Ethical Issues and Value Conflicts Faced by Japanese Care Workers in Geriatric Care: A Qualitative Study

Marking excellence in contributions to the gerontological nursing literature.

Special Report: Ethical Decision-Making in Contemporary Psychiatric Practice—An Evolving Challenge

The purpose of this study was to explore Japanese care workers' attributions, beliefs and cultural explanations of physically and psychologically aggressive behaviour symptoms. Physically and psychologically aggressive behaviour symptoms by older people with dementia have been associated with occupational stress among care workers in the United States and other Western countries and may contribute to staff turnover. However, few studies related to this issue have been conducted in Japan, where care worker reaction to physically and psychologically aggressive behaviour symptoms might be different because of cultural and customary differences in how care is provided for older people. This study reports on the results of three open-ended questions that were part of a larger study that explored Japanese care workers' experiences with aggressive behaviour symptoms in persons with dementia. Convenience sampling was used to recruit 137 care workers in 10 nursing homes in the northern and western areas of Japan. The answers to the open-ended questions were analysed using a content analysis. Most of the participants indicated that they believed that physically and psychologically aggressive behaviour symptoms came from residents' stress from dementia. Approximately, one-fourth of the participants responded that Japanese values such as chu (loyalty) and joge (hierarchy) influenced their work with residents with physically and psychologically aggressive behaviour symptoms. Seventeen participants (12%) commented either that they respected older people or that they respected older people as persons who had had many experiences in life. Interestingly, 43 responses (41.0%) indicated that physically and psychologically aggressive behaviour symptoms influenced quality of care positively, while, not surprisingly, about 30 responses indicated that those behaviour symptoms influenced quality of care negatively. Findings from this study indicate that the training and education needs to focus on understand and preventing the effects of stress for individuals living with dementia to reduce aggressive incidents and increase recruitment and retention of care workers.

In 2017, to address the shortage of long-term care workers, the Japanese government drastically changed policies for permitting foreigners to fill these jobs. This included creating a new immigration status, “Kaigo”(long-term-care) and adding a new job category to “Ginou-Jissyu”(technical-intern-training) immigration status. This study examined differences in views of hiring foreign care workers and these policy options between administrators and Japanese care workers at long-term-care institutions for older adults before these policy changes were in place as a way of understanding receptivity towards them. A nationwide survey was conducted during September to October of 2014. Structured questionnaires were sent to 3,932 randomly selected institutions, and a total of 722 responses were obtained from administrators(response rate:18.4%) and 586 responses(14.9%) from Japanese care workers. Preliminary analyses revealed that there were statistically significant differences between administrators and care workers in views of hiring foreign care workers(p<.001), language proficiency needs(p<.001) and ability to provide quality care(p<.05), and the three policy options proposed at the time(p<.01). For example, administrators agreed more with hiring foreign care workers and were less concerned with Japanese language skills than care workers. Moreover, administrators agreed more with creating a new immigration status and adding a new job category to “Ginou-Jissyu” immigration status than care workers. Given the recent policy enactment, it is suggested that administrators need to be aware of these differences in order not to accelerate already higher turnover rates of Japanese care workers and to pay attention to if and how the new policies are changing care workers views.

Ethical conflicts among nurses can undermine nurses’ psychological comfort and compromise the quality of patient care. In the last decade, several empirical studies on the phenomena related to ethical conflicts, such as ethical dilemmas, issues, problems, difficulties, or challenges, have been reported; however, they have not always deeply explored the meaning of ethical conflicts experienced by nurses in geriatric care. This study aims to understand the lived experiences of ethical conflict of nurses in geriatric hospitals in South Korea. A phenomenological study was conducted. In-depth, face-to-face interviews were performed with nine registered nurses who cared for elderly patients in geriatric hospitals in South Korea between August 2015 and January 2016. Three main themes emerged from the analysis: (1) confusing values for good nursing, (2) distress resulting from not taking required action despite knowing about a problem, and (3) avoiding ethical conflicts as a last resort. It was found that for geriatric nurses to cope with ethical conflicts successfully, clear ethical guidance, continuing ethics education to improve ethical knowledge and moral behaviors, and a supportive system or program to resolve ethical conflicts involving nurses should be established.

Attitudes of nurses towards the use of physical restraints in geriatric care: A systematic review of qualitative and quantitative studies

According to the United States Census Bureau, there was a 15.1% increase in the sixty-five and older population between 2000 and 20101 and is expected to climb to 16.3% by 2020.2 In addition, older adults have shown a greater need for health care resource utilization in America; while only 12.8% of the U.S. population in 2008, older adults accounted for 26% of office visits, 35% of hospital stays, and 38% of emergency medical services.3The increase in care necessary for the aging population paired with the ebb of resident interest in geriatrics4 has prompted many to call for a more focused effort toward expanding awareness of and recruitment to geriatrics.5-8 Toward these ends, Saint Louis University (SLU) developed a university-level undergraduate course in ethics and geriatric care designed to expose students to the field prior to beginning formal post-baccalaureate medical education. In addition to regular classroom discussion of issues in geriatric care, students spend significant time learning through direct exposure to geriatrics by spending one hour shadowing clinicians and two hours visiting an elder at the nursing home. Students are assessed on classroom participation, completion of required hours, regular reflection papers integrating nursing-home experiences with classroom discussion, and completion of a quality improvement (QI) project.This course is unique for three reasons. First, it is one of the only university-level undergraduate courses engaging students in direct experiences with long term care residents. Second, it was designed in collaboration with undergraduate pre-professional students, who were surveyed to incorporate their needs into the course curriculum (pre-development needs analysis). Finally, it integrates reflection on and discussion of ethical issues related to geriatric long-term care with the students’ time at the nursing home, thereby grounding the practical experiences in theory and animating theory with real-world examples. Course design The course was designed to meet several stakeholders’ interest simultaneously. First, the Division of Geriatric Medicine at SLU School of Medicine expressed a desire to increase awareness of common geriatric care issues and to pursue more volunteers to spend meaningful time with nursing home residents. Second, the pre-professional students at SLU completed a needs-based assessment to delineate student-driven course objects. The survey answers were qualitatively analyzed for common themes: 1) gaining experience with patients, 2) improving medical school applications, 3) increasing shadowing opportunities, 4) understanding the geriatric population, and 5) exposure to medical-ethical discussion. Finally, the University’s Center for Health Care Ethics was seeking opportunities for students to engage in real-world health care experiences while receiving course credit toward a minor degree in Health Care Ethics.The interests of these three stakeholders were combined to develop an internship-based service-learning course with resident companion contact hours, shadowing hours, classroom discussion, and ethics education. Students gain relevant knowledge and skills through real-world learning contexts and insight through volunteer and community service experiences. Upon completion of the course, students should be able to identify: (1) medical and professional challenges to geriatric care, (2) related ethical issues inherent in geriatric and end-of-life care, (3) effective communication and patient-centered skills with elder patients, and (4) principles of ethical care-giving.

BackgroundThe experiences and perceptions of geriatric specialist nurses are pivotal to understanding the complexities of managing delirium and to developing effective nursing interventions. This qualitative study aims to explore these experiences and perceptions to inform the enhancement of clinical geriatric nursing and care practices.MethodsUtilizing a qualitative exploratory design, this research engaged a convenience sample of geriatric specialist nurses at a tertiary hospital in Shanghai, China through focus groups and semi-structured interviews. Data were rigorously analyzed using Colaizzi’s phenomenological method, which facilitated the identification of themes that emerged from the narratives of the geriatric specialist nurses.ResultsThe thematic analysis yielded three major themes that encapsulate the nurses’ experiences and perceptions. Theme 1: Understanding of Delirium, highlighted the nurses’ awareness of the condition’s significance, yet it was often deprioritized due to the pressing demands of managing more acute and immediately life-threatening conditions. Theme 2: Barriers in Application, brought to light the multifaceted challenges faced by nurses, including language barriers, the frequency and consistency of delirium assessments, the social determinants of health, and the nurses’ own competencies in assessment. Theme 3: Evolution of Nursing Approaches, detailed the adaptive strategies employed by nurses, such as managing nursing adverse events, improving communication with patients’ families, and adopting a proactive stance towards long-term patient outcomes.ConclusionsThe findings suggest that while geriatric specialist nurses recognize the importance of delirium assessment, there are several barriers to effective application. The study underscores the imperative for the advancement of more refined delirium assessment and care protocols, tailored to address the unique requirements of geriatric nursing care.

Ethical and legal issues are increasingly being reported by health caregivers; however, little is known about the nature of these issues in geriatric care. These issues can improve work and care conditions in healthcare, and consequently, the health and welfare of older people. This literature review aims to identify research focusing on ethical and legal issues in geriatric care, in order to give nurses and other health care workers an overview of existing grievances and possible solutions to take care of old patients in a both ethical and legally correct way. Using a systematic approach based on Aveyard, a search of the PubMed, CINAHL, and Ethicshare databases was conducted to find out the articles published on ethical and legal issues in geriatric care. The approval for the study was obtained from UMIT-The Health and Life Sciences University, Austria. Only 50 articles were included for systematic analysis reporting ethical and legal issues in the geriatric care. The results presented in this article showed that the main ethical issues were related to the older people's autonomy, respect for their needs, wishes and values, and respect for their decision-making. The main legal issues were related to patients' rights, advance directives, elderly rights, treatment nutrition dilemma, and autonomy. Further education for professional caregivers, elderly people, and their families is needed on following topics: care planning, directive and living wills, and caregiver-family member relationships to guide and support the elderly people within their decision-making processes and during the end-of-life care.

BackgroundOccupational physicians (OPs) have complex relationships with employees, employers, and the general public. OPs may have simultaneous obligations towards third parties, which can lead to variable conflicts of interests. Among the various studies of ethical issues related to OPs, few have focused on the Korean OPs. The aim of the present survey was to investigate the ethical contexts, the practical resolutions, and the ethical principles for the Korean OPs.MethodsAn email with a self-administered questionnaire was sent to members of the Korean Society of Occupational and Environmental Medicine, comprising 150 specialists and 130 residents. The questionnaire was also distributed to 52 specialists and 46 residents who attended the annual meeting of the Korean Association of Occupational and Environmental Clinics in October 2015, and to 240 specialists by uploading the questionnaire to the online community ‘oem-doctors’ in February 2016. The responses to each question (perception of general ethical conflicts, recognition of various ethical codes for OPs, core professional values in ethics of occupational medicine, and a mock case study) were compared between specialists and residents by the chi-squared test and Fisher’s exact test.ResultsResponses were received from 80 specialists and 71 residents. Most participants had experienced ethical conflicts at work and felt the need for systematic education and training. OPs suffered the most ethical conflicts in decisions regarding occupational health examination and evaluation for work relatedness. Over 60% of total participants were unaware of the ethical codes of other countries. Participants thought ‘consideration of worker’s health and safety’ (26.0%) and ‘neutrality’ (24.7%) as the prominent ethical values in professionality ofoccupational medicine. In mock cases, participants chose beneficence and justice for fitness for work and confidential information acquired while on duty, and beneficence and respect for autonomy in pre-placement examinations.ConclusionsThis study evaluated the current perception of and attitude toward ethical issues among the Korean OPs. These findings will facilitate the development of a code of ethics and the ethical decision-making program forthe Korean OPs.

Although ethical values and principles guide oncology nursing practice, nurses often are challenged to fulfill every professional core duty and responsibility in their everyday practice. Nurses commonly encounter clinical situations that have ethical conflicts, and they often have difficulty recognizing and articulating them. Unresolved conflicts can cause feelings of frustration and powerlessness, which can lead to compromises in patient care, job dissatisfaction, disagreements among those in the healthcare team, and burnout. This article reviews the ethical principles and values individual nurses bring to their practice as well as those basic to the profession of nursing. This article also discusses ethical conflicts in oncology practice and describes how nurses, especially students and novice nurses, may react to such situations with moral uncertainty or distress. In addition, a process for analyzing and resolving ethical problems in clinical situations is outlined. Increasing awareness and dialogue about ethical issues is an important first step in the process. Additional resources in the clinical setting may encourage nurses to actively participate in ethical decision making and take deliberate action as moral agents.

Aggressive behaviors (ABs) related to dementia in older adults have been associated with increased occupational stress among care workers (CWs) in the United States and other Western countries, and they may contribute to staff turnover. However, few studies related to this issue have been conducted in Japan. The current cross-sectional study examined (a) the relationship between CW frequency of exposure to dementia-related ABs and CW occupational stress (i.e., job burnout, job satisfaction, and intention to resign), and (b) mediator effects between frequency of exposure to dementia-related ABs and CW occupational stress. A total of 137 CWs in dementia special care units from 10 nursing homes in Japan were recruited as study participants. Major findings indicate that the relationship between exposure to ABs and work outcomes was fully mediated by the appraisal of stress. Findings from this study may be used to develop culturally relevant training and educational interventions targeted at reducing ABs in individuals with dementia and occupational stress from exposure to ABs among CWs.

Developmental Strategies for Nursing Ethics Education

Language communication in caregiving between care recipients and care workers is essential for the well-being and overall care experiences of both parties. However, challenges arise in language communication when care workers and/or recipients are linguistic minorities. With the increasing reliance on migrant workforces in the care industry globally, language communication challenges require careful attention. Research indicates that migrant care workers, many of whom are linguistic minorities, often report lower job satisfaction due to high job demands, limited social support, stress related to acculturation, and discrimination both within work and outside of their care roles. However, current studies on aging, health, and migration often overlook the exploration of language communication experiences in caregiving from the perspective of care workers. Unlike conventional research that frames language communication challenges merely as "language barriers," our study critically examines the experiences of Japanese care workers' experiences, through the lens of linguicism, language ideologies, and Bourdieu's symbolic violence theory. Drawing insights from in-depth interviews (n = 10), our analysis reveals various forms of linguicism faced by the study participants. Some participants experienced discrimination due to their accents and overall language proficiency, both from care recipients and co-workers. Interpersonal linguicism is evident, but many participants also internalized language oppression.

Introduction: Nurse managers (NM) face ongoing ethical issues when they work with older adults in long-term care settings (LTCS), including around end-of-life care. Legislation and healthcare ethics guide the provision of ethical care to older adults in a changing societal and global context. Research Aim: Our aim was to describe the ethical issues encountered by NMs. Methods: This qualitative study involved 23 NMs from seven randomly selected organisations who participated in semistructured focus group interviews in 2021. We analysed the data using inductive content analysis. Ethical Considerations: The subject of this study was sensitive and reflected the participants' individual views. They provided informed consent and their anonymity was guaranteed. Results: Ethical issues faced by NMs are related to residents' rights to self-determination, ethical decision-making about staff and procedures, providing ethical leadership despite having conflicting roles, and defending ethics in LTCS on a societal level. NMs struggled to spend sufficient time supporting their staff during everyday care. Conclusions: The ethical issues encountered by NMs are multidimensional and have both external and internal causes. NMs often deal with ethical issues on their own. Structuring their roles so that they can focus more on daily care could help NMs to provide more effective leadership and get more involved in their organisation's decision-making. Further research into the impact of NMs' backgrounds on their performance and responsibilities could provide new insight which would be useful in educating NMs and designing relevant organisational structures. Implications for Nursing Management: Our research can be applied to practice, policy, education and research. Practice: NMs' daily work should be organised in a way that enables them to work closely with residents and staff. Reducing their secondary tasks could increase the time available to manage staff and provide individual coaching for those with different independent abilities. Being present during daily care would make it easier to deal with ethical issues in a timely manner, which could reduce staff's moral distress and increase their well-being at work. Policy: Understanding the importance of the role of NMs could help policy makers in planning LTCS care. Involving NMs in decision-making in organisations and society could increase awareness about the relevant ethical issues and improve the care that residents receive and the well-being of staff and new members. For example, how many employees a single NM can manage could be defined in the same way as the number of staff per resident has been determined. Implementing ethics committees in LTCS could provide a mechanism for considering the views of NMs. Education: Ethical issues in the care of older adults should be included in the curriculum of those studying for the profession. Ethical issues change over time as the world around them changes. Addressing ethical issues should be a continuous theme in continuing education for relevant workers. Research: This qualitative study gave a voice to LTCS NMs in a society with a rapidly ageing population and labour shortages. Ethical issues faced by NMs were related to implementation of nursing and healthcare values in the daily care of residents. In the future, generalisable knowledge is needed about what is the ethical climate in LTCS workplaces, and what is the role of NMs' and care workers' ethical competencies and attitudes towards ageing when performing daily care in the LTCS. In addition, it is noteworthy that the ethical issues' NMs faced were related to policy decisions made in the surrounding society, and NMs felt they had no power or ability to influence on them. In the future, more knowledge is needed to understand how NMs in LTCS, but also in other areas of nursing, identify and consider their role in ethical issues related to health policy.