Yonago Acta medica 2000;43:69–72

The Necessity of Ethical Education for Clinical Nurses in Japan
Miyuki Adachi, Ikuko Miyabayashi* and Mihoko Miyawaki†
Division of Nursing, Tottori University Hospital, *Division of Child Neurology, Institute of
Neurological Sciences and †Major in Nursing, School of Health Sciences, Faculty of Medicine,
Tottori University, Yonago 683-0826, Japan
In complex and diversified clinical settings, social needs for patients’ rights areincreasingly demanded. Although clinical nurses have not received systematic ethics
education, 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 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 lookback 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.
Key words: continuing education; ethical education; medical ethics; nursing ethics

the 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 nursing
education on ethical issues, including our practical experiences.

The health care environment is becoming more
technically complex and all health professions
are facing complicated medical ethical issues
especially in morale decision-making; however, many nurses in current practice have had
little education in this field. In Japan, basic
education in nursing ethics began as an independent subject in 1951 (Sakuraba, 1990).
However, because of the criticism against its
use of nursing morale-based ethics, it wasdeleted from the nursing curriculum in 1968
(Kojima, 1991). Since then, nursing ethics has
not been treated as an independent subject.
In 1997, in response to social needs whichemphasize education in nursing ethics, thesubject was reincorporated into the nursing
curriculum (Yamada et al., 1999). As a result,nursing ethics has become an independent
course, usually called bioethics and nursing
ethics in the basic nursing curriculum. However, the revised basic nursing courses still
provide only traditional didactic lectures, andMaterials and Methods

Current status of Japanese nurses on ethical issues
General 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-wide
survey was conducted in 1997 from 293 Japanese 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 death69

M. Adachi et al.

Table 1. Subjects for nursing ethics
Subject

Incidence (%)*

123
4
56
78
910

Death with dignity, mercy killing
94.1
Informed consent
91.6
Brain death, organ transplantation
88.8
Truth telling of the disease
86.4
Artificial abortion
76.9
Moral ethics for nurses†
71.3
Medical intervention for life prolongation
71.3
Gene therapy
42.0
Opposition in nursing care and treatment between nurses and physicians
33.9
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.

or organ transplantation were items which weremost frequently treated as educational subjects
in Japan.
What types of situations do Japanese clinical nurses, who directly deal with patients andtheir family members, consider as ethical problems? What do the nurses do in those situations?
The Committee on Nursing Ethics in Japan
Nursing Science Association studied the responses of nurses to ethical issues (Committeeon Nursing Ethics in Japan Nursing Science Association, 1993). In the report, when the nurses
face ethical problems, they: i) follow the ordersof physicians, ii) facilitate communication between 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 responses
were caused by a perceptional recognition andrejection of the hierarchy system between physicians and nurses (nurses must obey physicians’ orders), by a disorganized work system,by an unclear understanding of a nurse’s assigned task due to a team approach for a given problem or by too much dependency on his or her
team. Similar problems indicating conflict between nurses and physicians have been also
reported 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 develop in the clinical field without an educational foundation.
Considering these situations and to solvethese problems, nurses are required to increase
their knowledge and insight of underlying ethical concepts and decision-making. To respondto their needs, we conducted a seminar on ethics
for clinical nurses at Tottori University Hospital.

Seminar on ethical problems
A seminar on ethics for clinical nurses at Tottori
University Hospital was conducted on April 28,
1998.
Attendees of the seminar were 66 female
nurses 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 attendees
were 11 head nurses, 12 assistant head nurses
and 38 staff nurses.
Seminar contents
The contents of the seminar included: i) understanding of nursing ethics in the medical field,ii) the principle of ethics and iii) themes related
to patients’ rights.
At the end of the seminar, a survey was conducted on the contents of the seminar and nursing ethics. The main contents of the survey
70Ethical education for clinical nurses

No answer 7%

"No"
44%

"No"
44%"Yes"56%

No. 1) "Experience in recognitionof ethical problem"

"Yes"
49%

No. 2) "Preservation of ethical standards or criteria"

No answer
2%

"No"
15%

"No"
21%
"Yes"
79%

No. 3) "Support of patients' rights"

"Yes"
83%

No. 4) "Effects of ethical seminaron each participant"Fig. 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 are
ethical 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?

were as follows: No. 1) Have you ever thought
about any ethical problems? If “yes”, in whatsituations did you think there are ethical problems? 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 patients’ rights or that patients’ rights are advocated? No. 4) Was your understanding of nursing ethics deepened after this seminar?

tients about their health status. In these situations, the nurses worried about how they canface their patients. The nurses felt an ethicaldilemma in prioritization between the care of
the patients and obeying the physicians’ orders.
On the other hand, 44% answered for question
No. 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 least
some criteria for ethical judgment (No. 2), and
44% of them had no criteria. Among nurses
who answered “yes”, their criteria were basedon the Japanese Nurses Associations’ ethicalstandards (Hatano, 1999) in 27% and the remaining 73% had their own standards. Seventynine percent answered “yes” to question No. 3.
On the other hand, 21% did not agree with thisquestion, indicating the insufficient protection

Results and Discussion
In 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 undefended
patients’ rights, the patient-doctor relationshipand the lack of physicians’ explanation to pa71

M. Adachi et al.

of patients’ privacy and the unwilling enforcement 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 possibly
improve their understanding, indicating a needfor continued education on nursing ethics.
Social needs in medical practice has beenchanging, and the sense of values has become
more 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 bigger
issue since treatment will be more frequent, andracial discrimination may be more of a problem
since more foreigners will enter Japan. Currently many clinical nurses are facing complex
bioethical dilemmas without any formal educational background. In these situations, it is
not likely that nursing ethics in the proper careof patients will spontaneously develop inclinical settings. In our series of studies, whennurses had ethical problems, their responses
were (in the order of frequency): i) discussing
the 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 action 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 opportunity for nurses to review his or her nursing
practice, to consider what ethical problems are
and to think about what is expected of nurses inresolving ethical problems.
Brock et al. (1995) suggested that there is no
single correct way to educate nurses in ethics;
however, one solution is continuing education,
including service programs, case studies, workshops and teaching sessions. Smith et al. (1996)
also emphasized the necessity of continuing
education for the development of nursing ethi-cal judgment. As indicated by these studies, itis strongly suggested that continuing education
on nursing ethics seems imperative in nursing
practice. A variety of effective learning methods needs to be considered for future planning.

Acknowledgments: The authors would like to express our profound gratitude to Mses. M. Fukada andH. Matsuura, Major in Nursing, School of Health
Sciences, Faculty of Medicine, Tottori University,and Mses. T. Yoshimochi and K. Hiroe, Division ofNursing, Tottori University Hospital, for their guidance and criticism of this study. The authors greatly
appreciate Dr. Maeta’s support, Assc. Prof. of theFirst Dept. of Surgery, Faculty of Medicine, Tottori
University.

References
1 Bagg JG. Collaboration between nurses and physicians: what is it? Dose it exist? Why dose itmatter? In: McCluskey JC, Grace HK, eds. Current issues in nursing. 5th ed. St.Louis: MosbyYear Book; 1994. p. 519–524.
2 Brock MJ, Shank MJ, Schelhause E, Bruening
WH. Teaching ethics to Nurses. J Nurs St Dev
1995;11:271–274.
3 Committee on Nursing Ethics in Japan Nursing Science 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 trouble
partnership. Ann Surg 1999;30:279–288.
5 Hatano S. [Nursing management] In: Hatano S,ed. Keito Kangogaku Koza Senmon I. Kiso Kangogaku I. Kangogaku Gairon. Tokyo: Igakushoin;
1999. p. 190–250 (in Japanese).
6 Kojima M. Nursing ethics. Hoken No Kagaku
1991;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 Cont
Edu 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)

72