Doing Nursing Ethics in Japan

From Nursing Ethics; 1880s to the Present (p. 356-359)
Used by permission 2024 © Marsha Fowler
Chapter 11 Notes

I am enjoying my time and space in an apartment for retirees. My story begins with a short conversation with a nursing student, Maki, who works part‑time on weekends at our dining room.

Maki, a Nursing Student

One Saturday morning when we sat down for breakfast, Maki came to serve. I said, “Hi, Maki, I didn’t see you for a while, how are you?” She replied with no smile, “Clinical, one more week.” I had known from her that she was a second grader at a three‑year vocational nursing school run by a city medical association. “But,” she continued, “assignments are overwhelming, our scary teacher checks my per- formance all the time, and worse is, during the clinical weeks, we must live in the hospital dorm because of the Corona virus. No food is provided, so we eat only cup Ramen we buy from the vending machine, and we are not allowed to go home for a rest.” Her clinical experience appeared to be far from enjoyable. Maki said further, “I may not be able to continue school.” Hearing this, the word “sustainability” came to my mind—sustainability in nursing will possibly be at risk. In Japan, while BSN programs are steadily increasing in number, more than half the licensed fresh graduates are from diploma schools. What could I do for her?

Bioethics Conference

On that day, I attended an online conference of the Japan bioethics association. It in- cluded three symposia on ethics consultation and clinical ethics committee (CEC). The speaker groups, bioethicists, and nursing scholars together, had started to pro- vide community outreach consultation for home-care nurses and care-workers. This is a remarkable change. When several Japanese hospitals began to have CECs in the early 1980s, the typical focus was on big “difficult cases” such as brain death and removing life support from coma patients.²

In its 30‑year history, something has been overlooked by this bioethics association—something very important to nursing, such as Maki’s experience. There had been no focus on the voices of nurses or nursing students, or on the dailyness or trivialness of life. Issues surrounding health workers’ work environ- ment or students’ learning environment have rarely been on the agenda. Environ- ment is where virtuous nurses and other professionals are produced and nurtured.

Japan Nursing Ethics Association

In 2008, a small group of nurse educators and practitioners established the Japan Nursing Ethics Association (JNEA). From San Francisco, Dr. Anne Davis sent us a message, “Start small and grow.” Now, JNEA has grown to have 850 members, of whom half are practicing nurses and several are bioethicists, and has continued to hold annual conferences and publish its journal every year.

Among JNEA’s past discussions that ranged from clinical to social issues, taken up here is an article in our ethics journal.³ The authors, all clinical teachers, presented stories about their students who were practicing in hospital wards. One of the stories is quoted here:

It was the first clinical practice for Yumi, a first‑year nursing student. Mrs. C was Yumi’s patient with aphasia. Yumi did not impose herself, but shared time with Mrs. C, looking out the window and sometimes folding origami. From other people’s perspective, Yumi was doing nothing. However, when Mrs. C was with Yumi, her face was peaceful and lively. Nurses in the ward were saying, “To see them sitting side by side makes us feel peaceful, too.” For patients with aphasia, nurses usually rely on tools such as character boards or simple sign language to gain quick and efficient communication. Whereas Yumi just relied on time, so slowly, thus establishing communication and a warm relationship with the pa- tient. At the end‑of‑the‑week meeting, a nurse said, “Yumi, we know you were devoting time for the patient in order to understand what the patient wanted to say. We do not have that time, and so we are using this lack of time as an excuse. You have made us realize that we have forgotten the importance of an effort— effort that you were making in order to know the patient.”

In the article, the authors say that teachers and nurses have much to learn from what students see, feel, and think.

Teaching and Learning Nursing Ethics in Japan

From 1995, Anne taught nursing ethics for six years at my former school Nagano College of Nursing⁴ and then she came to Japan several times to give lectures in many places until 2015. During this time, a network of “Anne sensei’s children” was gradually formed and its size is still growing.

In her lectures, Anne often suggested to us, “Japanese nursing must decide its own ethics content and methods of teaching nursing ethics. You have a unique culture.” Perhaps I could say that Anne’s suggestion has partly been responded to by the following: 1) establishing JNEA in 2008, and 2) publishing a nursing ethics textbook. The first edition of this book⁵ was the earliest nursing ethics textbook in Japan in that all the authors were Japanese nursing professionals, most of whom being “Anne’s grown‑up children.” It is wonderful that several other nursing eth- ics textbooks have been published recently by bioethicists and nursing scholars. However, unlike those other textbooks where principle-based ethics is the core, our textbook has independent chapters from the beginning on (a) the Japanese value of harmony (Wa); (b) East Asian values of politeness (Rei), family (Ie), filial piety (Oya koukou), and face (Mentsu); and (c) virtue ethics in the East and the West. Also included are many case studies and stories from nurses’ practice fields. In the more recent editions,⁶ the content has been widened to include an independent chapter on ethics of care; more social issues such as domestic violence, poverty and prisoners; and more international issues including assisting nursing in developing countries and care for international patients.

To teach nursing ethics in class, paying special attention to Japanese culture and values, is most challenging. From our perspective, the “West” is more logical and expressive, so it is relatively easier for Japanese teachers to give Western knowl- edge to students. Indeed, bioethics principles such as autonomy, do good, and do no harm appear in the national nurse‑licensing exam every year. Whereas, the “Japan” style is more tacit, and there is a meaning in what is left unsaid.

For my seminars with master students and practice nurses, I find the follow- ing phrase by Jonhstone⁷ to be most helpful. “Unlike other approaches to ethics, nursing ethics recognizes the ‘distinctive voices’ that are nurses, and emphasizes the importance of collecting and recording nursing narratives and stories from the field.”

I encourage students to write narratives. Their examples are problems arising from nurses’ “thin understanding” of bioethics principles, the autonomy principle in particular; nurses’ actions or no actions due to unconscious influence of Japanese values on nurses, such as politeness, modesty, and tacit understanding of other peo- ple’s feelings; nurses’ uncertain feelings about what to do; and sometimes nurses’ joys. Sharing the stories in class, students are often in tears and my class becomes a kind of moral space. Then we get back to related chapters of our ethics textbook. From my teaching and learning experiences in class, I think the following two things are important: (a) Students need to know Western bioethics principles be- cause these are common language in the Japanese health care, related laws and guidelines. But teachers must be careful so that students do not understand these principles superficially, the autonomy principle tends to have such pitfalls. Nar- ratives, stories, and case studies are helpful tools against this problem. (b) Moral distress is important but risky to teach at the beginning. Once students learn this term, they are tempted to explain problems as moral distress and go no further. But I know Japanese nurses, who do not know this concept, are making efforts to find a way out of the action barriers. Such nurses are resilient and polite in order to protect patients. Japanese traditional values illuminate their behaviors.

Back to Maki

That Saturday, I gave Maki a copy of the clinical teachers’ article mentioned above and another student’s narrative:

On my 4th day of practice, my patient Mr. A suddenly became unconscious and was connected to a respirator. At Mr. A’s bedside, I could do nothing but gaze at the patient and rub his cold arms and legs all that day. I was doing the same thing until the evening of the next day. Feeling depressed and miserable that I was doing nothing for the past two whole days, I came back to the nurse station. But my teacher, showing me the printout of Mr. A’s ECG monitor, said, “Hiro, see this, during the time you were in Mr. A’s room, his irregular and weak pulses improved. You have done the core of nursing, even experienced nurses cannot do such a great thing, you are fantastic!” My teacher made me aware of my worth, which I did not notice. He taught me that I did good for the patient. I was really saved.

Final Words

Two weeks later, Maki came back to the dining room. She reported to me, “I read it all! I learned that there are so many good teachers and nurses. Sure, I will become a nurse.”

Perhaps those stories had touched her heart, although she may not be mature enough to see that ethics was residing in those stories. But I look forward to seeing her practicing as a nurse in the near future. Then, she will surely think about nurs- ing ethics and say that “I am glad I am a nurse.”

In an editorial of our ethics journal, Miki Ono, one of Anne’s children, writes, “Nursing ethics is home for nurses to come back to, confirm who they are, and go back to work.”⁸