2.1 Capacity for ethical judgment

The capacity for ethical judgment concerns the content from Article 1 to Article 15 of the Code of Ethics for Nurses [3], and the content of each article is evaluated at three levels: awareness, judgment, and action. The awareness level concerns noticing discomfort during everyday nursing work, based on knowledge related to ethical norms and concepts necessary for taking ethical action. The judgment level has to do with collecting information related to discomfort noticed during everyday nursing work, as well as formulating an action plan after clearly defining the ethical problem. The action level to resolve the ethical problem deals with providing nursing care while considering one’s value and duty to protect and respect the patient.

2.2 Continuous nursing education

Continuous nursing education is an activity that supports the learning process for improving knowledge, technology, and attitudes necessary for providing the best possible patient care. Such education is provided after a nurse acquires his/her nursing license [3]. In this study, we defined Clinical Ladder I as nursing experience of less than one year; Ladder II is between one and three years of experience; Ladder III is three to five years of experience; Ladder IV is five to 10 years of experience; and Ladder V is more than 10 years of experience.

3.1 Literature review

We searched the Igaku Chuo Zasshi, MEDLINE, and CINAHL databases. The following keywords were used: “nursing ethics,” “nursing practice,” and “ethical education and nurse.” The search period was between 2008 and 2018, and references were limited to research papers (original papers, research reports, practical reports, and materials) that covered nurses working in hospitals (excluding nursing managerial positions). As a result of our search, we were able to extract 22 relevant references.

3.2 Method of analysis

We classified the 22 papers according to the clinical ladder of continuous nursing education. We organized the capacity for ethical judgment by nurses from the viewpoint of the Code of Ethics for Nurses [3], which covers the guidelines of action for nurses. Furthermore, we evaluated the level of capacity to make ethical judgments acquired according to the awareness level, judgment level, and action level.

Next, we read detailed information regarding the ethics training as a part of continuous nursing education in order to examine the current status and future challenges. This helped ensure the reliability and validity of each paper’s content.

4.1 Relevant references

Of the 22 references, four belonged to Clinical Ladder I, one to Clinical Ladder II, none to Clinical Ladder III, one to Clinical Ladder IV, and none to Clinical Ladder V. Thirteen references did not disclose the number of years of nursing experience among participants. Furthermore, four references were related to nursing ethics training as part of a continuous nursing education program.

4.2 Capacity for ethical judgment

For Clinical Ladder I, the capacity for ethical judgment corresponded to Articles 1, 4, 5, 6, 8, and 10. For example, a nurse could be experiencing an ethical dilemma related to patient care whereby the patient is refusing agonizing treatment; however, the nurse carried out the treatment because the family provided consent [7]. The acquisition level regarding capacity for ethical judgment comprised awareness and action but no reports at the judgment level (Table 2).

Table 2: Acquisition level of capacity for ethical judgment as part of continuous nursing education.

There were no references related to Clinical Ladder III.

For Clinical Ladder IV, the capacity for ethical judgment corresponded to Articles 2, 4, 6, and 11. For example, a nurse could experience ethical problems related to a more complicated situation, such as parents refusing treatment for disabled newborns, or nurses excessively restraining patients to prevent risks [11]. Here, nurses also reviewed their own work by assessing the practices of other nurses [11]. These examples covered the awareness, judgment, and action levels.

There were no references related to Clinical Ladder V.

For reports where no years of nursing experience were provided, the capacity for ethical judgment corresponded to Articles 1, 2, 4, 5, 7, 8, 9 and 10. For example, a nurse could recognize the need for “respecting the patient” and “paying attention to the patient’s values” as a way to respect the patient while providing palliative care [14]. Furthermore, reflecting on a time when nurses were only able to make records of physicians’ instructions regarding sudden changes to a patient’s condition, nurses recognized that they had not been fulfilling the loyalty and duty to their profession [16]. These examples were at the awareness, judgment, and action levels.

4.3 Ethics training as part of continuous nursing education

For Clinical Ladder I, ethics training as part of continuous nursing education, targeted new nurses, presenting content that would ideally be taught as part of one’s basic nursing education. This was done to primarily raise nurses’ awareness and judgment levels [7,26]. Furthermore, most new nursing staff training was comprised of nursing ethics education outlined through case examples [20].

For Clinical Ladder II, in order to raise nurses’ level of ethical judgment, a method was provided to focus on nurses “wanting to understand” and “wanting to share” through exercises rather than a lecture format. These exercises were presented in a personal and practical context [10].

There were no reports related to nursing ethics education that targeted Clinical Ladder III, Clinical Ladder IV, or Clinical Ladder V.

In one report where the number of years of nursing experience was not provided, nurses working in departments of psychiatry in Turkey were aware of the need for nursing ethics education. Here, ethical problems were thought to be associated with inappropriate words and actions taken against patients; the belief was that there was a need to maintain knowledge and assume responsibility through further nursing practice and education [13]. As a specific educational method, stakeholders had been placing nursing ethics scholars in the hospital in order to provide ethics education based on expert knowledge. This provided support for dealing with ethical conflict and the emotional pain associated with advances in healthcare so as to improve capacities for ethical judgment [27].

5.1 The current status of nurses’ capacity for ethical judgment

It is necessary for nurses to learn the entire Code of Ethics for Nurses [3], starting from first exposure to basic curriculum. However, results of the present study revealed that the capacity for ethical judgment, in consideration of this code, is not currently sufficient. One reason for this deficiency could be the difficulty in teaching individual virtues. Nurses carry out their duties in a complex manner, combining their own individual virtues with those valued by the nursing profession. As individual characteristics form each person’s identity, trying to correct a nurse’s virtues through educational intervention can be very challenging to the nurse’s established personality. A second reason could be that many nurses think that organizational efforts, such as social systems and policies, are tasks for administrative staff. However, given that the nursing code includes elements of organizational management for patient care and nursing management regarding the practicing environment through systems and policies, nurses should also be equipped with these skills.

With respect to acquisition levels, there were reports related to all levels as a part of continuous nursing education. However, it has been reported that nurses are struggling to understand the best judgment to make and action to take when faced with ethical problems [5]. Basic nursing education only offers the capacity to make ethical judgments at the knowledge acquisition level. Being equipped with the awareness level through basic nursing education alone, without acquiring the judgment level, is not sufficient for engaging the action level. For this reason, continuous nursing training should provide education that allows nurses to gain and strengthen their judgment level, instead of focusing only on education at the action level. This takes into consideration continuity from basic to advanced nursing education.

5.2 Ideal form of ethics training as a part of continuous nursing education

Davis et al. [28] argue that a lecture format tends to limit the development of clinical thinking, and that more conversation and discussion is required for ethics training. In order to respond to even more complicated ethical problems that arise with rapid progression in healthcare, it is necessary to examine methods and systems. Here, nursing ethics education should be provided by nursing ethics scholars and educational nurses who can disseminate their expert knowledge, rather than relying solely on conventional methods of education that employ lectures, case studies, and group work [27].

Furthermore, the programs for continuous nursing education examined in the present article did not reveal that current education easily fits into each clinical ladder. For instance, we did not observe any continuous form of education for Clinical Ladders I, II, and IV. Thus, one future challenge is to arrange a nursing ethics education program that corresponds to each clinical ladder stage and construct a step-wise educational program that provides continuity in training.