In the field of pediatric nursing, in the perinatal period, numerous ethical issues arise alongside the advancement of medical technology. However, sufficient education on bioethics is not provided in the pediatric nursing domain of basic nursing education. The purpose of this research is to examine the current status of bioethics education in the pediatric nursing domain of basic nursing education and explore the challenges perceived by the pediatric nursing faculty regarding bioethics education. The research method was a questionnaire survey on 100 randomly selected pediatric nursing faculty members from nursing universities across Japan. The results revealed that although bioethics issues were considered important, the emphasis remained primarily on addressing bioethics as part of nursing that respects children’s rights. Furthermore, respondents expressed difficulties regarding teaching methods and content related to bioethics.
As medical technology continues to advance, ethical challenges in the realm of bioethics are on the rise, particularly within the field of pediatric nursing. Presently, pediatric nursing is founded on the principles of pursuing the best interests of children in the healthcare setting, as defined by the United Nations Convention on the Rights of the Child, which enshrines children’s rights. However, due to the nature of the physical and psychological development of children during their formative years, respecting their preferences and prioritizing their choices regarding treatment and procedures can be challenging, often leading to a conflict between adherence to children’s rights and practical decision-making.
Furthermore, the increasing prevalence of severely physically and mentally disabled children presents even greater complexity, as expressing their own preferences becomes considerably more challenging due to their physical conditions. This poses the difficult question of what constitutes the “best interests” of such individuals. Recent legislative changes, such as the 2010 amendment to organ transplant laws in Japan, have made it possible to obtain organs from children under 15 years of age with family consent in cases where their own consent is unavailable, thereby sparking various debates. Thus, bioethical issues can arise across a wide range of age groups, but they have a particularly profound impact on the landscape of pediatric healthcare.
Ethics education within the current nursing foundational curriculum is often limited to lectures and codes of conduct [
In response to this situation, efforts have been made within pediatric nursing education to address topics such as laws, treaties, guidelines related to children’s rights, evolving perceptions of children, the rights of children in healthcare, child abuse, and more. Additionally, initiatives have been undertaken to incorporate conferences during pediatric nursing practicums, providing students with opportunities to recognize the importance of exploring children’s rights and ethical dilemmas [
However, it is noteworthy that more than half of the educators in the field express dissatisfaction with the current state of education concerning child rights advocacy [
Given this context, this study aims to examine the current status of bioethics education in the pediatric nursing domain of basic nursing education and explore the challenges perceived by the pediatric nursing faculty regarding bioethics education.
To collect data for this study, the following methods were employed:
• Utilizing the list of member universities of Japan Association of Nursing Programs in Universities (JANPU), 100 universities were randomly selected.
• A document requesting cooperation in this research and providing access to the web-based survey (conducted using SurveyMonkey) was sent to these universities.
• Only pediatric nursing faculty members who approved the contents of the document were invited to access and complete the web-based survey.
• Responses were collected anonymously and using a free-text format.
The questionnaire included the following items:
1) How many years of experience do you have in the field of pediatric nursing education?
2) Currently, what type of courses do you teach?
3) Does your current university offer courses related to bioethics in the field of pediatric nursing?
• If yes, please provide detailed information about the content, methods, target student year, and class size of these courses.
4) Have you been involved in teaching bioethics in your previous experiences in nursing foundational education, including lectures, exercises, or clinical training, outside the field of pediatric nursing?
5) Do you encounter any challenges in bioethics education in the field of pediatric nursing?
6) Do you have any particularly memorable experiences related to bioethics education?
7) Regarding bioethics education in the field of pediatric nursing within nursing foundational education, do you believe there are specific content areas that are particularly important?
8) Concerning future bioethics education in the field of pediatric nursing, what are your thoughts or considerations (including challenges, hopes, prospects, methodologies, etc.)?
The data obtained through the questionnaire were subjected to qualitative analysis using the following four steps for each questionnaire item:
Step 1: All responses from the questionnaires were read to gain an overall understanding, and major themes within the responses were identified.
Step 2: Attention was given to opinions, emotions, and experiences expressed by the respondents, and these were categorized.
Step 3: Extracted categories were further analyzed to identify larger themes.
Step 4: The entire questionnaire was interpreted using these themes and categories.
Although this survey was anonymous, an explanation was provided in writing regarding the research’s purpose, content, and methodology during the request for research cooperation. Participation in the research was voluntary, and it was explained that expressing an intent to participate by entering the web survey did not carry any disadvantages. It was ensured that no harm would come to participants even if they chose not to cooperate.
This research has been conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Review Committee of Hyogo University (Approval Number: 21008).
The research cooperation request documents were sent to 100 nursing universities in Japan, and responses were received from 40 faculty members. The breakdown of respondents based on their teaching experience is shown in
As shown in
As indicated in
As shown in
| Experience in Nursing Education | Number of Respondents |
|---|---|
| 1 - 5 years | 4 |
| 6 - 10 years | 6 |
| 11 - 15 years | 7 |
| 16 - 20 years | 12 |
| >20 years | 11 |
| Total | 40 |
| Category | Subcategory | Specific Examples |
|---|---|---|
| Class year | 1st year (1)a, 2nd year (17), 3rd year (6), 4th year (2) | |
| Classes covered | Introduction to pediatric nursing (8), practicum (6), nursing ethics (medical ethics) (5), pediatric nursing methodology (2), assistance theory (2), bioethics (2), seminar (2) | |
| Class formation | Lecture (17) | |
| Group work (7) | Discussion about finding ethical issues from newspaper articles and other sources, what needs to be done to solve (improve) them, method, and the role of nurses. | |
| Case study (4) | ||
| Conference (4) | Exchange of students’ opinions on ethical situations. | |
| Report submission (4) | ||
| Practical training/exercise (4) | Faculty members make students aware of the need to consider bioethical perspectives regarding the patients they receive during their practical training. | |
| Details | Ethical issues and challenges in pediatric nursing (7) | |
| Rights and dignity of children (6) | Living like a child and what it means, the child’s right to life, growth, and development, etc. | |
| Children with congenital diseases and disabilities and their families (5) | ||
| End-of-life and palliative care (4) | ||
| Prenatal diagnosis (2) | ||
| Organ transplantation and decision-making (1) | ||
| Abuse/suicide (1) |
aNumbers in parentheses indicate number of respondents.
| Category | Subcategory | Specific Examples |
|---|---|---|
| Classroom methods and techniques | Difficulties in teaching and communicating (4)a | How to communicate to students who do not yet have much experience. |
| Communicate to promote visualization. | ||
| Feeling limitations because of expertise required. | ||
| There are many absolutes in bioethics that are difficult to communicate. | ||
| Methodology concerns (3) | Cases addressed tend to be abstract and sentimental. | |
| Discrepancy between theoretical knowledge and reality. | ||
| No teaching experience dealing with bioethics. | ||
| Limitations | Insufficient time (4) | Insufficient time for lectures. |
| Practical training period does not deepen learning to the point of considering bioethics. |
aNumbers in parentheses indicate number of respondents.
| Category | Subcategory | Details |
|---|---|---|
| Location/place | Practical training (6)a, exercises (1) | |
| Opportunity | Conferences (3), lectures (1), prenatal diagnosis (1), common routine procedural situations (1) | |
| Subjects | Children (4), critically ill children (2), terminally ill children (1) | |
| Theme | Children’s rights, consideration for children (5) | Ethics in prenatal diagnosis. |
| Happiness for severely ill children who cannot exercise their will. | ||
| Student perceptions and statements about children. | ||
| Terminally ill children, the right to life and the right to die for severely mentally and physically handicapped children. | ||
| Student awareness and learning (4) | The importance of daily life and nursing care through the death of a child patient. | |
| Awareness of ethical issues in routine procedural situations. | ||
| The question of how you would handle the situation if you were a ward nurse. | ||
| Realizing that you are actually in contact with children. |
aNumbers in parentheses indicate number of respondents.
In response to the question about what they consider important in bioethics education, approximately one-third of the respondents (13 individuals) emphasized children’s rights and human rights, as shown in
| Category | Subcategory | Specific Examples |
|---|---|---|
| Human rights and dignity | Human rights and rights of children (13)a | Respect for children’s rights and self-esteem. |
| How children’s rights are reflected in the pediatric nursing setting. | ||
| The right to know the origin of the child. | ||
| Understanding the perspective of the child’s own experience. | ||
| Be child-centered. Do what is best for the child. | ||
| Ethical education that values all children. | ||
| Nursing care for the dignity of children. | ||
| Self-determination (6) | Who makes the decisions and how to support them. | |
| Position of the child who is unable to make self-determination. | ||
| Respect for the child’s wishes, parents’ thoughts and ideas, procedures that cause pain, treatment, restraints, etc. | ||
| Rights and dignity of children with disabilities and illnesses (3) | The rights of severely disabled children. | |
| How to protect the dignity of the child in the nursing care of children with disabilities. | ||
| Nursing care for children with birth defects or diseases that require medical treatment. | ||
| Children and families | Thoughts of the family (5) | Parent-child disagreements about self-determination, support for consent, transplantation medicine, etc. |
| Best interests of the child and family (3) | Sensibility to protect the best interests and logical thinking to figure out how to do it. | |
| Bioethical thinking | Understanding the value of life (5) | Thinking seriously about life. |
| The value/importance of life. | ||
| That it is never only when life is nearing its end that we consider bioethics. | ||
| Various issues such as abuse, abortion, bullying, suicide, end of life, etc. | ||
| Ability to think, keep thinking (3) | Students should expand their ideas through group discussions that include other faculties. | |
| Understand the need to think about this on an ongoing basis. |
aNumbers in parentheses indicate number of respondents.
Regarding their perception of their own challenges in bioethics education (shown in
| Category | Subcategory | Specific Examples |
|---|---|---|
| Teaching methods and constraints | Improvement of teaching methods (8)a | Lectures by lecturers with high expertise. |
| Learn lecture content in depth onsite, not online. | ||
| To help children understand the world they are experiencing, and to construct teaching materials and educational methods for this purpose. | ||
| Education that incorporates practicum. | ||
| Multiple case understanding and care review are handled in the same unit and shared with the entire class. | ||
| Thinking by example, use of various media such as film and YouTube. | ||
| Conducted child rights conferences with clinical experts. | ||
| Careful selection of content to be covered specifically in pediatric nursing. Engagement and guidance to carefully connect what is learned in lectures with what is learned in practical training. | ||
| Take time to cover bioethics in class and practice (3) | To cover as much as possible in class or practice, even if you don’t have time. | |
| Want to share with the clinical staff but cannot do so because of the length of the conference. Want to be involved in ward cases but cannot go to the wards in a timely manner. | ||
| To educate in classroom and practical training with an awareness of children’s rights (currently there is not much awareness of bioethics). | ||
| What to communicate | Communicating about respect for the will and rights of the child (4) | Want to tell them that living is a child’s right to be respected, but that it has been put on the back burner because of parental wishes. |
| That the child’s wishes can be respected and that their health is protected, and the family should be supported in a better direction. | ||
| To convey the importance of continuing to think (3) | Bioethics is something we will continue to think about as we continue our nursing careers. Want to be involved in classes and practical training in a way that will make people continue to think about it and be interested in it. | |
| Nurses often find themselves caught up in the demands of their work, attempting to justify their actions with the belief that “the best for the child equals efficient medical care”. Hope that nurses take a moment to pause and reflect, questioning whether their actions truly align with the best interests of the child. | ||
| To continue to think about what it means for the child, for the family, and for the medical professionals around them. | ||
| Students’ own growth | Fostering ethics and thinking skills (3) | To communicate about medical care, end of life, restraints, and other questions that should be asked in the development of ethics. |
| To consider nursing ethics from the perspective of not only bioethics but also nursing ethics, and to help students think about the role that nursing takes in team medicine. | ||
| Classes that allow each student, with little experience in the field, to think about the subject matter as their own. Creating opportunities to make students think in exercises and practical training situations. | ||
| Others | Other (3) | Considerations for students (e.g. recalling past experiences). |
| Basic education is not enough; clinical education is needed. |
aNumbers in parentheses indicate number of respondents.
Based on the survey results, it has become evident that in the field of pediatric nursing, many educators consider it important to teach the necessity of respecting children’s rights, especially their right to self-determination. They also view their teaching methods and content as areas for improvement. This discussion will explore the survey results, incorporating specific quotes from the respondents.
As mentioned earlier, many respondents consider the teaching of nursing that respects children’s rights to be of utmost importance in bioethics education. On the one hand, nursing that respects children’s rights places a strong emphasis on recognizing children as individuals with independent rights. It values children’s opinions and emotions, striving to keep children as comfortable and safe as possible during treatments. This approach includes providing information and obtaining consent, offering psychological support, ensuring physical comfort, involving families, and catering to individual needs. On the other hand, bioethical consideration for children involves a broader application of universal ethical principles (autonomy, non-maleficence, beneficence, justice, etc.) to all patients, including children. While considering children’s needs, it also takes into account broader ethical aspects of medical procedures, such as the appropriateness of treatment, patient autonomy, and justice among stakeholders. Bioethical consideration for children provides a comprehensive framework for addressing ethical dilemmas and encompasses a wide range of issues, including clinical judgments, resource allocation, and meeting the needs of diverse patient populations.
Both nursing approaches, those that respect children’s rights and those that consider bioethics, share a common goal of pursuing the best interests of children. However, this shared goal raises new questions about what constitutes the best interests of children. In the survey, a respondent provided the following insight under the question about challenges in bioethics education:
“I think about what is best for the child. However, sometimes what I think is best for the child may prioritize the convenience of healthcare providers. For example, the idea that ‘it would be better for the child to not explain but quickly complete the procedure, resulting in less pain for the child’, can be a convenient perspective for healthcare providers, but it takes away the opportunity for the child to try their best to be patient. It is important to recognize that in pediatric nursing, things often take time, but as nurses become busier, they may justify the idea that ‘what is best for the child equals smooth medical care’. However, I hope nurses will become individuals who stop and reconsider whether that is truly in the best interests of the child. During practical training, I set aside time for an ethics conference to think about what is in the best interests of the child and discuss it.”
The foregoing quote highlights the challenge of whether current nursing and nursing education personnel unintentionally create favorable conditions for healthcare providers by using the term “the best interests of the child”. This respondent raises the important point that healthcare providers need to recognize the depth of ethical considerations in pediatric nursing, particularly when there are no clear-cut answers. This ethical dilemma requires students and healthcare professionals to engage in reflective ethical thinking. The best interests of children in healthcare extend beyond just medical treatment. It involves considering the overall quality of life and happiness of children comprehensively. Therefore, healthcare providers must support decision-making processes that aim to maximize children’s health and well-being. Even procedures such as blood draws should be critically examined to ensure they are truly in the child’s best interests, and this critical thinking should be instilled through nursing education.
In this survey, many responding educators indicated that they presented cases during lectures and engaged students in group work and report writing. Furthermore, there was a strong reflection of educators’ belief that merely teaching general theories in lectures is not sufficient. They expressed the need to incorporate experiences from practicum cases into conferences and other activities.
To bridge the gap between theory and practice, it is possible to utilize real-life cases or hypothetical scenarios, allowing students to analyze problems from different perspectives. This enables students to learn how to apply theoretical knowledge to specific situations. Through discussions based on actual cases, students can experience decision-making processes when faced with complex ethical dilemmas. This goes beyond theoretical knowledge, helping students develop practical problem-solving skills.
Handling real cases also allows students to gain a deeper understanding of the patient’s perspective and cultivate emotional empathy, which is crucial in providing patient-centered care. By applying theoretical ethical principles and guidelines to actual clinical situations, students can understand how these concepts impact real decision-making.
Addressing ethical challenges related to pediatric nursing through case presentations provides students with valuable knowledge and fosters problem-solving skills. However, in the survey, a respondent described case presentation as follows:
“For children’s rights, it tends to become abstract and sentimental episodes, and while the importance of bioethics is understood, it is not being addressed in specific learning.”
When using cases related to bioethics, such as parental refusal of treatment, organ transplantation, or disclosing terminal conditions to children, the situations directly touch upon life and death, and values, making them memorable but potentially overly sentimental. In short learning sessions, students might only be left with the impression of confronting such realities without deeper understanding.
It is important to be aware of these ethical issues related to life, which can be addressed as social problems, and to deepen one’s individual thoughts on these issues. However, it is also necessary to conduct research on ethical issues that are more routine, often involving nurses and persisting in the daily lives of patients. Ethical issues that persist involve small decisions integrated into the individual lives of the patients in question, and they may go unnoticed by others [
When providing cases for bioethics consideration, it is crucial for educators and students to engage in educational dialogue through cases. Reflecting and deepening learning through this dialogue is essential.
According to the survey results, some educators recognize the challenge of allocating sufficient time within the nursing foundational curriculum but still consider it quite a task to incorporate even a small amount of time for discussing ethical issues and connecting them to clinical practicum experiences. They emphasize the importance of continuous reflection as well as making students realize the significance of ongoing critical thinking.
“In lectures, we discuss case scenarios and stimulate students’ ethical perspectives to increase readiness, but during practicum, the duration is short, and we cannot reach the depth of learning where students contemplate life ethics.”
“Regarding life ethics, I think students should continue to ponder throughout their nursing career. I hope to provide lessons and interactions during courses and practicum that will make them interested and willing to continue thinking.”
It seems that there are limitations to what can be taught within the scope of courses subject to evaluation. However, it is essential to convey the importance of continued reflection, especially during the basic nursing education stage. Education on life ethics should not be a once-off one-time occurrence but rather an ongoing process of learning and reflection. Even if students cannot put their learning into action in the actual clinical practice setting, continuing their learning can lead to the development of students who can make ethical judgments and provide support in various situations [
It is crucial for nurses to continually contemplate ethical issues and engage in lifelong learning throughout their careers. Basic nursing education should focus on enhancing students’ sensitivity to life ethics, ensuring that it carries forward into their future endeavors.
The results of the nationwide survey conducted among educators in the field of pediatric nursing revealed the significance of addressing bioethics in basic pediatric nursing education. Educators emphasized the importance of nursing education that: 1) respects children’s rights and incorporates bioethics education, and 2) aims to pursue the best interests of children.
Furthermore, the survey shed light on the challenges faced in bioethics courses, including: 1) the difficulty of integrating theory and practice using case studies, and 2) the importance of continuous reflection and increasing sensitivity, highlighting the complexity of teaching methods.
The response rate for this survey was 40%. One contributing factor to the relatively low response rate may have been the timing of the survey, which coincided with the period when most universities were conducting specific practicum sessions for various nursing fields, creating a busy period for educators. Originally, interviews with nursing educators were planned for this research, but due to the challenges posed by the COVID-19 pandemic, the methodology was changed to a web-based survey, which may have presented difficulties, including open-ended questions that were not easy for respondents. In the future, conducting interviews with educators will be considered to delve deeper into the subject.
We would like to express our heartfelt gratitude to all the educators who understood the purpose of this research and cooperated with us.
This manuscript was supported by JSPS KAKENHI, Grant Number JP20K19154.
The authors declare no conflicts of interest regarding the publication of this paper.
Nemoto, J., Kubota, C. and Yoshikawa, Y. (2024) Challenges of Bioethics Education in Pediatric Basic Nursing Education: A Faculty Perspective. Health, 16, 105-117. https://doi.org/10.4236/health.2024.162010