Ethical issues in practice: A survey of home-visiting nurses in Japan

Authors


Kiyomi Asahara, St Luke's College of Nursing, 10-1 Akashicho, Chuo-ku, Tokyo 104-0044, Japan. Email: asahara@slcn.ac.jp

Abstract

Aim:  The purposes of this study were to identify specific components and frequencies of ethical issues that home-visiting nurses encountered in their practice, relationships between ethical issues and demographic data, and experience of ethics education and workplace environment.

Methods:  A self-administered questionnaire was distributed to home-visiting nurses in Japan. Usable data (1961) were analyzed.

Results:  Item and exploratory factor analysis for the frequency of encountering ethical issues revealed: (i) concern about respecting client or relationships with relevant professionals; (ii) differences in treatment or care-taking views among home-visiting nurse and client and family, or relevant professionals; and (iii) discrepancy of intention between family and client or home-visiting nurse. All factors were significantly positively related to the current position, duration of working experience as a home-visiting nurse, and type of nursing education; age was significantly negatively related. Home-visiting nurses noted that programmed continuing education systems and staff-training programs were not sufficiently available.

Conclusion:  The findings of this study indicated the characteristics of ethical issues that home-visiting nurses encountered in their practice and insufficient continuing education system including ethics education. Ethics education programs tailored to home-visiting nurses ethical concerns and traits and continuing education systems are needed.

INTRODUCTION

The interest in home care is increasing, because many countries face a growing population of elderly people, a large percentage of whom are vulnerable to or have specific health problems. In particular, Japan is an extraordinarily rapidly aging society, with those aged 65 years and over constituting 22.7% of the population in 2009, and by 2025, that percentage is projected to increase to 30.5% (Health and Welfare Statistics Association, 2010). In response to these demographic changes and increasing medical costs, the Japanese government implemented programs of the Long-Term Care Insurance system for the Elderly in 2000. The home-visit nursing service is one of the most important home-care services of the programs in this system. Most nurses who provide such nursing services to client and family (C/F) at their own homes belong to home-visiting nursing stations, which are similar to home care nurse agencies in North America. In Japan, those nurses are called home-visiting nurse (HVN). HVNs work together in the community with relevant professionals such as physicians in charge of clients, care managers, and home-helpers (they are similar to nurse aids in North America).

Studies concerning ethical issues for nurses, including public health nurses providing home care identified three issues. First, because nurses visit clients' homes, the clients' families are present and therefore the family members may be intimately involved in caring for the vulnerable client. Such moral dilemmas have been reported among nurse and C/F (Ladd, Pasquerella, & Smith, 2000; Oberle & Tenove, 2000). Studies on ethical issues for Japanese HVNs identified discrepancies between the intentions of nurses and families (Shuda et al., 2002). Second, due to the long-term nature of the care these nurses provide for C/F and the close relationships they form with C/F, nurses have to balance risks and benefits to achieve the greatest good for C/F while at the same time maintaining supportive relationships with them (Horstman & Rens-Leenaarts, 2002; Oberle & Tenove, 2000). To keep such balance, Öresland, Määttä, Norberg, Jörgensen, and Lützen (2008) reported that home care nurses had two stances, namely, the “professional position” and the “guest position”. They said that the professional position was a way of helping and supporting clients as professional nurses, whereas the guest position was a ticket to enter clients' homes, and it represented nurses' understanding of and relationships with clients as people. Third, nurses care for C/F interacting with many other professionals from separate organizations. Ethical issues such as conflicts between nurses and other professionals (Oberle & Tenove, 2000) and maintaining C/F confidentiality and privacy have been reported (Folmar, Coughlin, Bessinger, & Sacknoff, 1997; Wagner & Ronen, 1996).

The published work on ethics in home care nursing is sparse compared with that on ethics of nursing in hospitals. Furthermore, previous research on ethics in home care nursing was conducted by interviews or surveys with a small number of subjects. Especially in Japan, research on ethical issues of HVNs has been very limited.

The published work indicates that ethics education for nurses in the hospital setting is a significant predictor of ethical practice (Dodd, Jansson, Brown-Saltzman, Shirk, & Wunch, 2004; McDaniel, 1998) and that ethics education contributes to the retention of the nursing workforce (Hart, 2005; Schluter, Winch, Holzhauser, & Henderson, 2009). Japanese studies have shown that ethics education for hospital nurses enhanced their moral sensitivity in practice (Katsuyama, Katsuhara, Hoshi, Kamata, & Williamson, 2010). Regarding HVNs, however, only 17.5% had received ethics education after beginning their practice (Shuda et al., 2002).

The “ethical work environment” (Corley, Minick, Elswick, & Jacobs, 2005; McDaniel, 1997) or “ethical climate” (Hart, 2005; Olson, 1998; Schluter et al., 2009) has been studied as an organizational variable that affects nurses' ethical practices. Hart (2005) defined ethical climate as “the organizational conditions and practices that affect the way difficult patient care problems, with ethical complications, are discussed and decided”. This climate includes perceptions of the organizational culture, adherence to policies, administrative concerns (Corley et al., 2005; Leino-Kipli, Suominen, Mäkelä, McDaniel, & Puukka, 2002; McDaniel, 1997), relationships of nurses with peers, patients, managers, hospital staff, and physicians (Hart, 2005; Olson, 1998; Pauly, Varcoe, Storch, & Newton, 2009), and safe staffing practices (Corley et al., 2005). Although researchers have conducted numerous studies on the ethical environment or climate in acute care settings, few researchers have focused on this concept in home care settings.

Against this background, this study aimed at identifying: (i) components and frequency of ethical issues experienced by Japanese HVNs in practice; (ii) differences in the frequency of encountering ethical issues based on HVNs' demographic data; and (iii) HVNs' experiences of receiving ethics education and perceptions of the workplace environment as they relate to ethical practice.

In this paper, an ethical issue is defined as “any situation that requires ethical deliberation or ethical decision making, or a conflict of moral values” (Fry & Johnstone, 2008).

METHODS

This study was conducted as parts of a larger study, examining the ethical practice of Japanese HVNs. Data were collected on HVNs throughout Japan in 2009.

The questionnaire of the larger study was developed based on existing published work and our previous study (Asahara et al., 2011). The data for the content analysis were collected via an open-ended qualitative survey with 55 HVNs (age, 44.5 ± 9.1 years; work experience as a HVN, 4.9 ± 3.4 years; staff, 81.8%) and interviews with eight HVNs (age range 29–53 years; work experience as a HVN range 7 months to 9 years; staff, 75.0%). It included 139 forced-choice and eight open-ended questions. Forced-choice questions were divided into six sections: (i) frequency of encountering ethical issues (16 items); (ii) moral competence (90 items); (iii) experiences influencing HVNs' decisions in practice (11 items); (iv) experiences with ethics education (4 items); (v) workplace environment related to ethical practices (7 items); and (vi) demographic data (11 items). This study focused on sections (i), (iv), (v), and (vi).

Measures

Frequency of encountering ethical issues

Specific items related to ethical issues in HVNs practice were developed based on the results of the content analysis of data mentioned above. Survey respondents and interview participants were asked questions such as: “Have you had conflicting experiences in judging good or bad, right or wrong, or duties or rights in your everyday practice?” and “Please describe the details or cases that stood out most recently.” As a result, 16 items were identified for inclusion in this survey. Respondents were asked to rate their responses using a 4-point Likert scale (ranging from 1 = “none” to 4 = “very frequently”).

Experiences with ethics education

The data for experiences with ethics education were collected using the following four items, each rated 1 = “yes”, 2 = “no”. Respondents were asked to indicate: (i) if they had participated in ethics education; (ii) type of ethics education (i.e. nursing education at technical school, junior college, university or college; continuing education program in the workplace; seminars outside of the workplace; self-education such as reading books or published work); (iii) content of the ethics education (i.e. bioethics, nursing ethics); and (iv) use of ethical knowledge gained from ethics education in their nursing practice.

Workplace environment related to ethical practices

Data regarding workplace environment related to ethical practices were collected from the following six items. Respondents were asked to indicate conditions/systems within their workplace environment that might affect their ethical practice: (i) environmental framework allowing nurses to receive consultation and support; (ii) support system to promote participation in continuing education programs or seminars; (iii) programmed continuing education system consistent with education obtained in nursing school; (iv) staff training programs that allow sharing knowledge with related professionals/organizations; (v) workplace environment that facilitates discussion and free exchange of views; and (vi) opportunity to exchange views or discuss cases with relevant professionals/organizations. Responses were given on a 5-point Likert scale rating the environment's preparedness for offering suitable conditions/ programs, and scores ranged from 1 = “never prepared” to 5 = “very prepared”.

Demographic data

Respondents were asked to provide their age, sex, type of nursing school, duration of work experience as a HVN, duration of work experience as a nurse at a facility, and current position.

Data collection procedures

Among all 5407 home-visiting nursing stations in Japan (Ministry of Health, Labor and Welfare, 2009), 2150 (∼50%) were drawn by stratified sampling based on the ratio within each prefecture using SPSS software (SPSS, Chicago, IL, USA). The four questionnaires were mailed to each of the 2150 home-visiting nursing stations for potential subjects. A cover letter indicated the purposes and procedures of the study and the option to refuse participation. Return of the anonymous questionnaire was considered as the respondents' consent to participate. Only one mailing was performed, and no reminders were sent. Prior to conducting the survey, we obtained ethical approval from the Research Ethics Committee of the first author's institution.

Data analysis

The data were analyzed using SPSS Statistics ver. 17.0. Initially, descriptive statistics were analyzed. Subsequently, exploratory factor analysis was conducted concerning items of frequency in encountering ethical issues to reveal components (factors) that represented underlying relationships among items. The relationships between each factor score and demographic data were analyzed by multiple regression analysis.

RESULTS

Sample characteristics

A total of 8600 questionnaires were distributed and 1989 were returned (23.1% response rate). Usable data were obtained from 1961 (22.8%). Most respondents were women (98.5%), and their mean age was 44.0 years (standard deviation [SD] = 8.3) (Table 1). The majority of the respondents graduated from 3 year technical nursing schools (87.1%), while others graduated from junior colleges (8.9%), or 4 year universities or colleges (1.8%). The mean duration of working experience as a HVN was 6.2 years (SD = 5.1), while that of working experience as a nurse at a facility, including a hospital, was 14.0 years (SD = 8.3). Two-thirds of the respondents were staff members, and one-third worked at the managerial level.

Table 1. Demographics, experience with ethics education, and perception of the workplace environment by percent (N = 1961)
Characteristicn%
  1. SD, standard deviation.

Sex  
 Female193198.5
 Male301.5
Age, mean 44.0 years (SD = 8.3)  
Type of nursing school  
 Technical nursing school170887.1
 Junior college368.9
 University or college331.8
Duration of working experience as a home-visiting nurse, mean 6.2 years (SD = 5.1)  
 <1 year25513.0
 1–5 years78440.0
 ≥6 years88345.0
Duration of working experience as a nurse at a facility, mean 14.0 years (SD = 8.3)  
 <1 year80.4
 1–5 years27414.0
 ≥6 years165784.5
Current position  
 Staff123462.9
 Assistant managerial level1467.4
 Managerial level46023.5
Experienced ethics education  
 Yes169586.4
 No24112.3
Type and location of ethics education  
 Nursing education at technical school, junior college, university, or college121461.9
 Continuing education in the workplace54227.6
 Seminars outside of the workplace48024.5
 Self-education1176.0
Content of education  
 Nursing ethics158280.7
 Bioethics43822.3
Use of ethics knowledge in practice128665.6
Workplace environment (“very prepared” and “somewhat prepared”)  
 Workplace environment that facilitates discussion and exchange of views150876.9
 Environmental framework to receive consultation and support138470.6
 Support system to promote participation in continuing education117259.8
 Opportunity to exchange views with relevant professionals110356.2
 Programmed continuing education system51826.4
 Staff training programs sharing with related professionals40420.6

Components and frequency of encountering ethical issues

The 16 items that measured the frequency of ethical issues were refined on the basis of our item analysis. Two criteria were used to delete items: (i) item scores ≥3.5 or ≤1.5 and (ii) correlation coefficients ≥0.8 in the item correlation matrix. No item met these criteria, thus all 16 items were retained. Next, exploratory factor analysis with maximum-likelihood factor analysis and promax rotation was used to select the factor structure. Four criteria were used in selecting the number of factors and items within a factor: (i) a scree plot that showed a distinct break between the steep slope of the large factors and the gradual trailing of the rest; (ii) an item-factor loading ≥0.4; (iii) a Cronbach's Alpha ≥0.70 or more; and (iv) a possibility of factor's interpretation. Thus, two of the 16 items were eliminated, leaving 14 items. A three-factor model was selected as the most interpretable solution (Table 2). The factors that were included in this model were: factor 1, concern about respecting client or relationships with relevant professionals (ordinary concern); factor 2, differences in treatment or care-taking views among HVN and C/F or relevant professionals (differences in views concerning care); and factor 3, discrepancy of intention between family and client or HVN (discrepancy of intention with family). Correlations among factors ranged 0.57–0.66. Cronbach's Alphas ranged 0.70–0.82. Three-factor contribution scores were similar (3.59–4.19).

Table 2. Factor scores and item scores, exploratory factor analysis of the frequency of encountering ethical (N = 1961)
 MeanSDFactor 1Factor 2Factor 3
  1. Factor loadings ≥0.4 are boldface. C/F, client and family; “ordinary concern”, concern about respecting client or relationships with relevant professionals; “differences in views concerning care”, differences in treatment or care-taking views among home-visiting nurse and client and family or relevant professionals; “discrepancy of intention with family”, discrepancy of intention between family and client or home-visiting nurse; SD, standard deviation.

Factor 1: Ordinary concern (Cronbach's Alpha = 0.78)14.902.67   
  1: Insufficient support from related professionals/organizations2.580.64 0.68 0.03−0.07
  2: Insufficient respect for client's wishes2.560.61 0.58 −0.030.10
  3: Concern about whose intention should be respected because the client cannot make his or her intention known2.600.66 0.55 −0.060.12
  4: Concern about the number of related individuals/professionals/organizations who handle personal information and extent that information should be shared2.230.67 0.54 0.04−0.05
  5: Differences in views between relevant professionals/organizations and you on the scope of work and role sharing2.370.64 0.53 0.24−0.11
  6: Differences in understanding between C/F and relevant professionals/organizations concerning disease notification or life-prolonging treatment2.590.67 0.50 −0.010.20
Factor 2: Differences in views concerning care (Cronbach's Alpha = 0.82)11.992.41   
  7: The discrepancy of views between relevant professionals/organizations and you on the client's treatment and medical procedure2.390.64−0.03 0.82 −0.04
  8: The discrepancy of views between relevant professionals/organizations and you on the client's means of care or use of services2.400.610.17 0.74 −0.16
  9: The discrepancy of views between relevant professionals/organizations and you as to whether the home or the institution is the appropriate place for the client's recuperation, living, and care2.390.65−0.03 0.58 0.21
 10. The discrepancy of intention between C/F and you on the client's means of care or use of services2.450.620.08 0.47 0.16
 11: The discrepancy of intention between C/F and you on the client's treatment and medical procedure2.360.62−0.06 0.44 0.38
Factor 3: Discrepancy of intention with family (Cronbach's Alpha = 0.70)7.541.50   
 12: The discrepancy of intention between client and family as to whether the home or the institution is the appropriate place for the client's recuperation, living, and care2.680.640.11−0.16 0.76
 13: The discrepancy of intention between C/F and you as to whether the home or the institution is the appropriate place for the client's recuperation, living, and care2.390.66−0.120.14 0.69
 14: The discrepancy of intention between client and family on the client's treatment and medical procedure2.480.620.160.11 0.43
Factor contribution  3.964.193.59
Correlations among factors
 1  1.00  
 2  0.661.00 
 3  0.570.631.00

Table 2 shows factor-mean scores and item-mean scores. Item-mean scores ranged 2.23–2.68 (possible, 1.0–4.0). On five of the 14 items (35.7%), more than 50% of the respondents answered that they “very frequently” or “frequently” encountered the specific listed ethical issue in their everyday practice. These five items were: item 12 (65.3%), “the discrepancy of intention between client and family as to whether the home or the institution is the appropriate place for the client's recuperation, living and care”; item 6 (57.3%), “differences in understanding between C/F and relevant professionals/organizations concerning disease notification or life-prolonging treatment”; item 3 (56.7%), “concern about whose intention should be respected because the client cannot make his or her intention known”; item 1 (55.6%), “insufficient support from related professionals/organizations”; and item 2 (54.0%), “insufficient respect for client's wishes”.

Experience of ethics education and workplace environment

The large majority (86.4%) of respondents had received ethics education via the following: nursing education at technical school, junior college, university or college (61.9%); continuing education programs in the workplace (27.6%); seminars outside of the workplace (24.5%); or self-education (6.0%). Two-thirds (65.6%) of the respondents said that these ethics education experiences were useful for their current practice (Table 1).

The majority of respondents indicated that their workplace environment or framework was “very prepared” or “somewhat prepared” to discuss and exchange views, and to receive consultation and support (Table 1). Also, more than half of the respondents reported that their workplace was “very prepared” or “somewhat prepared” for the nurses' participating in continuing education or seminars (59.8%), and they had opportunities to exchange views or discuss cases with relevant professionals/organizations (56.2%). A minority of respondents answered that their work environment was “very prepared” or “somewhat prepared” in providing “programmed continuing education systems consistent with education obtained in nursing school” (26.4%) and “staff training programs that allow sharing with related professionals/organizations” (20.6%).

Multiple regression analysis of the frequency of encountering ethical issues and demographic data

Relationships between each factor score of frequency of encountering ethical issues as a dependent variable and demographic data (age, type of nursing school, duration of working experience as a HVN, duration of work experience as a nurse at a facility, and current position) were analyzed with a stepwise method of multiple regression analysis (Table 3).

Table 3. Stepwise multiple regression analysis of the frequency of ethical issues and demographic data (N = 1961)
Independent variablesDependent variables
Ordinary concernDifferences in views concerning careDiscrepancy of intention with family
β P β P β P
  1. Independent variables that entered into analysis are age, type of nursing school, duration of working experience as a HVN, duration of working experience as a nurse at a facility, and current position. β, standardized coefficient β; “ordinary concern”, concern about respecting client or relationships with relevant professionals; “differences in views concerning care”, differences in treatment or care-taking views among home-visiting nurse and client and family or relevant professionals; “discrepancy of intention with family”, discrepancy of intention between family and client or home-visiting nurse; HVN, home-visiting nurse. Type of nursing school (0, technical nursing school; 1, junior college, 4 year university or college).

Age−0.1110.000−0.0620.021−0.0940.000
Current position0.1280.0000.0920.0010.1260.000
Duration of working experience as a HVN0.1150.0000.1300.0000.1170.000
Type of nursing school0.0550.0210.0870.0000.0870.000
R 2 (P)0.036 (0.000)0.034 (0.000)0.040 (0.000)

All three factors were significantly and positively related to the same three variables: current position; duration of working experience as a HVN; and type of nursing school. Namely, HVNs who had longer work experience scored higher than those who had a shorter work history. Also, compared with HVNs who were staff members or who had graduated from technical nursing school, those who were in higher positions (assistant managerial or managerial level) or who had graduated from junior college or a bachelor course (university or college) tended have higher scores. Interestingly, age, the fourth variable was significantly inversely related to all three factor scores (β = −0.111, −0.062, −0.094, respectively). Thus, HVNs who were younger scored higher than those who were older. Factors' R2 ranged 0.034–0.040.

DISCUSSION

Ethical issues in home-visiting nurses' practice

We found three factors related to the frequency of encountering ethical issues. They showed satisfactory reliability with this study's sample.

As one of the factors, “differences in treatment or care-taking views among HVNs and C/F or relevant professionals” was found. This factor focused on treatment and care. Nurses, as health professionals, have considerable responsibilities for caring for clients and assisting them to have as high a quality of life as possible in their own home. They visit clients' homes alone and must decide and provide appropriate care or treatment for them. Thus, nurses must be sensitive enough to perceive differences in treatment or caring views espoused by relevant professionals or C/F.

We found “discrepancy of intention between family and client or HVN” as another of the factors. Furthermore, the item “the discrepancy of intention between client and family as to whether the home or the institution is the appropriate place for the client's recuperation, living and care” of this factor indicated the highest score of frequency of encountering ethical issue. This result corresponds with conclusions reached in previous studies (Horstman & Rens-Leenaarts, 2002; Oberle & Tenove, 2000). Ladd et al. (2000) indicated a unique moral dilemma among nurses who cared for patients in their home that related to the intense involvement of the family to care for or make decisions for the patient. Furthermore, in Japan, because of its group and family-oriented cultural norms and values, the boundary between an individual and his/her family is not so clear and individuals sometimes submit his/her family's desires (Okuno, Tagaya, Tamura, & Davis, 1999). Thus, family members not only influence their vulnerable relatives' decision making, but also sometimes make health care decisions in their place (Asahara, & Momose, 2003). In fact, Japanese nurses sometimes view the patient's family as a critical partner in decision making (Konishi, & Davis, 2001). Thus, because Japanese HVNs value decisions of the family as well as the client, it seems that HVNs who care for clients in their home would face ethical issues concerning the discrepancy of intentions between these two parties.

Compared with the other two factors, “concern about respecting client or relationships with relevant professionals” did not demonstrate obvious value conflict situations. Because four items (ethical issues) that constituted this factor were included in the top five that more than 50% of the respondents answered “very frequently” or “frequently” encountered, this factor may express HVNs ordinary concern or awareness in their everyday practice. Additionally, it seems that ethical issues of this factor are associated with ethical concepts for nursing practice, namely advocacy and cooperation (Fry & Johnstone, 2008). “Advocacy” means to respect clients and to protect clients' rights, dignity, privacy, and choices, while “cooperation” means coordinated, collaborative, trust-based, and productive interactions between members of the numerous professionals involved in the delivery of safe, high-quality care (Fry & Johnstone, 2008). The meanings of these concepts are expressed in various nursing codes of ethics (Fry & Johnstone, 2008; Japanese Nursing Association, 2003; The International Council of Nurses, 2006). Thus, it seems that nurses learn them from their nursing education, continuing education, and their experiences in their practice. Of course, studies of nurses in hospital settings identified ethical issues concerning clients' autonomy or dignity (Katsuyama et al., 2010; Pavlish, Brown-Saltzman, Hersh, Shirk, & Nudelman, 2011); however, the advocacy concept may be special for HVNs. In home care settings, a power balance exists based on territory and it is associated with HVNs practice. HVNs enter clients' homes as “outsiders,” whereas clients are the subjects and have ownerships in their homes. Therefore, HVNs are called upon to respect clients when they care for them in ways that are not called forth in the hospital (Öresland et al., 2008). Furthermore, nurses care for clients who may have different goals and interests from nurses. So, HVNs have to forge a trusting relationship with clients and have a process of negotiation with them. In this negotiation process, nurses put forth the greatest possible effort to respect and accept clients' intentions and lifestyles to reach an agreement. Horstman and Rens-Leenaarts (2002) described nurses as balancing between the needs of C/F and their professional (scientific) knowledge – in other words, their medical or nursing evidence-based knowledge – to achieve the greatest good for C/F. They stated that it is a highly contextual continuous process; consequently, nurses might experience ethical dilemmas through this moral work.

Home-visiting nurses ethical issues of cooperation and conflict with relevant professionals have also been reported (Oberle & Tenove, 2000; Öresland et al., 2008; Shuda et al., 2002). Because relevant professionals who work together with nurses in the community belong to separate organizations, it is assumed that it is not so easy to share purposes, procedures, or contents of care among them.

Variables related to the frequency of encountering ethical issues

With regard to all of the factors, HVNs who had longer work experience scored higher than those who had a shorter work history. Also, compared with HVNs who were staff members, those who were in higher positions had a tendency to have higher scores. Also, the β-values of these two variables were higher than other variables in each factor. These results correspond with conclusions reached in a previous study that was conducted for HVNs in Japan (Shuda et al., 2002). Two potential explanations may be presumed for this. First, HVNs with more work experience and higher positions may be entrusted with cases that have many complex problems or need nurses' coordination among many related organizations or professionals. Therefore, they are often caught in the middle of a variety of different views. Second, nurses with more work experience and higher positions may be able to identify ethical issues more through their accumulated experiences with cases that require ethical considerations.

Furthermore, compared with HVNs who graduated from technical nursing school, those who graduated from junior college or bachelor courses tended to have higher scores. Numminen and Leino-Kilpi (2007) indicated that the findings of research on relationships between theoretical education and practice should be interpreted taking into account the varying cultures and nursing education systems. In 2004, the Ministry of Education, Culture, Sports, Science and Technology (MEXT, 2004) established a framework of achievement levels and contents of nursing competencies required for bachelor course students graduating from college or universities. MEXT asked universities and colleges to educate and evaluate this framework in a curriculum integrated with liberal arts. The levels and contents of ethical competency were included in this framework. Because the students in the integrated curriculum had significantly higher moral reasoning levels than those in the traditional curriculum (Mustapha & Seybert, 1989), it may be presumed that nurses who graduated from bachelor courses have a tendency to be more aware and sensitive in understanding or perceiving ethical issues. However, Mizusawa (2009) indicated that there were no significant differences in the frequencies of encountering ethical issues by types of nursing education among Japanese nurses working at hospitals. In our study, the percentage of respondents who graduated from bachelor courses was only 1.8%. Hence, the relationships between the experience of ethical issues and ethical sensitivity have not been clear. Therefore, we must be cautious when interpreting this result.

Interestingly, regarding all of the factors, HVNs who were younger scored higher than those who were older. Mizusawa (2009) also indicated that there were no significant correlations between the frequency of encountering ethical issues and age for nurses working at hospitals. Studies of Japanese HVNs (Kuritani & Ago, 2011) and public health nurses (Negishi, Asahara, & Yanai, 2010) reported that nurses understood the lives of clients or people in the community through the experiences of their own lives as residents. Therefore, it is presumed that younger nurses who have had fewer social life experiences could not understand ethical situations that they encountered and perceive them as “issues” compared with older nurses. However, all factors' R2 were low. It may be presumed that the characteristics of the station caused more variance.

Implication for home care nursing practice

Compared with the results of hospital nurses in Japan (Mizusawa, 2010), HVNs in this study had fewer opportunities to attend ethics education outside of the workplace after beginning their work at home-visiting nursing stations. Gallagher (2006) noted that it is necessary for nurses to receive ethics education to promote ethical competence in practice. We have already initiated an ethics education program for HVNs. It is a (half-day) or (one-day) program consisting of a lecture, case deliberation using a model for ethical analysis, decision-making, or narrative approach, and reflection among members in a small group. However, additional ethical education for HVNs as well as nursing students that is based on the characteristics of specific ethical issues encountered in home care nursing practice is needed. Based on the results of this study, the authors will create cases or topics for lectures and group deliberation that express the components of ethical issues that were found in the three factors.

Many of the respondents perceived that their workplace environment was conducive to open discussion and the exchange of views with colleagues, however, programmed continuing education systems and staff training programs were not sufficiently available. A nationwide report indicated that the main contents of continuing education were seminars outside the workplace and only case deliberation; while half of them did not have a budget for continuing education (Japan Visiting Nursing Foundation, 2009). Although organizations related to home-visiting nursing stations and prefectural governments provided long-term or short-term seminars or training courses, respectively, HVNs had minimal participation because Japanese home-visiting nursing stations are small-scale organizations whose mean number of staff members is only 5.4 (Ministry of Health, Labor and Welfare, 2011).

To develop and provide ethics education programs that would fit with such an environment of home-visiting nursing stations effectively, network systems are needed to make home-visiting nursing stations in particular areas come together to establish and provide continuing education programs. Furthermore, organizations related to home-visiting nursing stations, prefectural governments or colleges and universities should support those systems.

Gutierrez (2005) and McDaniel (1998) highlighted the importance of nurse administrators' role in ethics education and in establishing an ethical climate. Because approximately 80% of those in charge of continuing education are nurse administrators of home-visiting nursing stations (Japan Visiting Nursing Foundation, 2009), ethics education is greatly need for nurse administrators in home-visiting nursing stations. Ongoing educational programs and support systems for nurse administrators are necessary.

Limitations of the study and future research

This study was limited by the response rate. We mailed the four questionnaires to each home-visiting nursing station for potential subjects. Because the mean number of nurses and care workers per home-visiting nursing stations is 4.5 (Ministry of Health, Labor and Welfare, 2011), it seems that many home-visiting nursing stations did not have enough nurses who could respond to the four questionnaires. Therefore, it may be presumed that the actual response rate might be higher than the one this time. However, the sample number was almost 2000 and it was drawn by random sampling. Furthermore, this study was the first nationwide survey to determine ethical issues perceived by HVNs in Japan and the findings provide important consideration about effective practices and continuing education for HVNs.

Further research is needed to clarify the relationships among ethical issues, experiences of ethics education, ethical environment, moral competence, and other variables. To develop effective ethics education programs to enhance HVNs' ethical competency, we will develop and verify reliable and valid outcome measures for evaluating ethical competency for HVN.

CONCLUSION

This nationwide survey addressed the ethical concerns of HVNs in their practice. Three factors were found that explained the frequency of HVNs encountering ethical issues. HVNs were exposed to discrepancy of intention with family as well as with relevant professionals or C/F focusing on treatment or care. Another factor, concern about respecting the client or relationships with relevant professionals, was also revealed. It seemed that it expressed HVNs' ordinary concerns and ethical values related to the characteristics of their everyday practices. Each of these factors was significantly positively associated with the current position, years of working experience as a HVN and type of nursing school, and significantly negatively associated with age.

Furthermore, the results of this study indicate that Japanese HVNs working at home-visiting nursing stations did not receive systematic continuing education including ethics education. Establishment of a continuing education system in a comprehensive community-based network among home-visiting nursing stations, professional organizations, governments, and colleges/universities must be considered as soon as possible.

ACKNOWLEDGMENT

This work was supported by the Grant-in-Aid for Scientific Research (B) from the Japan Society for the Promotion of Science (grant numbers 19390571).

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