Blackwell Science, LtdOxford, UKNHSNursing and Health Sciences1441-07452004 Blackwell Publishing Asia Pty LtdJune 200462131140Research ArticleNurses’ ethical concernsP. L. Wros et al.
Nursing and Health Sciences (2004), 6, 131–140
Research Article
Ethical concerns: Comparison of values from two cultures Peggy L. Wros,1 rn, phd, Dawn Doutrich,2 rn, phd and Shigeko Izumi,3 rn, phd 1
Linfield-Good Samaritan School of Nursing, Linfield College, Portland, OR, 2Washington State University College of Nursing, Vancouver, WA, USA and 3Fukuoka Prefectural University School of Nursing, Fukuoka, Japan
Abstract
The present study was a secondary analysis of data from two phenomenological studies of nurses in the USA and Japan. The study incorporated hermeneutics and feminist methodologies to answer the following questions. Are there common values and ethical concerns and values within the nursing cultures of Japan and the USA? What are some commonalities and differences between Japanese nurses’ ethical concerns and those of American nurses? Findings indicated that nurses from the USA and Japan share common values and ethical concerns as professional nurses, including competence, respect for the patient as a person, responsibility, relationship and connection, importance of the family, caring, good death, comfort, truth-telling, understanding the patient/situation, and anticipatory care. Although ethical concerns are similar, related background meanings and actions often look different between cultures; truth-telling is described as an example. Nurses in each country also hold unique values not found in the nursing practice of the other country. Understanding these commonalities and differences is critical for the development of global nursing ethics.
Key words
end-of-life care, international nursing, nursing ethics, truth-telling, values.
INTRODUCTION Discussions between nurse colleagues from Japan and the USA and ongoing research in multicultural nursing ethics suggest that common ethical concerns may exist within nursing across cultures, specifically between Japan and the USA (Doutrich et al., 2001). While some moral meanings and actions of nurses reflect the global culture of nursing, others reflect the unique values and traditions of the two countries and may differ.
Literature review There is a newly developing body of literature describing values and ethical concerns of nurses from a variety of cultures and countries. A review of nursing research in English language journals about Japanese nursing ethics shows that, while Japanese nursing values are
Correspondence address: Peggy L. Wros, Linfield-Good Samaritan School of Nursing, Linfield College, 2255 NW Northrup Street, Portland, OR 97210, USA. Email:
[email protected] Received 17 December 2002; accepted 5 November 2003.
not generally incompatible with those of nurses in the West, the focus and meaning of these values are different based on the cultural context. Given the differences, the influence of ethical theory from the West creates tension for nurses trying to resolve moral issues in daily practice. Pang et al. (2003) described respect for persons and beneficence as shared values between nurses from China, the USA and Japan. They concluded that, while there is considerable overlap, American nurses had higher preference for principlebased ethics, Chinese nurses for virtue-based ethics, and Japanese nurses for care ethics. The majority of English language articles describing the values and ethical concerns of Japanese nurses focus on issues related to the Western notion of autonomy. Takemura and Kanda (2003) described a holistic view of the patient that centered around the patient’s subjective world and knowing the patient as a way of caring as the basis for ethical decision-making. Much of the nurses’ understanding of patients and the patients’ choices were based on non-verbal communication. Although nurses in the study valued the patient’s wishes and tried to plan care accordingly, they acknowledged competing concerns and values based
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on their holistic understanding of the patient and the situation. Advocacy is a strong value among American nurses, but Japanese nurses indicated that they should advocate for patients only if that is what the patient wants (Davis et al., 2003). Several studies have compared Japanese nurses’ perspectives on decision-making at the end of life with those of nurses in the USA and other Western countries. In a study by Konishi and Davis (1999), Japanese nurses reported that patients with serious illnesses are not informed about their condition or prognosis. While many nurses are concerned about the lack of information disclosure at the end of life, others remain concerned with telling too much. In another study, Konishi and Davis (2001) identified both similarities and differences in American and Japanese nurses’ views of patients’ decision-making about the right-to-die and duty-to-die. The differences reflected cultural group orientation and less attention to issues of resource allocation among Japanese nurses. Japanese nurses supported withdrawal of artificial food and fluid from terminally ill patients only at the patient’s request and to relieve their suffering (Konishi et al., 2002). Tanida et al. (2002) reported that Japanese nurses were less supportive of voluntary active euthanasia (VAE) than Australian nurses and tended to consider patient requests for VAE as irrational. According to Konishi (1998), patients in Japan are not generally included in do not resuscitate (DNR) decisions. While nurses in Japan viewed DNR policies as important and thought that DNR should be based on patient choice, very few believed that the development of DNR policies and practices were feasible and some thought that perhaps they were not culturally appropriate. An underlying theme in the published research indicates that many of the ethical ideas in nursing that are developing in the West are being imported and superimposed on nursing theory in countries such as Japan that have very different values, traditions and practices, sometimes without first examining what might be culturally embedded within the ideas (Davis & Mitoh, 1999). This overlay of the Western paradigm could conceal unique and culturally sensitive practices and prevent appreciation of the underlying richness and diversity of nursing philosophy. Because nursing ethics continues to evolve, there is an opportunity to truly incorporate the voices and perspectives of nurses from many different countries into an inclusive ethical theory. Austin (2001) believes that universal nursing ethics is possible and necessary to address global health issues. The current study is an attempt to build on the knowledge base informing multicultural nursing ethics by examining and comparing the background meanings and values behind the ethical concerns of nurses
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from Japan and the USA, using a feminist approach to hermeneutic analysis.
Purpose The present study was a secondary analysis of data from a combined data set from two interpretive studies (Wros, 1993; Wros, 1994; Doutrich, 1998). The purpose was to describe that part of nursing ethics which is universal and that which is particular to Japan and the USA. Not wanting to assume similarities or differences in nursing ethics between countries, the research sought to answer the following questions: (i) Are there common values and ethical concerns within the nursing cultures of Japan and the USA? and (ii) What are some commonalities and differences between Japanese nurses’ ethical concerns and those of American nurses? Consistent with phenomenological theory, values were assumed to be part of a person’s background meaning that underlies ethical concern and guides behavior. Background meaning is a personally held, but culturally derived, sense of reality which is taken for granted and transparent. It is often difficult for a person to articulate their meanings and values, but they are always present. In research, background meanings can best be accessed through the study of actions and stories within the hermeneutic circle of interpretation by researchers who share common cultural aspects and seek understanding (Benner & Wrubel, 1989; Leonard, 1989).
METHODS In this qualitative study, hermeneutic interpretive methods and feminist approaches were used to reinterpret data from two previous studies. Interpretive phenomenology (hermeneutics), the philosophical approach guiding both previous studies, is based on the work of Martin Heidegger and has been popularized within nursing by Benner et al. (Benner, 1984; Benner & Wrubel, 1989; Benner, 1991; Benner, 1994; Benner et al., 1996). The focus of interpretive phenomenology is ontological; the goal is to understand and become sensitized to what it means to live in the situation of the other person, or in the case of the current study, nurses from Japan and the USA (Ruangjiratain & Kendall, 1998; Walters, 1995). The process of hermeneutics is a scholarly analysis of situations, embodied in text, in which the interpreter seeks to hear, understand and subsequently represent the participants’ subjective experiences and lived meanings in the findings (Benner, 1994). The purpose of this secondary inquiry inspired the researchers to incorporate feminist perspectives into
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the analysis. Because the intention was to contrast narratives from two hermeneutic studies and reinterpret data without assuming that ethical values in either group had higher worth, feminist methodology valuing non-hierarchical and dialogic was appropriate. Harding (1987) claims (as do many feminists) that there is not one specific feminist method, but instead there are multiple feminist approaches; these include phenomenological and narrative research (Gergen et al., 1999). Interpretive phenomenology inherently implies a relationship between researcher and participant that is consistent with feminist approaches: respectful, interactive and mutually beneficial. The ethical stance of the researcher must be one of respect for the voices and experiences described in the text (Benner, 1994), and involvement of participants in all phases of the research is an important part of interpretation (Walters, 1995). Narrative data for the current study came from individual interviews with 18 nurse educators carried out in Japan, and from focus group interviews with 15 critical care nurses from the USA who were experts in caring for dying patients. Individual interviews were conducted in Japan because there was a concern that in the Japanese vertical hierarchy, the most senior or most powerful nurse might be the voice for all. In addition, it was thought that the Japanese high value for harmony (‘wa’) might prevent diverse opinion (Lebra, 1976). In the USA, the group interviews stimulated memories that inspired discussion and story telling. The nurses in both data sets revealed values and ethical concerns through descriptions of patient situations and discussion of their responses to those situations, that is, whether they felt good or bad – a signal of ethical concern (Benner, 1991). Interviews had been previously transcribed into text. Data analysis began with a review of narratives from both previous studies during interpretive sessions to identify themes and develop a new series of codes. This approach gave equal voice to all nurse participants in both studies. Data were then reviewed and recoded using Ethnograph 5.0 (Scolari, Sage Publications Software, London, UK). Exemplars and paradigm cases were identified and interpretive writing progressed. In keeping with the feminist approach, issues of oppression, power, discrimination and researcher bias were considered during interpretive work.
FINDINGS Values and ethical concerns While a multitude of stories comprised the combined data set, two paradigm cases described below
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expressed many of the themes identified in the analysis. Stories such as these were compared and contrasted to identify a set of values describing the ethical domains of both Japanese and American nurses. The following is a narrative from a nurse in the USA which exemplifies many of the values that define the good of nursing. In this story, a teenage girl who had been arrested hung herself in her cell; she was brain dead and on a ventilator and the physicians were talking with the family about withdrawing life support. Her mother and brother were not educated and did not have many coping skills or resources. They did not bathe and were poorly nourished. And the mother was so distraught that she couldn’t touch her daughter. She just kept telling me, ‘If I can just hold her, if I can just hold her one more time’. So I put the side rail down and she went up and laid her head on her daughter’s chest and just kind of held her, and then I just scooted her to the side of the bed so her mother could get up and crawl in bed with her and just kind of hold her daughter. and I felt really good about that. Letting the family come in and be with her – and her brother was able to come in as well and just kind of hold her and get close to her, you know, while she was still warm. This story reveals much about the ethical context of this nurse’s practice. The nurse was clearly comfortable and competent in caring for ventilator dependent patients and their families. Despite the lower class status of the patient and family, the criminal and drug involvement of the daughter and the poor hygiene of the family, she demonstrated unconditional acceptance in her care. She respected her unconscious patient as a person who had been a loved daughter; she treated her in a caring and dignified way, not just as a ‘body in the bed’. This nurse understood the needs of the mother and the possibility for her to connect with her daughter one last time. She created an environment at the bedside where the family felt safe to grieve and transcend the technology. She responded to the mother’s need without hesitation; she did not hold out false hope to the family, but was present and connected to the moment. One can only imagine that the brief time spent lying in the hospital bed, holding their daughter/ sister, gave some meaning to the tragic situation for the family. This is an example of profoundly ethical nursing practice and reveals much about the values of nursing. Likewise, the following story from Japan was a paradigm situation that helped the nurse to understand the good of nursing practice. She described a woman she cared for in her early years of practice before becoming a nurse educator. The woman was dying
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from cancer. This story is unusual in Japan because the patient knew her diagnosis and that she was dying. While dying did not frighten her, she wanted to be able to do it quietly and with dignity. Although very frail, she wanted desperately to be able to feel the earth and touch the grass one more time before she died. The nurses carefully and gently bundled her down to the lawn around the hospital and laid her on the ground. Given the frailty of this dying patient, sheer logistics did not make this task easy. Touching the earth for what she knew would be her last time, the dying woman said, ‘I am really, really happy to touch the wild grass’. This situation was meaningful for the nurses because, as in the previous story, it embodied the good and the meaning of nursing practice. The nurses were connected with the patient and understood that she would die soon. Their actions were motivated by the demands of the situation. They were morally compelled in their care to go beyond what was required of them. They were involved and present; they understood and respected the woman’s needs and her situation, and they helped her to have a good death – the kind of death that she wished for. This kind of care is not based on rules or principles, but the moral good is highly contextual and reflects many of the values identified in the first case. In reviewing the data, it is apparent that some values and ethical concerns transcend culture. That is, the nurses studied from both Japan and the USA hold some similar values based on their membership of the nursing profession. The values and ethical concerns that the data showed were embraced by participants in both cultures included: competence, respect for the patient as a person, responsibility (to the patient, family, physician and institution/employer), relationship and connection, the importance of the family, caring, good death, comfort, truth-telling, understanding the patient/situation, and anticipatory (upstream) care. These are part of a complex web of values that are interrelated and overlapping. It was also interesting to note that, although the ethical concerns were similar, the related background meanings and actions often looked different between cultures. Culturally specific nursing practices and comportment that exemplify the common values and ethical concerns are described in Table 1. For example, although both Japanese and American nurses valued relationship and connection, how they developed the relationship and connected with patients was different. Japanese nurses tended to be much more indirect in their style, valuing understanding without telling and sometimes speaking in metaphors. They felt privileged to share patients’ secrets and responsible for keeping patients’ trust. On some level they shared the pain and
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suffering of those in their care. The American nurses also valued their relationship and connection with patients, and felt that this connection was important in a good death experience. In general, they understood direct and open communication as an important component of a good relationship, whether that connection was between themselves and others (e.g. with physicians) or between others (e.g. patients and family members). They prided themselves on their familiarity with the patient and family and their ability to advocate for the patient and ‘get action’. Analysis of the data also revealed that the nurses in each country held values that were not found in the nursing practice of the other country, despite the common nursing culture. These values were apparent by contrast when the two data sets were merged, but were not as apparent when the nurses from each country were studied separately. For example, nurses in Japan valued continuity, homogeneity, harmony, self-sacrifice and hard work. These values were reflected in their practices and interactions. Values evident in good nursing practice in the USA involved control, diversity, patient treatment choice and self-protection. These values seemed consistent with those within the context of the larger culture of the country and beyond nursing.
Implications of cultural background meanings on nursing practices Several values and ethical concerns of nurses were identified in the present study. Further discussion of one of these values, truth-telling, demonstrates that while there may be common ethical concerns between the two cultures, the cultural context of the underlying values may create very different meanings and result in different nursing practices. One of the common values that was discussed by the nursing participants in both Japan and the USA is truth-telling. Narratives were laden with data about diagnostic and prognostic disclosure. In-depth analysis exploring the complexities of ‘truth-telling’ was conducted because initial data segments revealed that feminist issues of hierarchy and power were clearly integrated into the stories and begged exploration within the feminist framework. Nurses from both data sets discussed concerns about patients knowing the diagnostic and prognostic truth about their illness, how truth (or lack of truth-telling) affected their nursing practice, and their role in disclosing sensitive information to patients and families. The data uncovered the complexities of the underlying truth value held by participants and revealed much about the contextual differences and similarities in Japanese and USA nursing ethical practice.
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Table 1. Nursing values and ethical concerns and examples of related background meanings and practices in Japan and the USA Value/ethical concern
Japanese nursing practice
USA nursing practice
Competence
Caring, doing good things, knowing limits
Respect for personhood
Protecting patient’s dignity (e.g. not force feeding patients, concern about patient’s feelings when nurse wears gloves) Conflicting responsibilities to patients, families, physicians, institutions; family may have primacy over patient; nurses’ routine starts with physician orders Understanding without verbal communication; being with the patient; keeping the patient’s secrets; sharing psychological and physical pain Family first; first information to family; family often decides on diagnostic disclosure; making place for family at bedside Helps find meaning in life; makes feel important and needed; interactive; mutual acceptance of interdependency/ dependency between cared-for and care-giver Natural, without technology; ‘dai ojo’, family decision-making ‘Gaman’ (cultural value meaning restraint) implies that patients need to have self-control conflicts with theories of pain management; use of nonpharmacological interventions; conflict with physicians over need to increase pain medication to relieve patient suffering Lying is not always bad; connection takes precedence; truth may not be a caring action; non-disclosure may interfere with nursing care Basis for anticipatory care; knowing the context is highly valued in Japan
Responsibility
Relationship/connection
Importance of the family
Caring
Good death Comfort
Truth/truth-telling
Understanding patient/situation
Anticipatory (upstream) care
Responding to patient’s needs without being asked; highly valued in Japanese nurse and culture
Having a skill, technological ability, knowing limits Holistic practice, treating the patient with dignity (e.g. protecting the patient’s body, talking with unconscious patients) Conflicting responsibilities to patients, families, physicians, institutions; patient has primacy over family; nurses ‘looking out for the family’ Death is an empty experience without connection; long-term relationship valued; familiarity with patient and family; basis for advocacy Making a place for the family at the bedside; decision-makers when patient is unconscious; helping family connect with patient Helping, protecting, emotional connection, focus on patient’s/family’s needs
Family involved/connected, comfortable, not lingering or prolonged Comfort is primary at end of life; pain, air hunger treated aggressively with narcotics; may cause respiratory depression
Highly valued; conflict with physicians when overly optimistic or prognosis not revealed
Knowing the patient, family, context as the basis for effective/good care; family as a way of knowing the patient Getting DNR orders; laying foundation for decision-making
DNR, do not resuscitate.
Japanese practices related to truth-telling Among the Japanese nurses, telling patients the diagnostic and prognostic truth was considered important. Yet, the disclosure was considered the physician’s domain and nurses’ practices related to disclosure were therefore restrained. In the following example, one
Japanese nurse discussed the powerlessness of the nurse within the health care hierarchy regarding truth-telling: In my country, a patient cannot ask a physician about diagnosis or prognosis and treatment because the patient thinks ‘obeying authority’ is
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much more important than getting information about treatment or diagnoses. So patients feel ‘I cannot ask the physician about my diagnosis’. The physician thinks ‘I told them everything’. The physician may have told the patient everything one time. But they [the patient] cannot understand. So there is big gap between patient and physician and the nurses can understand the patient situation so the nurses tell the physician ‘that patient doesn’t understand his situation or diagnosis or prognosis’. The physician says to the nurses, ‘I did my job already so I don’t want to explain again’. The nurses are between patient and physician and they cannot adjust the situation . . . Maybe in my country, most of my patients can ask the question to nurses. It’s easier for them. Some Japanese nurses can explain the diagnosis and the treatment, the prognosis, but some nurses don’t want to do that because . . . some nurses say ‘its not my role’. Sometimes if nurses tell the diagnosis or treatment to the patient, some physicians have anger about that because it is the physicians’ role in my country. But if nurses and physicians relationship are good, physicians don’t say so [don’t have anger]. At that time, nurses can explain the diagnosis or treatment to the patient but maybe some old fashioned physicians don’t want nurses to explain anything about treatment or diagnosis to the patient so some nurses can do that and some cannot.
less personal information than persons within the dominant culture of the USA. Still, some Japanese patients want more information about their diagnosis and prognosis. The patient, respectful of the physician’s high position, cannot make requests of him. But nurses, at a lower social level than physicians and mostly women, are often more accessible for the patient. Understanding the circumstances of the patient, the nurse is able to see a particular patient’s lack of comprehension and need for current information. Yet, she may lack the power to ‘adjust the situation’. Japanese nurses talked at length about how their caring practices were affected when patients requested information or wanted to talk about the meaning of their illness. For example, one of the participants described situations where nurses avoided patients’ rooms because those patients tended to ask questions about their prognosis and the nurses knew they could not answer truthfully. Sadly, in that case, discomfort with the forbidden diagnostic/prognostic questions prevented the nurses from connection or even adequately caring for these patients. Participants revealed that sometimes patients were inclined to spring their diagnostic questions on novice or student nurses, trying to get a surprise response.
This excerpt reveals the tenuousness of the Japanese nurse’s power regarding diagnostic and prognostic disclosure within this particular situation. Sometimes the nurse can talk with patients about their diagnosis (assuming the physician has already done so), but sometimes physicians become angry about this. According to this participant, nurses decide what to tell patients and their families based on the situation and especially based on their experience and their relationships with specific physicians. Japan is a country where position and hierarchy are more valued than in the comparatively more horizontal USA (Lebra, 1976; Stewart, 1987). As in the USA, physicians hold high social positions. But, in Japan, where there is more comfort with ambiguity, some patients are quite happy to let the patriarchal physician ‘carry the burden’ and make treatment decisions without the patient’s input. ‘Omakase shimasu’ means ‘I put my trust in you’ and some patients are happy to put their trust in their physician and forego verbal discussion of their situation (Suzuki et al., 1993; Okumo et al., 1999). Parenthetically, verbal discourse is not nearly as highly regarded in Japan as in the USA (Barnlund, 1989). Norms about self-disclosure differ, with Japanese persons disclosing
The implication here is that when the novice nurses panicked, the patient could ascertain information from her reaction. Some nursing practices were curtailed by the communication proscription; for example, one of the nurse educator participants described her student’s frustration at not being able to teach an oncology patient about the purpose and side-effects of his antineoplastic drugs. According to the participant, her student felt that the information was necessary for the patient to tolerate the inevitable side-effects; in fact, the patient threatened to stop taking the drug unless he knew the reason for it. Yet the student was unable to talk about the medication because the patient had not yet been told by the physician that he had a malignant tumor. Although this student surely struggled with the situation, expert clinicians described being able to talk around the limitation, revealing the meaning of the diagnosis or prognosis without labeling the illness, and staying with the patient in a connected way; ‘I could feel he needs something. Some kind of person-toperson communication about his disease’. They talked about helping the patient perceive the current situation:
Sometimes patients suspect their diagnosis and want to ask a student nurse because a student will react in a different way. Students sometimes become panicked or something.
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It’s not the information for everything, for every possibility . . . [but] the meaning of the information . . . When they start to have questions about what meaning does this have—start not from the concept [of informed consent] but more with the patients. Expert clinicians were often able to find a way to give information to patients indirectly, sometimes using metaphors or non-verbal messages, without breaking cultural rules of communication and hierarchy. The Japanese nurses who practised both in the USA and Japan told of seeing American patients who were overwhelmed with the ‘truth’ about their diagnosis and they argued that not everyone wants, needs, or can even comprehend their diagnosis/prognosis, especially not all at once. Telling too much may not be useful to the patient. They want to know what they want. They don’t want to know everything. That’s very hard for the health worker or physician. It’s easy to tell nothing or everything. But in between in the gray area, it’s very hard. For this person maybe this much; for this person, maybe a different amount. It should be that way but it’s very hard. So that it’s easy to say ‘tell everything’ or ‘tell nothing’. This excerpt illustrates the need for continued connected understanding of the patient and his/her situation in order to convey information at the patient’s (and family’s) pace. It also clearly calls for case-by-case clinical judgment based on a relationship and thoughtful understanding of the context. This contrasts with rule driven ‘one size fits all’ approaches to truth-telling but fits with these Japanese nurses’ expert ethical comportment. Another issue that is salient in Japan related to nurses’ ethical practices around diagnostic disclosure is the cultural norm that for decades physicians have told the family when a patient is terminal and the family then decides whether, or how much, and when to tell the patient (Konishi, 1998). The nurse often serves as confidante for both patient and family, which leads to the nurse being in the position of ‘keeping secrets’—assuming a position in between the patient and the family. Nurses reported that often in their opinions, patients are aware of their terminal diagnosis, whether or not they had been told directly. Nevertheless, when family members maintain they do not want the patient told, the nurse is left in conflict between the two. For example, in the following situation, the nurse recounts:
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The husband said ‘I know everything about my diagnosis but I behave like I don’t know anything’. He is thinking about his wife and the wife said ‘he doesn’t know anything about his diagnosis or the prognosis so I have to keep the secret’. and he said ‘don’t tell her these things because I have to keep my feelings from her’. But it’s a kind of omoiyari; he worries about her life after he dies but they cannot converse about it . . . he told me ‘don’t tell her’ so sometimes it is hard for the health provider. Omoiyari is a kind of caring that refers to carrying the other’s burden, sometimes by keeping quiet. For the nurses in between, carrying the burden of the secrets between family and patient could cause an ethical dilemma between two values: keeping a promise and creating good death for both the patient and family.
USA practices related to truth-telling The truth value was also held by nurse participants from the USA, although concern about truth-telling and related nursing practices differed from those in Japan. Consistent with the cultural norm of independence and autonomy, the nurses believed that patients and families should know their diagnosis and prognosis. Although diagnostic disclosure is common practice by physicians, nurses often found themselves frustrated when physicians were overly optimistic about patients’ conditions or did not tell patients and families bad news about prognoses. As a result, nurses often assumed a role as facilitator for catalyzing communication between the family and physician. The doctors are all saying this and his family’s saying this and they are not meeting in the middle. They’re not on the same wavelength here . . . they need to talk. and for whatever reason . . . it’s just like this huge miscommunication going on. There are just so many scenarios. It could be that the physicians do not realize how much the family is in never-never land over here. But I think nursing, because the nurse is in that position to see. They see the family and see the physicians . . . And you hear [the family say] ‘My aunt looks better today, don’t you think?’ and ‘Don’t you think that if I bring her nightgown in it’s going to make her feel better?’ . . . And then you kind of make some excuse to go out and you catch the team [of physicians] and go, ‘Wait, come back you guys. I think somebody needs to make a statement because I hear you guys saying this person’s
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going to die and I think this person is probably going to die. But the family is worrying about the nightgown’. The nurses in this situation understood the perspectives and language of patients, family and physicians and acted as intermediaries to positively affect outcomes. They insisted that the physicians talk directly with the family, so that the family’s expectations were more in line with the realities the nurse and physicians were predicting for the patient. As in Japan, nurses are in a position to know and understand the family’s expectations and to assess their need for information updates. Nurses often arrange for meetings or conferences to occur and then facilitate communication. But in the USA as well as Japan, most nurses agree that physicians should first discuss diagnosis and potential outcomes with the patient or family—physicians are viewed as the primary authority and decision-maker within the health care hierarchy. It’s the physician’s responsibility to tell the patient their diagnosis. Not that I won’t ever do that. But it’s their responsibility to initially sit down with the patient and family and say, ’this is what you have and these are your options’. After the patient/family is initially told it is acceptable, in fact expected, that the nurse will translate, clarify, discuss and support those involved as needed. The ability to understand multiple perspectives and translate from one group to another is a hallmark of expert practice in most, and perhaps all, nursing milieus. In the community these expert practices are labeled as multiperspective and multilingual (Diekemper et al., 1999), but the language referred to, rather than being Spanish or French, is the language of one group or another, like physicians or administrators, public health officials or consumers. One nurse talked about the importance of interpreting medical discourse for patients and families: I try to restate perhaps in more lay people’s terms what the physicians have said. A lot of times the physicians use medical terminology, and I know that when I go to get my car fixed and the mechanics are using car terms, I don’t say ‘I don’t understand what a carburetor is’. I go ‘yes, yes, yes’ and then I go home and I go, ‘God knows what they said’. The American nurses reported sometimes needing to coach physicians who were having a difficult time realizing the hopelessness of a situation towards understanding that the patient was not going to survive.
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Our oncology department here is known for going to the wall. They’ll resuscitate their patient until there is literally no, no, no, no, no, no, hope. They don’t talk to them about the potential that their leukemia is a terminal disease. If physicians will not talk to their patients, nurses in the USA have several options for recourse. Some, like the nurse below, may work through the family to ‘lay a foundation’ for discussion with physicians. If I’ve built up rapport with the family, I’ll say, ‘what has your oncologist told you about your disease? Have they talked about what we can do for you?’ and if the family responds ‘no they haven’t’, I suggest that the family talk together about what they might want if things come to the point of life support. In this day and age most people are real savvy about what we can do. They’ve seen it on TV. Other options for American nurses include going ‘over the head’ of the physician at the bedside to the attending physician, the medical director or higher in the hospital hierarchy to encourage communication. Most hospitals now have ethics committees and many are set up so nurses can request an ethics consult. All of these options, however, require that the nurse have courage and a willingness to be a strong advocate.
SUMMARY Data from this combined data set of narratives from nurses in Japan and the USA confirms that there are commonalities and differences in nursing values and ethical concerns. Nurses in both Japan and the USA hold common values that are woven into the fabric of their patient care; they also have many practices that are based on their cultural background and reveal the heterogeneity of nursing across the two cultures. One example of a common ethical concern between the two cultures is truth-telling, which results in nursing attitudes and practices that look very different but which are nevertheless culturally appropriate. Nurses in both Japan and the USA support telling patients and families ‘the truth’ about their illness when it is performed with an understanding of the patient’s situation and is for the good of the patient, although the nature of truth-telling and methods of disclosure differ between the two cultures. In Japan, truth-telling is valued theoretically, but is also approached with a great deal of ambivalence. When nurses do decide to tell they may speak metaphorically, allowing them to tell without telling, and giving the client space to interpret the ‘truth’ in their own way. This is a culturally consis-
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tent practice. Nurses in both countries are constrained by their placement in the health care hierarchy, but they are also steadfast in their belief that they need to preserve and protect the trust and relationship between the patient and physician for the sake of the patient. While many nurses are frustrated by their imposed limitations, expert nurses in the USA and Japan respond to the demands of particular situations and meet the needs of individual patients and families for information in skilled and culturally appropriate ways. The present study had some limitations that should be considered. First, the Japanese interviews were conducted and transcribed into English, which is an inherent limitation. All Japanese participants were primarily Japanese speakers. Although they were competent in speaking English, shades of meaning may have been missed in translation. Second, while both previous studies were phenomenological studies of nursing ethics, the groups were not matched. Japanese participants were nurse educators with some experience and knowledge of Western health care systems. Many were teaching but at the time of the study did not work directly with patients, and their nursing backgrounds/ specialty areas varied. The nurses from the USA were all practising critical care nurses. Third, in both original studies and consistent with feminist approaches, participants contributed to all phases of data analysis. While that was not generally possible during the secondary analysis, clarification from one Japanese participant was obtained. Fourth, generalizability is a limitation inherent in qualitative research. Although there were only 33 participants in the combined study, their stories were rich in detail describing the context. This detail allows readers to make judgments about the relevance of the data and conclusions for their particular situation. Studies such as this one, which describes nursing ethics in a cultural context, are the basis for the development of inclusive, multicultural ethics that can be meaningful for nurses around the world and facilitate international nursing. The values and ethical concerns identified in this study require further study. Additional research from fellow nurses in all parts of the world are needed to create a paradigm that represents the nature of nursing ethics for all nurses.
ACKNOWLEDGMENTS The present study was supported in part by the Japan Society for the Promotion of Science, Nagano College of Nursing, National Center for Nursing Research, Intercollegiate Center for Nursing Education/Hansen Research Funds, Washington State University, Vancou-
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ver Campus Peterson Foundation and the LinfieldGood Samaritan School of Nursing.
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