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A Pilot Study of Selected

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 Nursing Ethics
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A Pilot Study of Selected Japanese Nurses' Ideas on Patient Advocacy

Anne J Davis, Emiko Konishi and Marie Tashiro
Nurs Ethics 2003 10: 404
DOI: 10.1191/0969733003ne621oa

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 A PILOT STUDY OF SELECTED
JAPANESE NURSES’ IDEAS ON
PATIENT ADVOCACY
Anne J Davis, Emiko Konishi and Marie Tashiro

Key words: Japan; morality; nursing advocacy

This pilot study had two purposes: (1) to review recent Japanese nursing literature on
nursing advocacy; and (2) to obtain data from nurses on advocacy. For the second
purpose, 24 nurses at a nursing college in Japan responded to a questionnaire. The
concept of advocacy, taken from the West, has become an ethical ideal for Japanese nurses
but one that they do not always understand, or, if they do, they find it difficult to fulfil.
They cite nursing leadership support as necessary to enacting this role. Discussion on the
meaning of and the rationale for advocacy in a society where goodness or badness is
relative to social situations and its impact may reveal two parallel but overlapping views
of morality. Such a situation would not only influence notions of advocacy but also
possibly render them more complex.

Introduction
Patient advocacy, as a moral good and a professional nursing obligation, has
received much attention in English-speaking countries during recent years. For
example, one author speaks of the core values in nursing as commitment, caring,
compassion, integrity, competence, spirit of enquiry, confidentiality, responsibil-
ity and advocacy.1 At times this attention followed changes in nurse practice law
that made advocacy more of an integral and formal part of an expanded nursing
role in clinical practice. Although not directly stated in these laws, their wording
implies advocacy in the wider context of independent nursing functions. The legal
status of nurses made them professionally responsible for wrongdoings, includ-
ing those instances where someone overrode patient autonomy and caused ethical
harm.
Advocacy became an ethical ideal based on the notion that nurses know
patients better and in a different, more intimate way than other health care pro-
fessionals because they provide continuity of care. Seen not only as a legal require-
ment, advocacy became an ethical obligation in which nurses speak for patients

Address for correspondence: Anne J Davis, 158 Funston Avenue, San Francisco, CA 94118, USA.
E-mail: ajdavis@itsa.ucsf.edu

Nursing Ethics 2003 10 (4) © 2003 Arnold

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 Japanese nurses’ ideas on patient advocacy 405
when a situation calls for such action because of a real or potential ethical problem
that the patient or family cannot cope with alone. Furthermore, if nurses provide
patient centred care, then advocacy most likely becomes part of that care at one
time or another.
This advocacy role originated in legal practice where lawyers spoke for clients
because they could not speak for themselves owing to their ignorance of the law.
More recently, other nonlegal groups have defined themselves as advocates,
including those who advocate for human rights, children’s rights and animal
rights. In each case, these advocacy groups view those being advocated for as
vulnerable and experiencing difficulties with defending their rights against those
who may do them harm. Patients and their families, who are also in vulnerable
positions within the health care power structure, need someone to advocate for
them when they cannot speak for themselves or when others do not hear their
voice. These concepts of vulnerable patients/families and nurse advocates have
received recent attention in the Japanese nursing literature. These concepts arrived
later in Japanese nursing and mostly from non-Asian nursing sources, so this
article examines the Japanese nursing literature and a small selected sample of
Japanese nurses’ views on nursing advocacy.

Purpose
We have a twofold purpose in this article. Advocacy, a core value in international
nursing dominated by western nursing concepts and theories, has come to Japan,
but what advocacy means conceptually here remains unclear. We therefore first
examined the Japanese nursing literature published over seven years (1995–2001)
to detect the nature of and the extent to which nursing advocacy has been dis-
cussed. Secondly, we present the results of a pilot questionnaire study conducted
with a small selected group of Japanese nurses.

Sample and method

Twenty-four graduate student nurses and clinical teachers in an undergraduate
programme at a Japanese nursing college made up this sample. These two
groups, similar in age, educational level and clinical experience, can be treated as
a single sample. Because they have a higher level of education than most nurses
in Japan (who have three years of hospital school education) their responses
cannot be generalized to the total nursing population. However, given the current
developmental stage of Japanese nursing, these people may possibly become
leaders, so their views may help to shape nursing in the future. The sample com-
prised mostly women under 40 years of age with a median of 10 years’ clinical
experience; their educational level reflects their college student or faculty role.
Although most were enrolled in a master ’s programme, five already had this
degree.
For these Japanese nurses, who know the word ‘advocacy’ but may or may not
understand its full meaning, the questionnaire defined advocacy as follows:
Advocacy, originally a legal term, meant that a lawyer spoke on behalf of the

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Nursing Ethics 2003 10 (4)
406 AJ Davis et al.
client. Recently the term has been used in health care. For the purposes of this
research we define advocacy as protecting patients’ rights/benefits, speaking for
the patient, helping the patient make decisions, and protecting the patient’s
dignity and privacy in clinical settings. All questions were on clinical nursing
advocacy for adult patients, including those who are incompetent to make a
decision for themselves.
The questionnaire evolved from six years of research on ethical issues faced by
Japanese nurses.

Literature review on patient advocacy in Japan

In searching the Japanese nursing literature and using the key words ‘advocacy
in nursing ethics’ for the years 1995–2001, we found 20 articles that fell into the
following categories: (1) research (n = 2); (2) commentary/essay (n = 12); (3) case
study (n = 3); and (4) introduction of ideas from western writings (n = 3). All but
one of these articles had been published in nursing journals, with 16 of them
written by a nurse, one jointly by a nurse and a physician, and three by a physi-
cian or ethicist.
The central themes that emerged from a content analysis suggested that the
authors viewed patient advocacy as nursing’s professional role because nurses
have the closest physical and psychological contact with patients. They note that
nurses view patients holistically while others do not. Although these authors
defined advocacy as a nursing function and considered that nurses should be
aware of this ethical obligation, they also noted that many nurses do not have the
skills required to undertake this obligation. Furthermore, they reported that cir-
cumstances in the workplace do not support nurses in enacting this ethical role.
However, owing to recent social changes, assuming this ethical responsibility has
become a social demand according to these authors. They have suggested that a
team approach and system development could help nursing in its advocacy
function because they acknowledge that the physician–nurse power relationship
hinders nursing advocacy.
During the 1990s, four important articles focused on patient rights in Japan.2–5
The major theme was the right to informed consent, which included the patient’s
right to know the diagnosis and prognosis, to choose or refuse treatment, and not
to know the diagnosis and prognosis, so being able to maintain hope. In addition,
these articles discussed the patient’s right to be treated with dignity and the right
to privacy.
From 1996 to 1999, articles were published in the Japanese health science liter-
ature on the protection of patient rights in the form of an introduction to and a
commentary on the subject. This literature does not discuss the unique nature of
nursing advocacy but rather approaches advocacy as an ethical obligation of all
health professionals. Some confusion regarding the meaning of advocacy can be
found in this literature and it does not mention the social context of advocacy,
such as risk taking or institutional constraints.
In 2000, 56 articles written by Japanese authors on patient rights and advocacy
appeared in the professional health care literature. Nurses wrote 11 and nursing
journals published 12 of the total. Patient rights in these articles cover a wide

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 Japanese nurses’ ideas on patient advocacy 407
array of concerns, including the basic rights of all patients and also those of
special, vulnerable patient groups.
Most Japanese people think of advocacy as a legal term, so we examined
selected documents to see if they mentioned directly individual rights as a
concept. The Japanese Constitution, enacted in 1947, states that Japanese citizens
have fundamental human rights. The Health Care Law6 that provides the legal
foundation of health care services for all citizens notes that the principal philos-
ophy of health care provision centres on respect for life and respect for the indi-
vidual; the 1997 amendment recommended that informed consent should be
obtained. The Physician Practice Act7 deals with professional obligations and
states that physicians must not refuse care when patients or family members
request it. This document refers to patient rights only indirectly. The same can be
said about the Nurse Practice Act,8 the law that covers both licensed vocational
nurses and registered nurses. Both categories of nurses have the same legal duties
in Japan. The Code of Ethics for Nurses,9 developed by the Japanese Nurses
Association in 1988, includes a statement about nurses respecting life, dignity and
the rights of people. It also discusses the right to privacy. The Code of Ethics for
Physicians 10 has included such a statement about patient rights only since the latest
revision in 2000.
From this literature and selected document review, we can assume that the
Japanese health professions have an increased focus on advocacy for patients,
given these notions of patient rights and professional ethical obligations, but how
do these ideas of patient advocacy fit into the usual Japanese concept of morality?
This study begins to seek answers to that question.

Advocacy and Japanese notions of morality: the

cultural context
In any discussion about nursing advocacy, a basic question that needs attention
centres on why we think we need to advocate for patients.
Many western nurses would probably answer that the ethical responsibility of
this role focuses on protecting the rights of individual patients and interests in
health care settings. Since the 1980s, articles on advocacy have stated that this
means informing patients about their rights, providing facts about their health
care situation, and supporting them in the decisions they make, so that patients
can act as autonomous moral agents.11 One subtext of advocacy, whistleblowing,
receives some attention in the nursing literature of English speaking countries,
but often does not figure in these discussions on advocacy. People usually
advocate when another person’s individual rights are neglected or violated. If one
person (i.e. the patient) has individual rights, then someone else, such as a nurse,
has attending obligations. What happens, however, when obligations do not pre-
suppose this definition of the individual as an autonomous moral agent with
rights but relies on another sociocultural definition of the self?
Japan views individuals as embedded in social relationships. Japanese morality
therefore has a different value base to that of the individual and individual
rights. These basic values of belongingness, empathy, dependency, proper-place

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Nursing Ethics 2003 10 (4)
408 AJ Davis et al.
occupancy, and reciprocity mean that other values such as freedom and indi-
vidual rights do not necessarily flourish alongside those that are considered
important to maintain group harmony. Some authors describe the Japanese people
as extremely sensitive to and concerned about social interaction and relationships
and have labelled Japan as a culture of social relativism. 12 This means that
Japanese people invest much sensitivity, compulsiveness, circumspection and
refinement in the creation or maintenance of smooth and pleasant social rela-
tionships. Such a social investment aims at interpersonal and group harmony as
one of the highest values and ideals in Japan.
Imbued with a sense of harmony and affinity between the supernatural and
natural, between humans and other forms of life, Japanese people have tradi-
tionally seemed indifferent to ontological speculation on the universe and human
existence. Even after exposure to the foreign cultures of China, Korea and the
West, Japan has not changed fundamentally in this regard.13
These dimensions of Japanese culture have implications for the moral life. Japan
has a socially contingent morality in that the moral judgement of an act relies
upon its social effect (i.e. whether it hurts others or not). The clear-cut dualism
of good and bad, right and wrong, so characteristic of the West, is therefore not
congenial to the Japanese sense of morality. Goodness and badness are relative to
social situations and their impact. Essentially, Japanese morality stresses the recog-
nition of human frailty and the necessity for compassion and tolerance.
Traditionally, Japanese people have had no need to systematize moral doctrines
as independent entities given the social anchorage of morality, however, with the
international development of health care ethics receiving more attention in recent
decades, some people have raised concerns about this state of affairs.
For this article, the questions become: How does a select group of Japanese
nurses understand advocacy and their professional role in advocating for patients
and their families? What does that understanding mean within the Japanese
cultural context? It will help us if we remember that, within Japanese culture, not
all Japanese people are identical in their thought and behaviour. As one author
wrote over 30 years ago, the relationship between culture and personality should
be conceived not in terms of the replication of uniformity but of the organization
of diversity.14 Japanese people, like all social groups, exhibit both uniformity and
diversity in their thought and behavior. These mutually contingent characteristics
create a culture of partial cognitive and evaluative overlaps that we call cultur-
ally shared values and norms.

Findings (Table 1)
To discover what these nurses thought about advocacy as part of the nursing role,
we asked them whether Japanese nurses now have an advocacy role and whether
they should have such a role. Nineteen replied that at present nurses in Japan do
have a specific or strong advocacy role and 22 said that, ethically, they should
enact this role. However, most also thought that limits emerging from the social
environment of health facilities do not support nurses in this role.
Two nurses indicated that the patient should assume responsibility for advocacy
and that they should advocate for the patient only if the patient wishes. They

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 Japanese nurses’ ideas on patient advocacy 409

believed that nurses should not push their ideas and values on to patients. The
other 22 said that nurses should advocate for patients: (1) because nurses have
the closest contacts with patients; (2) to protect patients’ rights and interests; (3)
to protect patients from physician paternalism; (4) because of nurses’ respon-
sibility for patients’ holistic health; (5) because patients have a low status in

Table 1 How Japanese nurses perceive advocacy (n = 24)

Response items ‘Yes’ Valid

frequency %a

Nurses’ advocacy role:

Now have role 19 (79)
Should have role 22 (92)
Have experience of been an advocate 19 (79)
Special education/experience:
1) Special education necessary for advocacy 24 (100)
Had such education 7 (29)
Such education available in workplace 8 (33)
2) Special experience necessary for advocacy 23 (96)
Had such experience 12 (50)
Such experience available in workplace 16 (70)
Knowledge for advocacy:
Patient rights 24 (100)
The law 24 (100)
Ethics 24 (100)
Work environment for stronger advocacy:
1) Open communication with patients 24 (100)
My ward had this 16 (67)
2) Open communication with patient’s family 24 (100)
My ward had this 14 (58)
3) Open communication with other disciplines 24 (100)
My ward had this 17 (71)
4) Democracy in general 23 (96)
My ward had this 15 (63)
5) Scheduled team conference 24 (100)
My ward had this 17 (71)
6) Clinical ethics committee 22 (92)
My ward had this 2 (8)
Nurse leadership responsibility to help nurses to advocate:
Has responsibility 23 (96)
Took responsibility 14 (61)
Nurses apt to advocate with team work 16 (76)
a Some nurses did not respond to all questions

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Nursing Ethics 2003 10 (4)
410 AJ Davis et al.

hospitals and also have limited knowledge; and (6) to encourage nursing’s pro-
fessionalism.
Although these respondents did not define the nursing advocacy role as strong,
nevertheless, at times Japanese nurses do advocate for patients and families. Most
(79%) reported that they themselves had been an advocate. When asked about
the extent to which nurses in Japan advocated, they responded as follows: 8%
very often, 63% often, 29% seldom. They believed that nurses advocate in two
ways. First, they advocate in everyday nursing practice by such actions as giving
information to patients and their families, and by relaying information from them
to the physician. The second form of advocacy entails possible risk-taking behav-
iour, for example, if a nurse refuses to give nonbeneficial treatment or intervenes
when a physician gives unethical advice to a patient. Some nurses fear that such
behaviour could damage their relationship with the physician or the relationship
between the patient/family and the physician.
All respondents said that Japanese nurses need more knowledge to be able to
undertake the advocacy role, but most of them also said that they had not had
any special education, nor was such education available to them. According to
them, this knowledge should have a strong focus on ethics, with an emphasis on
patients’ rights and the law. Ninety-six per cent of them added that having expe-
rience in advocating for patients helped them to undertake this role later.
Ethics and advocacy always occur in some social environment, so we asked
about work environment characteristics that supported advocacy. Those listed
included: open communication with patients, families, physicians and other staff
members; democracy in general; scheduled team conferences to discuss patient
and family problems; and clinical ethics committees to deal with everyday
advocacy issues. Although, almost without exception, the nurses viewed these
characteristics as necessary for a social environment that promoted nursing
advocacy, they also added that their workplace lacked them to a large extent.
When reporting on factors that would promote advocacy, the nurses listed the
following (ranked by frequency mentioned): (1) patient centred care philosophy;
(2) physician as colleague; (3) general democratic environment on ward; (4) co-
operative spirit among nursing staff members; and (5) head nurse supports staff.
All except one nurse said that nursing leadership has a responsibility to help
nursing staff to advocate for patients and families. It is important to note that 14
nurses, or more than half, said the nursing leadership in their work environment
had assumed this responsibility. Seventy-six per cent thought that nurses can more
readily advocate when they work together as a team, which supports their earlier
response that nursing team spirit is the most important factor in speaking for
patients and their families. All of these nurses noted that physicians have strong
authority and that, generally, nurses are younger than physicians in the age-
graded stratified social structure of Japan. They therefore realize their vulnerable
position in the organizational structure of health facilities. They believe that,
without nursing leadership support for advocacy, patient care and protection can
become secondary to self-protection.
Regarding a nursing team approach to advocacy, 76% said that this constitutes
a useful and needed way of meeting this ethical ideal. The other respondents said
that, although nurses sometimes need team power against a stronger counter-
power, too much reliance on team action can hinder a variety of opinions from

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 Japanese nurses’ ideas on patient advocacy 411

arising, which may blind nurses to patients’ need for advocacy. They believed
that individual nurses can act alone and that this better protects patient privacy.
See Table 1 for a summary of these findings.
In summary, for the most part, these nurses view patient advocacy as ethical
action that should be part of the professional nursing role but one that remains
difficult to fulfil owing to the power imbalance between health professionals.
Therefore, many thought it imperative that the nursing leadership should lend
support to nursing advocacy for patients and families. Although they saw this as
necessary, they also thought that such support typically did not emerge in most
clinical situations. Owing to individual nurse vulnerability, they believed the team
approach would function best, but it was recognized that such an approach also
had limitations embedded in it.

Discussion
Traditionally, morality in Japan has combined values from Confucian thought, the
native religion, Shinto, and Japanese Buddhism. Together, these value sources
promote a group orientation and the virtues that maintain group harmony. These
foundational sources led to the development of a socially contingent morality that
relies on an act’s social effects to determine its goodness or badness. Yet the
Japanese nurses providing these data seem to rely on notions of patient rights as
the rationale for nursing advocacy. How can the concept of universal individual
rights, which draws its ethical sources from philosophical principles and there-
fore from outside a given immediate situation, fit into a socially contingent
morality?
One possible answer to this question is that viewing ethically each situation by
itself does not necessarily preclude the use of ethical principles from outside that
situation. Perhaps these nurses can see the social dynamics of a patient’s situa-
tion while at the same time keeping in mind notions of that person’s rights. In
other words, rather than using either elements of a socially contingent morality
or ethical principles from outside the situation, nurses use a combination of the
two. Socially contingent morality and ethical principles that transcend the situa-
tion may seem mutually exclusive to westerners, but they may not seem so to
Japanese people. Socially contingent ethics and principle based ethics may find
areas of overlap in a Japanese world-view.
Another possible answer to this question points to the fact that numerous
clinical nurses in our previous research on end-of-life ethics commented on the
problems that a socially contingent morality can create for patients and, at times,
for families. 15–18 With these socially contingent ethics problems in mind, they
perceive a rights based ethics as a means to solving these problems. If others,
such as families and physicians, view these two approaches as mutually exclu-
sive, then these nurses go against the cultural and morally defined norms. If this
is the case, nurses may be advocating for actions that are unacceptable to those
who are socially embedded in a specific situation. Although one suspects that few
people, including nurses and physicians, actually conceptualize ethics, they do
know when a disagreement about the right thing to do arises that leads nurses
to think they should advocate.

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Nursing Ethics 2003 10 (4)
412 AJ Davis et al.

Yet another possible but perhaps not as feasible an answer to the question may
stem from the influence in the English language books and journal articles so
often used in nursing education in Japan. A well-stocked college or nursing
library here includes books and journals written in Japanese and others in English,
and those originally written in English and translated into Japanese. Western
values and ethics, often not stated directly, fill these English language professional
readings.
A final but least likely explanation of the findings is that these nurses may not
have a deep understanding of nursing advocacy or its possible impact on sociol-
ogy and ethics in ethically problematic health care situations. Although advocacy
remains to some extent an ideal enacted best under conditions of nursing lead-
ership support, it also retains the possibility of two parallel overlapping views of
morality. Such a situation would not be the first time that the Japanese have
borrowed and incorporated from another culture while maintaining their own
cultural traditions. This and other possible meanings of nursing advocacy need
future exploration.
To gain a more detailed understanding of what nursing advocacy means to
Japanese nurses, and how they see this role enacted within the norms of Japanese
socially contingent morality, we require more comprehensive research using in-
depth interview techniques. The present study, limited to questionnaire data, has
raised these questions and suggested possible answers. A further study could now
build on these data to probe for the clearer meanings that nursing advocacy has
for nurses in Japan.

Anne J Davis, Emiko Konishi and Marie Tashiro, Nagano College of Nursing, Komagane,
Japan.

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