The Current Status of Ethical Judgment Capacity and Ethical Training Regarding Continuous Nursing Education

As such, while the need for nursing ethics education has been recognized in Japan, we have yet to provide specific content and methods for such education at each stage of the clinical ladder. The present nursing ethics education in Japan is the responsibility of each hospital to conduct, whereby educational programs have been offered on a trial-and-error basis. This leads to variation in the capacity of nurses to make ethical judgments. Additionally, if nurses are continually unable to deal with ethical problems, they can experience burnout or even leave the profession.


Introduction
The environment that surrounds healthcare has led to the diversification of ethical problems, notably due to rapid progression and complications regarding healthcare, as well as the development of cutting-edge prevention and treatment. For this reason, nurses will face ethical problems on a daily basis. Thus, we need to systematize nursing ethics training, during the course of continuous nursing education, in order to better understand the "Code of Ethics for Nurses" for appropriate use throughout professional practice.
Led by the International Council of Nurses (ICN) [1], several countries worldwide have presented their own guidelines for action. For example, the American Nursing Association (ANA) [2] enacted its Code of Ethics in 2001, which included principle ethics, special ethics (virtuous ethics), and patient care ethics as approaches to making ethical decisions. In other words, in order to respond to ethical problems that have become complicated with the advancement of healthcare and changes in society, it is necessary to look for solutions by combining various approaches.
In Japan, the Code of Ethics for Nurses (Table 1) comprises three parts and 15 articles. The articles are related to the ethical values and duties that nurses have to follow when providing care (Articles 1 to 6), articles related to efforts that are important for practical nursing (Articles 7 to 11), and articles related to individual virtue and organizational efforts that provide the foundation for nursing practice (Articles 12 to 15) [3]. This code serves as a guideline for action to be followed and also forms the basis for nurses to reflect on their practical work. For this reason, we believe Japan needs a more regimented form of education that covers the entire ethical code.
Continuous nursing education in Japan has established targets related to nursing ethics, including "Protect patient rights, " "Act based

Definition of terms 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.

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.

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

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.

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.

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).

Article on the ethical values and obligations that nurses should protect while providing nursing care
1. Nurses shall respect all human lives and the dignity and rights of all human beings. 2. Regardless of nationality, race, ethnicity, religion, creed, age, gender, sexual orientation, social status, economic status, lifestyle, and the nature of their health problems, nurses shall equally provide nursing care to their patients. 3. Nurses should do their best to establish a trustworthy relationship with their patients and to provide nursing based on that relationship. 4. Nurses must respect the patient's right to know, and to make, self-determinations and defend those rights. 5. Nurses must strictly adhere to their obligations regarding confidentiality and the protection of personal information, and if they share such information with others, it must be after making the proper judgment to do so. 6. Nurses need to protect their patients and secure their safety, including when caring for these people is being hindered or they are in dangerous situations.
Article on the efforts of nursing staff important for practice 7. Nurses should be well aware of their responsibilities and abilities as they provide care as individuals. 8. It is a nurse's responsibility to always try to maintain and develop his/her abilities through continual learning. 9. Nurses should cooperate with other nurses and other health and medical welfare workers to provide nursing care. 10. In order to perform the highest quality nursing care, nurses should set and implement helpful criteria for nursing practice, nursing management, nursing education, and nursing research. 11. Through research and practice, nurses always strive to create and develop specialized knowledge and techniques and contribute to the development of nursing science.

Article on basic personal virtues and organizational effort
12. Nurses must make an effort to maintain and improve their own physical and mental health in order to perform the highest quality nursing care. 13. Nurses must always conduct themselves as individuals worthy of the trust of society. 14. Nurses share responsibility with society regarding environmental issues to promote overall better health. 15. Through professional organizations, nurses should be involved in the establishment of institutions to enhance the quality of nursing care and contribute to the creation of a better society.
Japanese Nursing Association (2003) Art. 4 *Feeling the dilemma of having to carry out a procedure by holding down the patient because of family consent, even when the patient is refusing the procedure [7] *Sufficiently recognize "Informed Consent" as knowledge [8] Awareness Awareness Art. 5 *Feeling that a walking conference does not protect privacy [7] *Sufficiently recognize confidentiality, protection of a patient's personal information, and disclosure of information as knowledge [8] Awareness Awareness Art. 6 *Feeling the dilemma over having to hold down a patient due to risk of self-extubation or falling [7] Awareness Art. 8 *Recognizes the importance of continuing to learn as a professional person [7] *Attitude towards patient safety becomes more positive after receiving an educational program related to safety ethics using a DVD [6] Awareness Action Art. 10 *Identify desirable nursing care using senior nurses as a model [ Art. 1 *Nurses feel the dilemma with treatments that restrict physical activity among older adult patients [12] *Nurses regard inappropriate speech and conduct towards patients as a problem, due to lack of respect for patient dignity [13] *Nurses recognize the need for "Respecting the patient" and "Paying attention to the patient's value" as a way to respect the human being while providing palliative care for cancer patients [14] Awareness Judgment Awareness Art. 2 *Nurses recognize matters relating to resource allocation and equity in care as a problem [15] *Nurses harbor doubts that patients whose conditions become severe due to treatment complications have clear differences in content and frequency of care compared to other patients and that this may be a cause for special treatment [16] Awareness Awareness Art. 3 *Nurses feel the dilemma when communication with older adults, patients, and families is not smooth [12,17] *Nurses feel an ethical dilemma after recognizing a difference between the necessity of treatment and the patient's feelings [16] *Nurses engage with patients with an empathic attitude when patients are suffering or in pain [16] Awareness Awareness Action Art. 4 *Nurses feel an ethical dilemma with strong family requests asking not to tell or express the family's will to the patient [16] *Nurses regard the signing of consent form(s) by patients, that do not sufficiently understand the explanations, as an ethical problem [18] Awareness Judgment Art. 5 *Nurses value patient confidentiality and protection of privacy [19] Awareness Art. 7 *Looking back to when they were only able to make records of physician's instructions at the time of sudden changes in a patient's condition, nurses recognized that they had not been able to fulfill the loyalty and duty of their profession [16] Awareness Art. 8 *By learning from experience the ways to analyze the everyday scene of nursing practice from an ethical viewpoint, nurses had improved their knowledge needed to reach a particular resolution in situations that they felt were "odd" [21] *Nurses are aware that arrangement of an organizational system, as well as the implementation and continuation of ethical education for all staff, is necessary so that actions to resolve ethical problems can be taken by all staff [22] *By discussing the cases related to ethical problems that occur in sessions to which they are affiliated, nurses raised their awareness related to nursing ethics and had gained many ways of thinking and solving problems [23] Awareness Awareness Awareness Art. 9 *Nurses deal with ethical problems by consulting a colleague [24] *Despite having the dilemma of potentially interfering with a patient's will or desire, nurses had the experience of not being able to tell their opinion to senior nurses [25] Awareness Judgment Art. 10 *Nurses regard the situation of not being able to sufficiently provide nursing care to patients as a problem [24] Judgment 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.

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].

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.

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.

Conclusion
As a result of examining the current situation of nurses' capacity for ethical judgment and ethics education, we identified two challenges: 1) Nurses' capacity for ethical judgment does not cover the full Code of Ethics for Nurses; and 2) continuous nursing education does not currently fit into each clinical ladder. Future work should focus on designing educational programs according to each clinical ladder stage and providing ethics training that adequately ensures continuous professional development.