[Exploring Fatigue Patterns and Associated Factors Among Patients on Hemodialysis].

BACKGROUND: Fatigue in patients on hemodialysis varies based on disease and treatment situations. Most studies have assessed the effectiveness of interventions based on average fatigue during the past week. However, two different types of fatigue are identified: post-dialysis fatigue and continuous fatigue. Identifying different types of fatigue and related factors may facilitate the development of more-effective, type-specific measures to reduce patient fatigue. PURPOSE: The purpose of this study was to explore fatigue patterns and predictors in patients on hemodialysis during their eight-day dialysis cycle. METHODS: A perspective, observational research design was adopted. One hundred and two patients were recruited from three hospitals and one hemodialysis clinic in New Taipei City. During the dialysis, patients answered a structured questionnaire that included a demographic datasheet, Taiwanese depression questionnaire, hemodialysis social support scale, trait anxiety inventory, Pittsburgh sleep quality index, and fatigue visual analogy scale. After dialysis on each day, patients completed the fatigue visual analogy scale for a period of eight consecutive days every morning, noon, and night. Biochemical data and inter-dialysis weight gain were collected from medical charts. RESULTS: This study found three distinct fatigue status groups: fatigue adaptation, rapid change and continuous fatigue. After the day of dialysis, fatigue level was the lowest in the fatigue adaptation group, followed by the continuous fatigue group. The rapid change group reported the highest level of fatigue. With regard to the degree of increase in fatigue after dialysis (fatigue score after dialysis minus fatigue score before dialysis), the rapid change group had the highest average increase in score after dialysis, while the continuous fatigue group had the lowest. Sleep quality, trait anxiety, and health caregiver support were also found to be predictors of group affiliation. CONCLUSIONS: Nurses can provide individual social support interventions and methods to improve sleep quality and alleviate anxiety to reduce fatigue in patients on hemodialysis.

Factors influencing self-management among Indonesian patients with early-stage chronic kidney disease: A cross-sectional study.

AIMS AND OBJECTIVES: The purpose of this study was to explore the self-management of patients with early-stage chronic kidney disease (CKD) and its influencing factors. METHODS: A convenient sample of 226 patients with early-stage CKD was recruited from 63 Public Health Centers in Indonesia, from June to September 2020. Demographic characteristics, health literacy, illness perception, self-efficacy and self-management were assessed using self-reported questionnaires. Stepwise multiple linear regression analysis was performed to identify the factors influencing self-management. This study adhered to the EQUATOR checklist, STROBE. RESULTS: The mean estimated glomerular filtration rate was 63.45 ml/min/1.73 m2 (standard deviation [SD] = 15.34). The average scores for health literacy, illness perception, self-efficacy and self-management were 32.11 (SD = 4.46), 4.57 (SD = 1.46), 183.64 (SD = 38.23) and 76.92 (SD = 9.45), respectively. The influencing factors were education level, monthly income, family history of comorbidity, health literacy and self-efficacy, which accounted for 45% of total self-management score. CONCLUSIONS: Indonesian patients with early-stage CKD showed low level of health literacy, but positive illness perception and self-efficacy; these factors significantly affected CKD self-management. Health literacy was found to influence all dimensions of self-management: self-integration, problem-solving, seeking social support and adherence to the recommended regimen. RELEVANCE TO CLINICAL PRACTICE: Adherence to the recommended regimen is the most challenging dimension of CKD self-management. Health literacy was found to be a major determinant of self-management. Improving health literacy and motivation of patients with early-stage CKD may help sustain positive illness perception and self-efficacy, and improve self-management.

Development and testing of the hemodialysis symptom distress scale (HSD-22) to identify the symptom cluster by using exploratory factor analysis.

BACKGROUND: Patients receiving hemodialysis (HD) often experience multiple symptoms concurrently and these symptoms may impact their quality of life. A valid and reliable tool is needed to assess the symptom distress of patients receiving HD in terms of the perspective of symptom clusters. Although many studies have explored symptom clusters related to patients receiving HD, the clusters formed had problems with overlapping, vagueness, lack of cluster-specificity, and difficulty in discerning their common mechanism under the cluster. AIMS: To develop reliable measurement tool to identify the symptom clusters of patients undergoing HD. DESIGN: A cross-sectional descriptive study. METHODS: To examine the physiological properties of the HD symptom distress (HSD) scale, 216 participants were recruited from a HD center of a medical university hospital in southern Taiwan from February 2019 to April 2019. Construct validity was evaluated by exploratory factor analysis (EFA), and the internal consistency and test-retest reliability were estimated by Cronbach's alpha and intraclass correlation coefficient (ICC). RESULTS: The CVI value of the HSD was 0.89. The HSD scale was composed of five factors with 22 items, including insufficient energy/vitality, cardiac-pulmonary distress, sleep disturbance, musculoskeletal distress, and gastrointestinal distress, with factor loading ranging from 0.62 to 0.87, explaining 65.5% of the total variance. Cronbach's alpha coefficient of the HSD total scale was 0.93, and five subscales ranged from 0.73 to 0.89. The test-retest reliability was 0.92 (p < 0.001) by using the intraclass correlation coefficient (ICC) for the HSD-22 scale. CONCLUSION / IMPLICATION: Theoretical testing from our study indicated that the HSD-22 scale had satisfactory validity and reliability. Therefore, this assessment tool can be employed to identify the symptom clusters of patients receiving HD in the clinical setting. Such identification enables healthcare professionals to provide interventions to release patients' symptom distress efficiently.

A preliminary study on the effects of the Peer-Led Self-Management (PLSM) program on self-efficacy, self-management, and physiological measures in older adults with diabetes: A block randomized controlled trial.

This study explored the effects and feasibility of the peer-led self-management (PLSM) program for older adults with diabetes. Twenty-eight participants from 10 communities in southern Taiwan were randomly allocated to experimental and control groups. Those in the experimental group were enrolled in a 4-week PLSM program; those in the control group received a self-management manual and continued their usual clinical care. Improvement in outcomes (self-efficacy, self-management, physiological measures) over time in both groups were evaluated. After PLSM intervention, self-efficacy and self-management had improved; body weight and body mass index measures of the experimental group at post-test 1 and post-test 2 were significantly lower than those of the control group (p < .001); HbA1c, total cholesterol, and triglycerides at post-test 2 were also significantly better (p < .001; p = .03; p = .02). We discuss preliminary benefits and feasibility of the PLSM program.

Planning mass eradication of Helicobacter pylori infection for indigenous Taiwanese peoples to reduce gastric cancer.

BACKGROUND AND AIM: The aim of this study is to identify gastric cancer burden in Indigenous Taiwanese peoples and conduct a project to evaluate how to reduce the disparities most effectively in Indigenous communities. METHODS: First, we quantified the health disparities in gastric cancer in Indigenous peoples using data from the cancer registries during the period of 2006-2014. Second, we identified parameters that might be associated with Helicobacter pylori infection or help identify a good eradication strategy. RESULTS: Gastric cancer incidence (24.4 vs 12.3 per 100 000 person-years) and mortality rates (15.8 vs 6.8 per 100 000 person-years) were higher in Indigenous than in non-Indigenous, with 2.19-fold (95% confidence interval [CI]: 2.06-2.33) and 2.47-fold (2.28-2.67) increased risk, respectively. In Indigenous communities, H. pylori infection was more prevalent in Indigenous than in non-Indigenous (59.4% vs 31.5%, P < 0.01). Regression analyses consistently showed that either the mountain or plain Indigenous had 1.89-fold (95% CI: 1.34-2.66) and 1.73-fold (95% CI: 1.24-2.41) increased risk for H. pylori infection, respectively, as compared with non-Indigenous, adjusting for other baseline characteristics. The high infection rates were similarly seen in young, middle-aged, and older adults. Program eradication rates using clarithromycin-based triple therapy were suboptimal (73.7%, 95% CI: 70.0-77.4%); the habits of smoking (1.70-fold, 95% CI: 1.01-2.39) and betel nut chewing (1.54-fold, 95% CI: 0.93-2.16) were associated with the higher risk of treatment failure. CONCLUSION: Gastric cancer burden is higher in Indigenous Taiwanese peoples than in their non-Indigenous counterparts. Eliminating the prevalent risk factor of H. pylori infection is a top priority to reduce this health disparity.

Factors influencing self-management behaviours among patients with type 2 diabetes mellitus in the Solomon Islands.

AIMS AND OBJECTIVES: This study aims to explore the current state of self-management behaviours among persons with type 2 diabetes mellitus in the Solomon Islands and to discuss the factors influencing these behaviours. BACKGROUND: The prevalence of diabetes and diabetes complications is increasing in the Solomon Islands. However, the effective diabetes prevention and care are not provided in the country. DESIGN: This is a cross-sectional study. METHODS: A convenience sample of 150 persons with type 2 diabetes mellitus was recruited from a hospital in the Solomon Islands from August 2017-September 2017. Self-report questionnaires were used to measure the self-management behaviours, diabetes knowledge and illness perception. In addition, the study adhered to the EQUATOR checklist, STROBE (see Appendix S1). RESULTS: The overall score for self-management was 56.9 ± 13.2 and diabetes knowledge and illness perception, as influencing factors of self-management, earned total scores of 13.3 ± 4.0 and 55.8 ± 12.0, respectively. Stepwise regression analysis identified illness perception, diabetes knowledge and smoking as significant influencing factors, explaining 20.8% of the total variance in self-management. CONCLUSIONS: The level of diabetes self-management behaviours demonstrated by persons with type 2 diabetes mellitus in this study was rated as less than ideal. Diabetes knowledge and illness perception were the two main factors influencing patient self-management in the Solomon Islands. RELEVANCE TO CLINICAL PRACTICE: The study addressed the current state of the self-management behaviours of persons with diabetes and discussed the factors influencing these behaviours. The findings indicated that knowledge and illness perception of diabetes were the two main factors and provided baseline information for policymakers, health planners and healthcare providers highlighting diabetes as an important issue in Solomon Islands.

Development and cross-validation of a new instrument to measure nurse's positive energy of retention: A methodological study.

AIM: The aim of this study was to develop and psychometrically test a new instrument for measuring nurse's positive energy of retention (NPER). BACKGROUND: The shortage of professional nurses is an unresolved global issue. Few studies explored the issue of the retention of nurses in terms of a positive psychological viewpoint. DESIGN: Methodological study. METHODS: Data collection was from June 2016-August 2017. Nurses (N = 947) recruited from northern, central and southern Taiwan covering different levels of hospitals were divided into three samples, which were used for explaratory factor analysis (EFA), confirmatory factor analysis (CFA) and cross-validation respectively. RESULTS: EFA resulted in a three-factor solution: proactive and persevering characteristics, nursing professional identity and passion accounting for 61.8% of total variance. The proposed three-factor model was confirmed by CFA. Cross-validation provided further evidence for the construct validity of the NPER instrument with 24 items. Cronbach's alpha coefficient of three subscales of the instrument were 0.95, 0.89, and 0.92 separately and 0.96 for the total scale. CONCLUSION: Psychometric properties indicate that the newly formulated NPER instrument is a valid and reliable assessment tool to recruit nurses who are more likely to remain in nursing. IMPACT: The study addressed the personal intrinsic factors, which are very important for nurses' retention. The NPER instrument consisted of three subscales is a reliable and psychometrically valid new instrument. Managers could apply the NPER instrument to recruit nurses possessing the attributes of positive energy of retention. Furthermore, researchers could use the rigorous process provided in the study to establish a new instrument.

Psychometric evaluation of the Informed Consent Process Scale in Chinese.

BACKGROUND: Informed consent is essential for the ethical conduct of clinical research and is a culturally sensitive issue. But, a measurable Chinese version of the scale to evaluate the informed consent process has not yet been explored in the existing literature. RESEARCH OBJECTIVES: This study aimed to develop and psychometrically test the Chinese version of the Informed Consent Process Scale. RESEARCH DESIGN: Back-translation was conducted to develop the Chinese version of the questionnaire. A cross-sectional survey was administered, after which an exploratory factor analysis was conducted. PARTICIPANTS: We recruited a total of 375 participants who had experience in signing an informed consent form within the previous 3 years in Taiwan. ETHICAL CONSIDERATIONS: This study was approved by two Institutional Review Boards and the autonomy of the participants was respected. FINDINGS: The Chinese version of the Informed Consent Process Scale is composed of three factors with 23 items showing evidence of acceptable reliability and validity. Three major factors were extracted and labeled: Factor 1 - 'Understanding of the research', Factor 2 - 'Trust and confidence' and Factor 3 - 'Doubt and uncertainty'. The three factors accounted for is 52.954 of the total variance with Cronbach's α of .917. DISCUSSION AND CONCLUSION: The finding corroborates previous studies showing that participants had too little understanding on the informed consent forms they signed and implied the need to clarify the critical points in clinical research. The psychometric results indicated good internal consistency and validity for this newly constructed instrument, and it was found worthy of conducting further testing and application.

Identifying the positive energy for retention in clinical nurses: A focus group study.

AIM: To identify the 'positive energy' that inspires nurses' retention in the profession. BACKGROUND: Previous studies focused on the negative extrinsic factors associated with nurses leaving the profession. However, scant research explored the personal intrinsic essence regarding why nurses remain in the profession. METHOD: This study used a qualitative descriptive design. Ten focus groups including 53 participants were recruited by purposive sampling from five hospitals in Taiwan. Data were collected between March 2015 and January 2016 through semi-structured focus group interviews. The data were examined by content analysis. RESULTS: Six themes were identified, including sense of mission, achievement, passion, meaning of nursing, personal characteristics and intrinsic coping. CONCLUSION: Findings emerged from this study characterizing 'positive energy' as a steady inner strength, not easily changed with the external environment, which inspires the retention of staff nurses. IMPLICATIONS FOR NURSING MANAGEMENT: The themes identified in this study can be used to develop an instrument for assessing nurses' inner attributes which may help managers recruit nurses possessing 'positive energy' of retention. Future researchers may develop an intervention programme to cultivate nurses 'positive energy' and further test its effect on nurse retention.

[Roll With the Punches: Applying Resilience to Caregiver's Burden].

Social and economic problems related to population aging are becoming increasingly prevalent in many industrialized nations. Moreover, life-related stresses is causing caregivers to become fatigued and exhausted, with some even choosing to end their life due to their overwhelming burdens of care. Evidence demonstrates that failure to cope effectively with the burdens of care greatly increases the risk of personal physical, mental, and family problems for the caregivers. Therefore, caregiver burden is an increasingly important issue and challenge for the long-term care service system. Positive psychology has been studied widely in recent years, and current related research has focused on exploring caregivers' positive coping experiences. Empirical studies indicate that caregivers overcome crisis because they acquire coping strategies and learn to adjust during the caring process. Furthermore, these articles show the successful handling of caring stress to be highly correlated with resilience. This research examined caregiver's burden and resilience. The findings suggest how nurses may identify the potential of caregivers in the caring processing and what kind of support that nurses should provide to caregivers. Further, this study elaborates on how caregivers build resilience. According to the literature, current nursing interventions should enhance caregiver's resilience. In general, this research aimed to offer a new direction for long-term care based on positive energy and caregiver resilience. It is hoped that this introduction provides insights for healthcare professionals in clinical practices.

[Applying Shared Decision Making With End-Stage Renal Disease Patients Undergoing Renal Replacement Therapy to Reduce Decision Making Conflicts].

The shared decision making (SDM) is an innovative, emerging clinical medical decision model in Taiwan. This model allows patients to understand the possible benefits, hazards, and risks of different treatment options and to choose the treatment option that best aligns with their values and preferences, thereby reducing patients' decisional conflicts. The survival rate of patients with end-stage renal disease (ESRD) has improved, in part due to the rapid development of medical technologies and treatment modalities. However, survival requires that patients face the choice conflicts associated with renal replacement therapy. All of the various renal replacement therapy treatment options impact the physical state of patients, cause changes in their daily life, and undermine their normal work and social roles. Patients often deal with conflict, uncertainty, and hesitation when they engage in making decisions about renal replacement therapy, as the course of treatment is long-term and the effects accompany the patients for the remainder of their life. This article discusses the decisional conflicts of ESRD patients in renal replacement therapy and its influencing factors. The authors propose the SDM approach to renal replacement therapy as a care reference for clinical health professionals.

A systematic review and meta-analysis: Effectiveness of internet empowerment-based self-management interventions on adults with metabolic diseases.

AIM: To synthesize the effects of Internet empowerment-based self-management interventions on adults with metabolic diseases. BACKGROUND: Metabolic diseases are prevalent and burden healthcare systems; they have become a major health problem worldwide. The effects of IESMIs on lifestyle changes have been shown to improve adults' physiological and psychological conditions. However, we found no systematic review evaluating these effects. DESIGN: Systematic review and meta-analysis of randomized and non-randomized controlled trials, conducted according to the Cochrane handbook. DATA RESOURCES: A literature search was conducted using the Airiti Library, Association for Computing Machinery, CINAHL, Cochrane Library, Embase, ProQuest, PubMed/MEDLINE and Index of the Taiwan Periodical Literature System databases (earliest-June 2016). REVIEW METHODS: Two reviewers used the Cochrane Collaboration bias assessment tool to assess the methodological quality of included studies. Extracted data were entered and analysed using RevMan 5.3.5 software. Inverse variance was used to estimate effect sizes. Weighted and standardized mean differences with 95% confidence intervals were calculated using a random effects model. Subgroup and sensitivity analyses were performed. RESULTS: Twenty-one randomized controlled trials were reviewed. Meta-analysis showed that the intervention significantly improved adults' exercise habits, glycated haemoglobin (HbA1c) levels, body weight, empowerment levels and quality of life. CONCLUSION: The intervention significantly improve the health status of adults with metabolic diseases, in particular their exercise habits, HbA1c levels, body weight, empowerment and quality of life. The intervention provides more convenient and faster access to healthcare for busy individuals with time constraints. These results suggest that healthcare professionals could develop accessible and friendly interactive online interfaces for patients to expand the use of these interventions in the clinical setting.

[The Use of Informed Consent in Clinical Nursing Practice].

Obtaining informed consent and ensuring patient autonomy are critical to implementing a patient-centered model of healthcare. Informed consent is a complex process of communication that includes three elements: disclosure, competence in making decisions, and voluntariness. However, individual patient factors, doctor-patient interaction, and cultural issues are known to influence the process of obtaining informed consent. Individual patient factors include the ability of patients to understand and determine their intent; doctor-patient interaction includes communication skills; and cultural issues include the expectations of patients with regard to family involvement in medical decision-making and in decision-making motives. After assessing the relevant influencing factors, healthcare providers typically provide patients with comprehensive information on the benefits and risks of treatment as well as related alternatives. Moreover, healthcare providers typically provide patients with audio/video, Internet, and written information with illustrations based on individual patient needs. In addition to the above, we suggest that healthcare providers proactively adopt the perspective of patients in order to better encourage patients to address questions, to engage with patients in more productive discussions, and to take the initiative to explain and clarify patients' questions in order to minimize anxiety. This approach will help ensure that patients are adequately informed and free from coercion so that they make appropriate healthcare-related decisions. However, even under this optimal situation, healthcare providers must emphasize the needs of their patients and respect their decisions.

[Constructing a Peer-Led Self-Management Program for Elderly Patients With Metabolic Syndrome].

Changes in lifestyle and increasing age are associated with an increased risk of metabolic syndrome. In order to better control the incidence of metabolic syndrome nationwide, healthcare providers must provide age-appropriate care information to their elderly patients that addresses critical factors such as physiological function, social psychology, and emotional and health literacy in order to empower these patients to self-manage their condition and to enhance their self-care-related motivation and confidence. Using peer leaders with relevant experience may be helpful in promoting the learning of self-management skills, as these leaders share backgrounds that are similar to elderly patients in terms of culture and disease-care needs. The present paper proposes a peer-led, self-management program for metabolic syndrome for the elderly that is based on a theoretical framework of self-efficacy. We expect to test this program for effectiveness and feasibility in clinical practice in the future.

[The Effectiveness of Abdominal Massage on Neurogenic Bowel Dysfunction in Patients With Spinal Cord Injury: A Systematic Review].

BACKGROUND: Neurogenic bowel dysfunction is a common comorbidity in spinal cord injury patients that may result in fecal incontinence. Abdominal massage is one intestinal training method that is used to improve bowel movement and defecation. PURPOSE: To review the effectiveness of abdominal massage on neurogenic bowel dysfunction in patients with spinal cord injury. METHODS: A systematic review of Chinese and English-language articles was performed in six databases using the following key words: spinal cord injury, abdominal massage, neurogenic bowel dysfunction, and bowel training. Relevant studies published prior to June 2016 that met the inclusion and exclusion criteria were selected. The Downs and Black scale was used to appraise the quality of each of the included studies. Eight studies were included in the final analysis. RESULTS: Four of these studies indicated that abdominal massage significantly improved bowel functions and the regularity and frequency of bowel movements. Although two of the studies indicated that abdominal massage significantly reduced the use of glycerin and laxatives, the remaining six did not. The eight studies earned respective quality scores ranging between 13 and 25. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The current literature lacks consensus on the efficacy of abdominal massage in terms of improving bowel dysfunction in patients with spinal cord injuries. Future studies should use more stringent experimental designs such as randomized controlled studies to explore the correlations among massage time and frequency and bowel function improvements in order to provide guidelines for clinical care applications.

Psychometric evaluation of the Diabetes Self-Management Instrument Short Form (DSMI-20).

PURPOSE: Accurately assessing the self-management of patients with diabetes requires a valid and reliable assessment instrument. The purpose of this study was to revise and simplify the original assessment instrument (DSMI-35), and to evaluate the psychometric properties of the new short form (DSMI-20) in order to enhance its practicality in clinical settings. METHODS: The short form instrument (DSMI-20) was created by revising our previous longer instrument (DSMI-35) through having in-depth small group discussions and validation by experts. The draft (DSMI-20) was pilot tested, and its items were analyzed. We verified the draft (DSMI-20) by conducting an exploratory factor analysis (EFA) and correlating the (DSMI-20) with the diabetes empowerment scale (DES). We tested its reliability including internal consistency and established its test-retest reliability using Cronbach's alpha and Pearson correlation coefficients. RESULTS: EFA identified four factors with loadings ranging from -0.727 to -0.535 and 0.547 to 0.907: communication with HCPs, self-integration, self-monitoring of blood glucose, and problem solving. These factors accounted for 57.110% of the total variance. The Cronbach's alpha coefficient of the DSMI-20 total scale was 0.925 and of subscales ranged from 0.838 to 0.892. The test-retest correlation for the DSMI-20 total scale was acceptable (r=0.790, p<0.001). Correlation with the DES was r=0.552 (p<0.001). CONCLUSION: The DSMI-20 is a rapid, viable assessment tool for identifying self-management problems among patients with diabetes.

[Promoting Living Kidney Transplantation].

Kidney transplantation is the best approach for treating patients with end stage renal disease, offering patients the best chance of returning to normal health. While the techniques used in kidney transplantation surgery are mature and highly successful, there is a severe shortage of donor organs. Statistics show a serious imbalance between organ donations and patients on the waiting list for organ transplantation. Moreover, evidence from empirical studies has shown a better transplantation outcome for patients who receive living donor transplantation than for those who receive organs from cadavers. Although using relatives as donors offers an effective way to reduce the problem of organ shortage, this strategy faces many challenges and many other factors affect the promotion of living donor transplantation. This article elaborates how cultural and psychological factors, kidney transplantation awareness, and ethics and laws impact upon living kidney donations and then proposes coping strategies for promoting living kidney transplantation.

[Applying Mishel's Uncertainty Theory to the Care of a Patient After Living-Donor Kidney Transplantation: A Care Experience].

Kidney transplantation greatly benefits end-stage renal disease patients, as they no longer must bear the torment of hemodialysis. However, the effectiveness of living-donor kidney transplantation is often negatively impacted by various complications, which patients may learn to control through related self-care strategies. However, lack of information on these complications and related strategies may lead to feelings of uncertainty and worries over the prognosis. This article discusses a nursing experience with a patient who underwent living-donor kidney transplantation and who suffered from immense uncertainty and prognosis-related worry. Based on the assessment framework of Mishel's uncertainty theory, the authors identified the cause of the subject's uncertainty and offered thorough information regarding post-transplant care. During the period of care, the subject gained self-care knowledge and skills. Furthermore, he learned to apply self-recording, a technique that enabled him to self-monitor the progress of his disease progress, which reduced his sense of insecurity significantly. Ultimately, the subject turned uncertainty into motivation in order to actively participate in his treatment and to maintain optimum health status.

[Constructing an ACP Simulation-Situation Communication Training Program for Patients With Chronic Kidney Disease].

The aging population and changing lifestyles have lead to the increased general risk of chronic kidney disease. Taiwan currently has the highest incidence and prevalence of end-stage renal disease (ESRD) of any country or region in the world. Hemodialysis patients must endure comorbidities and face the uncertainties of death. The best way to achieve a good death is for patients to sign advance care planning (ACP). However, the key factors contributing to low ACP signature rates have been the lack of communication skills and related training among medical staffs. This article explores the dilemma of ACP using an example of chronic kidney disease (CKD) and proposes a theory-based approach to develop a theoretical framework for an ACP simulation-situation communication training program that integrates the simulation situation model, PREPARED model, and scaffolding theory. Readers may use this framework to design ACP simulation-situation communication training programs that conform to their own conditions and then test the effectiveness and feasibility of these programs in clinical settings.

[Introduction to Integrated Diabetes Care].

Diabetes is a huge problem that has been recognized as an important healthcare issue by most national governments. Diabetes affects patients not only in terms of physical health but also in terms of mental health. Furthermore, the medical costs that are associated with diabetes are considerable. Many countries have developed integrated care models for the treatment of diabetes and pay particular attention to assisting patients that require complicated care. Evidence from empirical studies shows that the integrated care of diabetes reduces complications, increases patients' health literacy, and decreases medical costs. Accordingly, integrated care has been applied to the treatment and care of diabetes patients. In the integrated care model, patients not only receive multidisciplinary care during hospitalization but also receive medical services after their return to the community. There has been a dearth of scholarly discussions in Taiwan related to the integrated care of diabetes. Therefore, we present in this paper the concept of integrated diabetes care and the role of the advanced practice nurse (APN) in the multidisciplinary model. It is hoped that this introduction provides practical insights for healthcare professionals into the essence of integrated care.