Relationship Between Teams' Leader-Member Exchange Characteristics and Psychological Outcomes for Nurses and Nurse Managers: A Cross-Sectional Study in Japan.

INTRODUCTION: The Leader-Member Exchange (LMX) theory, based on the social exchange theory, relates to positive psychological states among nurses. However, the influence of various LMX qualities coexisting within a team on nurses or nurse managers is still uncleared. OBJECTIVE: This study examines the relationship of nurses and nurse managers' psychological states with the average LMX and LMX dispersion among nurses in their units. METHODS: The study was conducted at two university hospitals in March 2017 using anonymous questionnaires. Nurses completed the LMX-7 scale and the subscales of job satisfaction, achievement, and growth from the Checklist on Commitments Related to Work. Nurse managers completed the subscales of management satisfaction, effectiveness, and extracting extra effort from the Multifactor Leadership Questionnaire. Both nurses and managers completed the Intention to Continue Working scale. The nurses' data were analyzed using a multilevel analysis to clarify associations between nurses' psychological states and LMX, average LMX, and LMX dispersion. Hierarchical multiple regression analysis tested to test the correlations of the psychological states of nurse managers with average LMX and LMX dispersion. RESULTS: Data from 586 nurses and 28 managers were analyzed. The LMX and average LMX of nurses were positively related to positive psychological states. Nurse managers displayed significant associations between high LMX dispersion and good psychological states. When average LMX was low, management effectiveness increased as LMX dispersion increased; when average LMX was high, management effectiveness was almost constant. CONCLUSION: The unit's LMX characteristics appear to be related to the psychological states of both nurses and nurse managers. Increasing the LMX of each nurse may lead to positive psychological states for not only that nurse but all nurses in the unit. When LMX with subordinates is low, increasing LMX with a portion of nurse managers should be a priority to improve their psychological states.

Prevention of diabetic foot ulcers using a smartphone and mobile thermography: a case study.

OBJECTIVE: Early identification of pre-ulcerative pathology is important to preventing diabetic foot ulcers (DFU), but signs of inflammation are difficult to detect on the feet of patients with diabetic neuropathy due to decreased sensation. However, infrared thermography can objectively identify inflammation. Therefore, a device that allows patients to visualise thermograms of their feet might be an effective way to prevent DFU. We aimed to determine the effects of a novel self-monitoring device to prevent DFU using a thermograph attached to a smartphone. METHOD: A self-monitoring device comprising a mobile thermograph attached to a smartphone on a selfie stick was created, and its effects in two patients with diabetic neuropathy and foot calluses assessed. RESULTS: For one patient, he understood that walking too much increased the temperature in the skin of his feet (a sign of inflammation). The other patient could not detect high-risk findings, because the temperature of his skin did not increase during the study period. CONCLUSION: This device might provide self-care incentives to prevent DFU, although some issues, such as the automatic detection of high-risk thermographic changes, need to be improved.

Factors Associated with Callus Formation in the Plantar Region through Gait Measurement in Patients with Diabetic Neuropathy: An Observational Case-Control Study.

Callus has been identified as a risk factor leading to severe diabetic foot ulcer; thus, it is necessary to prevent its formation. Callus formation under the first, second, and fifth metatarsal heads (MTHs) is associated with external forces (pressure and shear stress) during walking. However, the gait factors increasing the external forces remain undetermined. Thus, this study aims to identify the factors increasing the external forces to prevent callus formation. In 59 patients with diabetic neuropathy wearing their usual shoes, the external forces, and the lower extremity joint angles were measured using MEMS force sensors and motion sensors. The external forces and their relationship with the lower extremity joint angles and footwear size were determined. Risk factors causing high external forces on the first MTH included small flexion of the knee joint (p = 0.015) and large ankle pronation motion (p = 0.034) to obtain propulsion. For the second MTH, wearing excessively long footwear was identified (p = 0.026). For the fifth MTH, high external force was related to tight width footwear (p = 0.005). An effective intervention for preventing callus formation for the first MTH would involve assisting the push-off foot motion using rocker-sole footwear or gait training. For the second and fifth MTHs, wearing appropriate size footwear would be effective.

Quality of work among part-time nurses and its relationship to job satisfaction and work values: A cross-sectional study.

This study compared the quality of work between part-time and full-time nurses and investigated the relationship between quality of work and satisfaction with the work itself among part-time nurses. Quality of work was measured by specific work content and job characteristics. It was hypothesized that work content would affect satisfaction mediated by job characteristics. Furthermore, the moderating effects of intrinsic work values on the relationship between job characteristics and satisfaction were examined. A cross-sectional survey was conducted with 444 part-time and 795 full-time nurses working in Japanese hospital wards in 2017. The Mann-Whitney U test, χ2 test, and hierarchical multiple regressions were used. Work content differed between part-time and full-time nurses; however, job characteristics and satisfaction showed little difference. Work content was not associated with satisfaction mediated by job characteristics. Within the job characteristics, autonomy and feedback had positive effects on the satisfaction of part-time nurses, whereas interaction with work values was insignificant. When assigning work, it is important to allow part-time nurses to experience higher levels of autonomy and feedback regardless of their intrinsic work values.

Nursing activities at clinics in rural areas in Japan: gaps between recognition of importance and implementation.

This study determined the level of implementation and the importance placed on various nursing activities at clinics in rural areas of Japan in order to explore the achievement and perceived importance of implementing certain nursing roles and activities at such clinics. To identify these items, a questionnaire was administered to 40 nurses working in rural clinics. The results showed that activities related to "Basic Nursing Practice" and "Community Understanding" were recognized as important and were performed by almost all nurses. Some activities related to "Administration and Operation" and "Cooperation with Local Government" were recognized as important, but were not implemented, thereby hampering the continuum of care across the health system. These activities, which are related to collaboration with hospitals and local governments that support the clinics, included adjustment of staff inside and outside the facilities to guarantee the use of paid holidays, as well as collaboration with acute care, remote medical systems, and local governments during emergencies and for disaster preparation. Additional support for nurses in collaboration between clinics in rural areas, hospitals, and regional administrations that support the clinics remains a challenge to be addressed.

Frontline nurse managers' visions for their units: A qualitative study.

AIMS: To elucidate frontline nurse managers' visions of their units. BACKGROUND: Managers have the opportunity to imagine and share their visions for effective unit management. METHODS: Semi-structured interviews were conducted with 12 frontline nurse managers working at inpatient units in two hospitals between 2016 and 2017. Data were qualitatively analysed using an inductive approach, focusing on participants' intents. RESULTS: Although participants showed four types of difficulties in verbalizing visions, five categories and 18 subcategories were extracted through analysis of their descriptions about actual cases reflecting their visions. The categories were (a) provide excellent care to ensure patient recovery based on reliable knowledge and skills, (b) make efforts to broaden patients' futures, (c) create a climate for pursuing better practice, (d) all staff continuously pursue professional development and (e) provide nursing care that responds to external changes. All categories were common to all participants' images of the future and linked together to form each manager's vision. CONCLUSION: Frontline managers experienced difficulty in articulating their visions. However, through episodes, they represented images of visions. The managers' visions comprised five categories reflecting various perspectives. IMPLICATIONS FOR NURSING MANAGEMENT: Using a conceptualized vision framework, and identifying difficulties in verbalizing their images, can help managers articulate their visions.

Validity of DMIST for monitoring healing of diabetic foot ulcers.

A new diabetic foot evaluation scale was proposed, using the seven domains of depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunneling/undermining. This scale was named "DMIST" as an acronym from the initials of the domains. The purpose of this study was to evaluate the validity of DMIST. Secondary analysis was conducted in three investigations performed using the diabetic foot ulcer assessment scale (DFUAS) in Japan and Indonesia. Secondary analysis was assessed using DMIST, PUSH, and DESIGN for 4 weeks based on DFUAS score and photographs of diabetic foot ulcers by researchers. Concurrent validity was determined from the correlation of total DMIST scores with PUSH and DESIGN scores. Construct validity was determined by comparisons between total DMIST score and grade of the Wagner classification. Predictive validity was determined by receiver operating characteristic curve analysis for wound non-healing 4 weeks later. Subjects comprised 35 Japanese patients and 118 Indonesian patients. Correlations of total DMIST score with PUSH and DESIGN scores were 0.831 and 0.822, respectively. Comparison of total DMIST scores with grade of the Wagner classification (Grade I vs. Grade II/III vs. Grade IV/V) was p < 0.001. Based on an area under the curve of 0.872, a DMIST score of 9 was selected as a cut-off, offering sensitivity of 0.855 and specificity of 0.786 for wound non-healing 4 weeks later. Our findings suggest that DMIST offers high validity.

Relationship between nurses' perceptions of nursing assistant roles and information-sharing behaviors: A cross-sectional study.

Information-sharing between nurses and nursing assistants is necessary for appropriate inpatient care. Nurses who perceive nursing assistant roles highly may display positive behaviors related to information-sharing with nursing assistants. This study aims to examine the relationship between nurses' perceptions of nursing assistant roles and the frequency of their sharing information with nursing assistants. Using a self-administered, cross-sectional survey questionnaire, data from 2,642 nurses in 182 hospitals were collected. Nurses' perceptions of nursing assistant roles were measured with a scale containing four factors: (i) improving patients' abilities through daily care; (ii) caring for various patients using broad perspectives; (iii) facilitating co-ordination and co-operation among team members; and (iv) increasing the amount of information on patients among team members. Information-sharing behaviors included "expressing," "asking," "linguistic response," and "feedback." Multiple regression analyses for each nurse's information-sharing behaviors were conducted. Nurses' perceptions of nursing assistant roles were positively correlated with the frequency of sharing information with nursing assistants. The degree of the correlations differed, depending on the type of information-sharing behavior. Therefore, improving nurses' understanding of nursing assistant roles might increase their information-sharing behaviors.

Effects of skin care education for care staff at elderly care facilities on skin conditions of the residents.

Asteatosis is common in elderly people due to a decrease in the moisture content of the epidermal stratum corneum through a loss of skin barrier function caused by aging. Because itching often accompanies asteatosis, this condition may cause a decrease in quality of life. Care staff in elderly care facilities have many opportunities to provide care for residents. In this study, we examined how educational training on skin care changed the thoughts and actions of care staff in these facilities and how these changes impacted the skin conditions of residents. The subjects for the training were all care staff in facilities because these staff work most closely with facility residents. We performed skin care training for the subjects and investigated changes in the skin conditions of the residents before and after the training. The training promoted the understanding of skin care among the care staff and improved the skin symptoms of residents with asteatosis. However, there were no changes in the severity of itchiness based on a verbal rating scale and in interviews of residents. This study showed that skin care training for the care staff in facilities is effective to improve skin conditions of residents. In addition, it was suggested that a full grasp of the residents' skin symptoms based upon an interview on itching alone was difficult, and thus there is a need to observe skin conditions directly.

Differences Between Patient-Reported Versus Clinician-Observed Nonulcerative Signs and Symptoms of the Foot in Patients With Diabetes Mellitus.

PURPOSE: The primary aim of this study was to compare patient reported versus clinician-observed nonulcerative foot conditions in patients attending a diabetic foot clinic and deemed at risk for diabetic foot ulcers. DESIGN: Retrospective review of medical records. SUBJECTS AND SETTING: The medical records of 126 patients with diabetes mellitus and deemed at risk for developing diabetic foot ulcers were reviewed. All patients received care from a diabetic foot outpatient clinic in a university-based hospital in Tokyo, Japan, between November 2008 and October 2009. METHODS: We compared patients' self-identified foot complaints with clinically observable conditions affecting the feet of these individuals with diabetes mellitus. Patients' medical records were retrieved, and patient complaints and identified preulcerative signs of the foot were documented. All clinical observations were made by nurse specialists with knowledge of diabetic foot conditions. Nonulcerative diabetic foot conditions we observed included calluses, corns, abnormal nails, fissures, tinea pedis, and tinea unguium. Patient sensitivity to correctly identify these signs was calculated using the following formula: patient-reported foot signs divided by clinically identified preulcerative signs. RESULTS: Patient sensitivity for identifying nonulcerative signs varied based on the foot condition was 51.4% for calluses, 47.8% for pincer nails, 44.4% for corns, 33.3% for fissures, 19.4% for nail abnormalities, 3.9% for scales/maceration between the toes, 2.6% for interdigital tinea pedis, and 18.2% for tinea unguium. CONCLUSION: These findings suggest that persons with diabetes vary in their awareness of conditions affecting their feet and enhancing their risk for the development of diabetic foot ulcers. We recommend additional education on foot-related self-care including how often to observe their feet and how to recognize symptoms that may elevate their risk for diabetic foot ulcers.

The Association between Tinea Pedis and Feet-Washing Behavior in Patients with Diabetes: A Cross-sectional Study.

OBJECTIVES: To examine the correlations between elements of feet-washing behavior, presence of tinea pedis (TP), and patients' background characteristics in order to identify a concrete intervention method to prevent TP. DESIGN AND PARTICIPANTS: A cross-sectional study of 30 patients with diabetes (16 with TP) who were admitted to or visited the university hospital. MAIN OUTCOME MEASURES: The presence of TP was confirmed by the detection of dermatophytes by direct microscopy. Data on elements of feet-washing behavior, such as scrubbing between the toes, were collected by observing recorded videos of participants normally washing their feet as they do at home. The patients' background characteristics included demographic data; diabetes-related factors; patient knowledge regarding diabetes, foot problems, and TP prevention; purpose for feet washing; and any difficulties in feet washing. MAIN RESULTS: The number of times patients scrubbed between their toes while washing with soap was significantly lower in patients with TP (odds ratio, 0.95; P = .036; with a cutoff value of 35 times) and those who had difficulty in reaching their feet with their hands (B = -14.42, P = .041). CONCLUSIONS: An effective foot-washing protocol should include specific instructions for patients to scrub between their toes at least 35 times in all 8 spaces while washing with soap. Appropriate advice is also needed for individuals who have difficulty reaching their feet with their hands. Education about appropriate foot-washing behavior may potentially prevent TP.

Thermographic findings in a case of type 2 diabetes with foot ulcer due to callus deterioration.

ABSTRACT: A number of studies have reported the usefulness of monitoring skin temperature at local points in reducing the risk of ulceration. Thermography has the advantage of being able to visualize morphological temperature distribution. We reported that inflammation was detected by thermography in 10% of diabetes mellitus (DM) patients with foot calluses, and the area in which increased skin temperature was observed was limited to the callus. However, no reports have described thermographic findings of calluses deteriorating into foot ulcers. We report a case monitoring the skin temperature distribution using thermography, which might be useful for predicting ulceration. CASE: A 53-year-old male patient, diagnosed with type 2 DM, was treated with insulin therapy. The duration of DM was 4 years. He was also diagnosed with dyslipidemia and hypertension. Using thermography, the skin temperature was evaluated in the patient with calluses on the 5th metatarsal heads. Areas of increased skin temperature were observed, involving not only the callused part, but also the plantar arch. We shaved his calluses once a month and explained the importance of his therapeutic shoes to prevent the ulcers. After 43 months, an ulcer developed. DISCUSSIONS: Thermographic findings of an extended area of increased skin temperature not limited to the callus may suggest the progression of a callus to ulcer. Expansion of the area of increased skin temperature might show the inflammation or infection extending along the fascia. Based on these findings, thermography could provide a useful assessment of callus in DM patients with a high risk of progression.

Factors Associated With Callus in Patients with Diabetes, Focused on Plantar Shear Stress During Gait.

BACKGROUND: The aim of this study is to identify whether plantar shear stress in neuropathic patients with diabetes with callus is increased compared with those without callus. METHOD: The differences in foot deformity, limited joint mobility, repetitive stress of walking, and ill-fitting shoes between patients with callus and those without callus were also determined. Subjects were recruited from the Diabetic Foot Outpatient Clinic. A newly developed in-shoe measurement system, which has flexible and thin insoles, enabled measurement of both plantar pressure and shear stress simultaneously when subjects walked as usual on a 10 m walkway. RESULTS: It was found that plantar shear stress adjusted for weight during the push-off phase was increased by 1.32 times in patients with callus compared with those without callus (mean ± SD: 0.0500 ± 0.0160 vs 0.0380 ± 0.0144, P = .031). Moreover, hallux valgus deformity, reduction in dorsiflexion of the ankle joint and increase in plantar flexion were showed in feet with callus. Increased plantar shear stress may be caused by gait change that patients having callus push off with the metatarsal head instead of the toe as a result of foot deformity and limited joint mobility. CONCLUSIONS: It was found that plantar shear stress adjusted for weight during the push-off phase was increased in patients with callus compared with those without callus by using the newly developed measurement system. These results suggest that reduction of plantar shear stress during the push-off phase can prevent callus formation in neuropathic patients with diabetes.

Shear Stress-Normal Stress (Pressure) Ratio Decides Forming Callus in Patients with Diabetic Neuropathy.

Aim. Callus is a risk factor, leading to severe diabetic foot ulcer; thus, prevention of callus formation is important. However, normal stress (pressure) and shear stress associated with callus have not been clarified. Additionally, as new valuables, a shear stress-normal stress (pressure) ratio (SPR) was examined. The purpose was to clarify the external force associated with callus formation in patients with diabetic neuropathy. Methods. The external force of the 1st, 2nd, and 5th metatarsal head (MTH) as callus predilection regions was measured. The SPR was calculated by dividing shear stress by normal stress (pressure), concretely, peak values (SPR-p) and time integral values (SPR-i). The optimal cut-off point was determined. Results. Callus formation region of the 1st and 2nd MTH had high SPR-i rather than noncallus formation region. The cut-off value of the 1st MTH was 0.60 and the 2nd MTH was 0.50. For the 5th MTH, variables pertaining to the external forces could not be determined to be indicators of callus formation because of low accuracy. Conclusions. The callus formation cut-off values of the 1st and 2nd MTH were clarified. In the future, it will be necessary to confirm the effect of using appropriate footwear and gait training on lowering SPR-i.

Association between Washing Residue on the Feet and Tinea Pedis in Diabetic Patients.

Tinea pedis (TP) may lead to the development of foot ulcers in diabetic patients; thus, its prevention in diabetic patients is important. TP occurs after dermatophytes on the skin scales of TP patients attach to the feet. Therefore, it is necessary to remove the scales and dermatophytes, and this can be performed using various methods, including foot washing. This study aimed to objectively examine the association between the presence of TP and foot-washing habits. We included 33 diabetic patients, and, of these, 17 had TP. The presence of washing residue on the feet was determined by applying a fluorescent cream to the participants' feet, and images of the feet were captured under ultraviolet light before and after foot washing. Our results showed that diabetic patients with TP had higher levels of washing residue on their feet than those without TP. The importance of washing feet to prevent TP needs to be emphasized through educational programs for diabetic patients. Furthermore, the development of an effective foot-washing technique is essential.

Screening for tinea unguium by thermography in older adults with subungual hyperkeratosis.

AIM: The purpose of the present study was to assess the difference in foot temperature between tinea unguium-positive older adults with subungual hyperkeratosis and tinea unguium-negative older adults with subungual hyperkeratosis to develop a temperature-based screening method for tinea unguium. METHODS: The present cross-sectional, observational study investigated 51 residents with subungual hyperkeratosis in two facilities covered by long-term care insurance between October 2011 and December 2011. One dermatologist recorded the clinical signs of abnormal toenails. Nail specimens were collected from all abnormal nails, and the presence of tinea unguium was confirmed when fungus was detected by direct microscopy. Foot temperature was measured by infrared thermography. A receiver operating characteristic curve was used to assess the ability to determine whether residents with subungual hyperkeratosis have tinea unguium and to determine the cut-off point. RESULTS: Among the people with subungual hyperkeratosis, the mean toe temperature in the tinea unguium-positive group (30.2 ± 2.6°C) was significantly lower than that in the tinea unguium-negative group (32.8 ± 3.2°C, P = 0.001). The area under the receiver operating characteristic curve was 0.74 (95% confidence interval 0.621-0.876), and the threshold temperature was set at 33.0°C, resulting in a sensitivity of 81.8% and specificity of 65.7%. CONCLUSION: Our study suggests that foot temperature can be used to screen for tinea unguium in people with subungual hyperkeratosis. This non-invasive and simple screening method would help clinicians to set priorities in terms of carrying out direct microscopy to diagnose tinea unguium in elderly residents in care facilities.

Relationship between activity of daily living and asteatosis in the lower legs among elderly residents in long-term care institutions: a cross-sectional study.

This cross-sectional observational study investigated the relationship between the level of activities of daily living (ADL) and asteatosis in the lower legs among elderly residents. We enrolled 173 residents from a long-term care health facility and two special nursing homes for elderly persons in the Tokyo metropolitan area and Oshima Island, Japan. The level of ADL was measured by the Barthel Index. The relationship between the Barthel Index total score and the presence of asteatosis in the lower legs diagnosed by a dermatologist was analysed by multivariate logistic regression analysis. Among the residents, 79·2% had asteatosis in their lower legs. An increase of 1 point in the Barthel Index total score was significantly associated with a decreased probability of lower leg asteatosis after adjusting for age, sex and the type of institution (adjusted odds ratio = 0·982; 95% confidence interval: 0·966-0·998). A higher level of ADL is associated with a lower probability of having asteatosis in the lower legs among residents in long-term care institutions. Nurses should pay specific attention to residents with limited ADL for initiating preventive care for asteatosis.