Download The Japanese Value of Harmony and Nursing Ethics

The Japanese Value of Harmony
and Nursing Ethics
Emiko Konishi, Michiko Yahiro, Naoko Nakajima and Miki Ono
Key words: Confucianism; ethics education; harmony; Japanese traditional value; seniority
system; workplace harmony
Harmony is one of the most fundamental Japanese values. It is derived from Confucianism
and encompasses a state of mind, an action process and outcomes of the action. This article
draws on research data and discusses Japanese nurses’ perceptions of harmony as reflected
in their everyday practice. The most important virtues for these nurses were reported
as politeness and respect for other persons. The outcome from the nurses’ harmonious
practice, it is claimed, benefited patients and created peaceful, harmonious relationships
for all. Because of the unique link between harmony and the location of interaction,
the ideal ‘workplace harmony’ threatened some nurses’ professional decision making.
These nurses confused harmony with conformity by superficial agreement. The Japanese
seniority system could be a major factor contributing to this problem. Ethics education that
includes traditional values and concepts in Japanese culture is strongly urged.
Introduction
The flow of knowledge and values in nursing has long been almost exclusively one
way from the West to other parts of the world. This phenomenon has raised questions
about the confusion of value orientations among non-western nurses whose professional socialization is heavily influenced by western culture and whose personal and
clinical life depends on their own traditional culture. The nursing literature urges
the clarification of values that constitute the deep structure of non-westerners’ ethnic
collective unconscious in order to clarify the differences between western and nonwestern cultures.1–3 Taking Japan as a case in point, this article discusses harmony, one
of the most fundamental Japanese values, and its implications for nursing ethics.
Confusion of value orientation among Japanese
nurses
Many nurses in Japan perceive ethics as a difficult, abstract and remote discipline
existing only in books and not having anything to do with their practice.1,4 One factor,
Address for correspondence: Emiko Konishi, Saku University, 2384 Iwamurada, Saku City,
Nagano prefecture, 385-0022 Japan. Tel: +81 267 68 6680; Fax: +81 267 68 6687;
E-mail: [email protected]
Nursing Ethics 2009 16 (5) © The Author(s), 2009.
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10.1177/0969733009106654
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E Konishi et al.
among others, contributing to this perception is that Japanese nursing education is
heavily influenced by western culture. Concepts such as patient autonomy, individual
rights and advocacy are translated from English into Japanese and taught in nursing
ethics or bioethics classes.5 Although many people in the West espouse the philosophy
of liberalism that separates self from the other, people in Japan historically share the
philosophy of relationship with many other East Asian countries, in which the self is
viewed as part of a larger whole consisting of groups and relationships.1,6 Although
the world is rapidly becoming borderless, values such as togetherness, harmony, politeness, modesty and reverence for senior people still remain in Japan to differentiate its
ethics from western ethics. Although there are ethical universals, culture gives them
shape and emphasizes that difference. Every culture deals with ethics of the individual
and ethics of the group, but the emphasis differs. For example, the USA draws on
Eurocentric ethics and cultural values but many US citizens do not have a European
cultural background. One size of ethical thinking and acting does not fit all. How can
health professionals deal with ethnic diversity and ethical universals that are mostly
western in nature? This situation is compounded by the fact that ethics is often now
discussed in clinical ethics or research ethics committees and each committee has a
culture of its own.
The health care arena where nurses interact with patients, families, doctors, nurse
colleagues and other professionals is a miniature Japanese society, with its traditional
culture and value sources. In order for nurses to fulfill their role in this arena as morally
good beings and ethically right professionals, culturally appropriate language and
concepts must be clearly articulated. Against this background, we have launched a
culturally sensitive exploration of values that reside in Japan. Harmony is one important Japanese value, among others, and is the focus of this article.
Harmony is explored in two steps. The first step reviews the literature to clarify the
meaning of this concept and to provide an overview of how it is discussed in Japan
today. Using two sources, the second step sheds light on Japanese nurses’ perceptions
of harmony as reflected in their everyday practice: (1) data selected by the authors from
larger studies that focused on ethics in Japanese nursing practice7–10 (Appendix 1); and
(2) a case study seminar with nurses.
Harmony in literature
Dictionary definitions
The Japanese term for harmony is Wa and it has several meanings, including: (1) keeping a good relationship or getting along; (2) reaching a peaceful agreement, or conflict
between people being settled; (3) being in a good balance between two poles; (4) a
peaceful and gentle state of mind needed for actualizing the above three characteristics: (5) joining a person in reciting: (6) the sum of numbers or other mathematical
components; and (7) a Japanese style, such as Wa-food, Wa-clothes, and Wa-room.11–14
These meanings, overlapping with each other, suggest that the Japanese term harmony denotes at the same time a state of mind, an action process and the outcome of
the action.
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Historical background
Harmony as a Japanese ethical concept derives from Confucianism,3,13–16 the characteristic Asian ethics focusing on relationships. Yet a primitive sense of harmony already
existed in Shinto, the Japanese indigenous religion. To live a simple life in harmony
with nature and people has been and continues to be one of the most characteristic
themes in Shinto.3,16–18 When Confucianism was introduced in the fifth century CE from
China, it was well accepted in Japan. It has had a great influence on Japanese thought
over these many centuries.3,16,19,20 Social harmony is the great goal of Confucianism. It
teaches that harmony means working politely and keeping a good relationship in a
group, with full appreciation of the uniqueness of all members to reach the goal: goodness, peace and the growth of all members involved.13,19,20 It says:
Of the things brought about by the rites, harmony is the most valuable. Of the ways of the
Former Kings, this is the most beautiful, and is followed alike in matters great and small,
yet this will not always work: to aim always at harmony without regulating it by the rites
simply because one knows only about harmony will not, in fact, work (p. 61).21
This means that, according to the ancient kings, harmony is an excellent quality.
However, if people rely entirely on harmony without regulating it by the beauty of
rituals or politeness they become incapable of action. Rites or politeness and harmony
are, therefore, inseparably linked. This idea has influenced Japan for many centuries
and remains a central value.
Confucianism also emphasizes the difference between Wa (harmony) and Doh
(conformity by superficial agreement) by saying: ‘The great man agrees with others
without being an echo. The small man echoes without being in agreement (p. 122).’ 21
This means that a virtuous person acts harmoniously, but a non-virtuous person just
conforms by superficial agreement, goes along with everyone else and does not express
any other ideas so as not to ‘rock the boat’.13,20
Prince Shotoku (574–622 CE), the foremost governor and philosopher in early
Japanese history, laid the foundations for the rise of stable political and economic
systems by emphasizing harmony. Inspired by Confucius’ teaching and Buddhism,
he promulgated the 17-article constitution. Rather than as laws in today’s sense, this
document is viewed as one of the earliest moral documents in history.16,22 The first
article states:
Harmony is most valuable; not to contradict others is most essential. Everyone has biases
and few are far-sighted. Hence some disobey their lords and fathers and maintain feuds
with the neighbors. However, when the superiors are in harmony with each other and the
inferiors are friendly, affairs are discussed quietly. Once consensus is formed anything
could be accomplished (authors’ trans. from Nakamura (p. 409)23).
To unite the nation experiencing conflict among different social ranks, Prince
Shotoku contended that harmony does not mean that inferiors obey when superiors
take different opinions. Rather, it is moral guidance for maintaining the social
order.16,22–24 Along with Shotoku’s many other cultural and political achievements, his
idea of harmony has kept him in the public’s high esteem until today.
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Pellegrino25 states that every culture has a notion of the virtuous or paradigm
person, real or idealized, who sets the standards of virtuous conduct for a culture and
whose character traits exemplify the kind of person others in that culture ought to be
or emulate. These paradigm persons are celebrated in myths and stories, poetry and
ritual.25 Prince Shotoku is an example of a paradigm person in Japan.22
Discussions about harmony in contemporary Japan
In everyday life, Japanese people frequently talk about Shotoku in association with
harmony. His 17-article constitution is cited in many books, including children’s textbooks; however, the focus is only on the first sentence of the first article: ‘Harmony is
most valuable.’ The remaining clauses are rarely mentioned.
In philosophy, education and sociology, harmony is much discussed in connection
with social problems in Japan. Confucius’ caution ‘not to confuse harmony with conformity’ is frequently referred to.13,15,16,24,26,27 Takagiwa26 defines Japan as a ‘harmony
society’ and points to problems arising from people’s ‘too easy harmonizing’. These
include: people who avoid confronting serious problems; school children bullying
classmates just because they are different; and Japanese society’s lack of alternative
culturally accepted ways of dealing with diverse social systems. According to this
sociologist, the fact that Japanese people behave in this way can be partly explained by
the homogeneity and a tradition of avoiding unnecessary friction.26
Sakisaka14 analyzed the Japanese concept of harmony by comparing it with Greek
thought. He states that the Japanese term Wa has some similarities with Greek terms
such as coinonia (relating to people), symmetria (being symmetrical), harmonia (harmonizing) and homonoia (agreeing), but these Greek words have more logical or
reasoned meanings. Wa, by contrast, connotes more emotional, mild and sentimental
interpersonal closeness. When harmonizing, Greek people use reason, whereas the
Japanese use sentiment and try to fit themselves with people around them in order
to make a ‘good’ relationship, with vague definitions of the good. When discussing
harmony in Japanese society, it is necessary to clarify what this good means.14
Researchers of Japanese nursing often focus on nurses’ clinical competency.
Although some of the themes from such studies may be conceptualized as harmony,
the authors do not use this term.28,29 It may be that both the clinicians in the studies and
the researchers who observed their practices were not conscious of this concept. An
exception is Minami, who comments that the characteristics of the Japanese nurses’
clinical competency in these studies can be explained by the concept harmony.30 She
contends:
According to Sakisaka,14 harmony in the west could be said to be more logical and it may be
described as reasoned harmony whereas Japanese harmony has its base in people’s heart
or emotion. We harmonize by touching the other party’s heart ... As in the west, harmony
in Japan appreciates the uniqueness of each person, but what makes the Japanese harmony
unique is harmony beyond the person. In other words, Japanese people emphasize harmony in the place where they interact. Therefore, when Japanese people go to a new place,
they ponder how to behave so as to fit themselves with the place ... I value harmony but
what I mean by that is the feeling that my energy field (Ki in Japanese) is in tune with
that of the other party, which makes me comfortable. Therefore, I think that harmony is a
product of this kind of interaction (pp. 301–303).30
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Minami, the current (2005–2009) ICN president, posted ‘Harmony’ as the ICN
watchword at the ICN 2005 quadrennial conference in Taipei.
Japanese nurses’ perceptions of harmony
‘Workplace harmony’ and some nurses’ conformity
We admire Minami’s insight, particularly about the link of harmony with place. The
Japanese workers’ ideal ‘workplace harmony’ is one example of this link. However, what
her comments seem to have missed is the Confucian caution ‘not to replace harmony
with conformity’. In our larger study focusing on moral certainty and uncertainty in
Japanese nurses7 (Study 1: Appendix 1), one nurse told a story:
The patient had an intravenous infusion but the body was so swollen with edema that
the infusion fluid was leaking from the site of the needle. The family had requested that I
do something about this problem. However, the physician’s order was to continue the infusion, which I thought was not good for the patient. The patient was silent all the time but
his face was distorted, seemingly with pain. The infusion should be reduced, I thought,
but if I resisted the doctor, I was sure that he would become furious, and this would affect
my nurse colleagues. So I could do nothing but to follow the doctor’s order. I then went
to the patient’s family to suggest that they should ask the doctor to deal with the problem
(p. 300).7
At the end of the interview, this nurse commented, ‘I am working with many
question marks in my mind all the time.’ 7
In addition to relationships with physicians, nurses acknowledged similar problems
in relation to senior nurse colleagues. In our dialogue with clinical nurses, a junior
nurse shared an episode:
When we moved to a new unit, we noted that the nursing care in that unit was inefficient,
uncomfortable for patients, and burdensome to nurses. So we proposed another way
that our former units employed. However, a senior nurse rejected the idea saying in a
harsh tone that this was the traditional way in the unit. Although most of the staff there
thought that our idea was better, we could not say anything further to this colleague. The
traditional way continued but as soon as this nurse was moved to another unit, our new
idea was implemented.
These stories indicate that nurses are often in disagreement with physicians, senior
nurses and institutional rules. In such situations, some nurses would accept these
authorities’ instruction in order not to disturb the collegial relationships in the workplace. This can mean that the ideal ‘workplace harmony’ threatened these nurses’
professional decision making. At the same time, some uneasy feelings remained in
these nurses. In one of our other studies, ‘The Japanese nurses’ perceptions of the
good nurse’10 (Study 3: Appendix 1), a nurse blamed herself by saying: ‘Because of my
personal character, I tend to avoid confrontations with physicians or senior nurses. I
may be a self-centered bad nurse rather than a patient-centered good nurse.’ (p. 29).10
What is seen in this nurse is friction between her character, including her idea of
harmony, and the learned ideal of patient centeredness.
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Literature focused on Japanese nurses’ ethical dilemmas frequently discusses similar
situations in which nurses believe that they have no choice but to follow the physician’s,
senior colleague’s or institutional instructions.31–35 Although conformity or any other
related Japanese concepts are not used in these discussions, these phenomena could be
conceptualized as the nurses’ conformity in power relationships.
Other nurses’ perception of harmony in its original meaning
Our research data show that other nurses used harmony in an original Confucian sense.
In our study on the Japanese good nurse described above,10 a junior nurse expressed her
experience when she observed a discussion between her colleague and a physician:
I admire the nurse. Judging the doctor’s order as not acceptable, she proposed an alternative
idea to him. She did not accuse him but stated her position clearly, not emotionally, but
politely and calmly. The discussion reached a peaceful agreement. She was a quiet and
gentle person not only on this occasion. If some other nurses went to the doctor, I doubt
the outcome. I learned that the key is how you discuss (p. 27).10
This nurse noted the following characteristics in her colleague’s action: calm and
gentle personality, polite manner that expressed respect for the physician, clinical competence that enabled her to judge the inappropriateness of the physician’s order and
propose an alternative idea, and discussion skills that led to the goal: patient benefit
and a harmonious relationship in the workplace. These combined elements resulted
in harmony in the original Confucian meaning. In a similar situation, another nurse
stated:
I learn from nurses who protect patients. At times they fight against physicians, but their
‘fight’ is not aggressive and they keep a good relationship. Until recently, technically efficient nurses were my role model but now my role model has shifted to nurses who ‘fight’
while maintaining good relationships with co-workers (p. 27).10
It is obvious that the value of harmony resided not only in the nurses who interacted
with the physicians but also those who observed the interactions.
Harmony also emerged in a situation where nurses interacted with the patient
and the family. During a seminar for practice nurses, the following case study was
discussed.
Case study
Twenty-one-year old Ms A has lung cancer. She is now in the terminal stage of her illness
and has shortness of breath. Ms A has not been told the diagnosis because, while her father
supported the physician’s idea that the truth should be communicated to the patient, the
mother refused the idea. The mother says, ‘She is our only daughter and we have treasured
her. If the truth is told, she will surely be shocked and stop living. She is just a child.’ The
nurses know that Ms A is not a child and time is limited for her. What should the nurses
do and how?
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All the nurses at the seminar were of the opinion that Ms A should be told the truth.
When faced with the next question: ‘How should the truth be told to her?’ everybody
was at a loss. Someone’s idea was to ask Ms A’s father to convince the mother. If that
were possible, the truth would have been told a long time ago. There seemed to be no
answer.
After the meeting, a senior nurse, who had organized the seminar and observed the
discussion, came to us and shared her experience:
I experienced a very similar case. I knew that the mother was in deep distress. I went to
the mother directly and said ‘You are the one who is the most frightened, aren’t you?’
With this remark, the mother burst into tears. The next morning she visited the daughter
with her photo album. The mother and daughter, sitting side by side, traced the patient’s
growth from her childhood in the album in silence. A quiet time passed. Then the daughter
said, ‘Mom, I am sorry that I have to go earlier than you.’ The mother did not deny the
daughter and said, ‘I will soon go to your place too.’ That was the mother telling the truth
to her daughter.
This nurse continued:
I only wished for the patient’s good death by leaving a farewell message to her family.
Language such as truth telling or patient autonomy never occurred to me. The daughter
knew and helped her mother by letting her mother know that she knew. The mother
agreed by what she said.
The calm, reserved and warm atmosphere created by this nurse was most impressive.
What influenced the mother to tell the truth to the daughter was the combination of this
nurse’s wish for the best interests of both the patient and the family, her warm and calm
personality, and her clinical competency because of her sensitivity and communication
skills in particular. This nurse touched the heart of the mother.
Implications
Japan has traditionally valued homogeneity, seniority and avoidance of unnecessary
friction between people. However, as Takagiwa argues, ‘easy harmonizing’ or conforming may be more likely to happen in this society.26 Indeed, in the Japanese health
care system, the ideal ‘workplace harmony’ threatens some nurses’ professional
decision making. In order to act professionally, those nurses need to have a clear understanding of harmony.
Both harmony and conformity aim at maintaining human relationships by avoiding
friction, but these are very different concepts. By conforming, there is only superficial
agreement, no ideas or opinions are expressed and the intention is simply not to disturb
the relationship. The concept of harmony, in contrast, is a higher-goal oriented process,
as well as the result. In this process one takes a lead in a group interaction by using
one’s relational self. One behaves politely and appreciates and respects the uniqueness of all members. This harmony process produces the end result that is also called
harmony: goodness, peace and growth of the entire membership in the ‘place’. This is
the true workplace harmony.
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The ‘end result’ of harmony may be compared to Aristotle’s telos (goal). In health
care this would be the good of the patient.25 In Confucius’ original meaning, however,
the ‘end result’ is not limited to the patient’s good, but to all participants’ good and
growth. The Japanese nurses who practiced harmony in this meaning may well be compared with the conductor of a symphony orchestra, where the conductor maximizes
the uniqueness of each instrument to produce the most beautiful music. In this sense,
everyone in the group, patients, families, nurses and physicians alike, is an important
component in their own uniqueness.
Benner et al.36 say that nurses can work ethically when they are clinically competent.
Our data support this point because clinical competence was shown to be an important
element for the practice of harmony. Yet, in our data, harmony also emerged from
relatively junior nurses’ work.8–10 By their respectful and polite presence, the patients
found themselves comforted and relieved of anxiety, and they acquired peace of
mind8,9 (Study 2; Appendix 1). The patients’ positive feedback to those nurses in turn
also impacted positively on all the people in that place: a cyclical process.10 From
these observations, we contend that nurses with relatively less clinical experience
can also work ethically when they show politeness and respect. These two virtues are
indispensable elements for harmony and are considered as ‘rites’, formed by the repositories of past insights to make relationships smooth and maintain order in society.20
Confucianism teaches:
Unless a man has the spirit of the rites, in being respectful he will wear himself out, in
being careful he will become timid, in having courage he will become unruly, and in being
forthright he will become intolerant (p. 92).21
In Japanese society where conformity is likely to occur, we urge that high-ranking
health professionals such as senior nurses and physicians take their position more
seriously. In the multi-layered seniority system, people use honorific language to their
seniors, perceiving that those seniors are in powerful and sometimes threatening positions. However, this perception is not fully shared by seniors themselves, probably
because they also have their own seniors. Research data have shown that one of the
major causes of burnout in Japanese nurses is difficult relationships among colleagues
in the workplace.30 Minami comments that when one fails to harmonize in the place,
one can no longer live there.30
Japanese nursing has two other major concerns about the workforce.37 One is the
recent trend of novice nurses dropping out of nursing,38 and the other is the nurse shortage, which, according to many nurse administrators, is accelerated owing to the recent
revisions in Japanese health care-related laws. However, these three problems with
the nursing workforce – burnout, nurses leaving the profession and staff shortages –
cannot be discussed separately. We suspect that one factor among others that underlie
these problems would be the senior professionals’ unconscious pressure on their junior
colleagues. Nurse administrators are now working hard to make their workplace more
attractive for novice nurses as well as for future nurses. An important strategy for
this is to set up colleague support systems. Education for these senior nurses is also
strongly recommended because, in general, they have limited learning opportunities
compared with their juniors. The teaching material should include stories describing
situations in which nurses conform in order to help senior nurses to conceptualize the
problem and see the underlying factors more clearly.
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Such stories also help junior nurses’ professional development. When we are invited
to seminars for hospital nurses, we include the concepts of harmony and conformity
in the topic. When teaching these concepts, we use stories from nurses and patients.
These nurses are then encouraged to write down similar cases they have experienced.
By writing, the nurses can bring something deep from their unconsciousness to the
surface and share their descriptions with colleagues in the seminar. Nurses who blame
themselves for not having been patient centered realize they are not alone, but that
everyone has similar problems. From our feedback as facilitators, these nurses begin
to realize that the ideal of ‘patient centeredness’ can never happen unless nurses are
valued by others as well as by themselves. Harmony stories impressed these nurses
and taught them that even younger nurses can protect patients while at the same time
creating true workplace harmony. After one such seminar, a nurse said,
In our previous ethics seminars, we were often assigned drill work, such as to categorize
nurses’ dilemma cases or situations where patient rights were endangered. We were
instructed to use some foreign scholars’ framework. That kind of drill made me feel very
uncomfortable, like a kind of shortness of breath. Today’s seminar was different. Ethics
came to us. Now ethics is ours.
Through these teaching experiences, we have also learned the importance of
exploring traditional values central to our culture.
Conclusion
The Japanese term Wa (harmony) is a concept encompassing a state of mind, an action
process and the outcome of the action. The most important virtue for Japanese nurses
in our studies who practice harmony was politeness, expressed by respect for the other
party. By touching the hearts of the people concerned, the nurses created the outcome:
goodness, peace and growth of all members in the place, not limited to ‘the patient
good’. Because of the unique Japanese link between the concept of harmony and the
place where people interact, the ideal ‘workplace harmony’ threatened some nurses’
professional decision making. In this case, these nurses confused harmony with the
concept Doh (conformity) by superficial agreements. The Japanese seniority system
that pervades society could be one of the major factors contributing to this problem.
Ethics education that includes traditional values and concepts residing in the culture
is strongly urged; thus further research is required to uncover and examine other
Japanese values that could be used in nursing ethics.
Taking Japan as a case, this article discussed harmony from the virtue ethics perspective. By learning together, we believe that this discussion can enrich nursing ethics
internationally.
Acknowledgments
The authors would like to express sincere thanks to the following colleagues for their
valuable comments: Anne J Davis, Professor Emerita, University of California San
Francisco and Nagano College of Nursing; Shigeko Izumi, Post doctoral fellow, Oregon
Health & Science University; and Miki Tanaka, Nagano College of Nursing.
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Conflict of interest statement
The authors declare that there is no conflict of interest.
Emiko Konishi, Michiko Yahiro and Naoko Nakajima, Saku University, Nagano, Japan.
Miki Ono, Oita University of Nursing and Health Sciences, Oita, Japan.
Appendix 1
This article used the findings of the authors’ following three qualitative studies.
Study 17
In ‘Moral certainty and uncertainty in Japanese nurses’ we reported 20 clinical nurses’
responses to ethical problems in their everyday practice. Content analysis of these
responses using the moral certainty conceptual framework by Wurzbach39 revealed
the following: (1) morally certain nurses who took action based on their own moral conviction; and (2) morally uncertain nurses. Morally uncertain nurses, who were experiencing moral problems in the situation discussed, felt caught in the middle between
the human relationships involved and different opinions and, as a result, acted unprofessionally. Disrupting workplace harmony emerged as a major social factor that
threatened these morally uncertain nurses’ professional decision making.7
Study 28,9
A research project on ‘How Japanese patients characterize the good nurse’, part of
a larger cross-national phenomenological study of virtue ethics,40 was conducted by
listening to 26 Japanese cancer patients’ voices. The patients expressed their feelings of
vulnerability due to their illness and hospitalization. Good nurses impressed them as
those who were able to develop humane relationships with patients by a respectful and
polite presence and who had professional comportment. Patients experienced positive
transformation from the vulnerable state of being in their encounters with the good
nurses.
Study 310
‘Japanese nurses’ perceptions of the good nurse: junior nurses’ views’, also a phenomenological study, was based on interviews with 11 junior Japanese nurses. They
related experiences of when they were a good nurse, and also when they observed
other nurses who were good nurses. These data revealed the Japanese traditional
values of Wa (harmony), politeness and respect10.
Each of the studies received ethical approval from the authors’ institutional research
ethics committee. The participants were fully informed of the purpose of the study in
which they took part and were given assurances of confidentiality. Interviews were
conducted after obtaining their written consent.
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