Nursing ethics education in Japan was established in 1946 within the integrated curriculum for public health nurses, midwives, and general nurses, as a part of the subject “nursing history and nursing ethics.” In 1951, because of revision of the Regulations for Designation of Colleges and Training for Public Health Nurses, Midwives, and General Nurses, nursing ethics was established as an independent academic subject. This included cultivation of a service-oriented mindset, and it placed importance on submission to physicians’ authority and to organizations’ rules and disciplines. This approach was rejected to some extent with the spread of democratic values and advances in nursing education, and in the 1967 revision of the above Designation, nursing ethics was eliminated as an independent subject. However, during the period of approximately 30 years when nursing ethics was not included, both advances in healthcare and Japanese citizens’ increasing consciousness of their health care- related rights meant that nursing personnel faced various ethical problems. Therefore, in 1988 the Japanese Nursing Association prepared the “Ethics Guidelines for Nurses,” followed by the publication of a new document, “Code of Ethics for Nurses” in 2003, which was later revised in March 2021 as the “Code of Ethics for the Nursing Profession.” Nursing ethics education has thus been gradually incorporated into basic nursing education in the 21st century, and thorough nursing ethics education has been provided. Research on nursing ethics has been conducted from various perspectives. In particular, several reports of studies on the frequency of nurses encountering ethical problems have been published, and the most important issues identified have been “whether or not to ensure the patient’s safety by physical restraint and/or sedation,” “assignment of sufficient nursing personnel for satisfactory provision of nursing care,” and “respecting patients’ dignity”[1-3]. Nurses have experienced similar ethical problems in Japan and overseas. The above surveys were performed between 2000 and 2005. Since 2000, nursing ethics education has been greatly developed, and it is therefore considered necessary to perform a survey with nursing personnel who have received nursing ethics education as a part of their basic nursing education, covering whether they have experienced ethical problems in clinical practice and how these ethical problems have changed. This study aimed to clarify situations in which clinical nurses encounter ethical problems during nursing practice in Prefecture A.

Study design

We conducted qualitative and inductive research utilizing a questionnaire-based survey. Participants nursing personnel, consisting of general nurses, licensed practical nurses, midwives, and public health nurses, employed at 60 hospitals in a major Japanese provincial city were selected for the survey. Personnel at middle-management positions or higher were excluded, resulting in approximately 4,000 prospective respondents.

• Survey contents: The nurses were asked to freely enter details about situations in which they felt they had encountered ethical
• Analysis method: The Berelson content analysis method was After the study was approved by the research ethics review committees at the authors’ institutions, study-collaborating institutions and prospective participants were given written explanations of the study objectives, methods, and ethical considerations; their informed consent was confirmed by their returning completed questionnaires.

The analysis covered 361 entry units from 181 nursing personnel. (Table 1) shows the participants’ backgrounds.  The most common professional status was general nurse, constituting 90.1% of the participants. The proportion of participants who had received nursing ethics education, had undergone ethics training, and had attended one or more ethics conferences was 81.2%, 79.0%, and 66.9%, respectively.

Table 1: Participants’ backgrounds n =181.

Of the 361 entry units, 69 that could not be understood and/or were highly abstract were excluded, leaving 292 entry units in the analysis. The results were classified on the basis of the five principles of nursing ethics, nurses’ duties, cooperation and collaboration, nurses’ human rights and harassment by patients, and workplace atmosphere and environment (Table 2). The first of the five principles of nursing ethics is beneficence and non-maleficence, and two categories were established for this: “conflict with beneficence/non-maleficence” and “restraint.” The second principle is autonomy, and seven categories were established for this: “prioritization of family members’ wishes,” “difficulties with ascertaining patients’ own wishes,” “treatment despite patients’ refusal,” “obtaining satisfactory informed consent,” “insufficient intervention from nurses,” “treatment without informing the patient,” and “reliance upon the physician’s authority.” The third principle is justice for which one category was established: “unacceptable speech, conduct and attitudes, and offensive language.” The fourth principle is totality and integrity for which six categories were established: “anxieties and dilemmas about nursing practice,” “unfair nursing practice,” “inability to tell the truth,” “exasperation at not being able to wait,” “having to lie,” and “colleagues’ behavior leading one to be suspicious of their character.” The fourth principle is fidelity for which three categories were established: “talking inappropriately to other people,” “inappropriate access to electronic medical records,” and “use of sensors and/or monitoring cameras.” Four categories were established for nurses’ duties: “inability to provide satisfactory care due to understaffing,” “full involvement being impossible due to lack of time,” “lack of time available to consider nursing ethics due to pressing duties,” and “inability to discharge duties.” Five categories were established for cooperation and collaboration: “relationships with physicians,” “relationships among nursing personnel,” “relationships with superiors,” “inability to speak to colleagues,” and “relationships between professional fields.” Two categories were established for nurses’ human rights and harassment by patients: “verbal abuse impacting nurses’ human rights” and “harassment by patients.” One category was established for the workplace atmosphere and environment: “atmosphere and environment.” The categories that the largest proportion of nurses related to were “relationships with physicians,” “prioritization of family members’ wishes,” and “inability to provide satisfactory care due to understaffing.” Among the entry units excluded from the analysis were 30 units relating to prospects for practical nursing ethics and hopes for nursing ethics education.

Table 2: Situations in which clinical nurses encounter ethical problems.

This study aimed to clarify situations in which clinical nurses encounter ethical problems during nursing practice in Prefecture A. The results of the survey were classified on the basis of the five principles of nursing ethics, in relation to nurses’ duties, nurses’ human rights, and workplace atmosphere. The cooperation and collaboration categories within which there were numerous situations regarding ethical problems were “relationships with physicians” and “relationships between nursing personnel,” and this finding is similar to those from previous studies [1-3]. The issues relating to conflict with beneficence/non-maleficence, including problems with situations involving restraint, were life-prolonging treatment that involves pain or suffering and respecting patients’ and family members’ wishes in relation to treatment that involves risks. One of the issues debated in the 1980s was whether to use mechanical ventilation as life- prolonging treatment, whereas a currently debated issue is whether to create gastric fistulae [4]. Numerous nurses have recognized that, if the patient’s own wish cannot be ascertained, creation of a gastric fistula in accordance with the wishes of his/her family members is a situation that involves conflict in terms of beneficence/non-maleficence. However, these nurses considered that, in terms of making this decision, there was no opportunity for expressing opinions as to what was the best for the patients themselves, or for cooperation and collaboration between the physicians and nursing personnel. The participants additionally put forward the workplace atmosphere and environment as one factor influencing this inability. There were instances of the actions required to resolve these ethical problems not being taken because of the policies of the organization and/or the workplace atmosphere, despite personnel having had nursing ethics education and recognizing a situation as being ethically problematic. It is difficult for a single nurse to oppose the policies of an organization and/or a workplace atmosphere, and it is therefore necessary to incorporate ethics as a part of nursing administration. In terms of situations involving ethical problems with respect to autonomy, prioritization of family members’ wishes and the difficulty of ascertaining patients’ own wishes are being increasingly seen in Japan in connection with societal aging and the resulting increase in the number of patients with dementia. In the case of gastric fistula creation as a life-prolonging treatment for patients who have difficulty in taking sufficient nutrition, it is preferable to ascertain the wishes of the patients themselves, but this is considered a problem that will persist as people gradually lose their mental faculties as they age. In terms of situations involving ethical problems with respect to duties, chronic shortage of nurses and understaffing is a factor in satisfactory care being near impossible because of the impossibility of full involvement due to lack of time. In 2010, the mean number of nurses per 100 hospital beds in Japan was 64.3, but in Prefecture an it was less than 60, suggesting insufficient staffing [5]. The issue of not being able to care for patients sufficiently due to a lack of time should be viewed in the context of the current drive to reduce the duration of hospitalization, which is centered on acute-phase treatment. The most common ethically problematic situations, felt by a large proportion of participants, were similar to those in previous studies. The categories felt by the largest proportions of nurses were also at high levels in Ogawa’s survey on the frequencies of experiences with ethical problems (1) and Tanaka’s survey on the experience of psychiatric nurses (2). These situations are considered to represent ethical problems that occur universally, and, as the clinical situations remain unchanged, such problems continue to exist despite full provision of nursing ethics education in Japan. Nevertheless, it is hoped that promotion of on-site clinical nursing ethics training and attendance at nursing ethics conferences will change nurses’ awareness of nursing ethics. We also anticipate cooperation and collaboration with young physicians who have been educated in newer ways, so that nurses can, one by one, take a more progressive approach to ethics.

The following points were found regarding clinical nurses’ encounter with ethical problems:

• The nurses recognized ethical problems with cooperation and collaboration in terms of “relationships with physicians” and “relationships among nursing personnel.”
• With respect to autonomy, the nurses recognized the situations of “prioritization of family members’ wishes” and “difficulty of ascertaining patients’ own wishes” to result in ethical problems.
• In terms of situations that were ethically problematic with respect to nurses’ duties, the nurses had experienced “inability to provide sufficient care due to understaffing” and “impossibility of full involvement due to lack of time.”
• The results were similar to those of previous studies. The study identified that changes cannot be made on the basis of awareness of individual nurses and that the workplace atmosphere has a major effect.

We thank everyone who cooperated in the study. We would like to thank Editage (www.editage.com) for English language editing.

There are no conflicts of interest relating to this study

1. Mizusawa H. Characteristics of ethical problems experienced by ward nurses, ways of coping with these, and related factors. Japan Association for Bioethics. 2009; 19.
2. Ogawa K, Teraoka S, Terasaka Y, Eto E. Frequency and severity of ethical problems experienced by clinical nurses. Journal of Japanese Nursing Ethics. 2014; 6.
3. Park M, Jeon SH, Hong HJ, Sung-Hyun C. A comparison of ethical issues in nursing practice across nursing units. Nursing Ethics. 2014; 21.
4. Ministry of Health, Labour and Welfare. Estimates for future numbers of people with dementia, 2012.
5. Ministry of Health, Labour and Welfare. Materials relating to expected nursing personnel supply and demand, 2016.