High-Linear Energy Transfer Irradiation in Clinical Carbon-Ion Beam With the Linear Energy Transfer Painting Technique for Patients With Head and Neck Cancer.

Purpose: Dose-averaged linear energy transfer (LETd) is one of the important factors in determining clinical outcomes for carbon-ion radiation therapy. Innovative LET painting (LP) has been developed as an advanced form of conventional intensity modulated carbon-ion radiation therapy (IMIT) at the QST Hospital. The study had 2 motivations: to increase the minimum LETd (LETdmin) and to improve uniformity of the LETd distribution within the gross tumor volume (GTV) by using LP treatment plans for patients with head and neck cancer while maintaining the relative biologic effectiveness (RBE)-weighted dose coverage within the planning tumor volume (PTV) the same as in the conventional IMIT plan. Methods and Materials: The LP treatment plans were designed with the in-house treatment planning system. For the plans, LETd constraints and LETdmin, goal-LETd, and maximum-LETd (LETdmax) constraints for the GTV were added to the conventional dose constraints in the IMIT prescription. For 13 patients with head and neck cancer, the RBE-weighted dose to 90% (D90) and 50% (D50) of the PTV and the LETdmin, mean (LETdmean), and LETdmax values within the GTV in the LP plans were evaluated by comparing them with those in the conventional IMIT plans. Results: The LP for 13 patients with head and neck cancer could keep D90s and D50s for the PTV within 1.0% of those by the conventional IMIT. Among the 13 patients, the mean LETdmin of the LP plans for the GTV was 59.2 ± 7.9 keV/µm, whereas that of the IMIT plans was 45.9 ± 6.0 keV/µm. The LP increased the LETdmin to 8 to 24 keV/µm for the GTV compared with IMIT. Conclusions: While maintaining the dose coverage to the PTV as comparable to that for IMIT, the LP increased the mean LETdmin to 13.2 keV/µm for the GTV. For a GTV up to 170 cm3, LETd > 44 keV/µm could be achieved using LP, which according to previous studies was associated with lower recurrence. In addition, the LP method delivered more uniform LETd distributions compared with IMIT.

Blue light exposure enhances oxidative stress, causes DNA damage, and induces apoptosis signaling in B16F1 melanoma cells.

Studies have shown that visible light, specifically blue light, adversely affects cells, tissues, organs, and organisms. We investigated the effect of blue light on apoptosis, DNA integrity, and transcription of apoptotic and melanogenic genes using B16F1 melanoma cells. In this study, cells were irradiated with 2-50 W/m2 blue light (465 nm) for several time duration. Exposure to blue light decreased cell viability, but the pan-caspase inhibitor Z-VAD-FMK rescued blue light-induced cell death. Blue light also inhibited cell proliferation and arrested the cell cycle. Blue light-irradiated cells displayed several apoptotic features, like depolarized mitochondrial membranes and enhanced caspase-3 activity. Furthermore, blue light induced strand breaks in the genomic DNA in a dose- and time-dependent manner but did not induce the formation of cyclobutene pyrimidine dimers. The cell cycle inhibitor p21 and the pro-apoptotic gene Bax were upregulated in blue light-exposed cells, whereas the anti-apoptotic gene Bcl-2 and the apoptosis inhibitor survivin were downregulated. The key enzyme in melanin synthesis, tyrosinase, was upregulated after high-intensity (50 W/m2) blue light exposure and downregulated after low-intensity (0.2 W/m2) blue light exposure. Our study demonstrates that blue light triggers apoptosis and some of its effects are similar to those of ultraviolet radiation.

Association between nursing practice environment and sense of coherence among staff nurses: A cross-sectional study in Japan.

AIM: This study aimed to investigate the association between work environment and sense of coherence among staff nurses. BACKGROUND: In Antonovsky's salutogenetic theory, factors that causes stress are not always harmful when people's sense of coherence is high. Although the effects of sense of coherence have repeatedly been confirmed, few studies have examined factors that increase sense of coherence. METHODS: We used cross-sectional data (N = 6172) surveyed in 2017 from a 2-year longitudinal study in 2016 and 2017. Multiple group structural equation modelling was conducted for years of nurse experience of different groups. RESULTS: Work environment subscale scores for nurses with less than 5 years of experience ranged from 2.3 to 2.9 and for those with more than 5 years, from 2.1 to 2.7. The averages of sense of coherence for the groups were 36.9 and 39.7, respectively. For both groups, there was a statistically significant association between work environment and sense of coherence. CONCLUSIONS: Improvement of nurses' work environment may increase sense of coherence, leading to improvements in health. IMPLICATIONS FOR NURSING MANAGEMENT: The study suggests that nurse managers should improve the work environment to increase sense of coherence of staff nurses, leading to improved health for any length of a nurse's experience.

A concept analysis of psychological safety: Further understanding for application to health care.

AIM: To clarify the concept of psychological safety in a healthcare context and to provide the first theoretical framework for improving interpersonal relationships in the workplace to better patient care. DESIGN: A Rodgers' concept analysis. METHODS: The concept analysis was conducted using a systematic search strategy on PubMed, CINAHL, PsycINFO and Ichushi-Web. RESULTS: An analysis of 88 articles studying psychological safety in health care identified five attributes: perceptions of the consequences of taking interpersonal risks, strong interpersonal relationships, group-level phenomenon, safe work environment for taking interpersonal risks and non-punitive culture. The antecedents included structure/system factors, interpersonal factors and individual factors. The four consequences included performance outcomes, organizational culture outcomes, and psychological and behavioural outcomes.

[The Method for Estimation of Radiation Dose of Eye Lens Covered by Radiation Protection Glasses Using Personal Dosimeter for Trunk of the Body and X-ray Shielding Material].

PURPOSE: Radiation protection glasses is a useful tool for dose reduction of eye lens. However, the method to evaluate the dose of eye lens, which is covered with radiation protection glasses in actual radiation management situation, has not been established. We invented the easy-to-use procedure to estimate the dose of eye lens inside of radiation protection glasses for occupationally exposed person using an X-ray shielding material and an additional personal dosimeter for trunk of the body. The objective of this study was to evaluate the feasibility of the new method. METHODS: The radiation field in interventional radiology (IR) was reconstructed. A personal dosimeter was set to the eye position and neck position of medical staff phantom. Each dosimeter was covered by radiation protection glasses or X-ray shielding material, and the 1 cm or 70 mm dose equivalent quantity in the neck position was compared to the 3 mm dose equivalent quantity in the eye position. RESULTS: The dose equivalent quantity measured inside of X-ray shielding material in the neck position was similar to that of inside radiation protection glasses. Thus, the X-ray attenuation by radiation protection glasses was able to be simulated using the X-ray shielding material. CONCLUSION: It was suggested that the dose of eye lens inside of radiation protection glasses could be easily estimated by covering the conventional personal dosimeter for trunk of the body with the X-ray shielding material.

Preliminary Effect and Acceptability of an Intervention to Improve End-of-Life Care in Long-Term-Care Facilities: A Feasibility Study.

The number of deaths of older adults in long-term care settings will increase with the aging population. Nurses and care workers in these settings face various challenges in providing end-of-life care, and interventions for quality end-of-life care may be useful. This feasibility study aims to explore the preliminary effect and acceptability of an intervention named the EOL Care Tool to improve end-of-life care in long-term-care facilities. We conducted a single-arm quasi-experimental study using mixed methods. This tool consisted of multiple components: professionalized lectures, newly developed structured documents, regular conferences regarding end-of-life care, and educational support from administrators. Twenty-four nurses and fifty-five care workers employed in a long-term care facility participated. For nurses, improvement in attitudes toward end-of-life care (p < 0.05) and interdisciplinary collaboration (p < 0.05) were shown quantitatively. Regarding acceptability, nurses and care workers evaluated the tool positively except for the difficulty of using the new documents. However, qualitative results showed that care workers felt the reluctance to address the work regarding end-of-life care. Therefore, a good preliminary effect and acceptability for nurses were indicated, while acceptability for care workers was only moderate. Revision to address the mentioned issues and evaluation of the revised tool with a more robust research design are required.

Spatial and latent memory data in PS2Tg2576 alzheimer's disease mouse model after memantine treatment.

We herein present behavioral data on whether memantine, an adamantane derivative and medical NMDA-receptor antagonist, improves spatial and latent learning deficits in amyloid precursor protein/presenilin 2 double-transgenic mice (PS2Tg2576 mice). In PS2Tg2576 mice, early amyloid-ß protein (Aß) deposition at 2-3 months of age and progressive accumulation at about 5 months of age has been shown. Thus, PS2Tg2576 mice were subjected to Morris water maze (MWM) test for spatial memory and the water-finding test for latent memory testing at ages 3 and 5-6 months. In addition, memantine (30 mg/kg/day, p.o.) was administered 3-4 weeks before commencing the behavioral tasks to check for effects on cognitive function. The information provided in this paper adds to the literature and can be used for the selection of animal models and behavioral paradigms for Alzheimer's disease (AD) research.

Work environment for hospital nurses in Japan: The relationships between nurses' perceptions of their work environment and nursing outcomes.

AIM: To investigate nurses' perceptions of their work environment and to investigate the relationships between variables measuring the work environment (WE) and nursing outcomes (NOs ). DESIGN: A 2-year prospective longitudinal survey (2013-2015). METHOD(S): Descriptive statistics of nurse demographics, organizational WE and NOs were calculated by position. The associations between Practice Environment Scale of the Nursing Work Index (PES-NWI) and NOs were examined for each unit. RESULTS: The participants were 2,992 staff nurses, 137 nurse managers (NMs), and 8 chief nursing officers in Phase 1 and 7,849, 371 and 23 in Phase 2, respectively. The higher the job position, the better the WE was rated. The higher the PES-NWI scores, the better the outcomes. Descriptive statistics about organizational WEs and NOs and the statistically significant associations between the two were identified.

Realization and personalization by facing fatality: A grounded theory of developing the view of dying in people with heart failure.

AIM: To explore how people with heart failure develop and change their views of dying and death. DESIGN: A Straussian grounded theory approach. METHODS: Purposive and theoretical sampling were used. Data collection and analysis were repeated until reaching data saturation using the constant comparative method. We conducted semi-structured interviews between January 2019 and July 2020 with 24 people with heart failure from a university and a community hospital in Japan. RESULTS: Initially, participants' views of dying and death were unrelated to their disease. After the first turning point, namely the confirmation of the deterioration and incurability of the disease, their views became related to their own disease, adding to the suffering caused by the exacerbated symptoms. After the second turning point, namely when participants became tormented by the inevitability of death, they added their struggles with physical, psychological, and spiritual pain owing to medical interventions to their views of dying and death. Only a few participants reached the last stage of this process as it was emotionally distressing; some chose not to proceed to the next stage. CONCLUSION: Participants develop their views of dying and death gradually and in stages while they experience two turning points. Healthcare providers need to address this process while keeping in mind that proceeding this process requires some turning points, and it can be painful. IMPACT: This study provides a theoretical framework on the development of the views regarding dying and death of people with heart failure; it showed that these people need some turning points and to pass through stages to develop/individualize their views, and that this process is inherently distressing. This theory provides a cornerstone for healthcare professionals to understand the disease-specific transition in views of dying and psychological readiness, and it may help establish a therapeutic relationship that includes advance care planning.

The nurses' occupational stress components and outcomes, findings from an integrative review.

AIM: To identify, evaluate and summarize the components, factors and outcomes of nurses' occupational stress published between 2009-2019. DESIGN: Integrative literature review. METHODS: A literature search was conducted on PubMed, CINAHL and PsycINFO databases for articles published in English, between 2009-2019. RESULTS: The review included 132 studies. Most studies were conducted in the Confucian Asia and Anglo countries, but a growing number of studies were done in other countries. Almost all studies used a quantitative design, and changes in the use of scales indicated an increasing attention to career-related components. Factors were categorized into sociodemographic, work environment and personal resources. Sociodemographic factors were inconsistent across countries. Outcomes were categorized into health status, capability, affective and behavioural responses to work, and organizational performance with generally consistent results. Model validation studies showed the non-linear or non-direct associations between stress and outcomes.

Nurses' educational needs when dealing with aggression from patients and their families: a mixed-methods study.

OBJECTIVES: To explore the type of education needed for nurses when dealing with aggression from patients and their families. DESIGN: A two-phase sequential mixed-methods study. SETTING: This study was conducted in Japan, with phase I from March to November 2016 and phase II in November 2018. MAIN OUTCOME MEASURES: The challenges faced by nurses when dealing with incidents of aggression from the neutral perspective of neither nurse nor patient/family and perceptions of the educational contents developed in this study. Descriptive analyses were used to examine the data retrieved from both phases. PARTICIPANTS: Phase I entailed semistructured interviews among 11 neutral-party participants who observed aggressive incidents between nurses and patients/families. Phase II consisted of a web survey conducted among 102 nursing students and 308 nursing professionals. RESULTS: Phase I resulted in the identification of the following five main educational components: understanding the mechanisms of anger and aggression, maintaining self-awareness, observant listening, managing the self-impression, and communicating based on specific disease characteristics. Each component was related to improved communication through self-awareness. The results of phase II indicated that participants positively perceived these educational contents as likely to be effective for dealing with aggression from patients/families. CONCLUSIONS: This study clarified the type of education needed for nurses when dealing with aggression based on multiple viewpoints. Specifically, neutral-party interviews revealed that communication should be improved through self-awareness. A subsequent survey among nurses and nursing students showed that the identified educational contents were positively received.

Biological Activities of Z-Lycopenes Contained in Food.

Mono-(5Z)-, -(9Z)-, and -(13Z)-lycopenes are found in food containing processed tomato products, while tetra-Z-(7Z, 9Z, 7'Z, 9'Z)-lycopene (prolycopene) is found in tangerine-strain tomatoes. We prepared pure mono-Z-lycopenes from all-E-lycopene via chemical reaction (heating in CH2Cl2 at 80℃ for 1 h) followed by purification using preparative silica gel HPLC, while prolycopene was isolated from tangerine tomatoes by partitioning with n-hexane and 90% MeOH followed by silica gel column chromatography. A simple method of distinguishing the mono-Z-lycopenes using the 13C NMR chemical shifts of their Z-methyl carbons is proposed. Additionally, the 1O2 quenching and 3T3-L1 cell differentiation activities of the compounds were then compared with all-E-lycopene for the first time. All the evaluated Z-isomers showed 1O2 quenching activities that were equal to or slightly lower than that of all-E-lycopene, with the IC50 values for the 1O2 quenching activities of (all-E)-, (5Z)-, (9Z)-, (13Z)-, and (7Z, 9Z, 7'Z, 9'Z)-lycopene being 4.4±0.36, 4.0±1.44, 5.3±1.08, 6.9±1.67, and 8.7±0.34 µM, respectively. The mouse 3T3-L1 cell differentiation activities followed the order: (all-E) > (9Z) > (5Z) ≈ (9Z) ≈ (13Z) ≈ (7Z, 9Z, 7'Z, 9'Z).

Consistency of Trans-Abdominal and Water-Immersion Ultrasound Images of Diseased Intestinal Segments in Crohn's Disease.

The aim of this study is to clarify whether trans-abdominal ultrasound (TAUS) can reflect actual intestinal conditions in Crohn's disease (CD) as effectively as water-immersion ultrasound (WIUS) does. This retrospective study enrolled 29 CD patients with 113 intestinal lesions. Five ultrasound (US) parameters (distinct presence/indistinct presence/disappearance of wall stratification in the submucosal and mucosal layers; thickened submucosal layer; irregular mucosal surface; increased fat wrapping around the bowel wall; and fistula signs) that may indicate different states in CD were determined by TAUS and WIUS for the same lesion. Using WIUS as a reference standard, the sensitivity, specificity, and accuracy of TAUS were calculated. The degree of agreement between TAUS and WIUS was evaluated by the kappa coefficient. All US parameters of TAUS had an accuracy >70% (72.6-92.7%). The highest efficacy of TAUS was obtained for fistula signs (sensitivity, specificity, and accuracy values were 63.6%, 96.0%, and 92.7%, respectively). All US parameters between TAUS and WIUS had a definitive (p ≤ 0.001) and moderate-to-substantial consistency (kappa value = 0.446-0.615). The images of TAUS showed substantial similarity to those of WIUS, suggesting that TAUS may function as a substitute to evaluate the actual intestinal conditions of CD.

Rebuilding and guiding a care community: A grounded theory of end-of-life nursing care practice in long-term care settings.

AIMS: To investigate the end-of-life (EOL) nursing care practice process in long-term care (LTC) settings for older adults in Japan. DESIGN: A qualitative study based on grounded theory developed by Corbin and Strauss. METHODS: Sampling, interviewing, and analysis were performed cyclically, with results for each stage used as the basis for data collection and next-stage analysis decisions. Semi-structured interviews were conducted from March 2015-March 2019 with 22 nurses from eight LTC settings. Analysis was performed using coding, constant comparison, and emerging categories. RESULTS: The core category, "guiding the rebuilt care community to assist the dying resident" comprised five categories: "assessing the resident's stage," "harmonizing care with the dying process," "rebuilding a care community," "helping community members care for the resident," and "encouraging community members to give meaning." The participants were described as "traditional village elders" who were the integral members of the care community, as well as guides who helped and encouraged the community. CONCLUSION: Results revealed the holistic process of EOL nursing-care practice in Japan. Nurses aimed to allow LTC residents to die as social human beings, surrounded by people, and not just responding physical and psychological distress. Such practice requires nursing expertise, healthcare skills, and leadership qualities to build and serve care communities. Nurses must also consider residents' uncertainties and vulnerabilities as well as their cultural backgrounds. IMPACT: This study showed that the nurses hold unique roles in providing dying people with care from a community. These findings can potentially be applied for developing a universal model for LTC nurses in many aging populations, to modify their EOL care practice, educate new LTC nurses, and collaborate with other healthcare professionals.

Seasonal alternation of the ontogenetic development of the moon jellyfish Aurelia coerulea in Maizuru Bay, Japan.

Outbreaks of moon jellyfish Aurelia spp. are frequently reported from many parts of the world's coastal areas. Aurelia spp. canonically show a metagenetic life cycle in which planulae transform into sessile polyps, which can drastically increase in number through asexual reproduction. Therefore, their asexual reproduction has been recognized as one of the major causes of the outbreaks. Aurelia spp. also show direct development that lacks asexual reproduction during the polyp stage, which prevents us from understanding the mechanisms of its outbreaks. To clarify the seasonality of the metagenetic and direct-development life cycles of Aurelia sp. in Maizuru Bay, Japan, we conducted field observations and laboratory experiments throughout the year. Additionally, the two life cycle types were genetically analyzed to confirm that they belong to the single species Aurelia coerulea, which dominates in coastal waters in Japan. From July until October, Aurelia coerulea produced smaller eggs and planulae all of which developed into polyps. However, from December until May, larger eggs and planulae were produced and 90% of the planulae developed into planktonic ephyrae bypassing the sessile polyp stage. Our results demonstrated that a single species, A. coerulea, seasonally shifts between their two life cycle types at a water temperature threshold of 20°C in Maizuru Bay. The higher energy storage of larger planulae was suggested to enable the planulae to develop into ephyrae without external energy input through feeding during the polyp stage. The adaptive significances of the two life cycle types were also discussed.

Traumatic Brain Injury by Weight-Drop Method Causes Transient Amyloid-ß Deposition and Acute Cognitive Deficits in Mice.

There has been growing awareness of the correlation between an episode of traumatic brain injury (TBI) and the development of Alzheimer's disease (AD) later in life. It has been reported that TBI accelerated amyloid-ß (Aß) pathology and cognitive decline in the several lines of AD model mice. However, the short-term and long-term effects of TBI by the weight-drop method on amyloid-ß pathology and cognitive performance are unclear in wild-type (WT) mice. Hence, we examined AD-related histopathological changes and cognitive impairment after TBI in wild-type C57BL6J mice. Five- to seven-month-old WT mice were subjected to either TBI by the weight-drop method or a sham treatment. Seven days after TBI, the WT mice exhibited significantly lower spatial learning than the sham-treated WT mice. However, 28 days after TBI, the cognitive impairment in the TBI-treated WT mice recovered. Correspondingly, while significant amyloid-ß (Aß) plaques and amyloid precursor protein (APP) accumulation were observed in the TBI-treated mouse hippocampus 7 days after TBI, the Aß deposition was no longer apparent 28 days after TBI. Thus, TBI induced transient amyloid-ß deposition and acute cognitive impairments in the WT mice. The present study suggests that the TBI could be a risk factor for acute cognitive impairment even when genetic and hereditary predispositions are not involved. The system might be useful for evaluating and developing a pharmacological treatment for the acute cognitive deficits.

A purposeful Yet Nonimposing Approach: How Japanese Home Care Nurses Establish Relationships With Older Clients and Their Families.

Relationship development is crucial to nursing practice with families. However, little is known about the process of building relationships with multiple family members in home care settings and in various cultures. The objective of this study was to explore the experiences of home care nurses about how they established relationships with older clients and their families in Japan. Grounded theory was used to guide the research. Twenty-three expert home care nurses participated in semistructured interviews concerning their family nursing practice. The establishment of relationships with clients/family members was based on a purposeful yet nonimposing approach composed of four aspects: keeping a mindful distance from the family, not being a threat to family life, being a comfortable neighbor, and gaining trust as a competent nurse. Through a purposeful nonimposing approach, Japanese home care nurses promoted and nurtured nurse-family relationships and became involved in the life of the family. These findings provide a useful foundation to guide practice with families and grow knowledge about the process of establishing relationships with multiple family members in home settings.

The somatosensory-evoked potential in reaction time is gated and elicited earlier when the motor response to a somatosensory cue is faster.

The aim of this study was to investigate whether the somatosensory-evoked potential (SEP) is gated and elicited earlier when a motor response to a somatosensory stimulus is faster. In healthy humans, the left index finger and thumb were pinched in response to a somatosensory stimulus administered over the left median nerve. The SEP elicited by this stimulus when producing a fast motor response was compared with that when producing a slow motor response. The amplitudes of N18 and frontal P40 when producing a fast motor response were smaller than those when producing a slow motor response. The latencies of frontal P22 and P40 when producing a fast motor response were shorter than those when producing a slow motor response. These findings indicated that the responses of the primary sensory and frontal areas elicited by a somatosensory stimulus are gated and that the responses of the frontal areas elicited by this stimulus occur earlier when a motor response to this stimulus is faster. The enhanced efficiency or increased speed of the stimulus identification process may be related to the gating and early onset of the SEP components when producing a fast motor response.

Is nurse managers' leadership style related to Japanese staff nurses' affective commitment to their hospital?

AIM: To determine if nurse managers' leadership style is related to Japanese staff nurses' affective commitment to their hospital. BACKGROUND: In Western countries, nurse managers' transformational leadership style has been found to increase staff nurses' affective commitment to their hospital. However, there are few studies examining this relationship in the context of acute care hospitals in Japan. METHODS: Staff nurses completed measures of their nurse managers' perceived leadership style and factors related to their own affective commitment. The association between affective commitment and perception of leadership style was assessed with multiple logistic regression. RESULTS: Of 736 questionnaires distributed, 579 (78.9%) were returned, and data from 396 (53.8%) fully completed questionnaires were analysed. The intellectual stimulation aspect of transformational leadership positively increased staff nurses' affective commitment (odds ratio: 2.23). Nurse managers' transactional and laissez-faire leadership styles were not related to affective commitment among staff nurses. CONCLUSIONS: The intellectual stimulation aspect of transformational leadership may increase the retention of staff nurses through enhanced affective commitment. IMPLICATIONS FOR NURSING MANAGEMENT: To increase staff nurses' affective commitment to their hospital, we suggest that hospital administrators equip nurse managers with intellectual stimulation skills.

How nurse managers in Japanese hospital wards manage patient violence toward their staff.

AIM: This study explores nurse managers' experiences in dealing with patient/family violence toward their staff. BACKGROUND: Studies and guidelines have emphasised the responsibility of nurse managers to manage violence directed at their staff. Although studies on nursing staff have highlighted the ineffectiveness of strategies used by nurse managers, few have explored their perspectives on dealing with violence. METHODS: This qualitative study adopted a grounded theory approach to explore the experiences of 26 Japanese nurse managers. RESULTS: The nurse managers made decisions using internalised ethical values, which included maintaining organisational functioning, keeping staff safe, advocating for the patient/family and avoiding moral transgressions. They resolved internal conflicts among their ethical values by repeating a holistic assessment and simultaneous approach consisting of damage control and dialogue. They facilitated the involved persons' understanding, acceptance and sensemaking of the incident, which contributed to a resolution of the internal conflicts among their ethical values. CONCLUSIONS: Nurse managers adhere to their ethical values when dealing with patient violence toward nurses. Their ethical decision-making process should be acknowledged as an effective strategy to manage violence. IMPLICATIONS FOR NURSING MANAGEMENT: Organisational strategies that support and incorporate managers' ethical decision-making are needed to prevent and manage violence toward nurses.