Organ transplantations cannot be performed without a donor. In Japan, there are fewer cases of brain death and heart death transplantations than in other countries, and this makes it necessary for many organ transplantations to rely on living donor transplantation. Specifically in living donor transplantation, ethical issues are important issues for nurses. This is because of the complicated emotions that arise between recipients and donors over family relationships and conflicts of interest concerning the donor candidates. Cronin (2008) reported that living donor transplantations performed globally involve a range of aspects including social, cultural, economic, religious, and political issues, making living donor transplantations potentially very complicated . Today, there are increasing numbers of nursing studies on the ethics involved in organ transplantations in Japan and other countries. Specifically, the role of advocators who defend patients and donors  , the importance of support for recipients and donors in the decision making  , and the importance of case studies by specialists of other fields   have attracted attention.
As described above, the interest in nursing ethics is increasing in clinical settings, as the roles of advocators have become common knowledge among nurses. In Japan, recipient transplant coordinators (RTC) specialize in organ transplantations and ward nurses provide support to recipients, donors, and their families. In particular, RTC help these groups in the transitional process from the terminal stage of organ failure, through the perioperative and convalescent periods, and into the long-term periods following the discharge. However, in the field of organ transplantations, both RTC and ward nurses often experience ethically conflicted nursing situations, exposed to ethical dilemmas and distress caused by a lack of knowledge of appropriate ethical responses   . Further, even when nurses feel that something is unusual or uncertain, nurses may not always recognize that as an ethical issue. Previous studies reported that the origin of ethical practices is to understand what ethical problems are and what they involve, and this makes it important to develop the ethical sensitivity of nurses   .
With this background, and assuming that holding a series of study meetings and case study meetings where nurses can discuss and explore ethical issues that occur in daily nursing situations and the solutions would be helpful in that this may change the awareness of ethics and the perception of ethical practices, the authors conducted the action research reported in the following. This study conducts action research (AR) to identify how nurses are aware of ethical issues arising in daily nursing settings with organ transplantations and how nurses change ethical practices.
2.1. Research Design
The action research (AR) employed in this study is a mutual approach where researchers and nurses collaborate in the research by focusing on the issues that nurses wish to aim at. The word, “mutual” carries the implication of “interdependent”. With the mutual approach, researchers and nurses in clinical settings act as study participants and conduct the research while improving the understanding of each other from the same standpoint . The authors chose AR with a mutual approach so that the participating nurses can reflect on their own activities and can achieve their wishes for ethical practices related to the ethical issues arising in daily nursing settings.
2.2. Participants and Recruitment
Participants were nurses involved in organ transplantations. The authors recruited the participants by distributing information leaflets to Japanese academic societies and facilities related to organ transplantations, and those who expressed interest were selected as participants, explained the study outline including the purpose both orally and in writing, and formed a research group with those who expressed consent in the participation.
2.3. Outline of AR
The AR here is comprised of eleven sessions in total: clarification of wishes (once), study meetings (2 times), meetings to talk about matters experienced (7 times), and reflections (once) (Table 1). In the clarification of wishes, the
Table 1. Outline of action research.
*AR: action research.
participants discussed the motivation for participation in this study and difficult matters in ethical practices, and expressed their wishes for ethical practices.
At the study meetings, researchers provide knowledge and information related to ethical practices in nursing, and at the meetings to talk about experiences, the researchers and nurses talk and think about matters together as in a case study meeting.
2.3. Data Collection
2.3.1. Group Interviews at the First and Final AR Sessions (1)
The purpose of the interviews in the first AR meeting was to clarify the wishes for ethical practices of participants, and that in the final AR was to identify the awareness of ethical issues and changes in ethics related practices. Semi-structured interviews with the groups at the first and final AR were used an interview guide (Table 2).
2.3.2. Free Discussion in AR (2)
At the meeting to talk about experiences, we discussed the cases introduced in the 7th AR. The data from the free discussion was reflected in the analysis. The interviews 1) and discussion 2) were recorded on an electronic recording device with the permission of the participants.
2.4. Data Analysis
The data analysis was performed by the following procedure: 1) The authors transcribed the qualitative data obtained from the three types of sessions to make sure of the wishes, to talk about experiences, and to reflect on the own nursing. 2) The data were labeled for meaning and assigned to units, and then analyzed by text mining using WordMiner. 1.5. 3) Cluster names that represent the characteristics of clusters were assigned to the clusters generated by the clustering function of WordMiner. 4) Analyses and discussion were repeated among the participating researchers to ensure the credibility and dependability of the study.
2.5. Ethical Considerations
This study was conducted with approval from the ethics review committee of the
Table 2. Interview guide.
*AR: action research.
research institution to which the authors belong. The authors explained about the purpose and provided an outline of the study to the participants, as well as details of the means of protection of personal information, both orally and in writing. The participants expressed consent to the participation by attaching their signature to the informed consent form.
3.1. Details of the Participants in the Action Research (AR)
A total of 15 people recruited by the authors participated in the AR: 4 nurses from a transplant ward, 6 recipient transplant coordinators (RTC), and 5 faculty members. Among these 13 participants had no experience of training in ethical practices. The authors played the role of facilitators. The average number of AR participants per session including the facilitators was 7.4 (7 to 15 participants). Two participants attended 11 times and 3 attended 10 times. The length of a session was two to two and a half hours.
3.2. Details of the AR Sessions
3.2.1. Clarification of Wishes
The participants mutually confirmed the “shared wishes to improve the ability to be aware of potential ethical issues in organ transplantation and the skills to respond to these issues, and also improve the ethical practice of the nurses”, and all expressed their own wishes.
3.2.2. Study Meeting
Two facilitators provided their background knowledge. The topic of the first meeting was about “Ethical concepts and awareness of ethical issues in nursing practices”, and the second study meeting was about “Utilization of tools for ethical practice”.
3.2.3. Meetings to Talk about Experiences
These meetings were held seven times to talk about ethical issues the participants had experienced and cases where they had wondered if the issue they had in mind was an ethical issue in clinical settings. In the first half of the AR study, the participants talked freely about their feelings, thoughts, and ideas. In the latter half, they derived ethical issues using tools for ethical practice, and discussed what kinds of responses were desirable.
3.3. Changes in Nurses
Through the AR, participants became aware of “ethical practice in placing importance on the relationship with patients/their families and ethics attitudes as a nurse” based on the individual need, the “wish to improve understanding of ethics in their own skills to promote ethical practices and ethical interests”. Next, the awareness of ethical practices has expanded from individuals to the relationship with patients/their families and sharing ideas with medical staff. This developed into self-development as illustrated by “sharing ideas and information with medical staff, awareness of and action suitable for ethical issues, and increased interest in ethical issues”. The results of the content analysis about ethical practices are described below.
3.3.1. Clarification of Wishes for Ethical Practice at the First Session of AR
There were 27 labels in total. The results of the analysis showed 5 clusters (Table 3). Participants expressed their wishes to expand their perspectives on ethical issues and to acquire practical skills and coordination skills to respond to ethical issues.
3.3.2. Awareness of Ethical Practices at the Meeting to Talk about Experiences at the 7th Session of AR
The case discussed was “Cases who choose dialysis treatment again due to decreased functioning of a transplanted kidney”. The patient was an adult who underwent organ transplantations twice from living donors and once from a
Table 3. Results of the content analysis about ethical practices.
*AR: action research; *The numbers in the parentheses are the number of data.
brain dead donor, and wished to have transplantations from a brain dead donor (simultaneous transplantations of multiple organs). At the registration of the waiting list for donation from brain dead donors, the parents of the patient requested the medical staff not to talk about the transplant to the patient, and because the body size of the patient was small, the parents wanted to register in the waiting list for pediatric donors.
The medical staff had difficulty in assessing the wishes of this adult patient, whether to meet the requirements according to the ethics guidelines, because the medical staff could not confirm the intention of the patient without talking with the patient about the transplant, and because the self-care abilities of the patient were poor. This case was also a very difficult case in considerations of dealing with patients and their families who were not satisfied with the explanations given by the medical staff. At the meeting to talk about experiences, the participants discussed this case by reflecting on the situation of the patient and his family and the involvement of the medical staff. There were 67 labels in total here. The results of the analysis showed 8 clusters (Table 3). At the beginning of the AR study, the participants were mainly talking about the individual practical skills. However, in the 7th session (the 4th meeting to talk about experiences), comments on the relationships with patients and their families and the awareness of the roles and standing as a nurse increased. In this way, the perspectives of the participants changed from individual-centered remarks to relationships with patients and their families.
3.3.3. Changes toward Ethical Practices in the Final Session of AR
There were 70 labels in total here. The results of the analysis showed 8 clusters (Table 3). In the reflections, the comments were mainly about information sharing among medical staff and the importance of information sharing. Further, the cluster “Continuing efforts to challenge unexpected problems arising after transplantation” shows that the participants became more interested in ethical issues than previously. This suggests that there were improvements in practical ethics skills sufficiently high to deal with arising difficulties. For the wish to improve ethics sensitivity at the beginning of the study, the participants expressed an increased sensitivity, and an increased awareness that they developed as a nurse through the participation in the AR.
Changes in the awareness and ethical practices of nurses were shown through the three types of sessions, “clarification of wishes”, “meeting to talk about experiences”, and “reflection”. Specifically, through these sessions, the wishes to improve practical ethics skills of nurses changed to an awareness of the importance of sharing ideas and information among different professionals through the process of the coordination among patients, family members, and nurses, the specialty of nurses, and through the awareness of the relationship among the three parties. Rest et al. (1994) and Fry et al. (2006) stated that there was something more than moral judgment that develops the morality of professionals. These studies also stated that moral behavior is the final result of a psychological process of four components: moral sensitivity, moral judgment, moral motivation, and moral traits, and that moral behavior requires psychological strength and individuality, and if any of these components are lacking the moral behavior results in moral failure  . It can be assumed that if all four components are present, we can project and show moral behavior. With this assumption, we will discuss the results of this study.
“Moral sensitivity” is to be aware of how behavior affects others. Participants first stated that they “Wish to improve ethical sensitivity without becoming indifferent to ethics” and through the participation in the series of AR sessions, they may have noted “Difficulty in the process of achieving consensus with patients and their families”, “Realizing the heavy responsibility to be entrusted with the wellbeing of patients in an ethical involvement”, and “Importance of providing information helpful to visualize the future while identifying the true intentions and relationships of donors and recipients”, reaching an “Awareness that shifting the perspective of the staff to patients is the first step towards ethical thinking” and “Increased sensitivity resulting from being released from stereotypes in the ethics”.
“Moral judgment” is related to evaluating which action is the more morally acceptable or right compared to others. The participants were thinking about what is necessary and how they should do or react in specific situations, discussing the “Importance of dealing with problems in a consistent manner without being disturbed by details of the process”, “Awareness of need for listening to and thinking about the opinions of others”, and “Significance of pausing and communicating the importance of thinking ethically”. In general, the more complex and difficult a situation is, the more labor and time it takes. However, Wiegand et al. (2015) stated that the most important matter is to understand and respect the wishes of patients when an ethical dilemma arises, and that communication between the medical team and the patients and their families as well as between the members of the medical team needs to be clear, open, and honest . When we consider ethics issues, we may be unsure of how to act and experience conflicts between our own thoughts as an individual and as a professional, but it is very important to take time and carefully think about whether the medical and nursing care provided is of real benefit to patients. Further, creating an organizational culture that allows sharing of thoughts and information, rather than thinking alone, may lead to improvements in ethical practices and skills.
“Moral motivation” is to place more importance on moral values than on other kinds of values when making moral judgments. The five wishes for ethical practice (Table 3) could be a truly sincere attitude toward achieving the best moral outcomes, and the first stage in forming a moral motivation.
“Moral characters” include ego strength, perseverance, backbone, toughness, strength of conviction, and courage. Because these are characters of individuals, they do not appear in the results of the present study. However, it may be important to turn our eyes also towards moral characters, the characters individuals have in order to be able to improve ethical practical abilities. Arie (2008) states that individual coordinators of transplantations are required to have responsibility, as well as clear self-judgmental skills, discretion, and an awareness of the own ethical position . Arie (2008) also states that nurses involved in transplantations need to clarify their own ethical awareness and stance to themselves in a continuous process in accordance with the development and changes of technologies, social attitudes, and the roles of nursing . This suggests the importance for individual nurses to be aware of ethical issues and to act with strength to perform actions in order to solve ethical issues. The strength to perform actions here refers to attitudes to address ethical issues by being prepared to take responsibility and having the courage to deal with challenging situations.
In this study, AR was conducted for one year by holding a monthly session. The four psychological components of moral behavior, as described by Rest et al. (1994) and Fry et al. (2006)  , were related to the ethical practices shown through the results. It was found that the efforts expended in the AR were involved in the process of acquiring practical ethical skills. The findings suggest that the awareness of ethical practice changes from individual needs to sharing of ideas and information with medical staff, leading to ethical practices. A factor that affects nursing activities in dealing with ethical issues is moral sensitivity, the ability to recognize ethical issues as they arise before our eyes. It was also suggested that an organizational culture that addresses ethics can be considered important to improve practical ethics skills.
For institutional efforts, Jamshidian et al. (2018) reported the long-term effects of using a program to empower nurses in an institutional organization . The present study showed that it is not important for nurses to think of matters as simply based on principles while gaining awareness of issues, but that it is also important to become interested in what is going on and how the current situation is. The participants of the study reconsidered their sense of ethics as a nurse, and this improved their ethical sensitivity becoming manifested as a clear change. These findings suggest the necessity of conducting study meetings dealing with ethics in wards or hospitals as shown in this AR study.
The results were limited to changes in awareness and behaviors in wards because participants were recruited from different organizations. To improve practical ethics skills, an organizational culture that addresses ethics is important. This necessitates long-term and continuous efforts to hold discussions and study sessions on ethical practices in wards or hospitals. The findings also suggest that it would be necessary for one organization to take actions as shown in this study, rather than working on one individual to create an organizational culture that addresses ethical issues.
Through the AR sessions, the wishes to improve practical ethics skills of nurses changed to the awareness of importance of sharing ideas and information among different professionals through a process of the coordination between patients, family members, and nurses, a specialty of nurses, and becoming aware of the relationship among these three parties.
We wish to express our deep gratitude to all of the participants in the AR study for showing understanding of the purpose of the study.
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