering if you’re no good. Which is why you wanna try to get better bit by bit. Even if ya can’t be better than yesterday, try to be better than last week, or last month. It takes five years for a nurse to grow into the job. A veteran, laughing at a newbie… that ain’t right. We were all newbies at one point.”

Yamanouchi initially looks like she immediately undermines her own sage advice by adding that “if you ever wanna cry, this big rack’s open to ya; I can’t measure up to the Chief’s massive honkers, but I figure they’ll be comfortin’ enough.” But this is just another example of her lightening the mood somewhat after a heavy conversation; her spectacularly inappropriate comments frequently make people smile even when they’re going through difficult times.

And this is a key part of her position in the ward; even though she frequently exhibits behaviours that one would most certainly hesitate to call “professional”, her presence overall is one of positivity; one that makes patient and nurse alike feel rather more at ease than they might otherwise be. In a hospital environment, this is a critical part of both care for the patients, and ensuring that everyone can do their job effectively.

Kaori is surprised to see that Yamanouchi’s irreverent attitude carries across to when she is dealing with patients, too. When interacting with a long-term patient known as Mr. Ryukaku, who has been struggling somewhat with his offspring fighting over their potential inheritance, Yamanouchi is rather more “honest” (her words) with the elderly gentleman than one might think appropriate. But after Kaori confronts Yamanouchi on her manner after the fact, Yamanouchi makes it abundantly clear that she knew exactly what she was doing.

“Lemme level with you,” she responds to Kaori’s outrage. “We’re nurses, right? Who’re we taking care of?”

“Our patients,” Kaori responds meekly.

“Exactly,” continues Yamanouchi. “And we gotta change what we say based on our patients and their mental states. Did you know that Mr. Ryukaku was saying he wanted to die yesterday, lookin’ as sunk as he could? And it wasn’t even the depression of old age, either. This is a man that’s lived for decades, goin’ through the highs and lows of life… and he said he wanted to die.

“His drive to make sure his children didn’t want anything backfired on him,” she explains, “and now his kids and grandkids’re brawling with each other over who gets the pie he’s gonna leave behind. Mr. Ryukaku’s hurt. Hurt enough for such an old man to want to look away from reality. Which is why this dumb nurse skipped etiquette and brough ‘im back to reality. Made him realise that even if he doesn’t off himself, he ain’t got much left. If he doesn’t solve the problems on his plate, he ain’t gonna be able to face his wife on the other side.”

This idea of taking care of a patient’s mental and spiritual wellbeing rather than simply focusing on physical care is something that Kaori learns a lot about over the course of the various narrative routes. She learns that there is a lot more to being a nurse than simply doing what is expected of you — and Yamanouchi is a prime example of the fact that sometimes you might have to bend those rules and expectations a bit in order to do your job better.

There are questions of power structure and ethics to consider, too, though, and as time goes on and Mr. Ryukaku’s situation worsens, we start to see how this can end up being a struggle even for seemingly unflappable nurses like Yamanouchi. When Mr. Ryukaku’s family demand that he be put on life-extending treatment, yet Mr. Ryukaku himself has signed a Do Not Resuscitate form, the nurses are put in a difficult position, with little option other than to comply with the final choice the doctor in charge of his case makes. Respect the wishes of the patient, or his family?

The main “split point” in Nurse Love Syndrome’s various narrative paths comes at a stage where a combination of work-related stress and exhaustion cause Kaori to burn out completely — particularly when she starts receiving seemingly unprovoked harassment via phone, text message and email, which in turn cause traumatic flashbacks to a car accident she was involved in as a child. Depending on the choices you’ve made up until this point, either Nagisa, Chief Hatsumi or Yamanouchi will come after Kaori, initially furious that she seemingly skipped a day of work without telling anyone — but immediately softening when they see how terrified she is.

Yamanouchi’s take on this scene sees her going from two extremes of emotion. She seems the most genuinely angry that Kaori was absent from work — even the Chief doesn’t yell at her as much as Yamanouchi does — but she also seems the most invested in Kaori’s wellbeing once it becomes clear how much she is suffering. Only Yamanouchi insists that she goes to get a check-up in the outpatient ward, and Yamanouchi is the one who takes the most proactive steps to ensure that Kaori feels as safe as reasonably possible under the circumstances.

The subsequent scenes will be distressingly familiar to anyone who has ever had an inadvertent emotional breakdown in the workplace: Kaori, feeling very weak, embarrassed and alone after her ordeal, is surprised to discover that her colleagues are not, in fact, out to “get her”, and instead have her back. Up until this point, she’s been scared to rely on anyone other than Nagisa — and even then, there are things she hadn’t told her childhood friend, including the details of the accident in her youth.

But here, Kaori is told outright that she can talk about the things that are hurting her, and this is important. Kaori is someone who, although seemingly fairly meek, tends to default to trying to muddle through difficult situations on her own. If she’s not told to seek help from others, she won’t; and if she’s not told the “right” way to do something, chances are she’ll make a mistake. Therefore both Yamanouchi and the Chief recognising this and spelling things out for her is a key moment in her development.

“Ain’t a soul who’ll turn ya down if you wanna talk about your troubles in the station,” says Yamanouchi. “Was hopin’ you’d rely on us a bit before you let yerself get wrecked like that.”

It’s likely not a coincidence that shortly after this, Kaori starts feeling a distinct interest in Yamanouchi. She recognises that both Yamanouchi and Nagisa are fulfilling similar functions in her professional life — helping her learn things and develop her skills — but finds something about the way Yamanouchi interacts with her to be strangely compelling. Kaori finds herself covering for Yamanouchi when she makes a rare mistake — something which Yamanouchi very much appreciates, despite knowing that the Chief would never buy Kaori’s lies — and sees this as a good opportunity to finally be “owed” something for once, rather than always being the one owing something to someone else.

Kaori and Yamanouchi become a lot closer after this incident, and Nagisa notices, displaying some obvious jealousy — but respecting Kaori enough to stand back and let things unfold naturally rather than trying to interfere. She even ends up standing down as Kaori’s preceptor, though not entirely for Kaori’s benefit; as we see in her own route, Nagisa still has a lot to learn about the job, but it’s in Yamanouchi’s that she actually acknowledges this and decides to effectively “start over”.

This, naturally, leaves Kaori needing a preceptor — and what better candidate than the veteran nurse with whom she appears to be getting along so well?

Kaori recognises almost immediately that Yamanouchi’s teaching style is very different from Nagisa’s. While Nagisa was always there to support and correct her, Yamanouchi is so busy with her other duties that she often expects Kaori to think for herself and come back with answers. This isn’t to say that she neglects her, mind; judging by Kaori’s reactions, it’s fair to say that Yamanouchi’s teaching style is actually rather effective, as much of a culture shock as Kaori finds it initially.

“I try my best to follow Yamanouchi’s lead,” Kaori muses to herself in the hospital break room, “but the more progress I make, the more questions are thrown my way. By the time work is finished I’m exhausted. I’ve gotten a handle on things now, but that doesn’t stop me from tensing up whenever Yamanouchi checks over my work. But I’m not giving up! One day I’ll be the super partner that Yamanouchi always wanted. She’ll be yelling it from the rooftops!”

This is a marked contrast from the Kaori we see in Nagisa’s route, who would tend to make bold statements to herself and then immediately fold as soon as any difficulty presented itself. Here, Yamanouchi’s harsh but fair teaching methods ultimately help to give Kaori a degree of strength for herself — although there are times when some might argue Yamanouchi goes a little far with the “tough love” side of things.

One instance occurs when two of the patients in the internal medicine ward — one of whom is Mr. Ryukaku — start having significant difficulties. Yamanouchi takes the lead on one of the response teams, and Kaori dutifully follows along, doing what she’s told and eventually feeling a sense of relief at how “lucky” they were things ended well.

Yamanouchi doesn’t appreciate her skill being written off as “luck” and lays into Kaori for not thinking for herself — and Nagisa for spending too much time “showering her with praise” rather than really teaching her how tough the job is. And from this point, her criticisms seem to become all the more harsh; despite her strong start under Yamanouchi’s preceptorship, Kaori eventually finds her confidence being eroded, and goes back to thinking of herself as a “screwup”. We can perhaps interpret this as some hidden ugliness within Yamanouchi’s heart — or perhaps just her pride in her own work. Either way, Kaori isn’t ready for the increasingly harsh treatment she receives.

It’s Chief Hatsumi who brings some comfort to Kaori this time. While the Chief spends much of the narrative being stern and authoritative — it’s her job, after all — she frequently shows a softer side when interacting with Kaori, and especially when Kaori is suffering. There are a few conclusions we can draw about this, given a few little hints dropped through the narrative, but we’ll save them for when we explore the Chief’s route in earnest.

“Why do you do this job?” the chief asks Kaori. “For props from Fujisawa and Yamanouchi? You know that’s not why. We do this job for our patients. We’re expected to discharge our duties, even if our praises go unsung. There’s nothing like that high you get when you’re thanked for only doing what’s expected of you, is there? In most jobs you just leech, giving nothing in return. But how many jobs let you give back, and really make you feel alive? I don’t think you’ll find many.”

Kaori knows this — and deep down, she knows that this is what Yamanouchi is trying to impress on her, too. But she still finds it difficult; she still doesn’t quite know what kind of nurse she wants to become — and how to go about making that decision for herself, when she seems to be receiving so many conflicting messages from all around herself. Moreover, there are so many layers of seeming “beauty” and “ugliness” to Yamanouchi that Kaori finds it increasingly difficult to determine where she stands — both professionally and personally.

It’s during the after-death care for a patient who passes away that Kaori is able to re-establish her bond with Yamanouchi somewhat. While Kaori finds it difficult to stop the tears flowing, it becomes clear that Yamanouchi is sad in her own way; she just expresses it differently. In her case, she says what she is thinking, addressing it to the deceased patient they are taking care of, and knowing that Kaori will hear it, too.

“Hana’s tough as a box of nails,” Yamanouchi explains, speaking of the departed. “If she could speak she wouldn’t be fretting over what’s gone and done. That’s what it means to be a woman: ya might have fierce anger in ya head, but you act cool, and keep the peace. Ya could say Hana was a woman’s woman. Made a young ‘un like me look up to her, ya know?”

This is one of the most concrete glimpses we’ve got of what the “real” Yamanouchi is like. Throughout the rest of the narrative, we’ve seen that this is a young woman who keeps her personal and professional life starkly separate from one another — indeed, when Kaori first encounters Yamanouchi without makeup and wearing a shabby old tracksuit, she doesn’t even recognise her — and someone who, despite her seeming self-assuredness, is most definitely carrying around some heavy, ugly feelings.

To put it another way, she has fierce anger in her head, but she acts cool and keeps the peace. For the most part, anyway.

Throughout the narrative, we see Yamanouchi express herself through her art — specifically, manga art. And, in a quiet symbol of trust between the two of them, Yamanouchi invites Kaori to be her assistant quite early in the narrative. When she proves herself to be quite capable in this role, the two find themselves with plenty more opportunities to spend time with one another — and thus Kaori starts to feel like she’s getting a complete picture of who Yamanouchi “really” is, and why she likes her so much.

Which is why it’s so difficult for her to process when Yamanouchi finds herself with an offer to become a professional, full-time manga artist for a prestigious publication. Kaori, as we’ve seen pretty conclusively by this point, is dependent on others to a fault, and worries about what Yamanouchi leaving will mean for her — and for any possible relationship they might have been able to pursue.

Kaori is, of course, torn on whether or not she should express these feelings to Yamanouchi, or simply be supportive to the woman she has, by this point, fallen for. Should you make the decision for Kaori to do the latter, Yamanouchi does indeed end up departing, leaving Kaori to wonder forever what might have been. And Kaori’s broken heart isn’t helped by the fact that Yamanouchi’s chosen pen name “Sawanouchi” is clearly a portmanteau of their two names — and that her debut story features characters clearly based on the pair of them.

But what is the right answer? Kaori knows that her desire for Yamanouchi to stay where she is is selfish on her part — and she also knows from conversations with her peers that Yamanouchi has historically been quite flighty. It seems it took quite an effort for Chief Hatsumi to pin the talented nurse down to the internal medicine ward for as long as she had done up until now.

Things come to a head when it becomes clear that Mr. Ryukaku is either going to pass naturally as per his wishes, or that he needs to be hooked up to an artificial respirator. Yamanouchi, determined to put the patients first regardless of the family’s wishes, argues with the Chief over what she believes is best for Mr. Ryukaku, but the result, regardless of whether Kaori sides with her in the argument, is the same: Mr. Ryukaku is intubated, but still passes away shortly afterwards.

Yamanouchi’s narrative can come to one of several possible conclusions based on whether or not Kaori sides with her, and how quickly she recognises the anger and pain burning within Yamanouchi after Mr. Ryukaku’s passing. They are some difficult choices to make, to be sure; among other things, would the headstrong Yamanouchi appreciate Kaori charging in and claiming to know what she is feeling, when she’s already put up a fair amount of resistance on that front already?

Furthermore, the late narrative reveals — or perhaps confirms — that Yamanouchi has some pretty severe trust issues going on thanks to an exceedingly turbulent family life growing up. This not only makes Yamanouchi hesitant to trust anyone, it also means she has a tendency to push people away when they look like they’re getting close — which is, of course, exactly what she’s been doing with Kaori.

“Ma, Pa, even my big sister taught me one valuable thing,” she muses. “Don’t trust nobody. You’ll only get stabbed in the back. Now you know the kind of woman ya in love with. So, ya turned off yet? I was over the moon when Pa died, and straight up relieved when Ma hung herself after toiling away for years. Despicable, right?”

The exact outcome of the situation depends on whether or not Kaori manages to prove herself worthy of Yamanouchi’s trust — and in the “bad” ending we see that Kaori is willing to go to some pretty extreme levels in order to maintain what she believes is that “trust”. The Yamanouchi we see in this ending is certainly not above taking advantage of the situation, leaving Kaori in a position where we find ourselves questioning if she’s really doing what she’s doing because she wants to — or because she feels like she can’t escape from the hole she dug herself.

Ultimately a good relationship is built on genuine trust and honesty, though. Yamanouchi, as someone who has suffered in the past but doesn’t feel comfortable letting many people in on the details of exactly how and why, needs to feel like she is in a position where she is safe, and that people have her back. She’s seemingly spent her life moving on from situations where she feels like she’s lost that — or at the very least, wasn’t able to find that in a suitable timeframe — and indeed, in a couple of the possible conclusions we see just that happening once again.

In the best possible conclusion, though, we see a Yamanouchi who has been moved by Kaori’s honesty, loyalty and trustworthiness — and this inspires her to be more honest, too. Not just with herself, either; as we reach the “good” ending, we see a Yamanouchi who is perhaps a little too willing to express her affection for our dear protagonist in the workplace, and even happy to explain something as private as why she doesn’t like people — even those who are closest to her — using her first name.

Courting Yamanouchi is a difficult journey for Kaori thanks to the number of layers of “beauty” and “ugliness” she has to delve through to get to the truth — particularly as all of them are part of the “real” Yamanouchi. There’s her beautiful appearance in the hospital versus her scruffy appearance at home; there’s her mild, supportive manner with the patients and her irreverent attitude; there’s her keenness to help and her harsh, biting criticism; and there is, of course, her seeming willingness to let Kaori get close, then cruelly rebuff her because of her trust issues. It’s a challenge, for sure, but it all ends up not only helping Kaori grow as both an individual and a nurse, but also helping Yamanouchi come to terms with and move on with the traumatic aspects of her past that have been holding her back up until now.

Probably one of the most interesting things about the two Nurse Love visual novels is that their conclusions often feel like the characters involved have further significant challenges ahead of them — and that things aren’t necessarily tied up neatly with a bow at the end of it all. Once could argue that the way Kaori and Yamanouchi’s relationship begins in earnest perhaps isn’t the healthiest, most “perfect” way for them to get together — particularly given some of the possible alternative outcomes we see in the other endings. But when are things ever really perfect, anyway, and who are we to stand in the way of two people who found themselves drawn to one another despite everything?

Life isn’t simple, after all; things are rarely as they seem at first glance, and it takes time and effort to understand the truths of the world — and, more importantly, to feel able to share those truths with others.

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