In complex and diversified clinical settings, social needs for patients' rights are increasingly demanded. Although clinical nurses have not received systematic ethics education, they will face ethical problems on a daily basis. To solve these problems, we are required to offer ethics education to clinical nurses. We have conducted a seminar on ethics for clinical nurses at Tottori University Hospital. The purpose of this study is to clarify the current status of nursing ethics. Sixty-six clinical nurses attended this seminar from Tottori University Hospital. A questionnaire was used to collect data from 61 nurses. The following data were found: i) 56% had experience with ethical problems, ii) 49% have criteria for ethical judgment, iii) 83% answered that their understanding of ethics has deepened through this seminar and iv) almost all nurses who attended this seminar realized that nurses play an important role in advocating patients' self determination. Based on the results, we concluded that a seminar on nursing ethics provides opportunities for nurses to review his or her practice, to look back on their own nursing and to think about what ethical problems are. These findings also indicated the importance of continuing education on this problem for clinical nurses

Adachi, Miyuki

Miyabayashi, Ikuko

Miyawaki, Mihoko

Yonago Acta Medica

Tottori University Research Result Repository

69Yonago Acta medica 2000;43:69–72The Necessity of Ethical Education for Clinical Nurses in JapanMiyuki Adachi, Ikuko Miyabayashi* and Mihoko Miyawaki†Division of Nursing, Tottori University Hospital, *Division of Child Neurology, Institute ofNeurological Sciences and †Major in Nursing, School of Health Sciences, Faculty of Medicine,Tottori University, Yonago 683-0826, JapanIn complex and diversified clinical settings, social needs for patients’ rights areincreasingly demanded.  Although clinical nurses have not received systematic ethicseducation, they will face ethical problems on a daily basis.  To solve these problems, weare required to offer ethics education to clinical nurses.  We have conducted a seminaron ethics for clinical nurses at Tottori University Hospital.  The purpose of this study isto clarify the current status of nursing ethics.  Sixty-six clinical nurses attended thisseminar from Tottori University Hospital.  A questionnaire was used to collect datafrom 61 nurses.  The following data were found:  i) 56% had experience with ethicalproblems, ii) 49% have criteria for ethical judgment, iii) 83% answered that theirunderstanding of ethics has deepened through this seminar and iv) almost all nurseswho attended this seminar realized that nurses play an important role in advocatingpatients’ self determination.  Based on the results, we concluded that a seminar onnursing ethics provides opportunities for nurses to review his or her practice, to lookback on their own nursing and to think about what ethical problems are.  These findingsalso indicated the importance of continuing education on this problem for clinical nurses.Key words:  continuing education; ethical education; medical ethics; nursing ethicsThe health care environment is becoming moretechnically complex and all health professionsare facing complicated medical ethical issuesespecially in morale decision-making; how-ever, many nurses in current practice have hadlittle education in this field.  In Japan, basiceducation in nursing ethics began as an in-dependent subject in 1951 (Sakuraba, 1990).However, because of the criticism against itsuse of nursing morale-based ethics, it wasdeleted from the nursing curriculum in 1968(Kojima, 1991).  Since then, nursing ethics hasnot been treated as an independent subject.In 1997, in response to social needs whichemphasize education in nursing ethics, thesubject was reincorporated into the nursingcurriculum (Yamada et al., 1999).  As a result,nursing ethics has become an independentcourse, usually called bioethics and nursingethics in the basic nursing curriculum.  How-ever, the revised basic nursing courses stillprovide only traditional didactic lectures, andthe systematic educational program on ethicalissue is not yet established in Japan.The purpose of this study is to clarify thecurrent status of nursing ethics and nursingeducation on ethical issues, including our prac-tical experiences.Materials and MethodsCurrent status of Japanese nurses on eth-ical issuesGeneral concepts of nursing ethics are notalways obvious to nurses themselves nor for thegeneral public.  With respect to each subject innursing education on ethics, a national-widesurvey was conducted in 1997 from 293 Japa-nese institutions for nursing education, and theresults were published in 1999 (Yamada et al.,1999), as shown in Table 1.  Death with dignity,mercy killing, informed consent and brain deathM. Adachi et al.70or organ transplantation were items which weremost frequently treated as educational subjectsin Japan.What types of situations do Japanese clini-cal nurses, who directly deal with patients andtheir family members, consider as ethical prob-lems?  What do the nurses do in those situa-tions?The Committee on Nursing Ethics in JapanNursing Science Association studied the re-sponses of nurses to ethical issues (Committeeon Nursing Ethics in Japan Nursing Science As-sociation, 1993).  In the report, when the nursesface ethical problems, they:  i) follow the ordersof physicians, ii) facilitate communication be-tween patients and their physicians and iii) havea team conference among nurses.When the latter 2 scenarios occurred, it wasusually due to emotional responses of thenurses to cope with the way the physicians werehandling the patients.  The emotional responseswere caused by a perceptional recognition andrejection of the hierarchy system between phy-sicians and nurses (nurses must obey physi-cians’ orders), by a disorganized work system,by an unclear understanding of a nurse’s assign-ed task due to a team approach for a given prob-lem or by too much dependency on his or herteam.  Similar problems indicating conflict be-tween nurses and physicians have been alsoreported in the United States (Baggs, 1994;Greenfield, 1999).  In these situations, it is im-possible to expect that nursing ethics on theproper care of patients will spontaneously de-velop in the clinical field without an educa-tional foundation.Considering these situations and to solvethese problems, nurses are required to increasetheir knowledge and insight of underlying ethi-cal concepts and decision-making.  To respondto their needs, we conducted a seminar on ethicsfor clinical nurses at Tottori University Hospital.Seminar on ethical problemsA seminar on ethics for clinical nurses at TottoriUniversity Hospital was conducted on April 28,1998.Attendees of the seminar were 66 femalenurses who work at Tottori University Hospital.Their mean age was 36.8 years.  There was noinformation taken on the length of time of eachworking experience; however, the attendeeswere 11 head nurses, 12 assistant head nursesand 38 staff nurses.Seminar contentsThe contents of the seminar included:  i) under-standing of nursing ethics in the medical field,ii) the principle of ethics and iii) themes relatedto patients’ rights.At the end of the seminar, a survey was con-ducted on the contents of the seminar and nurs-ing ethics.  The main contents of the surveyTable 1.  Subjects for nursing ethicsSubject Incidence (%)*1 Death with dignity, mercy killing 94.12 Informed consent 91.63 Brain death, organ transplantation 88.84 Truth telling of the disease 86.45 Artificial abortion 76.96 Moral ethics for nurses† 71.37 Medical intervention for life prolongation 71.38 Gene therapy 42.09 Opposition in nursing care and treatment between nurses and physicians 33.910 Patients discrimination 26.9(race, nationality, religion, gender, social position, economic status)* Incidence in which each subject is treated as an educational one for nursing ethics among 293 Japaneseinstitutions.† Set forth by the Committee on Nursing Ethics in Japan Nursing Science Association (1993).Cited with our modification from the report by Yamada et al. (1999) with written permission.Ethical education for clinical nurses71No. 1) "Experience in recognition of ethical problem"No. 2) "Preservation of ethical stan-dards or criteria"No. 4) "Effects of ethical seminar on each participant"No. 3) "Support of patients' rights""No"44%"No"15%"Yes"83%No answer  2%"Yes"49%No answer  7%"Yes"56%"No"44%"No"21%"Yes"79%were as follows:  No. 1) Have you ever thoughtabout any ethical problems?  If “yes”, in whatsituations did you think there are ethical prob-lems?  No. 2) When you think of nursing ethics,do you have any standards or criteria?  No. 3)Do you agree that nurses try to advocate pa-tients’ rights or that patients’ rights are advo-cated?  No. 4) Was your understanding of nurs-ing ethics deepened after this seminar?Results and DiscussionIn our questionnaire, 61 out of 66 responded tothis survey (92%).  Results are shown in Fig. 1.Fifty-six percent answered “yes” to questionNo. 1, and gave situations such as undefendedpatients’ rights, the patient-doctor relationshipand the lack of physicians’ explanation to pa-tients about their health status.  In these situ-ations, the nurses worried about how they canface their patients.  The nurses felt an ethicaldilemma in prioritization between the care ofthe patients and obeying the physicians’ orders.On the other hand, 44% answered for questionNo. 1 that they had not thought about ethicalproblems, indicating a lack of interest.When the nurses thought about the ethicalissues, 49% answered that they have at leastsome criteria for ethical judgment (No. 2), and44% of them had no criteria.  Among nurseswho answered “yes”, their criteria were basedon the Japanese Nurses Associations’ ethicalstandards (Hatano, 1999) in 27% and the re-maining 73% had their own standards.  Seventy-nine percent answered “yes” to question No. 3.On the other hand, 21% did not agree with thisquestion, indicating the insufficient protectionFig. 1.  Questionnaire and responses.  Questions No. 1 to 4: 1) Have you ever thought about any ethical problems ?  If “yes”, in what situations did you think that they areethical problems? 2) When you think of nursing ethics, do you have any standards or criteria? 3) Do you agree that nurses try to advocate a patients’ rights or that patients’ rights are adovocated? 4) Was your understanding of nursing ethics deepened after this seminar?M. Adachi et al.72of patients’ privacy and the unwilling enforce-ment of interhospital rules.Eighty-three percent answered that theirunderstanding of ethics has deepened (questionNo. 4). However, 15% of the nurses answeredthat a single seminar alone could not possiblyimprove their understanding, indicating a needfor continued education on nursing ethics.Social needs in medical practice has beenchanging, and the sense of values has becomemore complex.  Accordingly, ethics issues arediversified, as shown in Table 1.  We expectthat these items will change as time passes; forexample, gene therapy may become a biggerissue since treatment will be more frequent, andracial discrimination may be more of a problemsince more foreigners will enter Japan.  Cur-rently many clinical nurses are facing complexbioethical dilemmas without any formal edu-cational background.  In these situations, it isnot likely that nursing ethics in the proper careof patients will spontaneously develop inclinical settings.  In our series of studies, whennurses had ethical problems, their responseswere (in the order of frequency):  i) discussingthe problems with the physicians and othernurses and ii) no action.  These answers suggestthat there were difficulties in handling ethicalproblems because of the unclear position ofnurses between patients and physicians.  No ac-tion reflected that the nurses were passive insolving the ethical problems by themselves.The results of the present study strongly suggestthat a seminar on nursing ethics provides an op-portunity for nurses to review his or her nursingpractice, to consider what ethical problems areand to think about what is expected of nurses inresolving ethical problems.Brock et al. (1995) suggested that there is nosingle correct way to educate nurses in ethics;however, one solution is continuing education,including service programs, case studies, work-shops and teaching sessions.  Smith et al. (1996)also emphasized the necessity of continuingeducation for the development of nursing ethi-cal judgment.  As indicated by these studies, itis strongly suggested that continuing educationon nursing ethics seems imperative in nursingpractice.  A variety of effective learning meth-ods needs to be considered for future planning.Acknowledgments:  The authors would like to ex-press our profound gratitude to Mses. M. Fukada andH. Matsuura, Major in Nursing, School of HealthSciences, Faculty of Medicine, Tottori University,and Mses. T. Yoshimochi and K. Hiroe, Division ofNursing, Tottori University Hospital, for their guid-ance and criticism of this study.  The authors greatlyappreciate Dr. Maeta’s support, Assc. Prof. of theFirst Dept. of Surgery, Faculty of Medicine, TottoriUniversity.References 1 Bagg JG.  Collaboration between nurses and phy-sicians:  what is it?  Dose it exist?  Why dose itmatter?  In: McCluskey JC, Grace HK, eds.  Cur-rent issues in nursing. 5th ed.  St.Louis: Mosby-Year Book; 1994.  p. 519–524. 2 Brock MJ, Shank MJ, Schelhause E, BrueningWH.  Teaching ethics to Nurses.  J Nurs St Dev1995;11:271–274. 3 Committee on Nursing Ethics in Japan Nursing Sci-ence Association, The.  The responses of nurses toethical issues when the nurses face the ethicalproblems.  Nippon Kango Kagakukaishi 1993;13:32–37 (in Japanese). 4 Greenfield LJ.  Doctors and nurses:  a troublepartnership.  Ann Surg 1999;30:279–288. 5 Hatano S.  [Nursing management]  In: Hatano S,ed. Keito Kangogaku Koza Senmon I.  Kiso Kango-gaku I.  Kangogaku Gairon.  Tokyo: Igakushoin;1999.  p. 190–250 (in Japanese). 6 Kojima M.  Nursing ethics.  Hoken No Kagaku1991;33:190–193 (in Japanese). 7 Sakuraba S.  Nursing and bioethics.  Why now?Kango Kyoiku 1990;31:516–521 (in Japanese). 8 Smith KV.  Ethical decision-making in nursing:implications for continuing education.  J ContEdu Nurs 1996;27:42–43. 9 Yamada S, Hatano S, Onodera T.  Current statusof nursing ethics:  from a curriculum survey in athree-year nursing program. Kango Kyoiku 1999;40:204–208 (in Japanese).(Received August 25, 1999, Accepted January 9, 2000)

The Necessity of Ethical Education for Clinical Nurses in Japan

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The Necessity of Ethical Education for Clinical Nurses in Japan

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