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.

Reliability and validity of the practice environment scale of the nursing work index for Japanese hospital nurses.

AIMS: The aim of this study was to examine the reliability and validity of the Practice Environment Scale of the Nursing Work Index (PES-NWI) for hospital nurses in Japan. DESIGN: A cross-sectional mail survey. METHODS: Participants in this study were 1,219 full-time ward nurses from 27 hospitals in Japan, using 31 items of the Japanese version of the PES-NWI questionnaire, from December 2008-March 2009. Construct validity, criterion-related validity and internal consistency of the PES-NWI were tested. RESULTS: The PES-NWI showed reliable internal consistency. The five-factor structure was supported by confirmatory factor analysis. The PES-NWI correlated significantly with job satisfaction, burnout and the nurses' intention to stay on the job, supporting criterion-related validity.

Evaluating cultural competence among Japanese clinical nurses: Analyses of a translated scale.

This paper describes the factor analysis testing and construct validation of the Japanese version of the Caffrey Cultural Competence Health Services (J-CCCHS). The inventory, composed of 28 items, was translated using language and subject matter experts. Psychometric testing (exploratory factor, alpha reliability, and confirmatory factor analyses) was undertaken with nurses (N = 7494, 92% female, mean age 32.6 years) from 19 hospitals across Japan. Principal components extraction with varimax rotation yielded a 5-factor solution (62.31% variance explained) that was labeled: knowledge, comfort-proximal, comfort-distal, awareness, and awareness of national policy. Cronbach α for the subscales ranged from 0.756 to 0.892. In confirmatory factor analysis using the robust maximum likelihood estimator, the chi-square test was as follows: χ2 (340) = 14604.44, P < .001. After correlated errors were introduced, there was evidence of improved model fit (χ2 (335) = 8681.61, P < .05) but the other indices showed improvement (RMSEA = .058 [90% CI, 0.057-0.059], TLI = .891, CFI = .903, and SRMR = .059). The discriminating power of the J-CCCHS was indicated by statistically mean differences in J-CCCHS subscale scores between predefined groups. Taking into consideration that this is the first foray into construct validation for this instrument, and that fit was improved when a subsequent data driven model was tested, and it has the ability to distinguish between known groups that are expected to differ in cultural competence, the instrument can be of value to clinicians and educators alike.

Four factor research awareness scale for nurses in Japanese: instrument development study.

AIM: Research awareness is an important consideration necessary for providing superior nursing care. However, a gap exists between research and clinical practice. A major obstacle to integrating research into clinical practice is the absence of research awareness among nurses. Studies on research awareness have focused primarily on three factors: attitude, competence, and encouragement for conducting research. The Research Awareness Scale for Nurses (RASN) in Japanese incorporates a critical, yet generally overlooked fourth factor of flexible structure for research. The aim of this study was to develop a nursing research awareness scale that could be used to determine the reasons for the lack of interest in research among nurses and to help nursing administrators take steps to integrate research into clinical practice. METHODS: The RASN was developed and tested in three stages. An item pool for the scale was generated from a published work review and focus group interviews. The scale was then tested in a pilot study, and finally in a main study. Reliability and validity were examined by exploratory and confirmatory factor analysis, Cronbach's alpha, one-way anova and correlation analysis. RESULTS: The RASN exhibited good validity in the four factor structure ("attitude", "competence", "encouragement", and "flexible structure"). Cronbach's alpha exhibited good internal consistency. The RASN was significantly and positively correlated with research-related education and activities. CONCLUSION: The RASN had good internal consistency, content validity, discriminant validity, and construct validity. These findings demonstrate that the RASN is a useful instrument for evaluating approaches toward the integration of research into clinical practice.

Physicians' perceptions of physician-nurse collaboration in Japan: effects of collaborative experience.

Studies of physician-nurse relationships have focused mainly on nurses' perceptions. Few studies have explored physicians' perceptions and related factors. This study had two aims: to describe physicians' perceptions of physician-nurse collaboration in Japan by focusing on attitudes toward collaboration and collaborative practice and to examine the effect of physicians' experiences related to collaboration on their perceptions of collaboration. A cross-sectional survey was conducted. Of the 520 physicians from four hospitals, 248 completed the survey. The survey included the Jefferson Scale of attitudes toward physician-nurse collaboration, the collaborative practice scales, learning experiences related to collaboration with nurses and experiences of joint activities with nurses. Multiple regression analysis revealed that learning experiences in undergraduate and out-of-hospital education and experiences of joint committee work were significantly associated with higher collaborative practice scores. Although participants' attitude scores had a strong association with practice scores, there were no variables significantly associated with the attitude score. This study supported the importance of education in undergraduate courses and suggested that it should be ongoing after qualification. Joint activities other than daily practice, such as continuous quality improvement, might also be effective. Factors that improve physicians' attitudes toward collaboration should be further explored.

Effects of mental workload on nurses' visual behaviors during infusion pump operation.

AIM: According to a national report on incident analysis, the mental workload that exists during the i.v. medication administration process might affect nurses' visual behavior and, thus, influence the accuracy of the process. This study examined changes in the visual behavior of nurses who operated an infusion pump under the influence of time pressure and dual tasking. METHODS: mTen nursing students, 13 experienced nurses, and nine inexperienced nurses, equipped with an eye tracker and instruments that measure the heart rate and breathing frequency, carried out an infusion pump operation in a simulated patient room under three mental workload conditions: without a mental workload, under time pressure, and while dual tasking. RESULTS: Under the time pressure condition, the total visual fixation duration of the procedures was shortened. The experienced and inexperienced nurse groups could shorten the tasks in order of priority but the student group could reduce the tasks only inconsistently. Dual tasking had no influence on the total fixation duration of the procedures. However, the fixation location was influenced by the dual-tasking condition. This condition caused dispersed attention in the student and inexperienced-nurse groups, but not in the experienced-nurse group. CONCLUSION: Time pressure appears to cause nurses to shorten the duration of infusion pump operation and to reduce the quantity of checking. Dual tasking appears to have no influence on the total visual fixation duration but causes dispersed attention, reducing the quality of checking.

Patient perception of nursing service quality; an applied model of Donabedian's structure-process-outcome approach theory.

BACKGROUND: Nursing is a labour-intensive field, and an extensive amount of latent information exists to aid in evaluating the quality of nursing service, with patients' experiences, the primary focus of such evaluations. To effect further improvement in nursing as well as medical care, Donabedian's structure-process-outcome approach has been applied. AIMS: To classify and confirm patients' specific experiences with regard to nursing service based on Donabedian's structure-process-outcomes model for improving the quality of nursing care. METHODS: Items were compiled from existing scales and assigned to structure, process or outcomes in Donabedian's model through discussion among expert nurses and pilot data collection. With regard to comfort, surroundings were classified as structure (e.g. accessibility to nurses, disturbance); with regard to patient-practitioner interaction, patient participation was classified as a process (e.g. expertise and skill, patient decision-making); and with regard to changes in patients, satisfaction was classified as an outcome (e.g. information support, overall satisfaction). Patient inquiry was carried out using the finalized questionnaire at general wards in Japanese hospitals in 2005-2006. Reliability and validity were tested using psychometric methods. RESULTS: Data from 1,810 patients (mean age: 59.7 years; mean length of stay: 23.7 days) were analysed. Internal consistency reliability was supported (α = 0.69-0.96), with factor analysis items of structure aggregated to one factor and overall satisfaction under outcome aggregated to one. The remaining items of outcome and process were distributed together in two factors. Inter-scale correlation (r = 0.442-0.807) supported the construct validity of each structure-process-outcome approach. All structure items were represented as negative-worded examples, as they dealt with basic conditions under Japanese universal health care system, and were regarded as representative related to concepts of dissatisfaction and no dissatisfaction. CONCLUSION: Patients' experiences with nursing service were confirmed using Donabedian's approach and can therefore be applied to improve quality of nursing practice by practitioners, managers and policy makers.

Influence of repeated painful procedures on prefrontal cortical pain responses in newborns.

AIM: We examined whether previous experience of repeated skin punctures altered the correlation between prefrontal cortical pain responses and Premature Infant Pain Profile (PIPP) scores, compared with infants who had no experience of skin puncture. METHODS: Eighty infants at 37-42 weeks of gestational age were observed during clinically required blood sampling: full-term infants with no experience of painful skin-breaking procedures before data collection (controls; n = 30), full-term infants with the experience of painful skin-breaking procedures (n = 20) and preterm infants with the experience of painful skin-breaking procedures (n = 30). RESULTS: We found no significant differences in PIPP scores among groups. In controls, prefrontal activation in both hemispheres correlated with facial expression score of the PIPP (r = 0.53 for right prefrontal area; r = 0.37 for left prefrontal area) and the total score. In full-term infants with the experience of pain, there was no correlation between cortical activation and clinical pain scores. In preterm infants, prefrontal activation in both hemispheres correlated with the physiological component of the PIPP score (r = 0.36 for right prefrontal area; r = 0.41 for left prefrontal area). CONCLUSION: Our findings may be useful in considering the effects of cumulative painful experience on emotion and stress in neonates.

Effect of gender and hand laterality on pain processing in human neonates.

BACKGROUND: Previous studies in adults have reported that handedness and gender can affect pain perception. However, it is currently unclear when these differences emerge in human development. Therefore, we examined prefrontal responses to pain stimulation among newborns during their first acute pain experience after birth. METHODS: Forty newborns at 4-6 days postnatal age were observed during clinically required blood sampling while prefrontal activation was measured with near infrared spectroscopy. Blood sampling in this study was the first experience of a procedure involving skin breaking for these infants. We divided subjects into a right-hand stimulation group (n=21) and a left-hand stimulation group (n=19), depending on whether blood was sampled from the right or the left hand. A three-way analysis of variance (ANOVA) was conducted to examine the effects of several variables on the magnitude of the oxy-Hb value in response to pain stimulus, including stimulus side (right hand or left hand), gender (male or female), recording side (right prefrontal area or left prefrontal area) and interactions between these variables. RESULTS: The data revealed a significant effect of stimulus side (F (1, 72)=9.892, P=0.002), showing that the right-hand stimulation induced a greater prefrontal activation than the left-hand stimulation. No significant gender difference or interactions were found. CONCLUSION: Our findings suggest that hand laterality affects pain perception even in neonates. However, gender differences in pain perception did not appear to occur during the neonatal period. Further investigations using brain-imaging techniques are required to identify laterality- or gender-related differences in pain processing in humans.

Nurse risk managers' criteria for dealing with near-miss events.

From the preventive point of view, it is very valuable for Japanese hospital safety managers to select important cases not only from among accident events, but also from near-miss events that involve errors that may result in the occurrence of future serious adverse events. The objective of this study is to investigate factors that determine the type of analysis that applies to hypothetical near-miss events. We sent self-administered questionnaires to 393 nurse risk managers from general hospitals in Japan. Hypothetical near-miss events were presented, and respondents assessed hypothetical events. Type of Analysis, Probability, Organizational Risk (effect on reputation and effect on cost), and Severity (possibility of harm, degree of harm, possibility of recovery, and possibility of delayed discharge) were included in the questionnaire. Response rate was 47.3% (186/393) and finally 175 nurses are analyzed. The respondents were 58 full-time safety managers (33.1%) and 117 who were safety managers concurrently with other work (66.9%). As a result of logistic regression analysis, probability, effect on reputation, possibility of harm and possibility of delayed discharge were significant (p < 0.05). Japanese safety managers consider near-miss events that have a lower probability to be more important. This finding differs from existing prioritization systems that were principally made for actual adverse events. It may suggest the problem of uncritically applying scales for accident events to near-miss events.

Effect of procedure light on the physiological responses of preterm infants.

AIM: Current recommendations for illumination in the NICU state that procedure light should be controlled with a rheostat to protect infants from high illumination. However, overhead fluorescent lights without a dimmer switch are still used in Japan. The aim of this study was to assess the effects of three different procedure lighting conditions (fluorescent with on/off switch rapidly increasing the level of light [FRL], incandescent with on/off switch rapidly increasing the level of light [IRL], and incandescent with dimmer switch slowly increasing the level of light [ISL]) on the respiratory rate (RR) and oxygen saturation (SpO(2)) in preterm infants with or without oxygen therapy. METHODS: Eight preterm infants, with a gestational age of 29-31 weeks, were included in a repeated randomized cross-over study. ANCOVAs, based on general linear mixed models, were used to examine physiological changes over time and across lighting conditions. In addition, the minimum SpO(2) values, after increasing the level of light, were classified into SpO(2) < or = 85%, SpO(2) = 86-91%, and SpO(2) > or = 92% for each lighting condition. RESULTS: With and without oxygen therapy, the RR and SpO(2) under the ISL were higher than under the FRL and IRL. SpO(2) < or = 85% was only observed under the FRL and SpO(2) = 86-91% was observed under the FRL and IRL. CONCLUSIONS: These data suggest that differences in the light conditions influence physiological responses in preterm infants and slowly increasing the level of light might make it easier for them to slowly adapt to high illumination and prevent declining SpO(2) values in neonates.

Expected roles and utilization of specialist nurses in Japan: the nurse administrators' perspective.

AIM: This study explored (1) expected roles for specialist nurses in Japan and (2) nurse administrators' experience-based management strategies for effective implementation of these roles. Background In Japan, specialist nurses have begun to be recognized as valuable human resources. However, managerial issues in utilizing specialist nurses, including unclear roles and lack of reports on effective management strategies, remain. METHOD: Three focus-group discussions were conducted. Nine nurse administrators participated. Data were analysed using qualitative content analysis techniques. RESULTS: The expected roles for specialist nurses were: (1) facilitating general nurses' learning; (2) monitoring and improving the patient care standard; and (3) developing new roles for nursing. Two management strategies were: (1) enhancing specialist nurses' influence, and (2) enhancing specialist nurses' motivation. CONCLUSIONS: Specialist nurses are important human resources able to assume responsibility for process improvement in nursing care. Effective ways to enhance specialist nurses' influence and motivation include developing their management and communication skills, and coordinating their workload and relationships with other health care professionals. IMPLICATIONS FOR NURSING MANAGEMENT: Process improvement indicators may be useful for evaluating specialist nurses' work. Nurse administrators can contribute to effective implementation of specialist nurses' roles not only by clarifying their roles but also by empowering them to keep up with changing organizational needs.

The relationship between incident reporting by nurses and safety management in hospitals.

AIM: This study examines the relationship between nurses' perceptions of incident reporting, the frequency of incident reporting on wards, and safety management in hospitals. METHODS: A self-administered survey was conducted on 528 nurses in 8 hospitals that provide core medical care in rural areas of Japan. Each of these hospitals is equipped with more than 90 beds. The relationship among perceptions of incident reporting, the frequency of incident reporting on wards, and safety management was examined using Pearson correlation coefficients calculated using ward scores. RESULTS: Safety managers' attitudes and safety management at the ward level were found to have significant correlation with fear of reprisal caused by incident reporting, willingness to carry out incident reporting, and recognition of the importance of incident reporting. CONCLUSIONS: On wards where staff and safety managers discuss incidents and their root causes, staff are less fearful of incident reporting, understand the significance of incident reporting, and report incidents more willingly. There is a need for ward managers not only to demonstrate leadership in terms of safety management but also to discuss incidents with staff.

An investigation of the risk factors for infection with methicillin-resistant Staphylococcus aureus among patients in a neonatal intensive care unit.

BACKGROUND: The aims of this study were to investigate the risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection among infants to establish effective infection control measures for neonatal intensive care unit (NICU). METHODS: Data were prospectively collected from 961 infants hospitalized in a teaching hospital in Japan, from July 2002 through December 2005. RESULTS: Among all infants, 28 (2.9%) developed MRSA infections. Multivariate logistic regression analyses demonstrated the risk factors for developing MRSA infections to include a low birth weight (odds ratio [OR], 0.91; 95% confidence interval [CI]: 0.93-0.99), the presence of eye mucous (OR, 6.78; 95% CI: 2.87-16.01), the practice of kangaroo mother care (OR, 3.82; 95% CI: 1.11-13.13), and the MRSA colonization rate (OR, 11.12; 95% CI: 1.32-93.89). CONCLUSION: The risk factors for developing a MRSA infection among infants in NICU were a low birth weight, the presence of eye mucous, the practice of kangaroo mother care, and a high MRSA colonization rate. Therefore, extra attention should be given to infants in high-risk groups demonstrating a low birth weight and the presence of eye mucous and who have undergone kangaroo mother care. As a result, the cohort isolation of infants with MRSA may therefore be an effective strategy to prevent MRSA infections.

Development of nurses with specialties: the nurse administrators' perspective.

AIM: This study clarified how Japanese nurse administrators consider the current status and future prospects of development and utilization of nurses with specialties. BACKGROUND: The demand for specialized nurses is not satisfied throughout the country. METHODS: Nine nurse administrators participated in three focus-group discussions. Data were analyzed using qualitative content analysis technique. RESULTS: On development of specialized nurses, four categories were abstracted: offering opportunities for career development; establishing an environment of life-term continuous learning; providing well-balanced support for the needs of organizations and individual nurses; and support for career development as a specialist. CONCLUSIONS: To develop specialized nurses effectively it is important to focus more attention on qualitative aspects of nurses' professional experience in in-service education and to support appropriate personnel for strategic human resource development. IMPLICATIONS FOR NURSING MANAGEMENT: Facilitating frequent contacts between specialized and general nurses should be highly valued as making an environment where nurses can face career goals daily leads to steady preservation of human resources. It is necessary for nurse administrators to keep human resources quantitatively and to clarify the developmental process after nurses obtain special roles to plan for continuous education.

Glove selection as personal protective equipment and occupational dermatitis among Japanese midwives.

This study was conducted to 1) evaluate the personal selection and use of protective gloves against bloodborne pathogens and management of glove selection in the workplace, 2) survey the experience with occupational dermatitis and other allergic symptoms, 3) explore the relationships between occupational dermatitis experience and glove use, and 4) determine the impact of glove selection upon occupational dermatitis among midwives. Subjects were 1,150 midwives working in Japan. Participants were selected from the members of Japanese Nursing Association and 835 responded to the survey. More than 30% of respondents wore gloves only when clients had an infectious disease, 41% reported experience of occupational dermatitis, 26% associated the dermatitis with medical glove use, and 2% had a diagnosis of latex allergy. Demographic variables that were significantly associated with occupational dermatitis included history of allergic symptoms other than due to occupational exposure, age, tenure and type of working institution. Using latex gloves during administering enema, shaving, changing pads, washing perineum, receiving newborns, suctioning, and handling waste significantly increased the risk of occupational dermatitis experience compared to not using gloves. Logistic regression analysis with backward stepwise elimination revealed glove selection management, such as availability of alternative glove types, using latex gloves for washing perineum, and using latex gloves for handling waste were significant predictors of occupational dermatitis. Occupational dermatitis is a significant issue and glove use as personal protective equipment is not standardized. Some occupational dermatitis may be preventable by managing appropriate glove selection.

Testing psychometric properties of the standard Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30).

BACKGROUND: Because cancer is now the first and second leading causes of death in both of urban and suburban area in China, there are increasing demands for measurement tools to assess quality of life in Chinese cancer patients. The objective of this study was to evaluate the psychometric properties of the standard Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30, version 3.0). METHODS: The questionnaire was administered before, during, and after treatment of 143 patients with breast, gynecological, or lung cancer in six hospitals in China. RESULTS: Cronbach's alpha coefficients for multi-item scales were greater than 0.70 before and during treatment, except for the cognitive functioning scale. Multitrait scaling analysis showed that most of the item-scale correlation coefficients met the standards of convergent and discriminant validity. All scales and items exhibited good reproducibility, criterion-related validity, and construct validity. Score changes over time were observed in the following scales: physical, role, and social functioning; global quality of life; fatigue; nausea/vomiting. Score changes were also observed in the appetite loss item. CONCLUSION: The standard Chinese version of the EORTC QLQ-C30 is overall a valid instrument to assess the quality of life of Chinese cancer patients.

Methods developed to elucidate nursing related adverse events in Japan.

Financial resources for quality assurance in Japanese hospitals are limited and few hospitals have quality monitoring systems of nursing service systems. However, recently its necessity has been recognized. This study has cost effectively used adverse event occurrence rates as indicators of the quality of nursing service, and audited methods of collecting data on adverse events to elucidate their approximate true numbers. Data collection was conducted in July, August and November 2000 at a hospital in Tokyo that administered both primary and secondary health care services (281 beds, six wards, average length of stay 23 days). We collected adverse events through incident reports, logs, check-lists, nurse interviews, medication error questionnaires, urine leucocyte tests, patient interviews and medical records. Adverse events included the unplanned removals of invasive lines, medication errors, falls, pressure sores, skin deficiencies, physical restraints, and nosocomial infections. After evaluating the time and useful outcomes of each source, it soon became clear that we could elucidate adverse events most consistently and cost-effectively through incident reports, check lists, nurse interviews, urine leucocyte tests and medication error questionnaires. This study suggests that many hospitals in Japan could monitor the quality of the nursing service using these sources.

How Japanese nurses provide care: a practice based on continuously knowing the patient.

AIM: Criticisms of the nursing process as a problem-solving approach have emerged recently. This study aimed to identify and describe a way of nursing based on the clinical practice of selected nurses in Japan. METHODS: Data were collected using semi-structured interviews and observations at one 300-bed Japanese hospital in 1999. The purposive sample consisted of 24 female nurses. Data analysis occurred simultaneously with data collection, and questioning and constant comparison were used for data analysis. Codes were clustered into categories and relationships among these were identified. In the final stage of the analysis, two group interviews with participants were carried out to enhance credibility. FINDINGS: This study identified a Japanese way of nursing intended to help patients explore and realize meanings and values of their experiences with illness. When nurses first contacted a patient, they quickly formed a patient image, but altered it each time they obtained new patient information. A patient image consisted of the patient's subjective world (the patient's perspective) and the holistic patient (nurses' perspectives of the patient). The nurses sometimes pursued strategies to know the patient's subjective world. The target, direction, conditions and ways of nursing care were decided based on continuously knowing the patient. The nurses related their knowledge and thoughts to the patient, and by talking with the patient promoted the patient's consideration and participation, and empowered the patient. Nurses continued attending to patients even when they could not provide specific nursing interventions. CONCLUSIONS: Knowing the patient was found to be especially important in determining nursing care. The model described in this study does not contradict the nursing process as a systematic approach to problem-solving. Rather, it has some alternatives that might be useful in providing individual care in Japan.

Evaluation of quality of life in Chinese patients with gynaecological cancer: assessments by patients and nurses.

Quality of life (QOL) has recently become one of the most important focuses in oncology nursing practice and research. The aims of this study were to evaluate the QOL in Chinese cancer patients under chemotherapy and to explore the discrepancy between patients' and nurses' assessments of the patients' conditions. The study participants included gestational trophoblastic disease patients (n = 68), ovarian cancer patients (n = 105), patients with other gynaecological cancer (n = 18), and their attending nurses (n = 25) at hospitals affiliated with universities in Beijing. The high level of some symptom subscales/items in patients suggested that innovative and more effective interventions should be developed and utilised in nursing practice. Patients with metastasis reported lower levels of QOL than those without metastasis. The nurses in this study tended to estimate the patients' QOL inaccurately, except for a few objective aspects. The results of this study can help nurses in planning interventions to enhance the QOL of patients with gynaecological cancer undergoing chemotherapy. The nurses need to be trained to become more sensitive and competent in assessing patients' subjective information.