Published papers

Aim: To develop and test the validity and reliability of a Japanese version of the Evidence-Based Practice Questionnaire. Methods: The Evidence-Based Practice Questionnaire was translated into Japanese, and a back-translation was performed. In March 2016, the survey was conducted among 843 nurses in 2 university hospitals in Japan. After 2 weeks, the same questionnaire for test-retest reliability was distributed to 197 nurses. We evaluated construct validity by factor analysis: convergent, discriminant, criterion-based and known-group validity, and reliability (internal consistency via Cronbach' alpha and test-retest reliability). Results: A total of 533 (66%) of nurses who agreed to our study returned the completed questionnaire, and 108 nurses (55%) agreed to the test-retest. Factor analysis confirmed that the original model of the Evidence-Based Practices Questionnaire was not statistically appropriate for Japanese nurses. Therefore, the final version of the Japanese version adopted 18 items and 4 subscales including practice, attitudes, and knowledge/skills related to research and practice. In the final version, the validity and reliability were moderate (Cronbach alpha =.90). Conclusion: The Japanese version of the Evidence-Based Practices Questionnaire is a reliable and valid tool and can be used to assess evidence-based practice, attitudes, and research knowledge/skills in Japan.

Aim: To develop Japanese version of the pressure ulcer knowledge assessment tool, a tool for measuring nurses’ pressure ulcer knowledge to effectively evaluate the efficacy of current educational programs, resulting in prevention and early treatment, and to verify its validity and reliability among Japanese nurses. Materials and methods: A total of 1716 nurses across three university hospitals participated in this study. All had been employed for at least one year. Managers, part-timers, and those in the operating room and the outpatient ward were excluded from the study as it is limited to bedside preventive care. The original tool was translated into Japanese using the Brislin's translation model. A cross-sectional study was used to examine the reliability and validity of the measure within a Japanese sample. Assessment of the multiple-choice test items included analysis of the validity (item difficulty and discriminating index), construct validity, internal consistency, and stability (test–retest reliability). Results: The item difficulty indices ranged from 0.17 to 0.95, whereas values for item discrimination ranged from 0.15 to 0.45. Known group validity of the scale was confirmed; therefore, the higher-expertize group consisting of wound, ostomy, and continence nurses significantly outperformed nurses certified in other fields. The overall internal consistency reliability was 0.86 with a two-week test–retest intraclass correlation of 0.60. Conclusions: The instrument may be applied as a reliable and valid measure to assess nurses’ pressure ulcer knowledge in the fields of nursing education, research, and practice in Japan.

This study aimed to develop an end-of-life (EOL) care nursing attitude scale for Japanese geriatric nurses (ELNAS-JG). The items of the ELNAS-JG were developed to cover important topics related to EOL care (eg, motivation for providing EOL care, pain and symptom management, and decision-making support care for older adults). Participants were 1663 nurses employed in 32 institutions across Japan. Of these, 1298 participants were analyzed. An exploratory factor analysis of the 26 scale items revealed a 3-factor solution describing the concepts of responsibility, willingness, and confidence: responsibility and willingness were captured in factor 1 (16 items), and confidence was split into factor 2 (6 items) and factor 3 (4 items) to capture individual and collaborative behaviors. The overall Cronbach α coefficient for the 26 items was 0.95, and the intraclass correlation coefficient was 0.83. Overall, the ELNAS-JG was confirmed to have good internal consistency, test-retest reliability, content validity, known-groups validity, and construct validity. It can comprehensively measure nurses' attitudes toward EOL care for older adults in any EOL setting. Furthermore, this scale can be used to evaluate educational programs aimed at improving care quality and encouraging related activities in facilities that provide EOL care.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP.

Objective: The present study examines the factor structure of the Japanese version of the Posttraumatic Growth Inventory (PTGI-J) among bereaved family members who lost loved ones to cancer after home-based palliative care in Japan. It evaluates the relationships between total score, each PTGI-J domain, and participants’ having a religious belief, gender, age, relationship to the patient, and time since patient death. Procedure: Bereaved family members (n = 849) completed the PTGI-J and a demographic questionnaire. The factor structure was tested using confirmatory factor analysis (CFA), and univariate analysis was used to test hypotheses. Results: Confirmatory factor analysis showed that the current sample moderately fitted to both 4-factor and 5-factor models. Univariate analysis revealed that having a religious belief and gender were associated with all domains and total PTGI-J score. Age, time since patient death, and relationship to the patient showed significant differences with the domains of PTGI-J. Conclusion: Clinicians may be able to adjust the support they provide based on patients’ personal characteristics. Future research should look at the mechanisms of PTG by examining the role of rumination, social support, and emotional distress among bereaved family members of patients with cancer.

A Do-Not-Attempt-Resuscitation (DNAR) order solely precludes performing cardiopulmonary resuscitation (CPR) following cardiopulmonary arrest. A patient’s personal status is known to influence a range of clinical practices, not only CPR, when a DNAR order is given. We assessed whether the absence of supporting relatives or a diagnosis of dementia can influence nurses’ perceptions of clinical practices for elderly patients with non-malignant and chronic diseases. A vignette-based questionnaire was used to evaluate nurses’ beliefs both before and after issuance of a DNAR order. Three vignettes were developed: the control vignette described an 85-year-old woman with repeated heart failure, the second and third incorporated a lack of relatives and a dementia diagnosis, respectively. The survey assessed the approach of nurses to 10 routine medical procedures, including CPR, clinical laboratory testing and nursing care, using a 5-base Likert-scale, for six vignette scenarios. A questionnaire was completed by 186 nurses (64% response). The pre-DNAR non-relative vignette showed significantly lower scores for CPR, indicating a deterioration in willingness to perform CPR, compared to the pre-DNAR control (median [interquartile]; 3 [2-4] and 4 [3-4] in the non-relative and control vignettes, respectively, p < 0.001). No significant differences were observed between the dementia and control vignettes. Absence of contactable relatives and resultant lack of communication can diminish the perception of nurses regarding the provision of CPR, even when a DNAR does not exist. This result suggests a necessity for comprehensive training all medical staff about issuance of DNAR orders and what care should be provided thereafter.

Background: People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death. Current clinical practice guidelines indicate the importance of discussing future care strategies with people with heart failure. Advance care planning (ACP) is the process of discussing an individual's future care plan according to their values and preferences, and involves the person with heart failure, their family members or surrogate decision-makers, and healthcare providers. Although it is shown that ACP may improve discussion about end-of-life care and documentation of an individual's preferences, the effects of ACP for people with heart failure are uncertain. Objectives: To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP. Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, Social Work Abstracts, and two clinical trials registers in October 2019. We checked the reference lists of included studies. There were no restrictions on language or publication status. Selection criteria: We included randomised controlled trials (RCTs) that compared ACP with usual care in people with heart failure. Trials could have parallel group, cluster-randomised, or cross-over designs. We included interventions that implemented ACP, such as discussing and considering values, wishes, life goals, and preferences for future medical care. The study participants comprised adults (18 years of age or older) with heart failure. Data collection and analysis: Two review authors independently extracted outcome data from the included studies, and assessed their risk of bias. We contacted trial authors when we needed to obtain missing information. Main results: We included nine RCTs (1242 participants and 426 surrogate decision-makers) in this review. The meta-analysis included seven studies (876 participants). Participants' mean ages ranged from 62 to 82 years, and 53% to 100% of the studies' participants were men. All included studies took place in the US or the UK. Only one study reported concordance between participants' preferences and end-of-life care, and it enrolled people with heart failure or renal disease. Owing to one study with small sample size, the effects of ACP on concordance between participants' preferences and end-of-life care were uncertain (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.91 to 1.55; participants = 110; studies = 1; very low-quality evidence). It corresponded to an assumed risk of 625 per 1000 participants receiving usual care and a corresponding risk of 744 per 1000 (95% CI 569 to 969) for ACP. There was no evidence of a difference in quality of life between groups (standardised mean difference (SMD) 0.06, 95% CI –0.26 to 0.38; participants = 156; studies = 3; low-quality evidence). However, one study, which was not included in the meta-analysis, showed that the quality of life score improved by 14.86 points in the ACP group compared with 11.80 points in the usual care group. Completion of documentation by medical staff regarding discussions with participants about ACP processes may have increased (RR 1.68. 95% CI 1.23 to 2.29; participants = 92; studies = 2; low-quality evidence). This corresponded to an assumed risk of 489 per 1000 participants with usual care and a corresponding risk of 822 per 1000 (95% CI 602 to 1000) for ACP. One study, which was not included in the meta-analysis, also showed that ACP helped to improve documentation of the ACP process (hazard ratio (HR) 2.87, 95% CI 1.09 to 7.59; participants = 232). Three studies reported that implementation of ACP led to an improvement of participants' depression (SMD –0.58, 95% CI –0.82 to –0.34; participants = 278; studies = 3; low-quality evidence). We were uncertain about the effects of ACP on the quality of communication when compared to the usual care group (MD –0.40, 95% CI –1.61 to 0.81; participants = 9; studies = 1; very low-quality evidence). We also noted an increase in all-cause mortality in the ACP group (RR 1.32, 95% CI 1.04 to 1.67; participants = 795; studies = 5). The studies did not report participants' satisfaction with care/treatment and caregivers' satisfaction with care/treatment. Authors' conclusions: ACP may help to increase documentation by medical staff regarding discussions with participants about ACP processes, and may improve an individual's depression. However, the quality of the evidence about these outcomes was low. The quality of the evidence for each outcome was low to very low due to the small number of studies and participants included in this review. Additionally, the follow-up periods and types of ACP intervention were varied. Therefore, further studies are needed to explore the effects of ACP that consider these differences carefully.

Aim: End-of-life care for people with dementia is becoming increasingly important as the global population ages. However, there is no agreed definition of a good death for people with dementia. The current review examined previous literature to establish the current state of knowledge on this issue. Methods: We conducted a scoping review using a standard methodological framework. Relevant studies were identified from four databases. Studies were included if they were in English, discussed palliative or end-of-life care for dementia, and defined or explained a good death. The definitions or explanations of a good death were categorized into subthemes, and grouped into broader themes. Results: We identified 11 articles discussing or explaining a good death in dementia, which were published between 2009 and 2017. Most of these studies drew on the views of healthcare professionals and/or family members of people with dementia, and only one considered the views of people with dementia themselves. Ten themes were identified, including pain-free status, peaceful/comfort, dignity, family presence, surrounded by familiar things and people, person-centered communication, spirituality, life completion, treatment preferences, and other. Conclusions: The characteristics of a good death in dementia showed similarities with those identified more generally. However, there were some themes that were specific to end-of-life care in dementia, notably “surrounded by familiar things and people” and “person-centered communication”. To obtain a fuller picture of the nature of a good death in dementia, researchers need to examine the views of people living with dementia.

This study developed an end-of-life (EOL) care nursing knowledge scale for Japanese geriatric nurses (ELNKS-JG) to measure nurse knowledge of EOL care for older adults. It also was used to evaluate the quality of The End-of-Life Nursing Education Consortium-Japan Geriatric. Participants were 1168 nurses employed in 32 institutions across Japan. The items of our measure were developed to cover 8 important topics: principles of EOL care for older adults; pain management; symptom management; ethics of care; cultural and spiritual considerations; communication; loss, grief, and bereavement; and caring for final days. The measure included 51 items with an overall Cronbach coefficient of 0.87 and an intraclass correlation coefficient of 0.81. Our measure, the ELNKS-JG, was confirmed to have good internal consistency, test-retest reliability, content validity, and known-groups validity. This scale's items included knowledge about noncancerous diseases, physical changes due to aging, family care, and multidisciplinary collaboration. The ELNKS-JG comprehensively measures a nurse's knowledge of EOL care for older adults in any EOL setting. Furthermore, this scale can evaluate educational programs aimed at improving care quality and encouraging related activities in facilities that provide EOL care.

Aims: To evaluate how a structured interactive two-day education programme for clinical nurses on end-of-life (EOL) care for older people affects nurses’ attitudes and knowledge. Design: Non-randomised controlled trial. Methods: Nurses were recruited separately for intervention and control groups. The intervention group assisted older patients with EOL care and recruited patients for the programme. To prevent sampling bias, control group nurses were recruited from a facility with numerous EOL care opportunities. The intervention was a two-day educational programme. Using valid and reliable scales, we evaluated the attitudes (total score range: 26–130) and knowledge (total score range: 0–51) of the intervention group four times (pretraining, post-training, 3 months, 6 months) and the control group three times (baseline, 3 months, 6 months) between January 2016 and April 2017. Analysis of covariance examined both groups’ score changes at 3 and 6 months while adjusting for confounding factors. Results: Participants were 338 nurses caring primarily for older people (intervention group: 164; control group: 174); 142 responded at all measurement points. The change in mean value of the attitude scale from baseline to 3 months (differences in the groups’ attitude scores = 7.33; 95% CI = 2.43–12.24; p =.004) and 6 months (differences in groups’ attitude scores = 5.77; 95% CI = 0.17–11.37; p =.044) was greater in the intervention group. Moreover, the mean knowledge scale score change from baseline to 3 months was greater in the intervention group (differences in groups’ knowledge scores = 5.74; 95% CI = 4.07 to 7.39; p <.001). There was no evidence of a change in this score between baseline and 6 months. Conclusion: The programme improved nurses’ medium- to long-term attitudes and knowledge. Thus, it may help nurses enhance the quality of care they provide. Implications for practice: A two-day educational program improves nurses’ medium- to long-term attitudes and knowledge on end-oflife care. For quality end-of-life care for older people, a structured and evidence-based educational program should be provided to nursing staff.

Objectives: The purpose of this study was (a) to describe the end-of-life experience of family caregivers of cancer patients, (b) to describe talking about death and dying of the patient to minor children, and (c) to examine the association of family caregivers' experiences by their characteristics and talking about death and dying of the patient. Methods: A cross-sectional nationwide survey of bereaved family caregivers was conducted. In total, 968 questionnaires were sent to bereaved family caregivers, and 711 were completed and returned. Fifty-three responses indicating patients had minor children were analyzed. Univariate analysis and principal component analysis were performed. Results: Family caregivers' experiences were divided into 3 domains by principal component analysis: protect children from the patient's imminent death, little regard for the children, and worry and concern about the children's emotional reaction. Family caregivers' common experiences were as follows: “I wanted to know how the children felt,” “I wanted to avoid making the children confused,” and “I did not have much time to talk with and/or play with the children.” About 30% of family caregivers reported that they “did not talk” about death and dying of patients to minor children. Spouses of patients and family caregivers who did not talk about death tended to experience distress and worry. Conclusions: Most family caregivers experienced worry and fear regarding minor children's emotional reaction; therefore, clinicians need to explain children's emotional and psychological reactions to family caregivers when a patient is at the end-of-life.

Aim: To synthesize qualitative evidence on nurses' end-of-life care practices in long-term care settings for older adults. Background: Qualitative evidence on how nurses describe their own end-of-life care practice has not been reviewed systematically. Design: Qualitative systematic review. Data Sources: Databases MEDLINE, CINAHL, PsycINFO, EMBASE, Mednar, Google Scholar, and Ichushi were searched for published and unpublished studies in English or Japanese. Methods: The review followed the Joanna Briggs Institute approach to qualitative systematic reviews. Each study was assessed by two independent reviewers for methodological quality. The qualitative findings were pooled to produce categories and synthesized through meta-aggregation. Results: Twenty studies met all inclusion criteria. Their 137 findings were grouped into 10 categories and then aggregated into three synthesized findings: playing multidimensional roles to help residents die with dignity, needing resources and support for professional commitment, and feeling mismatch between responsibilities and power, affecting multidisciplinary teamwork. Conclusion: Nurses play multidimensional roles as the health care professionals most versed in residents' complex needs. Managers and policymakers should empower nurses to resolve the mismatch and help nurses obtain needed resources for end-of-life care that ensures residents die with dignity.

Aim: To investigate the factors affecting nurse health-related quality of life (HRQOL) by considering the patient characteristics and ward characteristics. Background: Nurse health-related quality of life is an important health outcome, and should be promoted for quality nursing care. Method: This cross-sectional study was conducted on nurses who work in general acute care wards in three university hospitals in metropolitan Japan. Multilevel analysis was conducted to investigate possible factors related to nurse health-related quality of life. Result: Nurses who worked at a ward had a significantly lower physical health score (β = -0.13, P < 0.01). These nurses had a higher ratio of patients who could not understand medical instructions, had cognitive disabilities, or required assistance with activities of daily living (ADL). The number of beds was the only factor significantly related to mental health status of nurses (β = 0.19, P < 0.05). Conclusion: Work conditions that sustain nurse health should take into account not only the number of nurses, but also patient characteristics. Further large-scale studies are needed in order to investigate the effect of hospital characteristics on nurse health-related quality of life. Implications for nursing management: Increasing the number of nurses' aides and delegating assistance with ADL to them could support nurse health-related quality of life in the acute care setting. Copyright

Aim: To conduct a literature review in order to determine the predictors of nurses' health-related quality of life and to clarify the implications for nursing management and future study in this area. Background: Good health is essential to the performance of health care workers. Evaluation: Relevant studies were retrieved from PubMed, Medline, CINAHL, the Japan Medical Abstract Society, and the Technology Information Aggregator, Electronic. The studies selected for this review were published in English or Japanese between 1995 and 2012, investigated nurses' health-related quality of life. The identified predictive factors of each study were categorised according to type. Key issues: Based on the criteria, 22 studies were reviewed. The predictive factors of nurses' health-related quality of life were classified into eight categories. Conclusions: Age and occupational stress should be considered when examining unknown predictive factors of nurses' health-related quality of life. In addition, it may be useful to adopt a conceptual framework and consider patient and organisational factors in future research. Implications for nursing management: It is necessary to identify nurses' occupational stressors and consider age during job placement in order to support their health.

＜文献概要＞はじめに　Evidence-Based Practice(EBP)とは,「研究によるエビデンスと,臨床現場の専門能力,患者や家族の価値観を統合させ,協働で意思決定を行う過程」と定義され,看護領域での促進が望まれる。米国では臨床の実践者が主体のEBP促進のモデルとしてIOWAモデルがあり,活用例として開腹手術後の腸蠕動音聴取の取りやめや,手術時の手袋の二重装着の促進がある。しかし,日本の看護領域ではEBPは十分には普及していない。EBPの個人的バリアには,研究に価値を感じないなどの「価値観」,文献検索能力の不足などの「スキル」の側面がある。また,組織的バリアとして時間不足,情報検索ツールへのアクセスや,英文献の読解という言語的な壁も指摘されている。本調査ではこれらの阻害要因への対応となりうる活動として,学生のEBPプロジェクトが職員・学生の学習や大学と臨床現場の協働を促進する可能性に着目し,看護系大学の学部学生・教員・大学院生らが,文献の系統的検索,質の評価,結果の統合を行い,まとめたエビデンスを臨床看護職に提示する活動(便宜的にこの一連の活動をEBP活動と呼称する。この活動はEBPの促進を目的としたもので看護実践は含まない)を行い,その活動への看護職の評価を明らかにすることを目的とした。本調査から日本におけるEBP促進の示唆が得られることが期待される。

入院患者への看護師によるせん妄ケアのエビデンスをシステマティックレビュー、ランダム化比較試験(RCT)、ガイドライン、書籍・雑誌記事、質的研究の文献検討により収集し、統合することを目的に、Cochrane Library、医学中央雑誌Web版、PubMedなどを用い検索を行い、得られたわが国の看護師に適用可能と判断したシステマティックレビュー1件、RCT6件、ガイドライン10件、書籍・雑誌記事3冊、質的研究4件を分析した。その結果、システマティックレビューでは多職種による多面的介入がせん妄の発症を減少させる中程度のエビデンスが示され、個々のRCTでは、多職種による介入の具体的な内容がまとめられていたが、わが国で行われたRCTが存在しないことから、これらの多面的介入に含まれる内容から、各々の実践現場で適用可能な内容を選択し、多職種と連携しながら行っていくことが望ましいと考えられた。

Aim: To develop and test the validity and reliability of a Japanese version of the Evidence-Based Practice Questionnaire. Methods: The Evidence-Based Practice Questionnaire was translated into Japanese, and a back-translation was performed. In March 2016, the survey was conducted among 843 nurses in 2 university hospitals in Japan. After 2 weeks, the same questionnaire for test-retest reliability was distributed to 197 nurses. We evaluated construct validity by factor analysis: convergent, discriminant, criterion-based and known-group validity, and reliability (internal consistency via Cronbach' alpha and test-retest reliability). Results: A total of 533 (66%) of nurses who agreed to our study returned the completed questionnaire, and 108 nurses (55%) agreed to the test-retest. Factor analysis confirmed that the original model of the Evidence-Based Practices Questionnaire was not statistically appropriate for Japanese nurses. Therefore, the final version of the Japanese version adopted 18 items and 4 subscales including practice, attitudes, and knowledge/skills related to research and practice. In the final version, the validity and reliability were moderate (Cronbach alpha =.90). Conclusion: The Japanese version of the Evidence-Based Practices Questionnaire is a reliable and valid tool and can be used to assess evidence-based practice, attitudes, and research knowledge/skills in Japan.