Ethical Issues of Psychiatric Nursing in Japan: A Literature Review

Introduction

As areas such as regenerative medicine and end-of-life medical technology experience innovative growth, our society is becoming increasingly concerned with the ethical issues that arise from medical treatment.

Due to the nature of diseases encountered in psychiatric care facilities, however, the ethical issues that surround those patients differ from those in other medical fields. Mental illness is unique in that those who suffer from it might not even recognize that they have it, and they may believe that they don’t need treatment. But in some cases, these patients are legally compelled to begin treatment if a medical professional determines it to be necessary.

Additionally, psychiatric treatment in Japan involves a different set of ethical challenges than those faced in other nations. WHO [1] surveys have revealed that, compared to other countries, Japan presently has a large number of psychiatric hospital beds and its mental-health patients are admitted to psychiatric hospitals for long periods of time. This paper intends to elucidate the current ethical issues found within psychiatric nursing in Japan.

Purpose

The aim of this paper is to examine the latest research and literature related to psychiatric nursing in Japan in order to shed light on the ethical challenges that the field currently faces.

History of Psychiatric Practice in Japan

In the aftermath of the Second World War, Japan adopted a democratic mindset and established laws governing modern psychiatric treatments. But at the same time, the post-war revival of industry led the Public Health Department of what was then the Ministry of Health and Welfare to declare in “Current Situation and Issues of Mental Health in Japan” that “mentally disabled people hinder industry by more than ¥100 billion” and to adopt a policy of committing those individuals to isolated facilities. During this period, the number of mentally disabled people committed to psychiatric hospitals in the United States was also at its peak.

But Kennedy’s presidential message to Congress in 1963 set into motion a shift toward welfare policies for mentally disabled people in the US, a movement which eventually ended the practice of shuffling patients off to live in psychiatric facilities. Many other countries which had until then adopted similar policies of committing mental-health patients to psychiatric hospitals also began transitioning to welfare policies that allowed patients to live within their own communities. Japan has lagged significantly behind other advanced nations in this regard, with the Ministry of Health, Labor, and Welfare finally signaling a conversion to community-based policies in the guidelines published in 2006. Still, since many of the country’s mental-health patients have already lived in psychiatric hospitals for years, the transition to local care has been slow and unpromising.

Methods

A literature search was conducted using the keywords psychiatric nursing and nursing ethics within the search system of the Japan Medical Abstracts Society, a computer database of medical literature in Japan. We examined recent literature (2013–2018) as well as research articles on excited literature.

Results

We surveyed the existing literature and extracted 30 papers, then examined 24 of those related to ethics in psychiatric nursing.

Of the twenty-four papers, ten involved research into the ethical dilemmas faced by nurses engaged in psychiatric care [2, 3, 4, 5, 6, 7, 8, 9, 10, 11]; seven involved research into the ethical views and sensitivities of psychiatric nurses [12, 13, 14, 15, 16, 17, 18]; five were papers discussing methods for solving the ethical issues in psychiatric treatment [19, 20, 21, 22, 23]; and two involved research into ethical issues in psychiatric treatment from the viewpoint of the patient [24, 25].

Of the research into the ethical dilemmas faced by psychiatric nurses, five were case studies while the other five were investigative studies conducted using questionnaires and other methods. These studies showed that psychiatric nurses perceive their ethical dilemmas to be “an inability to respect the patient’s wishes,”“restricting the movement of patients,”“conflict between patients and their families,”“interaction with patients,” and “insufficient communication between treatment providers.” The inability to respect a patient’s wishes is an ethical dilemma that occurs when the opinions of the patient and the treatment provider are not in agreement. Due to their symptoms, patients who suffer from mental illness sometimes lose the ability to make rational and realistic decisions. If the wishes of the patient differ from the determination made by the treatment provider in the best interests of the patient, nurses who want to respect the patient’s wishes would perceive the situation as an ethical dilemma [5, 6].

Restricting the movement of patients involves physically restraining or isolating a patient for the purposes of treatment. Studies that conducted surveys on the ethical concerns of psychiatric nurses suggest that minimizing such restrictions is one of their biggest worries [4, 5, 6]. Some of the studies also presented examples of ethical dilemmas involving restricting a patient’s movement to prevent delirium or water intoxication [9, 10].

In one example of conflict between patients and their families, the family was opposed to the patient’s release from the hospital; in another, an elderly mental-health patient’s family did not want to inform the patient that cancer had also been detected. In such cases, nurses who respected the wishes of the family more than those of the patient felt trapped in an ethical dilemma [8, 18].

Patient interaction has to do with using the appropriate speech and behavior with patients. The use of coercive behavior or inappropriate speech by nurses toward patients was described as an ethical dilemma. Another point was the need for each treatment provider to reflect on whether his or her own speech and behavior was appropriate in the eyes of the patient [2, 3].

Nurses felt that a lack of communication among treatment providers created an ethical dilemma because it made it difficult for the medical team to reach a consensus regarding the treatment plan for a patient and led to the insufficient sharing of information. This is thought to be affected by the hierarchy-based power relationship between doctors and nurses. It is also considered to be a result of the insular nature of psychiatric hospitals in Japan [5, 6].

Research focused on clarifying the ethical views and sensitivities of psychiatric nurses has indicated that while such nurses are highly concerned about nursing ethics, they have low levels of awareness about the topic—few have actually read a code of ethics, for example. In addition, the ethical behavior expected of psychiatric nurses included “respecting the human rights of patients (respecting their wishes),”“fulfilling duties and taking responsibility,”“protecting the rights of patients,” and “caring (showing respect and gratitude to patients).” Both employment position and level of training were suggested as factors that influence this sort of ethical behavior [12, 14, 16, 17].

The research discussing methods for solving the ethical issues in psychiatric treatment noted that ethics conferences and case-study groups are effective ways of resolving such problems, as is improving the ethical sensitivity of nurses [19, 21, 22, 23]. Workshops were also mentioned as an effective means of increasing the ethical sensitivities of nurses [20].

Research into ethical issues in psychiatric treatment from the patient viewpoint revealed that patients want their nurses to have “good personalities” and to be “respectful to their patients [24, 25].”

Conclusion

Ethical issues of psychiatric nursing in Japan originated from problems unique to psychiatric treatment. On the other hands ethical issues caused unique to Japan’s psychiatric treatment system and some of Japan’s cultural aspects influence ethical issues in psychiatric treatment. Thus, it is essential that psychiatric nurses understand their own culture and maintain an ethical view as members of the nursing profession.