Experiences of dialogue in advance care planning educational programs.

BACKGROUND: Advance care planning (ACP) is a process in which adults engage in an ongoing dialogue about future medical treatment and care. Though ACP is recommended to improve the quality of end-of-life care, the details of the dialogue experience in ACP are unknown. OBJECTIVE: To explore participants' experiences of dialogue in an ACP educational program that encouraged them to discuss the value of a way of life. RESEARCH DESIGN: This qualitative descriptive study used the focus group interview method. Data were analyzed using qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT: A dialogue-based ACP educational program was conducted in four regions in Japan for local citizens to discuss the value of their way of life. A total of 66 individuals (mean age = 55.5 ± 17.2 years; 50 women and 16 men) participated in focus group interviews. ETHICAL CONSIDERATIONS: This study was approved by the Ethical Review Committee of Tokyo Women's Medical University (no. 4723) and Kyoto University (no. R2099). FINDINGS: Five main themes were extracted: discussing one's thoughts with others in a considerate manner, reflecting on one's way of life through others, feeling a sense of connection with others through storytelling, realizing the difficulties of talking about "what if" topics, and turning one's eyes toward the future through the dialogue. These themes were interrelated and illustrated the complexity of the experience of discussing values. CONCLUSIONS: The results suggest that dialogue in ACP is useful in clarifying values. They also indicated the need for dealing with the ethical challenges of discussing value and the importance of caring for the interlocutor to have a safe dialogue. In the ACP process, safety in dialogue may improve readiness in ACP, and health practitioners who support ACP need to address the ethical challenges entailing dialogue about values.

Consensus development of quality indicators for end-of-life care for elders in Japan.

AIMS AND OBJECTIVES: Quality indicators for end-of-life care have been published; however, none have been developed specifically for nursing in the cultural and traditional context of Japan. This study aimed to develop and build a consensus of quality indicators for end-of-life care for elders in Japan from the perspective of nursing science. METHODS: To develop the quality indicators, we used a literature review, expert panel process, and the Delphi technique among clinical nurse specialists in geriatrics. RESULTS: Quality indicators were identified in 7 major areas: advance directives and surrogate continuity, ethical daily care, care preferences and decisions about life-sustaining treatment, assessment and management of pain and other symptoms, daily care for the dying, family care, and institutional systems for end-of-life care. CONCLUSIONS: These quality indicators represent the first attempt to develop a best practices approach toward improving the quality of elderly end-of-life care in nursing.

Identifying structure and aspects that 'continuing nursing care' used in discharge support from hospital to home care in Japan.

This study investigated nursing practice in continuing nursing care with the aim of identifying the key factors in nursing practice during discharge support. A literature review of papers published in Japanese in 2000 and 2011 was conducted using 'case management', 'care management', 'continuing nursing care', 'discharge support', 'discharge planning' and 'elderly person' as key words. An analysis of 54 papers revealed the following five aspects of continuing nursing care: (i) a cyclical approach aimed at realising the lifestyle desired by the person concerned; (ii) management of medical conditions for lifestyle stability; (iii) support for the patient as someone who can live independently; (iv) support to raise the ability of families to care for themselves; and (v) team approach to achieve implementation of patient-centred care. Understanding these aspects allows nurses to recreate the lifestyle of patients and families and facilitate the implementation of a systematic team approach.

Collaborative support for child abuse prevention: Perspectives of public health nurses and midwives regarding pregnant and postpartum women of concern.

Child abuse is a globally prevalent problem, and its numbers have continuously increased in Japan over the past 30 years. Prevention of child abuse depends on the support available to pregnant and postpartum women from the time of pregnancy. Public health nurses and midwives are expected to provide preventive support in cooperation, as they can support pregnant and postpartum women from close proximity and recognize their health problems and potential signs of child abuse. This study aimed to deduce the characteristics of pregnant and postpartum women of concern, as observed by public health nurses and midwives, from the perspective of child abuse prevention. The participants comprised ten public health nurses and ten midwives with five or more years of experience working at the Okayama Prefecture municipal health centers and obstetric medical institutions. Data were collected through a semi-structured interview survey and analyzed qualitatively and descriptively using an inductive approach. The characteristics of pregnant and postpartum women, as confirmed by public health nurses, included four main categories: having "difficulties in daily life;" "a sense of discomfort of not feeling like a normal pregnant woman;" "difficulty in child-rearing behavior;" and "multiple risk factors checked by objective indicators using an assessment tool." The characteristics observed by midwives were grouped into four main categories: "mental and physical safety of the mother is in jeopardy;" have "difficulty in child-rearing behavior;" "difficulties in maintaining relationships with the surrounding people;" and "multiple risk factors recognized by an assessment tool." Public health nurses evaluated pregnant and postpartum women's daily life factors, while midwives evaluated the mothers' health conditions, their feelings toward the fetus, and stable child-rearing skills. To prevent child abuse, they utilized their respective specialties to observe those pregnant and postpartum women of concern with multiple risk factors.

Defining end-of-life care from perspectives of nursing ethics.

Despite increasing interests and urgent needs for quality end-of-life care, there is no exact definition of what is the interval referred to as end of life or what end-of-life care is. The purpose of this article is to report our examination of terms related to end-of-life care and define end-of-life care from nursing ethics perspectives. Current terms related to end-of-life care, such as terminal care, hospice care, and palliative care, are based on a medical model and are restrictive in terms of diagnosis and prognosis. Using codes of ethics for nurses as a framework, we attempt to identify people to whom nurses are responsible to provide end-of-life care and develop a definition of end-of-life care that is more inclusive and applicable to a broader range of people who would benefit from end-of-life care by nurses and other health-care providers.

Developing an Instrument to Assess the Readiness for Advance Care Planning.

CONTEXT: In recent times, advance care planning for patients' end-of-life care preferences has attracted much attention worldwide. OBJECTIVES: To develop the Readiness for Advance Care Planning (RACP) Scale. METHODS: Participants included 624 Japanese citizens who were registered with a web-based survey company as of February 2019. Items regarding the process of advance care planning (ACP) were developed based on a literature review and expert panel discussions. The expert panel included nine experts and practitioners in the field of end-of-life care. Construct validity, concurrent validity, internal consistency, and test-retest reliability were evaluated. RESULTS: Initially, 37 items were collected. Examination of the floor effect, item-total, good-poor analysis, and exploratory factor analysis yielded a five-factor model with 28 items. The goodness of fit of the model was GFI = 0.80, CFI = 0.91, and RMSEA = 0.08. The concurrent validity was statistically significant (rs = 0.26-0.45, ps < 0.001). Cronbach's alpha for the overall scale was 0.95. The corresponding values for the subscales ranged from 0.90 to 0.97. The intraclass correlation coefficients indicating test-retest reliability was 0.66 (P < 0.001) for the total scale and ranged from 0.52-0.65 for the five subscales. CONCLUSIONS: The validity and reliability of the scale were generally acceptable. The RACP is an appropriate instrument to evaluate the level of readiness for ACP behaviors among people of various generations at every health stage. More studies are needed to examine the clinical utility of the RACP, both nationally and internationally.

Defining a good death for people with dementia: A scoping review.

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.

[A framework for assessing essential public health nursing skills and achievement levels required for students graduating from schools that provide education for obtaining a license as a public health nurse in Japan].

PURPOSES: This study aimed to develop a framework for essential skills and the achievement levels necessary for students graduating from schools that provide education for obtaining a license as a public health nurse (PHN) in Japan. METHODS: Two rounds of questionnaire-based investigations using the Delphi methodology were conducted. Subjects were 197 PHNs from municipalities or companies and 146 nurse educators from universities, colleges, junior colleges, or technical nursing schools. RESULTS: (1) The essential skills framework consisted of three (macro, intermediate and micro) levels. Macro-level items were based on the principle of justice, a primary pillar of health care: (A) community assessment to identify health problems; (B) solving and improving particular health problems in collaboration with people to enable them to promote their own health; (C) promoting equitable access and distribution of community resources for health and daily living. Micro-level items had four achievement levels: (I) independent; (II) instructor-guided; (III) laboratory exercise; (IV) theoretical understanding. Micro-level items for A and B had two domains for achievement: individual/family and group/community. (2) In the first round over 70% of respondents said "very important," "important" or "acceptable" for all micro-level items. In the second round, over 90% said all micro-level items fit within macro and intermediate-level items. (3) In the second round, micro-level items attained 70% consensus among PHNs and nurse educators were 71 of 93 (76.3%). Micro-level expression was used for adjustment and the final framework of essential skills yielded 3 macro, 8 intermediate and 59 micro-level items and 95 levels of achievement. (4) In the final framework, the level of achievement for "individual/family" (Macro-level A and B) was almost level I, and for "group/community" almost II or III. The number of micro-level items at level IV for C was 14 of 21 (66.7%). (5) Compared with PHNs, educators generally assigned a more advanced achievement level for the same skill. CONCLUSIONS: This framework offers more clarity to the content and competency of practice and thus should be useful for basic and continuing PHN education. The assumption driving this study was the necessity to improve the nursing educational system, and develop an appropriate curriculum for the PHN national licensure.

[Implementation of discharge planning in the care of hospitalized older adults. Focus on involvement of home care providers at hospitals].

OBJECTIVES: The present study was conducted to assess current implementation of discharge planning in the care of hospitalized older adults, and to examine the association between implementation and involvement of home care providers at hospitals. METHODS: The subjects were 434 hospitals with 100 beds or more for general patients, nationwide. We conducted a questionnaire survey by mail of hospital staff responsible for the discharge planning, and assessed to what extent home care providers were associated with the implementation of discharge planning in the hospitals. The subjects were divided into two groups: an association group (138 hospitals) in which home care providers were associated with implementation in the hospitals, and a not-association group (296 hospitals). We compared the proportions of implementation of discharge planning between the two groups, and calculated odds-ratios. In the analysis, we controlled for affiliated institution and home care services. RESULTS: The association group showed significantly higher proportions of implementation for 13 items in a total 24 items for discharge planning than the not-association group (range of odds-ratio: 2.430-5.497). The three highest odds ratios were observed for "Arrangement and guidance for home care by outreach prior to discharge" [OR= 5.497, 95% confidence interval (CI): 2.604-11.602], "Adjusting relationship between patient and family" (OR=4.871, 95%CI: 1.323-17.930) and "Refining medical and nursing care so as to be sustainable at home" (OR = 4.740, 95%CI: 1.825-12.311). CONCLUSIONS: The present study showed that hospitals with involvement of home care providers had higher proportions of implementation of discharge planning for hospitalized older adults concerning "Arrangement and guidance for home care by outreach prior to discharge", "Adjusting relationship between patient and family", "Refining medical and nursing care so as to be sustainable at home" and so on. Further study should examine the effect of discharge planning on length of stay, rate of readmission, patient and family member's satisfaction controlling for patient characteristics and hospital's role in the community.

Nursing leadership in a rapidly aging society: implications of "the future of nursing" report in Japan.

The recent US Institute of Medicine (IOM) report about the future of nursing highlights the areas where nurses can serve, contribute, and move forward to improve health care in the United States. Japanese nursing scholars examined the IOM report for its implications in the Japanese context and explored the future of nursing in Japan. The purpose of this paper is to provide support for the premise that the report's recommendations could have implications for the future of nursing outside of the United States, especially in Japan. Particular areas and activities by nurses in Japan will be presented as examples of nurses taking leadership in designing care for the rapidly aging society of Japan.