Volume 3│Number 1

February 2024

Journal of International Nursing Research
Editor-in-Chief
Naohiro Hohashi, PhD, RN, PHN, FAAN
Graduate School of Health Sciences, Kobe University, Japan

Deputy Editor
Chia-Chin Lin, PhD, RN, FAAN
School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR

Editorial Advisor
Kiyoko Fukai, PhD, RN, PHN
Graduate School of Nursing, The Jikei University, Japan

Associate Editors
Mikako Arakida, PhD, RN, PHN
Kawasaki City College of Nursing,Japan

Polly Siu Ling Chan, RN, BHSc, MPHC,
DHSc
School of Nursing, Li Ka Shing Faculty of
Medicine, The University of Hong Kong,
Hong Kong SAR

John Tai Chun Fung, DN, Msc, RN,
APN (Education & Research) NCHKThe University of Hong Kong, Hong
Kong SAR

Shawn Yong-Shian Goh, BHSN, MN,
PhD
National University of Singapore,
Singapore

Elsi Dwi Hapsari, SKp, MS, DS
Faculty of Medicine, Public Health, andNursing, Universitas Gadjah Mada,
Indonesia

Rick Yiu Cho Kwan, RN, BN, MSc,
PhD
School of Nursing, Tung Wah College,
Hong Kong SAR

Kieko Iida, PhD, RN, PHN
Graduate School of Nursing, Chiba
University, Japan

Justina Yat-Wa Liu, RN, PhD
School of Nursing, Hong Kong Polytechnic University, Hong Kong SAR

Yasuko Shimizu, PhD, RN, PHN
Graduate School of Medicine, Osaka
University, Japan

Mayuko Tsujimura, PhD, RN, PHN
School of Nursing, Shiga Universityof Medical Science, Japan

Yoshie Yokoyama, PhD, RN, PHN
Graduate School of Nursing, Osaka City
University, Japan

Naoki Yoshinaga, PhD, RN, CPP, MSN
School of Nursing, Faculty of Medicine, University of Miyazaki, Japan

Publication information: The Journal of International Nursing Research (JINR) is an English-language publication launchedin 2022. It is the international journal of the Japan Society of Nursing Research (JSNR), the oldest and most prestigious nursing society in Japan, which was founded in 1975. For more information, please refer to the following website: https://www.jsnr.
or.jp/english/
Manuscripts: Visit https://www.jinr.jsnr.or.jp/. If you encounter any problems with online submission, please contact the Editorial Office, at jinr@kyorin.co.jp.

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Printed in Japan

Journal of International Nursing Research
Volume 3

Number 1

February 2024

Volume 3 Number 1 February 2024

Contents
Editorial
A pledge to acknowledge the “post-p <.05” era

e2023-0050

Naohiro Hohashi, PhD, RN, PHN, FAAN

Review Article
Assessment of insulin balls: A scoping reviewe2023-0010

Sayuri Nakamura, PhD, RN, PHN, Naoko Kageura, MSN, RN, Makoto Oe, PhD, RN, Yuko Matsui,
PhD, RN, Tomomi Horiguchi, PhD, RN, PHN, Terumi Ueda, PhD, RN, PHN, Natsuko Seto, PhD, RN,
Toshihiko Yanagita, MD, PhD, and Junko Sugama, PhD, RN

Original Research
Health-related quality of life of patients with heart failure using
noninvasive telemonitoring systems with and without visiting nursing
support: A longitudinal observational study

e2023-0007

Motohiro Sano, PhD, RN, PHN, Sho Okada, PhD, MPH, MD, Tomoko Majima, PhD, RN, PHN, andYoshio Kobayashi, PhD, MD

Developing a communication skills scale in the initial oncology nursing
consultation after a cancer diagnosis in Japan

e2022-0041

Takako Mitsuyuki, RN, MSN, Shyoko Ando, RN, PhD, Ayumi Sugimura, RN, PHN, PhD,
Shigeyoshi Maki, RN, PHN, PhD, and Kazuki Sato, RN, PHN, PhD

Risk of developing postpartum type 2 diabetes in women with a history ofgestational diabetes who did not undergo postpartum glucose tolerance
testinge2023-0006
Kanako Yamada, RNM, MA, and Kazutomo Ohashi, MD, PhD

Brief Report
Current state of advance care planning for patients with hematologic
malignancies in Japan: A nationwide survey

e2022-0006

Miki Fujimoto, MA, RN, Yoshiyasu Ito, MA, RN, and Yukihiro Sakaguchi, PhD

Learning outcomes from preventive home visits practicum in anundergraduate nursing program: A qualitative study

e2022-0035

Aya Shinohara, MSN, RN, Ayako Ogata, PhD, RN, PHN, Takayuki Kageyama, PhD,
Joan K. Magilvy, PhD, RN, FAAN, FWAN, and Sachiyo Murashima, PhD, RN, PHN

The relationship between sense of coherence, occupational stress,
organizational climate, identity, and mental health of newly graduatednurses in a specified functional hospital (secondary publication)
Satoshi Ikeda, PhD, RN, PHN

e2023-0012

https://doi.org/10.53044/jinr.2023-0050
https://www.jinr.jsnr.or.jp/

Editorial

A pledge to acknowledge the “post-p <.05” eraNaohiro Hohashi, PhD, RN, PHN, FAAN1, 2
Editor-in-Chief, Journal of International Nursing Research, and 2Graduate School of Health Sciences, Kobe University, Kobe, Japan
1

Although p-values have been used in numerous studies, a longstanding criticism has existed over the misuse and abuse of p <.05.
For example, in a correlation coefficient test (i.e., test of non-correlations), as a sample size becomes larger, its p-value becomessignificant even if the correlation coefficient is small. Conversely, if the sample size is small, no matter how large the correlation
coefficient is, the p-value may not be significant. It must be judged instead based on the correlation coefficient, which is the effectsize. This is one very obvious example.
In 2015, Basic and Applied Social Psychology (BASP) declared the null hypothesis significance testing procedure is invalid
and banned the use of p-values (Trafimow & Marks, 2015). Even the prestigious journal Nature published a paper in 2019 that
asserted “We should never conclude there is ‘no difference’ or ‘no association’ just because a p-value is larger than a thresholdsuch as .05 or, equivalently, because a confidence interval includes zero” (Amrhein, Greenland, & McShane, 2019). Whenreporting p-values, do not use adornments such as stars or letters to denote statistical significance and use sensitive precision (forexample, p =.021 or p =.13).
Moreover, in 2016, the American Statistical Association (ASA) published the “ASA statement on statistical significance and p-values,”
indicating six principles underlying the proper use and interpretation of the p-value and mentioned the use of Bayes factors instead of relying
only on p-value (i.e., test of statistical significance) (Wasserstein & Lazar, 2016). Furthermore, in 2019 the assertion was made that, “We
conclude, based on our review of the articles in this special issue and the broader literature, that it is time to completely dispense with use of
the term ‘statistically significant.’ Nor should variants such as ‘significantly different,’ ‘p <.05,’ and ‘nonsignificant’ survive whether
expressed in words, by asterisks in a table, or in some other manner” (Wasserstein, Schirm, & Lazar, 2019).
Since the 6th edition issued in 2009, the “Publication Manual of the American Psychological Association,” which is often usedin the nursing field, requires that p-values be expressed as specific numerical values, and that effect size and confidence intervalbe specified, among others. Under these circumstances, the Journal of International Nursing Research (JINR) hereby declares
the transition to the “post-p <.05” era. As a side note, I think I would also like to mention that JINR does not necessarily guaranteethat papers with statistically significant results are more likely to be accepted.
References
American Psychological Association. (2009). Publication
manual of the American Psychological Association (6thed.). American Psychological Association.
Amrhein, V., Greenland, S., & McShane, B. (2019). Scientists
rise up against statistical significance. Nature, 567 (7748),
305-307.
https://doi.org/10.1038/d41586-019-00857-9
Trafimow, D., & Marks, M. (2015). Editorial. Basic andApplied Social Psychology, 37 (1), 1-2.
https://doi.org/10.1080/01973533.2015.1012991

Wasserstein, R. L., & Lazar, N. A. (2016). The ASA statementon p-values: Context, process, and purpose. The American
Statistician, 70 (2), 129-133.
https://doi.org/10.1080/00031305.2016.1154108
Wasserstein, R. L., Schirm, A. L., & Lazar, N. A. (2019). Moving to a world beyond “p < 0.05”. The American Statistician, 73 (Suppl. 1), 1-19.
https://doi.org/10.1080/00031305.2019.1583913

JINR 2024, 3 (1), e2023-0050
Correspondence: N. Hohashi. Email: naohiro@hohashi.org
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 1https://doi.org/10.53044/jinr.2023-0010
https://www.jinr.jsnr.or.jp/

Review Article

Assessment of insulin balls: A scoping review
Sayuri Nakamura, PhD, RN, PHN1 , Naoko Kageura, MSN, RN1 , Makoto Oe, PhD, RN2 ,Yuko Matsui, PhD, RN3 , Tomomi Horiguchi, PhD, RN, PHN2 , Terumi Ueda, PhD, RN, PHN3 ,Natsuko Seto, PhD, RN4 , Toshihiko Yanagita, MD, PhD5 , and Junko Sugama, PhD, RN6
1

Faculty of Nursing, School of Health Sciences, Fujita Health University, Toyoake, Japan, 2Institute of Medical,
Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan, 3Faculty of Health Sciences,
Department of Nursing, Komatsu University, Komatsu, Japan, 4Faculty of Nursing/Graduate School of Nursing,
Kansai Medical University, Hirakata, Japan, 5School of Nursing, Faculty of Medicine, University of Miyazaki,
Miyazaki, Japan, and 6Research Center for Implementation Nursing Science Initiative, Research Promotion
Headquarters, Fujita Health University, Toyoake, Japan

Abstract
Insulin balls are subcutaneous induration caused by amyloid deposition due to repeated insulin injections to thesame site, and subcutaneous injections in this area cause poor glycemic control. Therefore, it is important to assess the site for insulin balls and change the injection site at an early stage, but the assessment method remains
unclear. Therefore, we aimed to clarify the available methods for insulin ball assessment. Using the scoping review
method, we searched Japanese and English literature from January 1964 to November 2022 using the keywords“insulin ball” and “assessment” and included those that met the selection criteria. Database searches were conducted in Japan Abstracts Society, PubMed, Scopus, and CINAHL. The number of adopted studies regarding insulin ball assessment was 11. Palpation and visual examination were the assessment methods used in all studies.
Blood tests and ultrasonography were both performed in nine articles, magnetic resonance imaging (MRI) was
performed in five articles, and computed tomography (CT) was performed in four articles. There were two types of
insulin balls: palpable and nonpalpable. A paper reporting that nonpalpable insulin balls can be detected by ultrasonography was noted. In addition to palpation and visual examination, imaging tests such as ultrasonography,
MRI, and CT are necessary because some insulin balls cannot be palpated. This study suggested that incorporating ultrasonography in addition to palpation and visual examination may be useful as a screening tool for the early
detection of insulin balls. We now need to validate the accuracy of the assessment by ultrasonography.
Keywords
assessment, insulin ball, insulin injection, scoping review, subcutaneous induration
JINR 2024, 3(1), e2023-0010

Introduction
In recent years, subcutaneous injections in insulin balls(insulin-derived amyloidosis) have gained attention in the
diabetes field as a cause of poor glycemic control (Nagase

et al., 2009). Although patients are instructed to self-inject
insulin at 2-3-cm intervals to prevent adipose tissue atrophy
or induration (Ohtani, 2013), several cases where patients
injected at the same site, resulting in poor glycemic control,
have been reported (Hauner et al., 1996; Nagase et al.,Correspondence: S. Nakamura. Email: sayuri@fujita-hu.ac.jp
Received: March 6, 2023, Accepted: September 4, 2023, Published: February 23, 2024
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 9JINR 2024, 3(1), e2023-0010

https://doi.org/10.53044/jinr.2023-0010

2014). Injections in the insulin ball tend to be concentrated
at the same site because it is less painful than the other sites(Hauner et al., 1996), but this site absorbs insulin poorly,
which results in poor glycemic control and leads to increased insulin dosages (Nagase et al., 2014). If the increased dose is injected in a site other than the insulin ball,the insulin formulation will become highly effective and hypoglycemia will occur. Thus, a vicious circle where a patient
repeatedly injects insulin at the same site has been reported(Nagase et al., 2009; Hunner et al., 1996). Therefore, we believe that it is essential for healthcare providers to make anearly assessment of whether an insulin ball is being formed
and to provide guidance on changing the injection site.
However, how insulin ball assessments are performed remains unclear. Scoping reviews are an effective approach
when information on a subject has not been comprehensively reviewed (Peters et al., 2015). If we can identify amethod by which insulin balls can be assessed, then it may
be possible to detect insulin balls and provide interventionsat an early stage. We hope to identify a method for insulinball assessment to help in stabilizing blood glucose levels inpatients with hyperglycemia caused by injections in insulin
balls. Therefore, this study will review the methods used forinsulin ball assessment.

Objective
This scoping review will provide an overview of the following: to clarify what methods for insulin ball assessment areavailable.

Definition of Terms
An insulin ball (insulin-derived amyloidosis) is defined as
subcutaneous induration caused by amyloid deposition due
to repeated insulin injections to the same site (Nagase et al.,2009; Ohtani, 2013) (Figure 1).

Methods
The scoping review method was used. Scoping reviews are
conducted to determine what research is being conducted ina particular field (Munn et al., 2018). Scoping review wasdeveloped by Arksey and O’Malley (2005). Here, we followed the five steps outlined by them: (1) identifying the research question, (2) identifying relevant studies, (3) study
selection, (4) charting the data, and (5) collating, summarizing, and reporting the results.
Identifying the Research Question
The research questions in the Patient/Concept/Context (PCC)
framework (Peters et al., 2015) are presented in Table 1,
where P, diabetic patients who had insulin injections; C, the2 of 9Figure 1. Typical physical appearance of insulin balls (insulin-derived amyloidosis) in two patients: patient A and patient B.
From: Nagase et al. (2014). Insulin-derived amyloidosis andpoor glycemic control: a case series. American Journal of
Medicine, 127(5), 450–454.
Note: Reprinted with permission from Dr. Nagase.
Table 1. PCC framework for creating research questions.
P: Patient
C: Concept
C: Context

Diabetic patients who had insulin injections
Insulin ball and assessment
Domestic and overseas research(Japanese and English), regardless of field

concept is insulin ball and assessment; and C, the context isdomestic and overseas research (Japanese and English) regardless of field.
Identifying Relevant Studies
The Japan Medical Abstracts Society was used for the Japanese literature search and PubMed, Scopus, and CINAHL
were used for the English literature search for relevant studies from January 1964 to November 2022 (search date: De-https://doi.org/10.53044/jinr.2023-0010

cember 1, 2022).
For the first concept of the PCC framework (#1, insulinball) mentioned earlier, the keywords used in the Japanese
literature search included “insulin ball,” “insulin-derived
amyloidosis,” “insulin AND induration,” and “insulin AND
mass.” In the English literature search, the keywords included “insulin ball,” “insulin-derived amyloidosis,” and “insulin AND induration.” In English literature, insulin balls
are generally described using these keywords. However, inJapanese literature, the terms “mass” and “induration” areused to describe insulin balls, and if “mass” is removed
from the keywords, the number of references becomes small
and references on insulin balls are omitted.
For the second concept (#2, assessment), the keywords“assessment” and “evaluation” were included in both Japanese and English literature searches.
We combined #1 and #2 with AND as a search formula
to answer the following question: “What methods are available for the assessment of insulin balls caused by insulin injection?”
Study Selection
1) The literature selection criteria were the following: (1)the literature must be on insulin balls caused by insulin injections, (2) it must describe methods used for assessing insulin balls, and (3) it must include evaluation indicators forassessment. The articles must be original papers, research
reports, and case reports in Japanese or English.
2) The exclusion criteria were the following: no mentionof insulin balls or assessment and the absence of meeting
minutes.
After adding the references identified from other sources
to those retrieved from the database and excluding duplicate
references, the first and second authors independently reviewed the article titles and abstracts to exclude articles that
did not meet the selection criteria. Full texts of the selected
articles were subsequently evaluated to exclude those that
did not meet the selection criteria, and the adopted literature
was selected. Articles that were difficult to determine wereselected through discussion between the two researchers.
Charting the Data
We constructed a study selection flowchart based on the
Preferred Reporting Items for Systematic Reviews andMeta-Analyses extension for scoping reviews (Tricco et al.,2018). We extracted the following data from the adopted literature: authors, themes, year of publication, country, objectives, subjects, implementers, assessment methods, evaluation indicators, and results. The extracted data were discussed by the first and second authors and tabulated using
Microsoft Excel 2019.

JINR 2024, 3(1), e2023-0010

Results
Study Selection
The study selection flowchart, which shows the selection
process, is shown in Figure 2. A total of 939 articles wereselected from database searches and 19 from other sources.
Of the 946 articles, excluding duplicates, 11 that met all eligibility criteria were selected. In total, 6 of the 11 studies
were conducted in Japanese (Nagase, 2020; Kitano et al.,2019; Kusuki et al., 2015; Yabe et al., 2015; Ohtani, 2013;
Yashizaki and Honda, 2012).
Insulin Ball Assessment
The assessment methods for insulin balls are shown in Table
2. Of the 11 studies, it was confirmed that palpation andvisual examination were performed in all studies. The next
most common assessment methods were both blood tests
and ultrasonography in nine articles, magnetic resonance imaging (MRI) in five articles, and computed tomography (CT)in four articles. Insulin balls were assessed using multiple
methods, and a definitive diagnosis was made by pathological examination.
Regarding the implementer, as shown in Table 2, one
study where a physician was listed as the implementer ofthe insulin ball assessment was noted (Kikuchi, 2017). No
studies where nurses conducted the assessment and summarized the evaluation and results were noted.
Table 3 shows what was evaluated using the assessment
method. Additionally, the assessment methods for each included study are summarized in Table 4. The presence of
palpation induration, hardness, size, part, skin color, mobility, and tenderness were confirmed by palpation and visual
examination. Blood tests confirmed decreased insulin absorption and increased blood glucose levels. Furthermore, it
was revealed that blood glucose control was poor in the caseof injection in the induration, but the blood glucose level
decreased after switching to healthy skin (Nagase et al.,2020; Kikuchi et al., 2017; Yoshizaki, 2012). Ultrasonography revealed echo level, pattern, induration size and depth,
skin thickness, and blood flow. In ultrasonography, nonpalpable amyloid deposits were identified from echo levels andblood flow (Nagase et al., 2020; Kikuchi et al., 2017) andtheir detection was reported to be very high (Kikuchi et al.,2017). Pattern and signal intensity were confirmed by MRI,
and the shape, size, and absorption intensity were confirmed
by CT.

Discussion
Insulin Ball Assessment
Palpation and visual examination were performed in all references to confirm the site, hardness, and size of the insulinball. However, there are also nonpalpable insulin balls, and
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Records identified through database searching(n = 939)
Japan Medical Abstracts Society
PubMedScopus
CINAHL(n = 756)(n = 111)(n = 71)(n = 1)

Additional records identified
through other sources(n = 19)

Records after deduplicates removed(n = 946)

Eligibility

Screening

Identification

JINR 2024, 3(1), e2023-0010

Records screened(n = 946)

Records excluded because did notreport on insulin ball or assessment(n = 919)

Full-text articles assessed
for eligibility(n = 27)

Full-text articles excluded,with reasons(n = 16)
・Not insulin ball (n = 6)・Insulin injection guidance (n = 6)・Not research article (n = 3)
・Not evauation indicator (n = 1)

IncludedStudies included in
scoping review(n = 11)
Japanese articles = 6
English articles = 5

Figure 2. Flowchart of insulin ball assessment.
Table 2. Assessment methods for insulin balls.
Assessment

Diagnosis

Author, YearCountry

Implementer

Palpation andvisual examination(n = 11)

Blood
test
(n = 9)Ultrasonography(n = 9)MRI(n = 5)CT(n = 4)

Pathologicalexamination(n = 11)

Murao et al. (2022)
Nagase (2020)
Nagase et al. (2020)
Samlaska et al. (2020)
Kitano et al. (2019)
Kikuchi et al. (2017)
Hagiwara et al. (2017)
Kusuki et al. (2015)
Yabe et al. (2015)
Ohtani (2013)
Yoshizaki and Honda (2012)

Japan
Japan
Japan
U.S.A.
Japan
Japan
Japan
Japan
Japan
Japan
Japan

—
—
—
—
—
Physician
—
—
—
—
—

○
○
○
○
○
○
○
○
○
○
○

—
○
○
—
○
○
○
○
○
○
○

○
○
○
—
○
○
○
○
○
—
○

—
○
○
—
○
—
—
—
○
—
○

—
—
—
—
○
—
○
—
○
—
○

○
○
○
○
○
○
○
○
○
○
○

Note: — = Not mentioned.

palpation and visual inspection alone may miss them. Therefore, imaging tests such as ultrasonography, MRI, and CT
are necessary to detect nonpalpable insulin balls. As amyloid
4 of 9deposits without masses were also identified with highpower of detection, ultrasonography can be used more extensively than palpation and visual examination alone. Re-https://doi.org/10.53044/jinr.2023-0010

JINR 2024, 3(1), e2023-0010

Table 3. Insulin ball evaluation by assessment method.
Assessment methods
Palpation and visual
examination (n = 11)

Evaluation indicators
Presence of palpation induration
Hardness

Size

Part

Skin color

Mobility
Tenderness

Blood test (n = 9)Insulin absorption rate※

Ultrasonography (n = 9)

Blood glucose level
Echo level
Pattern
Size

Depth
Subcutaneous tissue thickness
Blood flow

MRI (n = 5)

Pattern

CT (n = 4)

SignalShape

Size

Absorption

Results (total number of cases)
Palpable (n = 11)
Nonpalpable (n = 2)
Hard (n = 5)
Elastic (n = 4)
Not mentioned (n = 2)
1.5 cm (n = 1)
4 cm (n = 1)
5 cm (n = 1)
8 cm (n = 1)
8 × 5 cm (n = 1)
13 cm (n = 1)
Chicken-egg size (n = 1)
Not mentioned (n = 4)
Abdomen (n = 5)Upper arm (n = 2)
Not mentioned (n = 4)
Brown to purple-red (n = 1)
Mild subcutaneous bleeding (n = 1)
Not mentioned (n = 9)
Movable (n = 2)
Not mentioned (n = 9)
No tenderness (n = 2)
With tenderness (n = 1)
Not mentioned (n = 8)
Decreased (n = 6)
Not mentioned (n = 3)
Increasing (n = 9)Hypoechogenicity (n = 7)Hyperechoicity (n = 2)
Striped (n = 2)
Not mentioned (n =7)
23 × 8 × 22 mm (n = 1)
27 × 10 × 34 mm (n = 1)
66 × 85 mm (n = 1)
Not mentioned (n = 7)
20 mm (n = 1)
Not mentioned (n = 8)
16 mm (n = 1)
Not mentioned (n = 8)
Poor blood flow (n = 2)
No blood flow (n = 2)
Not mentioned (n = 5)
Stripes or dots (n = 2)
Not mentioned (n = 3)
Low intensity (n = 5)
Indefinite (n = 1)
Clear border (n = 1)
Irregular margin (n = 1)
Not mentioned (n = 1)
Approximately 60 mm (n = 1)
32 × 25 × 30 mm (n = 1)
47 × 25 × 40 mm (n = 1)
Not mentioned (n = 2)
High absorption (n = 1)
Isoabsorbed (n = 1)
Not mentioned (n = 2)

Note: ※The insulin absorption rate is calculated from the area under the curve (AUC) of serum insulinvalues and the ratio of the AUC between the amyloid deposition site and the normal site.

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Table 4. Summary of studies included (n = 11).
Author,Year
Murao
et al.
(2022)

Nagase(2020)
inJapanese

Subjects

Palpation and visual
examination

52 insulin-treateddiabetic
patients withabnormalfindings at the
self-injection
site (Group1:
36 patientswith subcutaneous induration, Group2:
16 patientssuspected ofhavingsubcutaneous
induration)“In Group1, 36
patients had well-defined subcutaneous
induration.
Sixteen patients inGroup2 had firm skinand subcutaneous
tissue but no obvious
induration.”

31 patientswith diabetes
mellitus

Palpable hard mass
with margins

Blood test

Ultrasonography

MRI

CT

—

• Skin and subcutaneous
tissue were considerably
thicker in the abnormal areas
than in the normal areas.
• The subcutaneous tissue had
a median thickness of 16 mm.
• When compared to thenormal area, the boundary
between the skin and subcutaneous tissue in the abnormal
area was indistinct.
• Ultrasonography revealed aconsiderable decrease inecholuminance in cases withamyloid deposition on pathology.

——• Insulin absorption at theamyloid site was 34% of
the normal site.
• Poor glycemic control• When he injected thesame amount of insulin
as before in the normal
abdomen, avoiding themass, he experienced
marked hypoglycemia.

• Hyperechoic findings with
subcutaneous stripes.
• Amyloid deposits withoutmasses can be detected.

Low-signal findingsin the form of stripes
or dots in the
subcutaneous fat.
—Nagaseet al.
(2020)

Two patientswith type 2
diabetes
mellitus

Case 1. There is no
palpable mass.
Case 2. Soft enlargement in the rightabdomen.

• Insulin absorption was
reduced to a maximum of40%.
• Inadequate glycemic
control• Hyperechoic streaks withloss of normal subcutaneous
fat tissue

Subcutaneous fat
had low-signal
findings in the formof stripes or dots.

Samlaska
et al.
(2020)

One patientwith type 1
diabetes

Four subcutaneous
indurations ranging
from 8 (abdomen) to
13 cm (left arm)

—

—

—

—

Kitanoet al.
(2019)
inJapanese

One patientwith type 2
diabetes
mellitus

Elastic soft skin massof 8 × 5 cm on the left
abdomen

Poor glycemic control• Epidermal thickening• Some uniform low densityarea

Low signal in both
T1- and T2-weighted images

Localized skin
thickening of theleft lower
abdomen withuniform interior

Kikuchi
et al.
(2017)

22 patientsdiagnosed with
Insulin-derived
amyloidosis bypathologicalexamination• Palpability• 59.1% were palpableand 40.9% were
nonpalpable• The insulin absorption
rate of the palpable typewas significantly lower
than that of the nonpalpable type.
• Poor glycemic control• HbA1c levels decreased
in 15 of the 20 patients
after the injection site
was changed.

• The detection ability of
IDLA on ultrasonography
was 100%.
• Amyloidosis was low echoic
and had low blood flow.
• Blood flow distribution waslargely decreased in thepalpable type compared with
the nonpalpable type.

——One diabetic
patient with
type 2 diabetes
mellitus• Two 50-mm mobile,
firm subcutaneous
masses in the right andleft abdomen• The mass surface issmooth, with some
subcutaneous bleeding• Tenderness• Peak blood glucose
levels were 2.23 times
higher at the mass site
compared to nonaffected
regions, and peak blood
insulin level were 0.77
times higher.
• He was advised torotate the injection sites,
which resulted infrequent hypoglycemia.

• A heterogeneous hypoechoic mass measuring 66 mm
high × 85 mm wide × 20 mmdeep was found in the
subcutaneous fat layer of theleft abdomen. A similar mass
was also present on the rightside.

Hagiwara
et al.
(2017)

6 of 9——In the left andright abdomen, a
subcutaneousmass withirregular margins
of approximately
60 mm wasdiscovered.

https://doi.org/10.53044/jinr.2023-0010

JINR 2024, 3(1), e2023-0010

Table 4. Summary of studies included (n = 11) (continued).
Author,Year

Subjects

Palpation and visual
examination

Blood test

Ultrasonography• Insulin absorption
decreased to 34% ± 22%
at the amyloid depositionsite.
• The lesion site hadhigher mean blood
glucose levels.

• There was a significant low
echogenic area with poor
blood flow and deep attenuation.

Kusukiet al.
(2015)
inJapanese

Ten patientswith insulin
injection-related subcutaneous induration(9 with type 2
diabetes and 1with type 1
diabetes)

There is subcutaneousmass present

Yabe etal. (2015)
inJapanese

One type 1 diabetic patient

On both the sides of
the umbilicus, asmooth, grayish-whitesubcutaneous induration about 4 cm in size
was discovered. The
induration was
rubbery, hard,
movable, and nottender.

The hyperglycemia
remained. After changing
the site of insulin
injection, blood glucose
levels were stabilized.

Ohtani(2013)
inJapanese

One type 1 diabetic patient

A 1.5-cm-large
brown-to-purplish-red
firm nodule with pale
purpura around it was
discovered on the rightupper arm.

Inadequate glycemic
control

Yoshizaki
andHonda(2012)
inJapanese

One diabetic
patient with
type 2 diabetes
mellitus• Palpable mass,electric and firm,
chicken-egg size, good
mobility, no tenderness, symmetricallylocated in the lower
abdomen, in line withthe site of insulin
injection.
• There is light
subcutaneous bleedingon the epidermis of the
mass’s surface.

• Insulin absorption wasconsiderably reduced at
the site of amyloid
deposition compared tonormal skin.
• Inadequate glycemic
control• After the insulin
injection site waschanged to healthy skin,blood glucose levels
dramatically dropped.

MRI

CT

—

—

The masses on the left andright were depicted as
hypoechoic areas of internal
heterogeneity with indistinct
borders, measuring approximately 23×8×22 mm on theright and 27×10×34 mm on
the left, with no blood flow
observed.

On T1-weighted
images, the mass
had a lower signal
than the surrounding
fat and a slightly
higher signal than
the surrounding fat
on fat-suppressed
T2-weighted
images.

It was depicted asa subcutaneousindeterminate
mass on both thesides of the umbilicus, with highabsorption whencompared to thesurrounding fatty
tissue.

———Without blood flow, theinduration was extracted as a
uniform hypoecho.

T1-weighted images(C) and T2-weighted
images (D) revealed
a low signal similar
to muscle.

It was depicted as
an isoabsorbed
mass with clear
borders on theright, measuring
47 × 25 × 40 mm
and 32 × 25 × 30
mm on the left.

Note: — = Not mentioned.

garding MRI and CT, they were performed in less than halfof the literature, but these are relatively large-scale examination methods and may not be performed early. Conversely,
we believe that the introduction of ultrasonography, which isrelatively simple and noninvasive, as an assessment methodof insulin balls, can contribute to early detection. Kikuchi etal. (2017) reported that “the detectability of insulin-derived
localized amyloidosis on ultrasonography was 100%,” andultrasonography is expected to be used as a screening tool
in clinical practice. It was suggested that if there is decreased insulin absorption or increased blood glucose levels,
it is advisable to check for subcutaneous induration by ultrasonography, even if it is not palpable.
No studies where nurses assessed and summarized theevaluation of insulin balls and results were noted. Because
insulin injections are often instructed by nurses, we believethat ultrasonography should also be introduced to nurses. It
has been reported that patients often inject at the same siteeven if the medical provider has instructed them to change
the injection site. However, it is expected that patients willmore likely change their behavior of injecting at the samesite if the presence of an insulin ball is visually confirmedby the medical provider and patient through ultrasound examination (Tanaka et al., 2019).
However, in reality, it has been reported that few nurses
utilize ultrasonography to assess the patient’s condition andlink it to care (Saito and Watanabe, 2018). Nurses are required to be pretrained to use ultrasonography and guide patients in collaboration with physicians.
The literature used in this study did not include nurses
among those who identified subcutaneous induration, which
may have suggested palpation and visual examination, blood
tests, and imaging tests as possible assessment methods. In
addition to these, knowledge of the patient’s insulin ball, insulin injection technique, and other factors may be used ininsulin ball assessment. In the future, it will be necessary to
7 of 9JINR 2024, 3(1), e2023-0010

conduct multifaceted insulin ball assessment from the perspective of nurses and to encourage patients to self-manage.
Furthermore, we believe that it is necessary to verify theusefulness of insulin ball assessment by nurses and to consider effective patient education.
Limitations and Tasks for Future Research
The reason for the large number of Japanese references isthat studies on insulin balls were pioneered by Nagase andhis colleagues in Japan. In this study, only articles written in
Japanese and English were included and those written inother languages were excluded. Therefore, the comprehensiveness of insulin ball assessment in Japan and abroad cannot be confirmed. Moreover, we aimed to extract data on insulin ball implementers, but because most of them were notlisted, we could not determine the current status of their implementation.
In the current study, we focused on insulin balls because
we believe that it is important to identify and intervene earlyon how to assess insulin balls with more impaired insulin
absorption. Lipohypertrophy is another cutaneous complication of insulin injection. Lipohypertrophy is a milder disorder of insulin absorption compared with insulin balls (Nagase et al., 2009), and it is a rubbery texture subcutaneous
induration of the skin in which insulin injections cause hypertrophy and hyperplasia of subcutaneous adipose tissue(Hauner et al., 1996). In the future, we are planning to study
lipohypertrophy.

Conclusion
It is necessary to incorporate imaging tests because palpation and visual examination alone cannot detect nonpalpable
insulin balls. It was suggested that in addition to palpationand visual inspection, the inclusion of relatively simple andnoninvasive ultrasonography as a screening method for the
early detection of insulin balls may be useful, but its accuracy needs to be verified in the future.
From now on, we believe that nurses will have a role inassessing the presence and extent of insulin balls using ultrasonography and in providing patient education to help patients manage them.
Acknowledgments
This study was conducted as a joint academic project between the Japan Academy of Nursing Science and the Japanese Pharmacological Society. We would like to thank you
for allowing us to conduct research on insulin ball assessment as the Nursing Care Group in the research organization
based on an academic project.
Author Contributions
Sugama, Yanagita, and Seto contributed to the conception
8 of 9https://doi.org/10.53044/jinr.2023-0010

and design of this study. Nakamura and Kageura searched
the literature and performed the screenings and study selection. Nakamura drafted the manuscript. Oe, Matsui,
Kageura, Horiguchi, and Ueda critically reviewed the manuscript. Sugama, Yanagita, and Seto oversaw the entire study
process. All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The authors declare no conflict of interest.
References
Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research
Methodology, 8(1), 19-32.
https://doi.org/10.1080/1364557032000119616
Hagiwara, S., Taneda, S., Fukumoto, T., Hagiwara, K., Kikuchi, M.,
Kimura, T., Nakayama, H., & Manda, N. (2017). Localized subcutaneous insulin-derived amyloidosis excised after evaluation using ultrasonography in a patient with type 2 diabetes mellitus.
Case Reports in Endocrinology, 2017, 3985214.
https://doi.org/10.1155/2017/3985214
Hauner, H., Stockamp, B., & Haastert, B. (1996). Prevalence of lipohypertrophy in insulin-treated diabetic patients and predisposing
factors. Experimental and Clinical Endocrinology and Diabetes,
104(2), 106-110.
https://doi.org/10.1055/s-0029-1211431
Kitano, T., Oishi, N., Sugishita, K., & Takazakura, E. (2019). Kyodai
na insulin ball [A case of giant insulin ball]. Practical Dermatology, 41(4), 369-372.
Kikuchi, M., Hirokawa, N., Hagiwara, S., Nakayama, H., Taneda, S.,
Manda, N., & Sakata, K. (2017). Ultrasonography improves glycemic control by detecting insulin-derived localized amyloidosis.
Ultrasound in Medicine and Biology, 43(10), 2284-2294.
https://doi.org/10.1016/j.ultrasmedbio.2017.06.011
Kusuki, K., Yoshizaki, T., Takeda, T., & Honda, M. (2015). Insulin
tyuusya ni yoru hika syuryuu no byouri soshiki, gazou syoken
oyobi insulin kyuusyuu ni tuite no kentou [The analysis of histology, imaging findings, and insulin absorption about subcutaneous
masses which occurred in insulin injection sites]. Journal of theJapan Diabetes Society, 58(6), 388-397.
Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., &Aromataris, E. (2018). Systematic review or scoping review?
Guidance for authors when choosing between a systematic or
scoping review approach. BMC Medical Research Methodology,
18(1), 143.
https://doi.org/10.1186/s12874-018-0611-x
Murao, S., Murao, K., Nagata, T., Shimizu, M., & Miyai, Y. (2022).
Repeated insulin injection without site rotation affects skin thickness - Ultrasonographic and histological evaluation. Journal of
Diabetes Investigation, 13(6), 997-1003.
https://doi.org/10.1111/jdi.13753
Nagase, T. (2020). Insulin yurai amyloidosis (insulin ball) no byoutai
to rinsyou [Pathogenesis and clinical features of insulin-derived
amyloidosis (insulin ball)]. Japanese Journal of Pharmaceuticaland Diabetes, 9(1), 92-96.
Nagase, T., Iwaya, K., Kogure, K., Zako, T., Misumi, Y., Kikuchi, M.,
Matsumoto, K., Noritake, M., Kawachi, Y., Kobayashi, M., Ando,Y., & Katsura, Y. (2020). Insulin-derived amyloidosis without ahttps://doi.org/10.53044/jinr.2023-0010
palpable mass at the insulin injection site: A report of two cases.
Journal of Diabetes Investigation, 11(4), 1002-1005.
https://doi.org/10.1111/jdi.13199
Nagase, T., Iwaya, K., Iwaki, Y., Kotake, F., Uchida, R., Oh-i, T.,
Sekine, H., Miwa, K., Murakami, S., Odaka, T., Kure, M.,
Nemoto, Y., Noritake, M., & Katsura, Y. (2014). Insulin-derived
amyloidosis and poor glycemic control: A case series. American
Journal of Medicine, 127(5), 450-454.
https://doi.org/10.1016/j.amjmed.2013.10.029
Nagase, T., Katsura, Y., Iwaki, Y., Nemoto, K., Sekine, H., Miwa, K.,
Oh-I, T., Kou, K., Iwaya, K., Noritake, M., & Matsuoka, T.
(2009). The insulin ball. Lancet, 373(9658), 184.
https://doi.org/10.1016/S0140-6736(09)60041-6
Ohtani, T. (2013). Insurimboru [The insulin ball]. Clinical Dermatology, 67(5), 18-22.
https://doi.org/10.11477/mf.1412103608
Peters, M. D. J., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D.,& Soares, C. B. (2015). Guidance for conducting systematic
scoping reviews. International Journal of Evidence-Based Healthcare, 13(3), 141-146.
https://doi.org/10.1097/XEB.0000000000000050
Saito, M., & Watanabe, T. (2018). Shinryou kangosi ga okonau chouonpa kensa no yuuyousei [The usefulness of ultrasonography performed by nurse practitioner]. Tohoku Bunka Gakuen University
Nursing Department Bulletin, 7(1), 3-10.
Samlaska, C., Reber, S., & Murry, T. (2020). Insulin-derived amyloidosis: The insulin ball, amyloidoma. JAAD Case Reports, 6(4),JINR 2024, 3(1), e2023-0010
351-353.
https://doi.org/10.1016/j.jdcr.2020.02.011
Tanaka, K., Shimizu, M., Kikuchi M., Katou M., Tanaka K., Nakazato
R., . . . Takeuchi J. (2019). Kangosi ni yoru tyou onpa kensa wo
mochiita jiko tyuusya no yuuyousei [The useful of subcutaneous
tissue ultrasonography in the insulin self-injection guidance bynurses]. Journal of the Japan Diabetes Society, 62(2), 76-83.
Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H.,
Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L.,
Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L.,
Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., . . . Straus,
S. E. (2018). PRISMA extension for scoping reviews (PRISMAScR): Checklist and explanation. Annals of Internal Medicine,
169(7), 467-473.
https://doi.org/10.7326/M18-0850
Yabe, S., Takahashi, H., Gotoda, H., Mori, T., Ikawa, H., Kudo, H.,. . . Sekiguchi, M. (2015). Insulin chuusya bui ni okeru insulin
yurai amyloidosis ni yori ichijirushii kettou control akka wo mitometa ichirei [A case of type 1 diabetes mellitus with marked
poor glycemic control caused by insulin-derived amyloidosis at
the site of repeated insulin injections]. Journal of the Japan Diabetes Society, 58(1), 34-40.
Yoshizaki, T., & Honda, M. (2012). Insulin kyuusyuu ni oyobosu
eikyou wo kentou shieta hika kyokushoteki amyloid chinchaku noichirei [Insulin absorption in a patient with local subcutaneous
amyloid deposition]. Journal of the Japan Diabetes Society, 55(10), 786-792.

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https://www.jinr.jsnr.or.jp/

Original Research

Health-related quality of life of patients with heart failure using
noninvasive telemonitoring systems with and without visiting nursing
support: A longitudinal observational study
Motohiro Sano, PhD, RN, PHN1 , Sho Okada, PhD, MPH, MD2 , Tomoko Majima, PhD, RN, PHN1 , andYoshio Kobayashi, PhD, MD2
1

Graduate School of Nursing, Chiba University, Chiba, Japan, and 2Department of Cardiovascular Medicine, Chiba
University Graduate School of Medicine, Chiba, Japan

Abstract
Objective: This study aims to measure the health-related quality of life (HR-QOL) of patients with heart failure(HF) after using two types of telemonitoring (TM) tools and to evaluate which type of tool contributes to improving
patient outcomes. Methods: We measured the HR-QOL and psychological status of patients with HF after using
two types of TM systems (smartphone application or web-based), and the data from baseline to six months werecompared. Results: A total of 24 patients with HF completed the study period of six months. The mean age of theparticipants was 60.58 ± 12.81 years, and 70.8% were male. The major differences between the study groups
comprised support and access to home visit services. The physical HR-QOL scores increased significantly frombaseline to six months in the web-based group (baseline vs. six months, 4.04 ± 1.02 vs. 4.58 ± 1.18, p = .034),
but no significant difference (baseline vs. six months, 5.05 ± 1.00 vs. 5.20 ± 1.24, p = .410) was found in thesmartphone application group. The mean scores for anxiety and depression in both groups were not significantly
different. Conclusions: Using the TM system for patients with HF may improve global HR-QOL and psychologicalstatus. In addition, adding nursing support using a TM system may be more effective in improving patient-reported
outcomes.
Keywords
heart failure, health-related quality of life, telemonitoring, visiting nursing, self-management
JINR 2024, 3(1), e2023-0007

Introduction
Heart failure (HF) remains a major cause of death worldwide, and it can also significantly reduce the quality of life
(QOL) of affected patients (McDonagh et al., 2021; Stretti
et al., 2021). Toback et al. proposed that improved selfmanagement might increase treatment adherence, promotepatient QOL, improve clinical outcomes, reduce hospital readmissions, and decrease hospitalization costs (Toback &Clark, 2017). Self-management interventions for chronic dis-eases during home care are effective in decreasing patientborne costs, the cost of health care, the number of outpatient, and emergency room visits, hospital stays, and healthrelated QOL (HR-QOL) (Kamei, 2013; Tsutsui et al., 2021).
In recent years, many clinical trials have been carried out
worldwide to assess the effectiveness of telemonitoring(TM) systems in HF management. The TM systems used in
HF management include various aspects, such as vital signmonitoring, telephone follow-up by nurses, video consultation, communication between healthcare providers, web-

Correspondence: M. Sano. Email: sano-m@chiba-u.jp
Received: February 20, 2023, Accepted: May 16, 2023, Advance Publication: November 21, 2023, Published: February 23, 2024
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 7

JINR 2024, 3(1), e2023-0007

based telemonitoring, remote hemodynamic monitoring, or
combinations of these. Since there are various types andaims of TM systems, different outcome measures have beenused in previous studies, and the reported results have beenheterogeneous (Nick et al., 2021).
Some studies have shown that noninvasive TM interventions reduce HF-related hospitalization and trends in total
mortality, as well as HF-related admissions (Bashi et al.,2017; Carbo et al., 2018; Kotooka et al., 2018; Ware et al.,2020). Moreover, these interventions also promote improvements in HR-QOL, HF knowledge, and self-care behaviors(Inglis et al., 2015; Jeong et al., 2018; Ware et al., 2020).
Specifically, well-established TM systems or nurse-led careprograms, including educational components, could improve
patient compliance, self-management behaviors, and early
detection of HF exacerbation (Ding et al., 2020; Mizukawa
et al., 2019). However, a systematic review on the topic
found that most TM programs demonstrate high methodological heterogeneity and concluded that further research iswarranted to identify the effective components of TM systems (Auener et al., 2021).
Therefore, in this study, we implemented two types ofTM systems for patients with HF following admission to
outpatient HF clinics. This study aimed to measure the HRQOL of patients with HF after using TM systems and evaluate which system might lead to the highest improvement inpatient outcomes. A better understanding of these aspects is
crucial for identifying the most effective components of TM
systems in the treatment of patients with HF.

Materials and Methods
Study Design
This study is a longitudinal observational study.
Settings and Participants
Eligible participants were recruited from one Japanese academic medical center with cardiovascular outpatient clinic
services. HF in this study corresponds to I50 in the International Classification of Disease, Tenth Revision.
The participants for this study were recruited from a Japanese university hospital with HF outpatient clinic services.
After obtaining consent, the researcher, or programmer instructed the participants regarding the use of the tool
through face-to-face interaction using a manual. Twenty participants were finally recruited for this study. Patients who
had a clinical diagnosis of HF were able to understand andspeak the Japanese language, operated mobile devices or
laptop computers, and were willing to provide informed
consent were eligible to participate. We used a targeted sampling procedure in the recruitment of participants, and patients were recruited by their direct care team during scheduled clinic visits.
2 of 7https://doi.org/10.53044/jinr.2023-0007

Ethical Considerations
Ethical approval for this study was obtained from the institutional ethics review board of the university with which theauthors are affiliated. The consent form that each eligible
patient received in-person provided information regarding
the aims, procedures, and potential risks, and benefits of thestudy. This manuscript adheres to the Strengthening the Reporting of Observational Studies in Epidemiology statement(von Elm et al., 2014).
Measurements
HR-QOL
This study used the MacNew Heart Disease HR-QOL Questionnaire, which assesses, and evaluates patients’ QOL fromtheir personal perspective. It is designed to evaluate the impact of treatment, including cardiac rehabilitation, and has
been shown to be valid, reliable, and responsive. It is simple
to administer and well-accepted by patients, and normative
data are available for patients with myocardial infarction,
angina pectoris, and HF. This questionnaire consists of 27
items that fall into three domains: a 13-item physical limitations domain scale, a 14-item emotional function domain
scale, and a 13-item social function domain scale. The maximum possible score in any domain was 7 (high HR-QOL),
and the minimum was 1 (poor HR-QOL) (Dixon et al.,2002).
Anxiety and Depression
The Hospital Anxiety and Depression Scale was developedby Zigmond and Snaith in 1983 to identify the caseness(possible and probable) of anxiety disorders and depression
among patients in nonpsychiatric hospital clinics (Zigmond & Snaith, 1983). Each question on this Likert-type
scale is scored from 0 to 3. Each survey received a maximum score of 21. Scores ranging from 0 to 8 indicate
healthy patients, scores from 8 to < 11 are near the lower
threshold, indicating the presence of depression or anxiety,and a value of !11 indicates the likely presence of a depression or anxiety disorder.
Data Collection
Baseline data were collected from the researchers’ electronic
medical records. QOL and psychological status, including
anxiety, and depression at baseline and six-month follow-up,
were collected either directly, or by mail. Participants who
provided informed consent received a gift card worth 2,000
yen. Data were collected from April 2020 to December
2021.
Data Analysis
The characteristics between the two study groups were compared using the independent group t-test for continuous vari-https://doi.org/10.53044/jinr.2023-0007

ables and the chi-square test for categorical variables. HRQOL changes within the group from baseline to six months
were compared using a paired t-test. Statistical significancewas defined as p < .05. All results are presented as meanvalues and standard deviations. All statistical analyses were
performed using IBM SPSS Statistics (version 27.0, IBM,NY, USA).
Description of TM Systems
This study used two types of TM systems for patients with
HF. System A was a smartphone application. Using this system, patients could see personal health data such as blood
test results, prescriptions, the history and schedule for clinic
visits, and previous histories. Healthcare providers in thehospital, such as primary physicians, can access the dedicated website and view patient data at the time of theirclinic visit. Thus, during this time, the physician provided
lifestyle guidance and prescriptions by referring to the patient’s home data. In addition, patients could enter their individual health-related data on a daily basis, including daily
blood pressure levels, pulse rate, body temperature, oxygen
saturation, and blood glucose levels. There was no alert
function in this application.
System B was web-based. Patients with HF accessed the
dedicated website and entered their daily data, such as bodyweight, blood pressure, pulse rate, and subjective symptoms
related to HF exacerbation, once daily using an Internetconnected tablet device (if the participants did not own a device, we lent it to them). Healthcare providers, such as physicians (including primary and visiting), nurses (including
hospital and visiting), and physical therapists (including hospital and visiting), were able to view graphs and tables
based on individual patient data via the dedicated website.
Thus, they were able to assess the patient’s condition without in-person visits. Therefore, healthcare providers, especially visiting nurses, could contact the patient if there were
any signs or symptoms of concern without visitation, sharepatients’ data with other healthcare providers, or consult
with their primary physicians. When visiting the patient’s
home, they viewed their data with the patient and discussed
their symptoms and lifestyle. There was no alert function inthis system.
Table 1 lists the characteristics of these two systems.

Results
Participants
A total of 24 patients with HF completed the six-monthstudy period. The system A group included 13 participants,
and the system B group included 11 participants. The mean
age of the 24 participants was 60.58 years (±12.81), and70.8% were male. Table 2 summarizes the baseline characteristics of the present study sample. The only significant

JINR 2024, 3(1), e2023-0007

Table 1. Characteristics of TM systems.
Types of system

A

B

Specification
User

Smartphone App
Hospital,patients

Web-based
Hospitals,
patients, clinics,
and home careservicesCapability

BP
P
BT
SpO2
HeightBW
BS
NYHA class
SOB
Edema
Urine volume
Dyspnea
BowelsLimits of BW
Past history
Prescription
Test results
feedback
History of clinic visit
Comment field
Patient’s goal


























Note: BP = blood pressure; P = pulse rate; BT = body temperature; BW= body weight; BS = blood glucose level; NYHA = New York Heart
Association classification; SOB = shortness of breath

difference found between the study groups was regarding
access to home visit services (72.7% in the system B groupvs. 0% in the system A group).
HR-QOLThe HR-QOL scores at baseline did not differ significantly
between study groups (Table 2). The physical HR-QOL
scores increased significantly from baseline to six months inthe system B group (baseline vs. six months, 4.04 ± 1.02 vs.
4.58 ± 1.18, p = .034), but no significant difference (baseline vs. six months, 5.05 ± 1.00 vs. 5.20 ± 1.24, p = .410)
was found in the system A group. The global HR-QOL
scores in systems A and B from baseline to six months were
4.93 ± 0.94 vs. 5.01 ± 1.08 (p = .620) and 4.41 ± 0.75 vs.
4.74 ± 0.94 (p = .135), respectively. The emotional HRQOL scores in systems A and B groups from baseline to six
months were 4.72 ± 1.07 vs. 4.72 ± 1.15 (p = .979) and
4.89 ± 0.60 vs. 4.91 ± 0.67 (p = .907), respectively. The social HR-QOL scores in systems A and B groups from baseline to six months were 4.92 ± 1.17 vs. 5.21 ± 1.37 (p =.127) and 3.84 ± 0.96 vs. 4.49 ± 1.61 (p = .055), respectively. Global and social (with the exception of emotional)
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JINR 2024, 3(1), e2023-0007

https://doi.org/10.53044/jinr.2023-0007

Table 2. Baseline characteristics of participants according to type of tool.
Characteristics

Total

A (n = 13)

B (n = 11)

p value*Age (years, mean ± SD)
Male (%)
LVEF (%, mean ± SD)
NYHA (%)
II
III
IV
Device therapy
CRT
ICD
None
Visiting Nursing Service
HR-QOL (mean ± SD)
GlobalPhysicalEmotional
SocialHADS (mean ± SD)
Anxiety
Depression

60.58 ± 12.81
17 (70.8)
34.88 ± 8.87

56.54 ± 9.96
10 (76.9)
33.82 ± 9.11

65.36 ± 14.53
7 (63.6)
36.41 ± 8.80

.093
.476
.515

17 (70.8)
6 (25.1)
1 (4.1)11 (84.6)
2 (15.4)0

6 (54.5)
4 (36.4)
1 (9.1).137

6 (25.0)
3 (12.5)
13 (54.2)
8 (33.3)

4 (30.8)
2 (15.4)
7 (53.8)
02 (18.2)
1 (9.1)8 (72.7)
8 (72.7)

.402

<.001

4.88 ± 0.93
4.90 ± 1.11
4.84 ± 0.99
4.80 ± 1.18

4.92 ± 0.87
4.97 ± 0.95
4.79 ± 1.00
4.91 ± 1.10

4.53 ± 0.95
4.45 ± 1.18
4.64 ± 0.97
4.31 ± 1.17

.285
.239
.707
.200

5.62 ± 3.73
8.24 ± 3.37

6.42 ± 4.10
8.33 ± 3.49

4.56 ± 3.04
8.11 ± 3.41

.269
.886

Note: LVEF = left ventricular ejection fraction; NYHA = New York Heart Association classification; CRT = cardiac resynchronization therapy; ICD = implantable cardioverter defibrillator;
HR-QOL = health-related quality of life; HADS = hospital anxiety and depression scale* Chi-square test and t-test

HR-QOL scores tended to increase, although no statisticallysignificant differences were observed between the baseline
and six-month follow-up assessments (Figure 1, Table 3).
Anxiety and Depression
Anxiety and depression scores were comparable between thegroups at baseline and did not differ significantly (Table 2).
The mean anxiety (6.27 ± 4.29 vs. 6.36 ± 4.47, p = .940)
and depression (8.36 ± 3.66 vs. 8.00 ± 3.71, p = .740)
scores in the system A group were not significantly different. Anxiety scores in the system A group increased, and depression scores in both groups decreased from baseline tosix months. The mean anxiety (4.40 ± 2.60 vs. 3.00 ± 2.23,
p = .108) and depression (7.80 ± 3.56 vs. 7.60 ± 4.72, p =.893) scores in the system B group were not significantly
different (Figure 2).

Discussion
In this study, most characteristics of the participants weresimilar between groups, with the exception that most participants in the system B group but none in the system A group
had access to home-visiting nursing services. We compared
the changes in HR-QOL, anxiety, and depression in patientswith HF using the TM system at baseline and six-monthfollow-up. In terms of results, HR-QOL, except for physical4 of 7

HR-QOL in the system B group, was not found to change
significantly, while overall, HR-QOL scores tended to increase. In recent studies, a nurse-led home-based HF selfmanagement program or cardiac rehabilitation improved
self-efficacy and HR-QOL and lowered depression levels
compared with the control group (Arjunan & Trichur, 2020;
Mo et al., 2021). Although no significant changes in depression scores were observed, visiting nurses supported patients’ daily activities or detected symptoms of HF exacerbation earlier through viewing patient data, which could have
improved the physical QOL scores observed in this study. In
terms of psychological aspects, emotional QOL scores inboth groups showed almost no change, whereas anxiety, anddepression scores in both groups tended to decrease. In a recent qualitative study, the experiences of patients with HF
using TM systems have been assessed, and it has beenfound that by simply using a TM tool, patients reported
higher feelings of safety (Sano et al., 2022). Thus, the introduction of a monitoring system alone may help ensure thepsychological safety of patients with HF. The intervention
that combined telephone calls and TM by nurses reduced readmission rates and improved QOL and self-care behaviors(Jeong et al., 2018; Ong et al., 2016; Mizukawa et al., 2019;
Son et al., 2020). Similar to previous studies, the results ofthis study suggest that using a TM system for patients with
HF, in addition to nurse support, has the potential to im-https://doi.org/10.53044/jinr.2023-0007

JINR 2024, 3(1), e2023-0007

PhysicalGlobal
5.25

5

4.75
4.25

baseline4

6 monthsA*baseline

6 months

B

A

Emotional

Social

5

5.5

4.8

4.5

4.6

baseline

3.5

6 monthsA

B

baseline

6 monthsA

B

B

Figure 1. HR-QOL changes at baseline to six months.

Table 3. Outcome measures at baseline and six months.
Tool A Group (n = 13)

Tool B Group (n = 11)

Variables
HR-QOL
GlobalPhysicalEmotional
SocialHADS
Anxiety
Depression

Baseline

6 months

Within Group

Baseline

6 months

Within Groupmean ± SD
4.93 ± 0.94
5.05 ± 1.00
4.72 ± 1.07
4.92 ± 1.17

mean ± SD
5.01 ± 1.08
5.20 ± 1.24
4.72 ± 1.15
5.21 ± 1.37

p value *
.620
.410
.979
.127

mean ± SD
4.41 ± 0.75
4.04 ± 1.02
4.89 ± 0.60
3.84 ± 0.96

mean ± SD
4.74 ± 0.94
4.58 ± 1.18
4.91 ± 0.67
4.49 ± 1.61

p value *
.135
.034
.907
.055

6.27 ± 4.29
8.36 ± 3.66

6.36 ± 4.47
8.00 ± 3.71

.940
.740

4.40 ± 2.60
7.80 ± 3.56

3.00 ± 2.23
7.60 ± 4.72

.108
.893

* Comparisons each group between baseline and 6 months using paired t-test** HR-QOL, health-related quality of life; HADS, hospital anxiety and depression scale

Anxiety

Depression

7

9
8

2

baseline

6 months
AB

7

baseline

6 monthsA

B

Figure 2. Anxiety and depression changes at baseline to six months.

prove QOL and psychological status in affected patients.
Consequently, this study compared the changes in HRQOL and psychological status between the two types of TM
systems. We believe adding home-visiting nursing supports
to the TM system may have contributed to the improvementin HR-QOL and psychological status, which is our study’s
strength. Our study’s results are consistent with previous
studies demonstrating that nurse-led HF management is ef-

fective in improving patient outcomes (Cajanding, 2016; Mo
et al., 2021).
As a major limitation of the study, the number of participants was small, and strict grouping was not conducted. In
system B, which can be used by multiple healthcare providers and facilities, participants who did not use home-visiting
nursing services were mixed. In future research, it will benecessary to conduct it with increased rigor so that differ5 of 7

JINR 2024, 3(1), e2023-0007

ences in characteristics do not occur.

Conclusions
We aimed to measure the HR-QOL and psychological statusof patients with HF after using two types of TM systems.
We found statistically significant changes in physical HRQOL in the TM system, including visiting nursing support.
Depression tended to improve in both groups. The use of
the TM system for HF management might exhibit positiveeffects on the psychological status of patients with HF. In
addition, we suggest a nurse-led support intervention using a
TM system to improve the QOL and psychological status ofpatients with HF.
Author Contributions
MS wrote the manuscript. SO, TM, and YK contributed tothe interpretation of the results and reviewed and edited themanuscript. All authors read and approved the final versionof the manuscript.
Declaration of Conflicting Interests
We have no conflicts of interest to disclose.
Ethical Approval
This study was approved by the Institutional Ethics Review
Board of the Chiba University Graduate School of Nursing[No. R2-3].
Funding
Our work was funded by JSPS KAKENHI, Grant Number:
JP 20K23186.
Informed Consent
Informed consent was obtained from all patients or participants involved in this study.
References
Arjunan, P., & Trichur, R. V. (2020). The impact of nurse-led cardiac
rehabilitation on quality of life and biophysiological parametersin patients with heart failure: A randomized clinical trial. Journalof Nursing Research, 29(1), e130.
https://doi.org/10.1097/JNR.0000000000000407
Auener, S. L., Remers, T. E. P., van Dulmen, S. A., Westert, G. P.,
Kool, R. B., & Jeurissen, P. P. T. (2021). The effect of noninvasive telemonitoring for chronic heart failure on health care utilization: Systematic review. Journal of Medical Internet Research, 23(9), e26744.
https://doi.org/10.2196/26744
Bashi, N., Karunanithi, M., Fatehi, F., Ding, H., & Walters, D. (2017).
Remote monitoring of patients with heart failure: An overview ofsystematic reviews. Journal of Medical Internet Research, 19(1),e18.
https://doi.org/10.2196/jmir.6571

6 of 7https://doi.org/10.53044/jinr.2023-0007
Cajanding, R. J. M. (2016). The effectiveness of a nurse-led cognitivebehavioral therapy on the quality of life, self-esteem and moodamong Filipino patients living with heart failure: A randomized
controlled trial. Applied Nursing Research, 31, 86-93.
https://doi.org/10.1016/j.apnr.2016.01.002
Carbo, A., Gupta, M., Tamariz, L., Palacio, A., Levis, S., Nemeth,Z., & Dang, S. (2018). Mobile technologies for managing heart
failure: A systematic review and meta-analysis. Telemedicine
Journal and e-Health.
https://doi.org/10.1089/tmj.2017.0269
Ding, H., Jayasena, R., Chen, S. H., Maiorana, A., Dowling, A., Layland, J., Good, N., Karunanithi, M., & Edwards, I. (2020). The
effects of telemonitoring on patient compliance with selfmanagement recommendations and outcomes of the innovative
telemonitoring enhanced care program for chronic heart failure:
Randomized controlled trial. Journal of Medical Internet Research, 22(7), e17559.
https://doi.org/10.2196/17559
Dixon, T., Lim, L. L. Y., & Oldridge, N. B. (2002). The MacNew
heart disease health-related quality of life instrument: Reference
data for users. Quality of Life Research: An International Journalof Quality of Life Aspects of Treatment, Care and Rehabilitation,
11(2), 173-183.
https://doi.org/10.1023/A:1015005109731
Inglis, S. C., Clark, R. A., Dierckx, R., Prieto-Merino, D., & Cleland,
J. G. (2015). Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database of
Systematic Reviews, 10, CD007228.
https://doi.org/10.1002/14651858.CD007228.pub3
Jeong, S., Choi, H., Gwon, S. H., & Kim, J. (2018). Telephone support and telemonitoring for low-income older adults. Research inGerontological Nursing, 11(4), 198-206.
https://doi.org/10.3928/19404921-20180502-01
Kamei, T. (2013). Information and communication technology forhome care in the future. Japan Journal of Nursing Science, 10(2),154-161.
https://doi.org/10.1111/jjns.12039
Kotooka, N., Kitakaze, M., Nagashima, K., Asaka, M., Kinugasa, Y.,
Nochioka, K., Mizuno, A., Nagatomo, D., Mine, D., Yamada, Y.,
Kuratomi, A., Okada, N., Fujimatsu, D., Kuwahata, S., Toyoda,
S., Hirotani, S. I., Komori, T., Eguchi, K., Kario, K., . . .
HOMES-HF study investigators. (2018). The first multicenter,randomized, controlled trial of home telemonitoring for Japanesepatients with heart failure: Home telemonitoring study for patientswith heart failure (HOMES-HF). Heart and Vessels, 33(8), 866876.
https://doi.org/10.1007/s00380-018-1133-5
McDonagh, T. A., Metra, M., Adamo, M., Gardner, R. S., Baumbach,A., Böhm, M., Burri, H., Butler, J., Čelutkienė, J., Chioncel, O.,
Cleland, J. G. F., Coats, A. J. S., Crespo-Leiro, M. G., Farmakis,
D., Gilard, M., Heymans, S., Hoes, A. W., Jaarsma, T., Jankowska, E. A., . . . ESC Scientific Document Group. (2021). 2021
ESC Guidelines for the diagnosis and treatment of acute andchronic heart failure. European Heart Journal, 42(36), 35993726.
https://doi.org/10.1093/eurheartj/ehab368
Mizukawa, M., Moriyama, M., Yamamoto, H., Rahman, M. M., Naka,
M., Kitagawa, T., Kobayashi, S., Oda, N., Yasunobu, Y., Tomiyama, M., Morishima, N., Matsuda, K., & Kihara, Y. (2019).

https://doi.org/10.53044/jinr.2023-0007
Nurse-led collaborative management using telemonitoring improves quality of life and prevention of rehospitalization in patients with heart failure. International Heart Journal, 60(6), 12931302.
https://doi.org/10.1536/ihj.19-313
Mo, Y., Chu, M., Hu, W., & Wang, H. (2021). Association between thenurse-led program with mental health status, quality of life, andheart failure rehospitalization in chronic heart failure patients.
Medicine (Baltimore), 100(10), e25052.
https://doi.org/10.1097/MD.0000000000025052
Nick, J. M., Roberts, L. R., & Petersen, A. B. (2021). Effectiveness oftelemonitoring on self-care behaviors among community-dwelling
adults with heart failure: A quantitative systematic review. JBI
Evidence Synthesis, 19(10), 2659-2694.
https://doi.org/10.11124/JBIES-20-00329
Ong, M. K., Romano, P. S., Edgington, S., Aronow, H. U., Auerbach,A. D., Black, J. T., De Marco, T., Escarce, J. J., Evangelista,
L. S., Hanna, B., Ganiats, T. G., Greenberg, B. H., Greenfield, S.,
Kaplan, S. H., Kimchi, A., Liu, H., Lombardo, D., Mangione,
C. M., Sadeghi, B., . . . Better Effectiveness After TransitionHeart Failure (BEAT-HF) Research Group. (2016). Effectivenessof remote patient monitoring after discharge of hospitalized patients with heart failure: The better effectiveness after transitionheart failure (BEAT-HF) randomized clinical trial. JAMA Internal
Medicine, 176(3), 310-318.
https://doi.org/10.1001/jamainternmed.2015.7712
Sano, M., Okada, S., Majima, T., & Kobayashi, Y. (2022). Patient perspectives of a non-invasive telemonitoring tool for patients withheart failure. SAGE Open Nursing, 8, 23779608221082025.
https://doi.org/10.1177/23779608221082025
Son, Y. J., Choi, J., & Lee, H. J. (2020). Effectiveness of nurse-led
heart failure self-care education on health outcomes of heart failure patients: A systematic review and meta-analysis. International
Journal of Environmental Research and Public Health, 17(18).
https://doi.org/10.3390/ijerph17186559

JINR 2024, 3(1), e2023-0007
Stretti, L., Zippo, D., Coats, A. J. S., Anker, M. S., von Haehling, S.,
Metra, M., & Tomasoni, D. (2021). A year in heart failure: An
update of recent findings. ESC Heart Fail, 8(6), 4370-4393.
https://doi.org/10.1002/ehf2.13760
Toback, M., & Clark, N. (2017). Strategies to improve selfmanagement in heart failure patients. Contemporary Nurse, 53(1),105-120.
https://doi.org/10.1080/10376178.2017.1290537
Tsutsui, H., Ide, T., Ito, H., Kihara, Y., Kinugawa, K., Kinugawa, S.,
Makaya, M., Murohara, T., Node, K., Saito, Y., Sakata, Y.,
Shimizu, W., Yamamoto, K., Bando, Y., Iwasaki, Y. K., Kinugasa,Y., Mizote, I., Nakagawa, H., Oishi, S., . . . Japanese Circulation
Society and the Japanese Heart Failure Society Joint Working
Group. (2021). JCS/JHFS 2021 guideline focused update on diagnosis and treatment of acute and chronic heart failure. Circulation
Journal, 85(12), 2252-2291.
https://doi.org/10.1253/circj.CJ-21-0431
von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C.,
Vandenbroucke, J. P., & STROBE Initiative. (2014). The
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. International Journal of Surgery, 12(12), 14951499.
https://doi.org/10.1016/j.ijsu.2014.07.013
Ware, P., Ross, H. J., Cafazzo, J. A., Boodoo, C., Munnery, M., &Seto, E. (2020). Outcomes of a heart failure telemonitoring program implemented as the standard of care in an outpatient heart
function clinic: Pretest-posttest pragmatic study. Journal of Medical Internet Research, 22(2), e16538.
https://doi.org/10.2196/16538
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361-370.
https://doi.org/10.1111/j.1600-0447.1983.tb09716.x

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Original Research

Developing a communication skills scale in the initial oncology nursing
consultation after a cancer diagnosis in Japan
Takako Mitsuyuki, RN, MSN1 , Shyoko Ando, RN, PhD2 , Ayumi Sugimura, RN, PHN, PhD3 ,Shigeyoshi Maki, RN, PHN, PhD3 , and Kazuki Sato, RN, PHN, PhD3
1

School of Nursing, Faculty of Medicine, Tokyo Medical University, Tokyo, Japan, 2School of Nursing, Ichinomiya
Kenshin College, Aichi, Japan, and 3Nursing for Advanced Practice, Division of Integrated Health Sciences,
Nagoya University Graduate School of Medicine, Aichi, Japan

Abstract
Objective: Psychosocial interventions during nursing consultations emotionally support and inform patients undergoing cancer diagnosis. In Japan, certified nurse specialists (CNSs) and certified nurses (CNs) mainly provide
nursing consultations. Using communication skills in therapeutic nurse-patient relationships is an effective advanced nursing practice when performed consciously. We developed a scale to measure the frequency of oncology nurses’ intentional use of communication skills in the initial oncology nursing consultation after a cancer diagnosis. Methods: Based on a literature review, we identified nine initial dimensions and developed a 32-item questionnaire. After the focus group interviews and pilot study between January and March 2018, the final questionnaire was administered to CNSs and CNs who offered nursing consultations to patients with cancer in Japanesehospitals. The properties of all scales and subscales were assessed using item-to-item and mean item-to-item correlations. The reliability was evaluated using Cronbach’s alpha. Construct validity was assessed using exploratory
factor analysis, correlations between all scales and characteristics, and contrast group comparisons. Results: The
communication skills scale comprised 29 items across six dimensions of communication skills: Exploring, Listening, Acceptance, Silence, Approval, and Empathy. The scale has good reliability and validity. Conclusions: This
scale is a valid and reliable item for self-assessing nurses’ communication skills in the initial oncology nursing consultation after a cancer diagnosis.
Keywords
communication skills scale, initial nursing consultation, cancer diagnosis, exploratory factor analysis
JINR 2024, 3(1), e2022-0041

Introduction
In Japan, there are more than 1,000,000 new cancer cases
each year and 380,000 cancer-related fatalities, making it theleading cause of death, accounting for 30% of total deaths(Cancer Statistics in Japan Editorial Board, 2020). Although
the cancer survival rate in Japan has improved, being diagnosed with a life-threatening disease is a shocking andstressful experience for patients and their families (Suzuki &Komatsu, 2002). Reportedly, 10%-20% of people with cancer experience stress-related mental health problems, such as
adjustment disorders and major depression (Akechi, 2018).
In particular, suicide rates are high within the first year aftercancer diagnosis (Yamauchi et al., 2014). Therefore, psychosocial interventions to improve the quality of life must also
focus on mental and psychosocial issues aside from physicalCorrespondence: T. Mitsuyuki. Email: t-mitsu@tokyo-med.ac.jp
Received: December 4, 2022, Accepted: June 21, 2023, Published: February 23, 2024
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 13JINR 2024, 3(1), e2022-0041

problems (Gabriel et al., 2020).
While physicians are responsible for making the cancer
diagnosis and obtaining informed consent for the treatment
plan, nurses, as part of the team of healthcare professionals,
provide patient-centered care and are involved in ongoing
follow-up after the cancer diagnosis (Kaneko et al., 2013).
In the course of their work, nurses collaborate with healthcare teams to offer emotional support to patients through interpersonal counseling and provide information about healtheducation and referrals to team professionals when needed(Kaneko et al., 2013; Warnock et al., 2010). Thus, a therapeutic relationship and effective communication between
nurses and patients are essential (Duxbury, 2000; Travelbee,1971). This communication is designed to understand patients’ fears and concerns, identify patients’ needs, andachieve nursing goals in meeting these needs (Duxbury,2000). Furthermore, this communication is backed by oncology nursing expertise and practical skills to support illnesscoping behaviors consistent with each patient’s values, preferences, and wants (Mazor et al., 2013).
Therapeutic communication has been defined as an “interpersonal exchange, using verbal and nonverbal messages
that culminates in the patient being helped” (Van Servellen,2018). Nurses practice therapeutic communication by encouraging patients to express their feelings and thoughts andconveying acceptance and respect to them (Van Servellen,2018). In this process, nurses intentionally use specificstrategies, such as communicating skillfully, preparing, introducing the communication environment, and providing
counseling (Duxbury, 2000; Fukuhara et al., 2004; Van
Servellen, 2018). Key skills comprise nonverbal behaviors(eye contact, voice quality, and body language), active listening (verbal tracking, using open and closed questions, encouraging, paraphrasing, focusing, and summarizing), observation, empathy, sharing of hope, humor, and self-disclosure(Fukuhara et al., 2004; Sharma & Gupta, 2022; Sherko etal., 2013). Successful communication allows patients to express themselves and satisfy their basic needs to be heard
and understood (Van Servellen, 2018). Further, it helps them
gain insight into their true emotions and face their current
reality (Sharma & Gupta, 2022). Oncology nurses effectively practice therapeutic communication and provide additional warmth and emotional support (Sinclair et al., 2017).
By empathically understanding the patient, the nurse conveys compassion and motivates the patient to act and alleviate their suffering (Katz, 2019; Sinclair et al., 2017).
Recent research on healthcare providers’ communication
has focused on palliative care conversations, including prognostic discussions (Ikander et al., 2022); however, the focus
on communicating cancer diagnosis and relaying bad news
is limited (Agnese et al., 2022). Previous intervention studies suggest that improved therapeutic communication by
nurses is associated with patients’ subjective assessments of
2 of 13https://doi.org/10.53044/jinr.2022-0041

pain improvement (Canivet et al., 2014), wellbeing (Arbour
et al., 2022), quality of life (Fukui et al., 2011), self-efficacy(Hochstenbach et al., 2015), and satisfaction with the carereceived (Lotfi et al., 2019). However, a cancer diagnosis isdevastating, and for patients expressing strong emotions,nurses often report communication difficulties, including theinability to convey empathy successfully and poor
relationship-building with patients (Banerjee et al., 2016;
Sheldon et al., 2006; Warnock et al., 2017). A lack of empathy during patient communication can be stressful enough tocause burnout among nurses (Yu et al., 2016).
Therapeutic communication between nurses and patientshas emotional, cognitive, and behavioral aspects, each ofwhich can be assessed using a comprehensive instrument(Moudatsou et al., 2020). However, these scales are intended
to assess communication between nursing students and patients for educational purposes (Campbell & Aredes, 2022;
Kondo et al., 2020) or between nurses and patients in primary healthcare or critical care, not just patients with cancer(Campbell & Aredes, 2019; González-Cabrera et al., 2020;
Granados-Gámez et al., 2022); thus, both scales are often inadequate for assessing the communication skills of oncology
nurses specific to the distress of patients with cancer.
Newman and Helft (2015) developed an instrument to assess communication between oncology nurses and patients;
however, it only assesses prognosis-related communication
at the end-of-life and does not evaluate communicationrelated emotional support for a cancer diagnosis. Given thenegative impact of a cancer diagnosis on patients, families,
and nurses and the importance of nurses’ roles, oncology
nurses must possess and develop strong communication
skills that build trust immediately (González-Cabrera et al.,2020). To fulfill their specialized role, oncology nurses devise ways to communicate with patients (Mishelmovich etal., 2016), but knowledge about the actual situation is scant.
Although initial oncology nursing consultations are practiced
early after a cancer diagnosis in Japan, no validated instrument exists to assess nurses’ communication skills. Therefore, this study aimed to develop a valid and reliable scale
to assess the intentional use of nurses’ communication skills
during initial oncology nursing consultations.

Materials and Methods
DesignThis study employed a cross-sectional observational design.
Procedure
The original scale was devised using a three-step procedure:
item extraction, pilot study, and scale development. The
steps are detailed below.
Step 1: Item Extraction
To extract items to assess the frequency of communication

https://doi.org/10.53044/jinr.2022-0041

skills used in nursing consultations for patients with cancer,
we used PubMed, CINAHL, and ICHUSHI Web databases
to perform an extensive literature review. This study aimed
to review the development of protocols and communication
measures between healthcare professionals and patients withcancer; nurses and patients with cancer; nurses and patients;
and between nursing students and patients. This review was
based on the concept of the interpersonal aspect of nursing(Duxbury, 2000). Travelbee (1971) described four phasesthat establish an interpersonal relationship: 1) initial encounter, 2) identification emergence, 3) empathy, and 4) sympathy. Therapeutic communication skills represent the nursing
skills used in each phase. Through integrating and synthesizing the findings, we established nine initial dimensions: Listening, Acceptance, Empathy, Reflecting on Emotions, Rephrasing, Summarizing, Questioning, Silence, and Approval.
We then discussed the created items to assess communication skills and determined the item pool comprising nine initial dimensions and 32 items. When administering the scale,
we asked the participants to recall a previous case in an outpatient setting and rate the frequency of their communication skills used in the patient’s initial oncology nursing consultation after a cancer diagnosis on a five-point scale ranging from 1 (never) to 5 (usually).
We conducted focus group interviews in November 2016
and February 2017 to enhance the content and construct validity of the item pool (Stalmeijer et al., 2014). Interviews
were conducted with two groups: One with 15 certified
nurse specialists (CNSs) and another with 14 certified nurses(CNs). Participants provided informed consent after receiving explanations about the voluntary nature of their participation and were assured that their anonymity would be preserved. The participants were asked to freely express theiropinions about the possible use of the item pool questions in
the initial oncology nursing consultation following a cancer
diagnosis; they were also asked to recommend modifications
and identify any shortcomings. One of the co-authors moderated the session, and the primary researcher documented
the meetings. The research team reviewed the results of theinterviews, and modifications that were difficult to understand or answer were made into expressions in the item
pool. With the help of another four CNSs and two CNs, thevalidity and response load of the items were rechecked.
Step 2: Pilot Study
Participant Selection
From September to November 2017, the questionnaire wasadministered to the 26 oncology nurses excluded in the final
study to ascertain the content validity and response load.
Each participant had been licensed by the Japanese Nursing
Association (2017) as either a CNS in Oncology Nursing ora CN in Palliative Care, Cancer Chemotherapy Nursing,Cancer Pain Management Nursing, Breast Cancer Nursing,or Radiation Oncology Nursing.

JINR 2024, 3(1), e2022-0041

Procedure
One co-author contacted the nursing directors of the target
hospitals in the three regions of Aichi, Mie, and Gife andasked them if they had provided nursing consultations in
outpatient units to patients with cancer. The survey was administered by mail to hospitals providing nursing consultations. The participants were informed about the voluntary
nature of participation, anonymity, and data handling, andtheir consent was obtained. We conducted a primary aggregation of the responses, confirmed no missing values or obvious outliers were present, and completed the questionnaire
for the final study.
Step 3: Scale Development
Participant Selection
We conducted a cross-sectional survey in Japan between December 2017 and March 2018. The survey targets were
CNSs and CNs providing nursing consultations for patientswith cancer in outpatient units of Japanese hospitals. In Japan, CNSs’ and CNs’ nursing consultations are subject tomedical fee calculation. Therefore, using the website of theJapanese Ministry of Health, Labour and Welfare (2017), we
determined the hospitals with medical fee calculation, as
these hospitals were considered to be ready to conduct-or
were already conducting-nursing consultations. Additionally,
the number of nursing consultations for which medical fees
were calculated was approximately three times greater for
outpatients with cancer than for inpatients with cancer (Japanese Ministry of Health, Labour and Welfare, 2017). Therefore, we recruited nurses who met the inclusion criteria ofoverseeing individual nursing consultations in an outpatientsetting. The inclusion criteria also included being licensed inJapan (JNA, 2017.) as CNSs in Oncology Nursing or CNs
in Palliative Care, Cancer Chemotherapy Nursing, Cancer
Pain Management Nursing, Breast Cancer Nursing, or Radiation Oncology Nursing. Nurses without experience inoutpatient nursing consultations were excluded. These participants were identified using the JNA (2017) website.
CNSs and CNs are registered nurses who have passed the licensing examination administered by the JNA in Japan(JNA, 2017; Komatsu, 2010).
Procedure
We sent each hospital director and nurse manager a letter
explaining the study’s purpose and methods. We asked thenurse managers who agreed to participate in distributing one
set of letters explaining the study’s purpose and methods,
the consent form, and the questionnaire to nurses in chargeof nursing consultation in the outpatient unit. Additionally,
we added a letter explaining that survey participation was
voluntary and anonymous and participation could be withdrawn at any time. We limited the participation to a maximum of two participants per site to avoid potential bias. To
prevent nurses from being identified, we selected hospitals
with at least three eligible nurses. The participants who
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agreed were asked to complete the questionnaire and return
it with the consent form in a postage-paid envelope within
two weeks. A signed informed consent form was required
before participating in the study, and responses to the questionnaire were anonymized.
Streiner et al. (2015) recommend a sample size of 5 to 10
times the number of items for exploratory factor analysis(EFA) in medical research; Rouquette and Falissard (2011)
recommend a sample size of 300 or more. Accordingly, we
set our sample size to between 300 and 320.
Ethical Considerations
This study was approved by the Nagoya University ClinicalResearch Review Board to which the primary researchers
belonged during the survey period approved this survey(Approval number: 17-129). All participants were informedin writing of their anonymity, data security, and the voluntary nature of their participation. All participants signed andreturned consent forms. We followed the guidelines of the
Declaration of Helsinki.
Statistical Analysis
Data were analyzed using SPSS versions 25 and 28 forWindows (IBM Corp., Armonk, NY, USA). All tests were
two-tailed, and the significance level was set at p < .05.
Participants’ demographic characteristics and communication skills were measured as percentages, means, standard
deviations (SD), and medians (interquartile ranges). Averagevalue assignment replaced the randomly occurring missing
values (five locations). Samples with numerous missing values were excluded from the analysis as they were considered invalid.
The communication skills’ total scale and subscale characteristics were assessed through item-total, interitem, andaverage interitem correlations. EFA with Promax rotation
was used to determine the construct validity (Streiner et al.,2015), and Bartlett’s sphericity coefficient and the KaiserMeyer-Olkin test were used to confirm the validity of thefactor analysis. Internal consistency reliability of the unidimensional scale and subscales were assessed by Cronbach’s
alpha coefficient. Construct validity was assessed by correlations between communication skills and characteristics andby intersubject comparisons. Based on previous research, wehypothesized that those with high levels of professional education in oncology nursing (Newman & Helft, 2015), moreexperience (i.e., years of practice) in oncology nursing as a
CNS/CN (Malloy et al., 2010, Mishelmovich et al., 2016),
and more experience with postprofessional education communication training (Fukui et al., 2008) would use communication skills more frequently. The communication skills
scores between groups were compared using t-tests.

4 of 13https://doi.org/10.53044/jinr.2022-0041

Results
Focus Group Interviews
We conducted focus group interviews in November 2016
and February 2017. We conducted focus groups to determine the questions/items that should be included on thecommunication scale we sought to create. Consent was obtained from 15 CNSs and 14 CNs who participated in thecollaborative meeting on oncology care in the three districts
where study collaboration was requested. The participants
were divided into two groups: one with CNSs only and one
with CNs only, and one focus group interview was conducted with each group. The interviews lasted 40 and 60
minutes. As a result, many participants agreed that all communication skills items might be used in the initial oncology
nursing consultation, suggesting the validity of the content.
However, the frequency of use may vary depending on thepatient’s condition. Based on a review of the results, the research team discussed modifying items that were difficult tounderstand or answer. Therefore, we modified the names of
all items from therapist to nurse and client to patient, making it easier to imagine the communication between nurses
and patients. Additionally, there was an opinion regarding
difficulty in conveying Reflecting on Emotions concretely;
hence, we added an example of how to express this to thepatients (No. 15). Finally, it was noted that the Silence items
comprised only the skills for nurses to break the silence,
hence, a section on how to respond until the patient resumes
talking was added to develop a questionnaire (Nos. 24-26).
Another four CNSs and two CNs, members of the research team, informally rechecked the validity and response
load of the items. The results indicated that the scores forcases where nurses did not intentionally use communication
skills to respond to a patient’s condition were unclear anddifficult to obtain. Based on this feedback, we added a description of the frequency rating on a five-point scale: 5(usually:80%-100%), 4 (frequently:60%-79%), 3 (occasionally:40%-59%), 2 (rarely:20%-39%), and 1 (never:0%-19%).
Pilot Study
The questionnaire was administered between September andNovember 2017. We sent the questionnaire to 36 eligible
hospitals, of which 28 nurses from 20 hospitals agreed toparticipate; hence, they completed and returned the questionnaire. Of the 28 responses, 26 from 20 hospitals were valid
without missing values or apparent outliers and were used in
the analysis. There were 20 participants (women = 19; CNS= 8; CN = 12), and the median age of all paeticipants was
46.0 years (IQR 43.0, 49.75). The median duration of working as a CNS/CN was 3.9 years (IQR 2.3, 8.1), and 15
nurses had experience in training communication skills in
consultation. By primary aggregation, the Listening, Acceptance, and Approval scores were medians of 5 (IQR 4, 5)https://doi.org/10.53044/jinr.2022-0041

JINR 2024, 3(1), e2022-0041

Table 1. Nurses’ demographic characteristics (N = 301).
n (%)
Age (years)
GenderMen
Women
Duration of work in nursing (years)
Professional qualifications related to cancer nursing
CNS
CN
Duration of work as CNS/CN (years)
Communication skills training in consultation
Yes
No
Number of years in charge of consultations
Number of consultation sessions in the last month
Ways to make time for a consultation session
Scheduled time
Adjusted nurse’s schedule
No scheduled time
Other
Type of room used for consultation
Private room
Exclusive place
Secure as needed
No room/place
Number of beds available to patients≤199
200-499≥500
Hospital type
Cancer medical treatment cooperation-based hospital
Other

Mean (SD)Median(IQR)
44.1 (6.2)

6 (2.0)295 (98.0)
21.3 (6.0)
56 (18.6)
245 (81.4)
6.3 (3.6)
206 (68.4)
88 (29.2)
4.4 (2.9)
10 (4, 20)
155 (51.5)
87 (28.9)
52 (17.3)
7 (2.3)99 (32.9)
14 (4.7)
165 (54.8)
23 (7.6)
11 (3.7)
134 (44.5)
156 (51.8)
208 (69.1)
93 (30.9)

Note: SD = standard deviation; IQR = interquartile range; CNS = certified nurse specialist; CN = certified nurse.

for the high items and medians of 4 (IQR 4, 5) for the low
items. Empathy, Reflecting on Emotions, Rephrasing, Summarizing, Questioning, and Silence scores were medians of
4 (IQR3, 5) for high items and medians of 3 (IQR 2.5, 4)
for low items.
Final Study
Demographic Characteristics
We sent the questionnaire to 649 eligible hospitals; of these,
338 nurses from 236 hospitals agreed to participate and returned the questionnaire. Of the 338 responses, 301 from
216 hospitals were valid and used in the analysis. Table 1
presents the participants’ backgrounds. Of the 301 participants, 98% (n = 295) were women, and the participants’mean age was 44.1 years (SD = 6.2). Further, 18.6% (n =56) were CNSs, and 81.4% (n = 245) were CNs. The average duration of working as a CNS/CN was 6.3 years (SD =3.6). There were 206 (SD = 68.4) nurses with experience incommunication skills training in consultation and 88 (SD =29.2) nurses without experience.
Item Analysis
Table 2 presents the descriptive data on oncology nurses’
communication skills. Skewness ranged from −.21 to −1.54
and kurtosis from −.01 to 2.53, indicating that most data deviated from a normal distribution. Item analysis was conducted to confirm the Pearson’s correlations for the total
items (r = .52-.74 [p < .001]) and interitem correlations (r =.14-.76 [p < .001]); 87% of the items were positively correlated (r !.3). However, as items 16, 17, 30, and 31 exhibited strong correlations (interitem correlations of !.7), we
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Table 2. Descriptive data on the communication skills scale in the initial oncology nursing consultation after a cancer diagnosis (N =
301).
Item
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Item

Mean

(SD)

Skewness

Kurtosis

ITC

I take care to come down to the patient’s eye level and avoid talking down to them.
I do not stare at the patient; I try to make eye contact to let them know that I am listening.
If the patient becomes nervous, I break eye contact to make it easier for them to talk.
I lean forward slightly and assume a relaxed posture and expression, conveying themessage to the patient, “Please talk, I’m listening.”
I adjust the tone of my voice and speaking speed to suit the patient.
I carefully listen to the patient’s story and keep up with what they tell me.
I am concerned with what the patient feels, what they think, and how they view
themselves and their surroundings.
I actively listen to the patient’s stories without my preconceptions or sense of values.
I encourage the patient to talk about their feelings and thoughts using non-verbal expressions such as nodding, pausing, and smiling.
I encourage the patient to talk about their feelings and thoughts using verbal expressions such as “I see,” “Tell me more,” and “What happened next?”
I do not criticize or evaluate the patient’s story and emotions with my sense of values. I accept the patient as they really are.
I repeat the patient’s story and convey that I have accepted what they have told me.
I try to look at the patient’s situation from their point of view. I accept the patient’s
emotions as my own.
I feel the patient’s emotions and this influences my viewpoint. I let the patient knowthat I understand their emotions and feel the same way.
I adequately express the patient’s emotions, perhaps using adjectives (For example,“Is it painful?” and “Were you sad?”)I carefully observe the patient’s unverbalized emotions and express those emotions
back to the patient.
Instead of just repeating the patient’s words, I feel their feelings and respond withwords that seem appropriate.
I clarify the meaning of the patient’s story and paraphrase it.
I do not merely paraphrase the patient’s story but also try to understand the background. I confirm with the patient whether my understanding is correct.
I briefly summarize what the patient tells me and confirm the main point.
I encourage patients to talk freely with open questions and listen to their thoughts
and feelings.
I confirm the facts with the patient using “closed questions” in which the patient answers with “yes” or “no.”I try to notice any inconsistencies or changes between the patient’s response and facial expressions/attitude and ask them with interest and focus.
I wait quietly for some time for the patient to respond.
I watch over the patient for a while until their emotional reactions such as crying
subside.
If the patient is silent, I will not immediately break the silence. I also try to be as quiet as possible, and I try to think about why the patient is being silent.
If I intentionally break the silence, I will focus on the patient’s feelings. For example,“Can you tell me how you feel now?”
I clearly tell the patient that I understand their feelings.
I appreciate the patient’s efforts to cope with the illness while they were worrying. I
affirm their feelings.
I encourage the patient about the future so that they feel relieved. I pledge to support
them and to think about their situation.
I clearly tell my patients that I want to support them.
I am grateful to the patient for what they have told me.

4.68
4.46

(.53)
(.62)

−1.54
−.81

2.22
.06

.51
.64

4.19
4.31

(.84)
(.78)

−.74
−.89

−.29
.14

.56
.62

4.45
4.41
4.27

(.67)
(.68)
(.76)

−.95
−.99
−.63

.31
1.24
−.55

.64
.70
.67

4.33
4.47

(.66)
(.68)

−.62
−1.10

−.01
.78

.70
.70

4.18

(.86)

−.92

.70

.72

4.37

(.67)

−.73

.02

.68

4.28
3.73

(.76)
(.89)

−.83
−.45

.20
.09

.70
.66

3.82

(.91)

−.59

.30

.74

4.23

(.77)

−.89

.86

.66

3.79

(.91)

−.46

−.27

.75

3.84

(.87)

−.58

.24

.75

3.65
3.77

(.91)
(.88)

−.21
−.30

−.26
−.18

.70
.71

3.96
4.20

(.85)
(.77)

−.71
−.66

.58
−.14

.67
.68

3.47

(1.12)

−.23

−.84

.53

3.67

(.98)

−.43

−.25

.72

4.05
3.87

(.88)
(1.20)

−.98
−1.07

1.22
.35

.67
.53

3.81

(1.13)

−1.01

.45

.58

3.36

(1.35)

−.45

−.96

.56

4.14
4.27

(.79)
(.81)

−.73
−1.25

.39
2.23

.70
.66

4.51

(.66)

−1.28

1.56

.70

4.43
4.25

(.78)
(.89)

−1.51
−1.15

2.53
1.02

.67
.54

Note: SD = standard deviation; ITC = Item-Total Correlation.

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JINR 2024, 3(1), e2022-0041

examined their content. Items 16 and 17 exhibited overlap- in a language appropriate for the patient.
ping content; therefore, item 17 was deleted. Item 31 was Verification of Reliability
deleted because its scope was limited and it could be Cronbach’s alpha coefficient was calculated to assess the inmerged with item 30.
ternal consistency of each factor. The coefficient for the total
Verification of Validity
scale was .95, and the dimensional range was .83-.88, conAn EFA was conducted to verify construct validity. The firming a high degree of internal consistency.
Kaiser-Meyer-Olkin test of sample validity value was .943, Control-Group Comparisonsand Bartlett’s sphericity value showed statistical significance The results of the control-group comparisons are presented(χ2[406] = 5382.675, p < .001), thereby confirming that in Table 4. We tested the hypothesis about differences in tothese data were suitable for factor analysis. We employed tal communication skills scores between demographic charnonweighted least squares for the EFA as applicable to the acteristics within this sample. The results showed that theanalysis of nonnormal distributions. Promax rotation was communication skill scores of the CNSs (mean = 125.27,
used because of the assumed interfactor correlations.
SD = 14.05) were significantly higher than those of the CNs
Table 3 presents the EFA results. The commonality (mean = 117.18, SD = 15.93). In addition, the scores ofamong the items remained unique at .46-.82, and no items nurses with communication skills training in consultation
were deleted. Four factors had eigenvalues > 1.0, accounting experience (mean = 120.19, SD = 16.30) were significantlyfor 60.7% of the variance. However, after Promax rotation, higher than those of nurses without such training (mean =the factor matrix comprising four factors had many items for 115.37, SD = 14.63), supporting the hypothesis. Contrary to
the first factor (ten items) and the second factor, 12 items, this hypothesis, the scores of nurses with fewer than 10
making it difficult to interpret the factors. Therefore, we se- years of CNS/CN experience (mean = 118.72, SD = 15.98)
lected a six-factor structure according to the interpretability were not significantly different from those of nurses withof the factors. The cumulative response variance explained more than 10 years of CNS/CN experience (Mean = 120.40,
by the six-factor structure was 67.1%. We extracted the six SD = 15.91).
factors using EFA, selecting items with factor loadings !
.35. Item 32 was deleted (factor loading = .29). We calcu- Discussion
lated interfactor correlations to ascertain each item’s uniqueness. Pearson’s correlation coefficients between the factors Three items of the self-rating scale developed in this study
were removed from the initial structure based on EFA,
were moderate or strong (r = .44-.74, p < .05).
The six extracted factors were named based on the initial thereby reducing the number of factors to six. The decrease
dimensions of the concept of this study. Factor 1 (eight in the number of factors is attributable to the initial four diitems) was named Exploring (Sherko et al., 2013). It in- mensions (Reflecting on Emotions, Rephrasing, Summarizcluded confirming the patient’s feelings, paraphrasing what ing, and Questioning) being combined to form the first facthe patient says, asking clarifying questions, and summariz- tor. The other factors comprised the initial dimensions anding the patient’s fears and concerns. Factor 2 (six items) was items, and we believe that this scale is a satisfactory reprenamed Listening. This factor represented nurses’ listening sentation of the preconstructed concepts. However, Factor 5
attitude and comprised nonverbal communication skills, such had a three-item structure, and Factor 6-a two-item structure;as maintaining eye contact, speaking speed, tone of voice, since the recommended number of items is at least three per
and conversation content. Factor 3 (six items), named Ac- factor, more items should be considered to increase measceptance (Sherko et al., 2013), represented nurses encourag- urement stability (Sato & Tsuchiya, 2022). Regarding reliing their patients to share their stories using minimal en- ability, Cronbach’s alpha coefficient (α = .95 for the total
couragement and accepting the stories without value judg- scale and α = .83-.88 for all subscales) exceeded the miniment. Factor 4 (four items) was named Silence (Hill et al., mum standard value of α < .7, suggesting good internal
2003). This factor refers to how nurses react to a patient’s consistency and reliability. However, to ensure reliability, asilence and how they wait for-and observe-the patient’s reac- confirmatory factor analysis should be conducted with a newtions and responses. Factor 5 (three items), named Approval sample, and the results should be compared to determine re(Hays & Larson, 1963), included nurses assuring the patient producibility. Construct validity was also assessed by comthat they understand their feelings, affirming the patient’s ef- paring the communication skill scores of the control group.
Two of the three control-group comparisons supported
forts to cope with the illness, encouraging the patient about
the future so that they feel relieved, and suggesting collabo- this hypothesis. Nurses with higher levels of professionalration regarding future care. Finally, Factor 6 (two items), education in oncology nursing (Newman & Helft, 2015) and
named Empathy (Derksen et al., 2015), included nurses con- those with experience in communication skills training aftersidering the situation from the patient’s perspective, accept- a professional education course (Fukui et al., 2008) obtained
ing the patient’s emotions as their own, and communicating higher communication skill scores. These results indicate the7 of 13JINR 2024, 3(1), e2022-0041

https://doi.org/10.53044/jinr.2022-0041

Table 3. Exploratory factor analysis of the communication skills scale in the initial oncology nursing consultation after a cancer diagnosis (N = 301).
Item
No.

Factor loading
1

Factor 1: Exploring (α = .88, Mean = 3.84, SD = 0.67)
20 I briefly summarize what the patient tells me and confirm the main point.
.94
18 I clarify the meaning of the patient’s story and paraphrase it.
.75
19 I do not merely paraphrase the patient’s story but also try to understand the .75
background. I confirm with the patient whether my understanding is correct.
16 I carefully observe the patient’s non-verbal emotions and reflect them back.
.55
22 I confirm the facts with the patient using “closed questions,” which the patient .52
answers with “yes” or “no.”15 I adequately express the patient’s emotions, perhaps using adjectives (For ex- .48
ample, “Is it painful?” and “Were you sad?”)21 I encourage patients to talk freely with open questions and listen to their .43
thoughts and feelings.
23 I try to notice any inconsistencies or changes between the patient’s response and .43
facial expressions/attitude and ask them about it with interest and focus.
Factor 2: Listening (α = .87, Mean = 4.42, SD = 0.54)
2 I do not stare at the patient; I try to make eye contact to let them know that I am .08
listening.
4 I lean forward slightly and assume a relaxed posture and expression, conveying −.05
the message to the patient, “Please talk, I am listening.”
3 If the patient becomes nervous, I will break eye contact to make it easier for .12
them to talk.
1 I take care to come down to the patient’s eye level and avoid talking down to −.13them.
5 I adjust the tone of my voice and speaking speed to suit the patient.
.01
6 I carefully listen to the patient’s story and keep up with what they tell me.
−.05
Factor 3: Acceptance (α = .88, Mean = 4.32, SD = 0.58)
8 I actively listen to the patient’s stories without my preconceptions or sense of −.07
values.
11 I do not criticize or evaluate the patient’s story and emotions with my sense of .04
values. I accept the patient as they really are.
7 I am concerned with what the patient feels, what they think, and how they view −.03
themselves and their surroundings.
9 I encourage the patient to talk about their feelings and thoughts using non−ver- .00
bal expressions such as nodding, pausing, and smiling.
12 I repeat the patient’s story and convey that I have accepted what they have told .29
me.
10 I encourage the patient to talk about their feelings and thoughts using verbal ex- .29
pressions such as “I see,” “Tell me more,” and “What happened next?”
Factor 4: Silence (α = .84, Mean = 3.78, SD = 0.95)
26 If the patient is silent, I will not immediately break the silence. I also try to be as −.01
quiet as possible, and I try to think about why the patient is being silent.
25 I watch over the patient for a while until their emotional reactions, such as cry- −.20
ing, subside.
27 If I intentionally break the silence, I will focus on the patient’s feelings. For ex- .13
ample, “Can you tell me how you feel now?”
24 I wait quietly for a little while for the patient to respond.
.15
Factor 5: Approval (α = .83, Mean = 4.31, SD = 0.65)
29 I appreciate the patient’s efforts to cope with the illness while they were worry- .06
ing. I affirm and approve the patient.
28 I clearly tell the patient that I understand their feelings.
.27
30 I encourage the patient about the future so that they feel relieved. I pledge to −.13
support them and think about their situation.

8 of 13

2

3

4

5

6

Communality

−.13
−.00
.01

.07
−.14
.13

−.09
.03
−.08

.03
.02
−.08

−.13
.13
.07

.67
.59
.63

.06
.00

−.03
.01

.09
−.01

.09
.19

.13
.02

.58
.31

.29

−.11

−.03

−.10

.04

.46

−.01

.39

.12

.02

−.20

.53

.18

−.06

.11

.01

.22

.55

.83

−.02

−.05

.01

−.08

.66

.79

.01

−.04

−.06

.12

.61

.73

−.00

.04

−.13

−.07

.51

.66

.01

.04

.19

−.14

.46

.62
.37

.15
.24

.04
.01

.03
.16

−.06
.13

.57
.55

.09

.86

.05

−.11

−.00

.69

−.02

.78

−.02

−.05

.04

.60

.08

.59

−.01

−.03

.19

.52

.13

.56

−.12

.16

.07

.59

−.04

.44

−.04

.05

.10

.54

.13

.36

−.03

.04

.04

.54

−.04

.09

.96

−.09

−.10

.82

−.01

−.07

.83

.06

.19

.65

.06

−.15

.64

−.02

.10

.50

.03

.20

.54

.07

−.13

.57

.03

−.07

−.06

.77

.06

.66

−.01
.00

−.11
.32

.03
.04

.71
.63

−.08
−.01

.62
.60

Item

https://doi.org/10.53044/jinr.2022-0041

JINR 2024, 3(1), e2022-0041

Table 3. Exploratory factor analysis of the communication skills scale in the initial oncology nursing consultation after a cancer diagnosis (N = 301). (continued)
Item
No.

Factor loading
1

2

3

4

5

6

Communality

.07

−.08

.12

.05

−.03

.78

.73

.23

−.07

.08

.04

.06

.63

.73

.62*** .74*** .52***.72*** .44***.47***-.67***.58***.69***.44***-.68***.48***.64***.46***.55***

Item

Factor 6: Empathy (α = .85, Mean = 3.78, SD = .84)
13 I try to look at the patient’s situation from their point of view. I accept the patient’s emotions as my own.
14 I feel the patient’s emotions and this influences my viewpoint. I let the patientknow that I understand their emotions and feel the same way.
Inter-factor correlation
Factor 1 Factor 2
Factor 3
Factor 4
Factor 5
Note: α = Cronbach’s coefficient alpha, SD = standard deviation.
Using the least squares method and Promax rotation, ***p < .001
Three items (17, 31, 32) were deleted by item analysis.

Table 4. Association between categorical variables related to demographic characteristics
and communication skills in the initial oncology nursing consultation after a cancer diagnosis(N = 301).
Communication skills scale
Demographic characteristics

Total score

Professional qualifications related to cancer nursing
CNS (n = 56)
CN (n = 245)
Duration of working as CNS/CN (years)< 10 years (n = 243)
> 10 years (n = 47)
Communication skills training in consultation
Yes (n = 206)
No (n = 88)

Mean

(SD)

p

Effect size d125.27117.18(14.05)(15.93)

<.001

.52

118.72120.40(15.98)(15.91).51−.11120.19115.37(16.30)(14.63).02.31

Note: Groups were compared by the no correspondence t-test. Cohen’s d coefficient was used for assessing the effect size. SD = Standard deviation.

validity of the Communication Skills Scale. However, thelength of cancer nursing experience (Malloy et al., 2010,
Mishelmovich et al., 2016) did not affect communication
skills utilization scores. This result may also be related tothe differences in the frequency of CNS/CN nursing consultations, suggesting the need for validation studies with larger
samples.
This study used therapeutic communication skills to represent each phase of establishing an interpersonal relationship between the nurse and the patient. Therapeutic communication is a counseling technique that has been developedin psychiatric nursing and psychology (Fukuhara, 2004), andthis study aimed to apply it to counsel patients exhibiting
anxiety following a cancer diagnosis. Thus, the assessment

items are represented in the specific context of the counseling session mentioned in previous studies: Listening, Acceptance, and Exploring through nonverbal and verbal communication skills. Empathy can be received and felt through theintentional use of these skills. The Empathy extracted in thisstudy included observation, sharing hope, and humor, as
identified in previous studies. Meanwhile, self-disclosure
identified in the previous study was included in item pools
31 and 32 but was excluded from this scale after analysis.
This suggested that nurses and patients do not frequently
use these skills. Thus, the Listening, Acceptance, Exploring,and Empathy in this study supported the skills identified inprevious studies on communication between nurses and patients.
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This study found that previous research did not recognize
Silence and Approval as independent skills between a nurse
and a patient; however, these aspects must be explicitly
measured. In other nurse-patient communication skills
scales, silence has been vaguely assessed (Ueno, 2005) or
has been treated as part of other skills (Campbell & Aredes,
2019; Granados-Gámez et al., 2022; Kondo et al., 2020).
However, many sensitive topics that nurses must address
with patients in the nursing consultation result in emotional
reactions from both patients and their families and sometimes from oncology nurses (Katz, 2019). Therefore, in oncology nursing consultations, each person needs some quiet
time to sort through their thoughts and feelings. Hill et al.
(2003) suggested that therapists use silence to lend patientsa margin for deep thinking and processing their problems
during communication. Intentionally including Silence as acommunication skill allows the patient to arrange theirthoughts, reflect on issues, and introspect about the relevant
agenda in the communication. “Silence,” as extracted in thisstudy, refers to the oncology nurse’s support for the patient’s
reflective thinking.
Approval, which might also be called assurance or reassurance, has been considered nontherapeutic communication
if skills are premature because it has been regarded as
arousing suspicion in patients and preventing them from expressing deeper emotions (Hays & Larson, 1963). This concept has also been incorporated into communication scales
between nurses and patients (Campbell & Aredes 2019).
However, the structure of communication skills extracted inthis study was not limited; rather, it encompassed Listening,
Acceptance, and Empathy, including deeply Exploring thepatient’s problems and needs and helping patients to reflect
and face them silently. This finding suggests that communication using such skills is therapeutic and involves deep
communication. In this study, Approval was identified as askill to be used in conversations providing positive support
for the patient’s coping, demonstrating a willingness to work
together to solve problems, and reassuring the patient ofcontinued involvement in the future. Such Approval is addressed in communication protocols in difficult conversations (Back et al., 2005) but is not found in nurse-patient or
nursing student-patient communication scales. Approval has
been considered a warm and caring response from a nurse
conveyed through empathy with appropriate communication(Komatsu, 2019; Sinclair et al., 2017). Moreover, such a response from the nurse encourages the patient with cancer toface themselves and motivates appropriate behavior change(Sinclair et al., 2017). Thus, Approval skills are necessary
for patients with cancer who are hurt and stressed by theircancer diagnosis and should be considered essential and independent skills for advanced cancer care practice.
In principle, oncology nursing consultations are individual
consultations from the viewpoint of privacy protection as
10 of 13https://doi.org/10.53044/jinr.2022-0041

they support patients after a cancer diagnosis, helping themmake decisions without causing distress. Therefore, nurses
should self-assess their skills after each initial consultation.
Recording the assessment history based on the scale helps
nurses repeatedly recognize their tendency to use communication skills and consciously improve them. However, communication skills must be intentionally used in the context
of a conversation according to the situation; therefore, using
every skill during a communication session is not mandatory. It may also be useful in educating nurses unfamiliar
with nursing consultations.
This study’s target population was outpatient nurses because most initial oncology nursing consultations in Japanare conducted in outpatient settings. Therefore, understanding the true needs of patients when there are few places andtimes for consultation may be a specific communication
skill. Nursing consultation after a cancer diagnosis may also
differ from the communication skills used in consultation
with inpatients; a notable issue for future research.
Limitations
The primary limitation of this study is that the sample only
represents some CNSs and CNs in Japan. However, notably,
the survey was administered in hospitals throughout Japan to
avoid sample bias. Additionally, the number of participants
was a maximum of two nurses from each hospital, regardless of the hospital size. However, the survey may be biased
toward the views of selected nurses within the hospital. Further, as data from nurses with multiple missing values were
excluded from the analyses, the results may only represent
the opinions of some nurses. Next, the number of items forthe two communication skills identified in this study was
small. Increasing the number of items is necessary to improve measurement stability. Additionally, the validation of
the reliability of the six communication skills identified inthis study was insufficient because we did not assess reproducibility with different samples. Future research should further refine and validate these skills and assess their replicability. We also recommend that educational interventions be
tested for effectiveness and scale validity should be assessed
for the six skill-based scales. Future research should develop
educational programs using this scale. In Japan, no scale has
been developed to assess nurses’ communication skills in initial nursing consultations following a cancer diagnosis. Future research should compare the results with theoretically
relevant scales and assess the criterion-related validity. Finally, this study was conducted entirely in Japanese translation to reflect communication in clinical oncology. An accurate English translation of the scale items, including comparative cultural studies, would be beneficial in the future.

https://doi.org/10.53044/jinr.2022-0041

Conclusions
The communication skills scale developed in this study,
comprising six subscales, is useful and reliable for oncology
nurses, and a future refined version may be a tool that canbe introduced in clinical oncology settings. Further, this tool
will enable the sharing of accumulated data and provide
useful information for developing educational programs fornurses who are new to nursing consultations or want to become experts in oncology nursing.
Author Contributions
Takako Mitsuyuki designed and conducted the study, analyzed and interpreted the data, and prepared the manuscript.
Shyoko Ando coordinated the research, data interpretation,and critically reviewed the manuscript. Kazuki Sato, Ayumi
Sugimura, and Shigeyoshi Maki interpreted the findings andcritically reviewed the manuscript.
Declaration of Conflicting Interests
We have no conflict of interest to disclose.
Ethical Approval
This study was approved by the Ethics Review Committeeof Nagoya University Graduate School of Medicine in July
2017 (No.17-129).
Funding
The Japan Society supported this study to promote Science
Grants-in-Aid for Scientific Research (C) (Project/Area
Number: 16K12061).
Informed Consent
Informed consent was obtained from all participants involved in this study.
References
Agnese, B. L., Daniel, A. C. Q. G., & Pedrosa, R. B. D. S. (2022).
Communicating bad news in the practice of nursing: An integrative review. Einstein, 20, 1-8.
https://doi.org/10.31744/einstein_journal/2022RW6632
Akechi, T. (2018). Psycho-oncology: History, current status, and future
directions in Japan. JMA Journal, 1(1), 22-29.
https://doi.org/10.31662/jmaj.2018-0001
Arbour, C., Tremblay, M., Ogez, D., Martineau-Lessard, C., Lavigne,
G., & Rainville, P. (2022). Feasibility and acceptability of
hypnosis-derived communication administered by trained nurses
to improve patient well-being during outpatient chemotherapy: A
pilot-controlled trial. Supportive Care in Cancer, 30(1), 765-773.
https://doi.org/10.1007/s00520-021-06481-6
Back, A. L., Arnold, R. M., Baile, W. F., Tulsky, J. A., & FryerEdwards K. (2005). Approaching difficult communication tasks inoncology. CA: A Cancer Journal for Clinicians, 55(3), 164-177.
https://doi.org/10.3322/canjclin.55.3.164.

JINR 2024, 3(1), e2022-0041
Banerjee, S. C., Manna, R., Coyle, N., Shen, M. J., Pehrson, C.,
Zaider, T., Hammonds, S., Krueger, C. A., Parker, P. A., & Bylund, C. L. (2016). Oncology nurses’ communication challenges
with patients and families: A qualitative study. Nurse Educationin Practice, 16(1), 193-201.
https://doi.org/10.1016/j.nepr.2015.07.007
Campbell, S. H., & Aredes, N. D. A. (2019). Global interprofessional
therapeutic communication scale (GITCS): Development and validation. Clinical Simulation in Nursing, 34, 30-42.
https://doi.org/10.1016/j.ecns.2019.05.006
Campbell, S. H., Aredes, N. D. A., Bontinen, K., Lim, Y., duManoir,C., Tharmaratnam, T., & Stephen, L. A. (2022). Global interprofessional therapeutic communication scaleⒸ short form (GITCSⒸ):
Feasibility testing in Canada. Clinical Simulation in Nursing, 65,
7-17.
https://doi.org/10.1016/j.ecns.2021.12.006
Cancer statistics in Japan editorial board. (2020). Cancer statistics inJapan 2019.
https://www.mhlw.go.jp/content/10901000/000682244.pdf
Canivet, D., Delvaux, N., Gibon, A. S., Brancart, C., Slachmuylder,
J. L., & Razavi, D. (2014). Improving communication in cancer
pain management nursing: A randomized controlled study assessing the efficacy of a communication skills training program. Supportive Care in Cancer, 22(12), 3311-3320.
https://doi.org/10.1007/s00520-014-2357-2
Derksen, F., Bensing, J., Kuiper, S., van Meerendonk, M., & LagroJanssen, A. (2015). Empathy: What does it mean for GPs? A
qualitative study. Family Practice, 32(1), 94-100.
https://doi.org/10.1093/fampra/cmu080
Duxbury, A. J. (2003). Mutsukashii kanjasan tono communication skill[Difficult patients]. (Hajiro, K. Trans.). Kinpodo: Japan.
Fukuhara, M., Ivey, A. E., & Ivey, M. B. (2004). Microcounseling noriron to jissen [The theory and practice of microcounseling].
Kazama-shobo: Japan.
Fukui, S., Ogawa, K., & Yamagishi, A. (2011). Effectiveness of communication skills training of nurses on the quality of life and satisfaction with healthcare professionals among newly diagnosed
cancer patients: A preliminary study. Psycho-Oncology, 20(12),1285-1291.
https://doi.org/10.1002/pon.1840
Fukui, S., Ogawa, K., Ohtsuka, M., & Fukui, N. (2008). A randomized study assessing the efficacy of communication skill training
on patients’ psychologic distress and coping. Cancer, 113(6),1462-1470.
https://doi.org/10.1002/cncr.23710
Gabriel, I., Creedy, D., & Coyne, E. (2020). A systematic review ofpsychosocial interventions to improve quality of life of people
with cancer and their family caregivers. Nursing Open, 7(5),1299-1312.
https://doi.org/10.1002/nop2.543
González-Cabrera, M., Ortega-Martínez, A. R., Martínez-Galiano,J. M., Hernández-Martínez, A., Parra-Anguita, L., & Frías-Osuna,
A. (2020). Design and validation of a questionnaire on communicating bad news in nursing: A pilot study. International Journalof Environmental Research and Public Health, 17(2), 457.
https://doi.org/10.3390/ijerph17020457
Granados-Gámez, G., Sáez-Ruiz, I. M., Márquez-Hernández, V. V.,
Rodríguez-García, M. C., Aguilera-Manrique, G., Cibanal-Juan,
M. L., & Gutiérrez-Puertas, L. (2022). Development and valida-

11 of 13JINR 2024, 3(1), e2022-0041
tion of the questionnaire to analyze the communication of nurses
in nurse-patient therapeutic communication. Patient Education
and Counseling, 105(1), 145-150.
https://doi.org/10.1016/j.pec.2021.05.008
Hays, J. S., & Larson, K. H. (1975). Kango jissen to kotoba. [Interacting with patients]. (Japanese Red Cross Medical Center. Trans.).
Medical Friend: Japan.
Hill, C. E., Thompson, B. J., & Ladany, N. (2003). Therapist use ofsilence in therapy: A survey. Journal of Clinical Psychology, 59(4), 513-524.
https://doi.org/10.1002/jclp.10155
Hochstenbach, L. M., Courtens, A. M., Zwakhalen, S. M., van Kleef,M., & de Witte, L. P. (2015). Self-management support intervention to control cancer pain in the outpatient setting: A randomized
controlled trial study protocol. BMC Cancer, 15(1), 416.
https://doi.org/10.1186/s12885-015-1428-1
Ikander, T., Raunkiær, M., Hansen, O., & Dieperink, K. B. (2022).
Nurses’ involvement in end-of-life discussions with incurable cancer patients and family caregivers: An integrative review. Palliative and Supportive Care, 20(4), 570-581.
https://doi.org/10.1017/S1478951521000596
Japanese Nursing Association. (2017). Certification system.
https://www.nurse.or.jp/nursing/qualification/
Kaneko, M., Tamasato, K., & Kondo, A. (2013). Current status and issues in nurses’ roles in counseling cancer patients: Perceptions ofcertified nurse specialists in cancer nursing. Tokyo Women’s Medical University Journal, 83(2), 79-85.
Katz, A. (2019). Compassion in practice: Difficult conversations in oncology nursing. Canadian Oncology Nursing Journal, 29(4), 255257.
Komatsu, H. (2010). Oncology certified nurse specialist in Japan.
Japanese Journal of Clinical Oncology, 40(9), 876-880.
https://doi.org/10.1093/jjco/hyq139
Kondo, J., Tomizawa, R., Jibu, T., & Kamide, K. (2020). Developing
an interpersonal communication skill scale targeting female nursing students. BMC Research Notes, 13(1), 43.
https://doi.org/10.1186/s13104-020-4896-6
Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M.
(2019). Assessment of nurse-patient communication and patientsatisfaction from nursing care. Nursing Open, 6(3), 1189-1196.
https://doi.org/10.1002/nop2.316
Malloy, P., Virani, R., Kelly, K., & Munévar, C. (2010). Beyond badnews communication skills of nurses in palliative care. Journal of
Hospice and Palliative Nursing, 12(3), 166-174.
Mazor, K. M., Gaglio, B., Nekhlyudov, L., Alexander, G. L., Stark, A.,
Hornbrook, M. C., Walsh, K., Boggs, J., Lemay, C. A., Firneno,C., Biggins, C., Blosky, M. A., & Arora, N. K. (2013). Assessing
patient-centered communication in cancer care: Stakeholder perspectives. Journal of Oncology Practice, 9(5), e186-e193.
https://doi.org/10.1200/JOP.2012.000772
Ministry of Health, Labour and Welfare. (2017). chiho kosei (shi)kyoku shozaichi ichiran [Local health and welfare agencies].
https://www.mhlw.go.jp/kouseiroudoushou/shozaiannai/chihoukous
eikyoku.html
Mishelmovich, N., Arber, A., & Odelius, A. (2016). Breaking significant news: The experience of clinical nurse specialists in cancer
and palliative care. European Journal of Oncology Nursing, 21(1), 153-159.
https://doi.org/10.1016/j.ejon.2015.09.006

12 of 13https://doi.org/10.53044/jinr.2022-0041
Moudatsou, M., Stavropoulou, A., Philalithis, A., & Koukouli, S.
(2020). The role of empathy in health and social care professionals. Healthcare, 8(1), 26.
https://doi.org/10.3390/healthcare8010026
Newman, A. R., & Helft, P. R. (2015). Reliability and validity of atool to assess oncology nurses’ experiences with prognosis-related
communication. Oncology Nursing Forum, 42(1), 64-73.
https://doi.org/10.1188/15.ONF.64-73
Rouquette, A., & Falissard, B. (2011). Sample size requirements forthe internal validation of psychiatric scales. International Journalof Methods in Psychiatric Research, 20(4), 235-249.
https://doi.org/10.1002/mpr.352
Sato, H., & Tsuchiya, M. (2022). Syakudo kenkyu niokeru COSMIN
guideline no doukou [Up to date COSMIN guidelines for a studyof measurement]. Japanese Journal of Behavioral and Cognitive
Therapies, 48(2), 123-134.
https://doi.org/10.24468/jjbct.21-005
Sharma, N., & Gupta, V. (ed.). (2023, January 30). Therapeutic communication. In StatPearls. StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK567775/
Sheldon, L. K., Barrett, R., & Ellington, L. (2006). Difficult communication in nursing. Journal of Nursing Scholarship, 38(2), 141147.
http://doi.org/10.1111/j.1547-5069.2006.00091.x
Shelton, G. (2016). Appraising Travelbee’s human-to-human relationship model. Journal of the Advanced Practitioner in Oncology, 7(6), 657-661.
https://doi.org/10.6004/jadpro.2016.7.6.7
Sherko, E., Sotiri, E., & Lika, E. (2013). Therapeutic communication.
JAHR-European Journal of Bioethics, 4(7), 457-466.
Sinclair, S., Beamer, K., Hack, T. F., McClement, S., Raffin Bouchal,S., Chochinov, H. M., & Hagen, N. A. (2017). Sympathy, empathy, and compassion: A grounded theory study of palliative carepatients’ understandings, experiences, and preferences. Palliative
Medicine, 31(5), 437-447.
https://doi.org/10.1177/0269216316663499
Stalmeijer, R. E., Mcnaughton, N., & Van Mook, W. N. (2014). Using
focus groups in medical education research: AMEE Guide No.
91. Medical Teacher, 36(11), 923-939.
https://doi.org/10.3109/0142159X.2014.917165
Streiner, D. L., Norman, G. R., & Cairney, J. (2015). Igakuteki sokutei
shakudo no riron to oyou [Health measurement scales: A practical guide to their development and use (5th ed.)]. (Kihara, M.,
Kaji, M., & Kihara, M. Trans.). Medical sciences international:
Japan.
Suzuki, K., & Komatsu, H. (2002). Hajimete byomei kokuchi woukete chiryo ni nozomu sounenki gan kanja no ninchi hyoka tosono henka [Cognitive appraisal of patients with cancer following
telling about the diagnosis]. Journal of Japanese Society of Cancer Nursing, 16(1), 17-27.
https://doi.org/10.18906/jjscn.2002-16-1-17
Travelbee, J. (1971). Ningen tai Ningen no kango [Interpersonal aspects of nursing]. (Hasegawa, H., & Fujieda, T. Trans.). Igakushoin: Japan.
Ueno, E. (2005). Kangoshi niokeru kanja tono communication skill
sokutei syakudo no kaihatu [Development of the patients-nurse
communication skill scale]. Journal of Japan Academy of Nursing
Science, 25(2), 47-55.
https://doi.org/10.5630/jans1981.25.2_47

https://doi.org/10.53044/jinr.2022-0041
Van Servellen, G. (2018). Communication skills for the health care
professional: Concepts, practice, and evidence (3rd ed.). Jones &Bartlett Publishers.
Warnock, C., Buchanan, J., & Tod, A. M. (2017). The difficulties experienced by nurses and healthcare staff involved in the processof breaking bad news. Journal of Advanced Nursing, 73(7), 16321645.
https://doi.org/10.1111/jan.13252
Warnock, C., Tod, A., Foster, J., & Soreny, C. (2010). Breaking badnews in inpatient clinical settings: Role of the nurse. Journal ofAdvanced Nursing, 66(7), 1543-1555.
https://doi.org/10.1111/j.1365-2648.2010.05325.x

JINR 2024, 3(1), e2022-0041
Yamauchi, T., Inagaki, M., Yonemoto, N., Iwasaki, M., Inoue, M.,
Akechi, T., Iso, H., & Tsugane, S. (2014). Death by suicide andother externally caused injuries following a cancer diagnosis: The
Japan Public Health Center-based prospective study. PsychoOncology, 23(9), 1034-1041.
https://doi.org/10.1002/pon.3529
Yu, H., Jiang, A., & Shen, J. (2016). Prevalence and predictors ofcompassion fatigue, burnout and compassion satisfaction among
oncology nurses: A cross-sectional survey. International Journalof Nursing Studies, 57, 28-38.
https://doi.org/10.1016/j.ijnurstu.2016.01.012

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Original Research

Risk of developing postpartum type 2 diabetes in women with a history ofgestational diabetes who did not undergo postpartum glucose tolerance
testing
Kanako Yamada, RNM, MA1 , and Kazutomo Ohashi, MD, PhD2
1Osaka Metropolitan University Graduate School of Nursing, Habikino, Japan, and 2Otemae University Faculty of
Global Nursing, Osaka, Japan

Abstract
Objective: This study aimed to examine the presence of high-risk women developing type 2 diabetes mellitus
among women with a history of gestational diabetes mellitus (GDM) who had not undergone a postpartum oral
glucose tolerance test (OGTT). Methods: This was a retrospective observational study. The participants wereJapanese women diagnosed with GDM and were managed at two perinatal medical centers. We compared therisk factors for developing type 2 diabetes between women who had undergone a postpartum OGTT (examinees)
and those who had not had it (nonexaminees). In addition, we divided the participants with a history of GDM into
high- and low-risk groups and examined the presence of high-risk women developing type 2 diabetes mellitus. Results: Of the 117 participants, 77 (65.8%) underwent a postpartum OGTT and 40 (34.2%) did not. There were no
significant differences in the risk factors for developing type 2 diabetes between the two groups, except for thepremature birth rate. We divided the 80 participants into two groups, including 30 nonexaminees and 50 examinees, and 34 high- and 46 low-risk women. Although there was no significant difference in the percentage of highrisk women who had undergone a postpartum OGTT, 10 (33.3%) of the 30 nonexaminees were assessed as
high-risk. Conclusions: Our results indicate that 10 (12.5%) of 80 women with a history of GDM did not undergoa postpartum OGTT despite being in the high-risk group and improving the rate of postpartum OGTT may contribute to the prevention and early detection of type 2 diabetes.
Keywords
developing type 2 diabetes mellitus, gestational diabetes, glucose tolerance test, Japanese, postpartum period
JINR 2024, 3(1), e2023-0006

Introduction
Gestational diabetes mellitus (GDM) is a risk factor for thedevelopment of type 2 diabetes mellitus. In a recent study,
the relative risk of developing type 2 diabetes mellitus in
women with a history of GDM was found to be 9.5-foldhigher than that in women who exhibited normal glucose
tolerance during pregnancy (Vounzoulaki et al., 2020). According to the Hyperglycemia and Adverse Pregnancy Out-

come follow-up study, after 11.4 years, the incidence of diabetes among women with GDM diagnosed according to the
new International Association of Diabetes and Pregnancy
Study Groups (IADPSG) diagnostic criteria (revised in2010) was 5.4 times that in pregnant women who did nothave GDM (Lowe et al., 2018). Therefore, the international
recommendation is to evaluate glucose tolerance in womenwith a history of GDM using a 75 g oral glucose tolerance
test (OGTT) within 12 weeks of delivery (American Diabe-

Correspondence: K. Yamada. Email: yamadak@omu.ac.jp
Received: February 10, 2023, Accepted: July 18, 2023, Published: February 23, 2024
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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tes Association Professional Practice et al., 2022; Feig et al.,2018). However, the examination rates of postpartum OGTT
have remained low because of mothers experiencing a senseof security from the temporary normalization of glucose metabolism after childbirth and being busy with childcare andunaware of the risk of developing diabetes (Bernstein et al.,2016; Van Ryswyk et al., 2016). Studies in several countries, including those in Asia, have also shown that the examination rates of postpartum OGTT among women with ahistory of GDM are low (18.5%-61.0%) (Pastore et al.,2018). Therefore, increasing these examination rates is ofurgent importance.
The postpartum OGTT rate among Japanese women is reportedly 67.6% (Kawasaki et al., 2020), which is higher
than that in other countries (Pastore et al., 2018). However,
because Asian women with a history of GDM are at ahigher risk of developing type 2 diabetes mellitus than Caucasian women (Lee et al., 2007), the current examination
rate among Japanese women is insufficient for follow-up on
the potential development of type 2 diabetes mellitus in the
future. Japan has postpartum support systems for womenwith a history of GDM, but a postpartum OGTT is not compulsory. Therefore, high-risk women with a history of GDM
who need follow-up for type 2 diabetes mellitus may beoverlooked. However, previous studies (Masuko et al., 2022;
Phaloprakarn & Tangjitgamol, 2022) on the risk factors fordeveloping type 2 diabetes mellitus in women with a historyof GDM after delivery only enrolled women who underwent
a postpartum OGTT, and a study including women who did
not undergo a postpartum OGTT was considered important.
If, as a result, a large number of high-risk women are included among the women who did not undergo a postpartum OGTT, the postpartum check-up system for womenwith a history of GDM needs to be revised.
In the present study, we examined the presence of risk
factors for developing type 2 diabetes mellitus in womenwith a history of GDM who had not undergone a postpartum OGTT.

https://doi.org/10.53044/jinr.2023-0006

diabetes mellitus and the use of insulin in pregnancy between women who had undergone a postpartum OGTT (examinees) and those who had not undergone a postpartum
OGTT (nonexaminees) (Cabizuca et al., 2018), and 16 of 21(76.1%) examinees and 52 of 131 (34.4%) nonexaminees
had used insulin during pregnancy. Therefore, the effect size
was 0.28, and the combined sample size was 98.
Data from January 2015 to December 2017 were collected from medical records. The data collection period wasfrom August 2018 to December 2019.
Risk of Developing Type 2 Diabetes Mellitus in Women
Who Did Not Undergo a Postpartum OGTT
Using the risk factors for type 2 diabetes mellitus reportedby Rayanagoudar et al. (2016), we compared the risk factorsof women who had and had not undergone a postpartum
OGTT. This review focused on 39 papers, mainly fromwestern countries, and included 95,750 women with a history of GDM. Individual risk factors for developing type 2
diabetes mellitus in women with a history of GDM included
advanced maternal age, maternal obesity, family history of
diabetes, and nonwhite ethnicity. Pregnancy-related risk factors include multiparity, hypertension disorder in pregnancy,
use of insulin in pregnancy, preterm delivery, an early diagnosis of GDM, and the fasting, 1-h, and 2-h plasma glucose
levels in the OGTT performed at the time of GDM diagnosis.
The review by Rayanagoudar et al. (2016) did not include
studies on Japanese participants. Risk factors for developing
type 2 diabetes mellitus among women with a history of
GDM have been recently reported in papers investigating
Japanese women (Nishikawa et al., 2017; Inoue et al., 2018;
Kawasaki et al., 2020; Masuko et al., 2022) and a review
targeting Asian women (Nouhjah et al., 2017). Although risk
factors have been examined in various papers, there havebeen insufficient comparisons of risk factors between Asianand Caucasian women. Asians are at a higher risk of developing diabetes, even with a slight weight gain, than Westerners (Caleyachetty et al., 2021). It has been reported that
Asian women with a history of GDM have a higher risk ofdeveloping type 2 diabetes mellitus as compared to CaucaMaterials and Methods
sian women (Lee et al., 2007).
Study Design
Therefore, we thought that it is necessary to investigate
This was a retrospective observational study. The partici- the risk factors for developing type 2 diabetes mellitus inpants were Japanese women who were diagnosed with Japanese women with a history of GDM. We used risk facGDM based on the IADPSG criteria (at least one of fasting tors for type 2 diabetes mellitus for Japanese women with aplasma glucose !92 mg/dL, OGTT 1-h plasma glucose ! history of GDM, as recently reported by Kugishima et al.
180 mg/dL, or OGTT 2-h plasma glucose !153 mg/dL is (2018), and these included 75 g OGTT 2-h plasma glucose
positive), which are the globally unified diagnostic criteria !183 mg/dL and HbA1c !5.6% at the time of GDM diagfor GDM. The deliveries were managed at one of two peri- nosis.
natal medical centers from January 2015 to December 2017.
Data Analysis
Cases of multiple pregnancy and overt diabetes during pregnancy were excluded. The sample size was calculated using Descriptive statistics were calculated for the participants’ ata study that compared the risk factor for developing type 2 tributes, 75 g OGTT results in pregnancy, and use of insulin
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Table 1. Maternal characteristics and 75g OGTT results in pregnancy.

Characteristics

All subjects
N = 117

Nonexaminees
n = 40

Examineesn = 77n (%) or Mean ± SD
Age (years)
Ethnicity, JapanesePrevious BMI (kg/m2)
Previous BMI ≥ 25 (kg/m2)
Multiparous
Family history of type 2 diabetes
75 g OGTT results during pregnancy
Fasting plasma glucose (mg/dL)
1-h plasma glucose (mg/dL)
2-h plasma glucose (mg/dL)
Use of insulin in pregnancy

34.4 ± 5.2
117 (100.0)
25.1 ± 5.7
51 (43.6)
66 (56.4)
50 (42.7)

33.4 ± 5.4
40 (100.0)
24.5 ± 4.6
16 (40.0)25 (62.5)
18 (45.0)

34.9 ± 5.9
77 (100.0)
25.5 ± 6.1
35 (45.5)
41 (53.2)
32 (41.6)

84.8 ± 12.1
181.5 ± 29.3
162.9 ± 35.6
45 (38.5)

83.7 ± 11.4
181.6 ± 24.7
159.1 ± 31.4
11 (24.4)

85.4 ± 12.5
181.5 ± 31.7
164.9 ± 37.6
37 (44.2)

Note: BMI = body mass index; OGTT = oral glucose tolerance test; SD = standard deviation.

in pregnancy. Using the risk factors for developing type 2
diabetes mellitus reported by Rayanagoudar et al. (2016),
the risk status was compared between women who did anddid not undergo an OGTT using a Pearson’s chi-square test,
Fisher’s exact test, and unpaired t-test. Moreover, the type 2
diabetes mellitus risk factors reported by Kugishima et al.
(2018) were used to divide Japanese women with a historyof GDM into a high-risk group (75 g OGTT 2-h plasma
glucose "183 mg/dL or HbA1c "5.6%) and a low-risk
group (75 g OGTT 2-h plasma glucose < 183 mg/dL andHbA1c < 5.6%), which were analyzed using Pearson’s chisquare test (Kugishima et al., 2018).
All statistical analyses were performed using SPSS for
Windows version 27 (IBM Inc., Armonk, NY, USA), andthe significance level was set at 5%.
Ethical Considerations
This study was approved by the ethical review board of the
Osaka Prefecture University Graduate School of Nursing(approval number 30-42). Informed consent was obtained in
the form of an opt-out procedure, and we ensured that theiranonymity was preserved. This research conformed to theprovisions of the Declaration of Helsinki.

Results
From January 2015 to December 2017, there were 1,944
and 2,498 deliveries at the two participating institutions and
101 and 52 women were diagnosed with GDM (incidence
rates of 5.1% and 2.1%, respectively).
From these 153 women, we excluded 7 with a history oftwin pregnancy, 4 foreign women, 11 with missing data, and14 who had been referred to other institutions for an OGTT,
and 117 women were included in the analysis (Table 1). Of
the women with a history of GDM, 40 (34.2%) had not un-dergone an OGTT and 77 (65.8%) had undergone testing(Table 2). The timing of the OGTT in the 77 participants
was !
5 weeks after delivery for 19 (24.7%), after 6-12
weeks for 40 (51.9%), and "13 weeks for 18 (23.4%)
women. After excluding 4 cases with missing data, the
OGTT result for the 73 participants was normal in 55(75.3%), was borderline in 14 (19.2%), and indicated diabetes in 4 (5.5%) women.
We compared the risk factors for type 2 diabetes mellitus
reported by Rayanagoudar et al. (2016) between 40 nonexaminees and 77 examinees (Table 2). There was a significantly higher rate of preterm deliveries in examinees (18/77,
23.4%) than in nonexaminees (3/40, 7.5%) (p = .034). There
were no significant group differences in the other parameters, including advanced maternal age, maternal obesity,
family history of diabetes, multiparity, hypertension disorders in pregnancy, an early diagnosis of GDM, 75 g OGTT
values during pregnancy, and use of insulin in pregnancy.
After excluding 37 women with missing data of the 75 g
OGTT 2-h plasma glucose and HbA1c values, we examined
the relationship between the risk level and postpartum
OGTT examination status in 80 patients (30 nonexaminees
and 50 examinees), but no significant relationships were observed with any risk level criteria (Table 3). However, 10(33.3%) of the 30 nonexaminees were assessed as high-risk
according to the Kugishima et al. (2018) criteria, suggestingthat 10 (12.5%) of 80 women with a history of GDM did
not undergo a postpartum OGTT despite being in the highrisk group.

Discussion
The GDM incidence rates in the two institutions in the present study were 2.1% and 5.1%, and the overall GDM incidence in Japan was 5.5% (Morikawa et al., 2017). Further,
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Table 2. Comparison of risk factors for developing postpartum type 2 diabetes
mellitus among nonexaminees and examinees.
Risk factors for developing
postpartum type 2 diabetes mellitus
Maternal characteristics
Advanced maternal age ≥ 35
Maternal obesity (BMI ≥ 25 kg/m2)
Family history of type 2 diabetes
Pregnancy factors
Multiparous
Hypertension in pregnancy
Preterm delivery
Early diagnosis of GDM (weeks)
75 g OGTT results during pregnancy
Fasting plasma glucose (mg/dL)
1-h plasma glucose (mg/dL)
2-h plasma glucose (mg/dL)
Use of insulin in pregnancy

Nonexaminees(n = 40)

Examinees(n = 77)

p valuen (%) or Mean ± SD
20 (50.0)
16 (40.0)
18 (45.0)

46 (59.7)
35 (45.5)
32 (41.6)

.31a
.57a
.72a

25 (62.5)
2 (5.0)3 (7.5)22.4 ± 7.3

41 (53.2)
8 (10.4)
18 (23.4)
21.3 ± 7.0

.33a
.49b
.03b
.43c

83.7 ± 11.4
181.6 ± 24.7
159.1 ± 31.4
11 (24.4)

85.4 ± 12.5
181.5 ± 31.7
164.9 ± 37.6
37 (44.2)

.46c
.98c
.40c
.07a

Note: BMI = body mass index; GDM = gestational diabetes mellitus; OGTT = oral glucose tolerance test; SD = standard deviation.
Notes: a Chi-square test; b Fisher’s exact test; c Student t-test.

Table 3. Relationship between risk level and postpartum OGTT examination status.
Risk factors for developing
postpartum type 2 diabetes mellitus
High risk group (2hPG ≥ 183 or HbA1c ≥ 5.6)
Low risk group (2hPG < 183 and HbA1c < 5.6)

Nonexaminees
n = 30

Examineesn = 50p valuen (%)
10 (33.3%)
20 (66.7%)

24 (48.0%)
26 (52.0%).19a

Note: OGTT = oral glucose tolerance test; PG = plasma glucose.
aChi-square test.

34.2% (40 of 117) of women with a history of GDM did
not undergo a postpartum OGTT, which was similar to thepostpartum OGTT of 32.4% in a previous study in Japan(Kawasaki et al., 2020).
We compared the presence of risk factors for developing
postpartum type 2 diabetes mellitus between nonexaminees
and examinees using risk factors reported in a systematic review of mostly European and American studies (Rayanagoudar et al., 2016). Risk factors, except premature delivery, did
not significantly differ between them in this study, suggesting that nonexaminees were just as likely to develop type 2
diabetes mellitus as examinees in Japan. Linnenkamp et al.
(2022) discussed that women’s low health awareness generally influenced postpartum screening behavior because
smoking during pregnancy and obesity before pregnancy
were significantly more frequent among nonexaminees than
examinees. Moreover, high levels of health literacy were associated with good postpartum screening (Jones et al.,2019), indicating that postpartum screening behavior is in4 of 8

fluenced by general health awareness. However, women witha history of GDM tended to underestimate their risk of developing type 2 diabetes, thinking that they were healthy
once their pregnancy ended (Hamel & Werner, 2017). Therefore, postpartum health awareness among women with GDMshould be increased, and a system where all women with ahistory of GDM can conveniently receive postpartum glucose tolerance testing be established.
We divided the participants into the high-risk and low-risk
groups for developing type 2 diabetes mellitus using risk
factors for Japanese women and examined the relationshipbetween risk levels and the presence of postpartum OGTT.
The results showed no significant difference between thetwo groups, and 10 (12.5%) of 80 women with a history of
GDM had not undergone a postpartum OGTT despite being
in the high-risk group. A high-risk group assessed using thesame criteria as this study showed a higher incidence of diabetes mellitus within five years after delivery, with a 7.02fold increase in incidence among women with a history ofhttps://doi.org/10.53044/jinr.2023-0006

GDM and 75 g OGTT 2-h plasma glucose !183 mg/dL,
and a 4.67-fold increase in incidence among women with ahistory of GDM and HbA1c ! 5.6% (Kugishima et al.,2018). In summary, women who did not undergo an OGTT
despite being in the high-risk group in this study missed an
opportunity to detect glucose intolerance, which means thatthey were unable to initiate appropriate interventions to prevent progression to type 2 diabetes.
In Japan, 12.1% of people suffer from diabetes (Ministryof Health, Labour and Welfare, 2016), and the percentage iscontinuously increasing as in other developed countries(Zhou et al., 2016). Medical spending on diabetes has also
increased in Japan, exceeding 1.1 trillion yen per year (Ministry of Health, Labour and Welfare, 2020). The number oflive births in 2017 was approximately 980,000 (Ministry of
Health, Labour and Welfare, 2019), and the GDM incidence
was 5.5% (Morikawa et al., 2017), resulting in an estimatednumber of 54,000 women with GDM. On the basis of ourresults, the overlooked rate of the high-risk group in the current postpartum check-up system for GDM was 12.5%, andthe number of overlooked women in the high-risk group was
estimated at 6,800 per year. Follow-up immediately after delivery on high-risk women with a history of GDM may aid
in the prevention and early detection of type 2 diabetes mellitus and is important because the incidence of diabetic complications is higher in cases of type 2 diabetes mellitus thatdevelop before age 40 than at a later onset (Huo et al.,2016). As a result, if we would not overlook such high-risk
women, we could reduce medical spending.
Furthermore, a review by Michael et al. reported that
1.3%-10.8% of women with a history of GDM developed
diabetes within 12 weeks of delivery (Carson et al., 2013).
Continuous follow-up of women with a history of GDM
through better postpartum OGTT examination rates may
have great social benefits. Therefore, it is necessary to consider methods to encourage women with a history of GDM
to undergo a postpartum OGTT within 12 weeks after delivery. Although Japanese guidelines recommend that womenwith a history of GDM need to undergo a 75 g OGTT by 612 weeks after delivery when the effects of pregnancy on
glucose metabolism disappear, only 40 women (51.9%) in
this study underwent a postpartum OGTT during this period.
Meanwhile, 24.7% of women with a history of GDM underwent a postpartum OGTT within five weeks after delivery.
This may be because their doctor scheduled the OGTT
along with the standard postpartum maternal check-up 4-5
weeks after delivery for mothers’ convenience. Such a situation is not only in Japan; a German study reported that
only 51.6% of women with a history of GDM underwent
the recommended postpartum OGTT 6-12 weeks after delivery (Linnenkamp et al., 2022). Recently, the American Diabetes Association (ADA) changed the timing of postpartum
OGTT from 6-12 weeks to 4-12 weeks postpartum (Ameri-

JINR 2024, 3(1), e2023-0006

can Diabetes Association Professional Practice et al., 2022).
To improve the postpartum OGTT rate, it may be necessary
to reconsider the current Japanese guidelines and adopt the
ADA standard. If the OGTT is taken at 4-12 weeks postpartum, which is considered less affected by pregnancy-related
insulin resistance, it could be conducted together with thegeneral postpartum maternal check-up at 4-5 weeks postpartum and it may increase the number of women who will undergo a postpartum OGTT. Furthermore, nursing professionals should educate women regarding the need for a postpartum OGTT during pregnancy to raise health awareness.
Moreover, even if the first examination is missed, the number of women who will receive the examination can be increased if the examination is offered along with the generalinfant check-up (4-month, 7-month, and 1-year-old childcheck-up) in Japan to women who wish to receive the examination.
The prevention and early detection of type 2 diabetes
mellitus require continuous follow-up after the initial postpartum OGTT. Numerous attempts to improve the continuous follow-up of women with a history of GDM have beenreported. Methods to improve the follow-up rate included reminders to patients and doctors (Cosson et al., 2015; Halperin et al., 2015) and education and counseling during pregnancy (Bounds et al., 2021; Soffer et al., 2017). In addition,
continuous follow-up helps in maintaining good health inwomen after delivery by preventing the onset of type 2 diabetes mellitus (Aroda et al., 2015). In other words, althoughsupport for lifestyle habits by medical professionals is necessary, continuous follow-up will not be effective unless
women with a history of GDM make a conscious effort toimprove their lifestyles. The initial postpartum OGTT is important as the first motivational factor to promote thischange, and it is thought to be the cornerstone for continuous follow-up. In addition, preterm delivery, which is aknown risk factor for the development of type 2 diabetes
mellitus, carries a risk of recurrence (Spong et al., 2007),with a recurrence rate of 22.3% among Japanese women(Seyama et al., 2022). Furthermore, a history of GDM andobesity are both risk factors for GDM during subsequentpregnancies (Schwartz et al., 2015). Therefore, it is considered important that nursing professionals must provide ongoing follow-up to women with a history of GDM and assume a role in preconception care for the health of the next
child. The initial postpartum OGTT is a good opportunity,
and the time spent waiting for the examination should be
used by nursing professionals to discuss future examination
schedules, next pregnancy, and weight control with womenwith a history of GDM.
This study had three limitations. First, the percentage ofparticipants who took the postpartum OGTT in this study
was low (65.8%). In Japan, the management of women with
GDM is centrally performed at the perinatal medical centers
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where obstetricians and diabetologists work together to pro- detection are mandatory, so it is necessary to increase thevide reliable GDM diagnosis and blood sugar management rate of initial postpartum OGTT. As such, it is necessary toduring pregnancy. However, a referral system (Yamada et reconsider the timing of postpartum OGTT, to conduct aal., 2018) and multidisciplinary cooperation (Matsunaga et postpartum OGTT as a part of regular medical tests, and toal., 2021) in postpartum follow-up examination remain not support continuous follow-up. In addition, according to a rewell developed. In the future, these issues need to be im- view of factors that promote postpartum OGTT (Dennison etproved to increase the percentage of women with a history al., 2020), it has been reported that the establishment of a
of GDM who will receive the OGTT.
protocol for sharing the history of GDM among medical
Second, the data on HbA1c at the time of GDM diagnosis professionals and the ability of women to receive medical
were sometimes deficient in the study because HbA1c was care together with their children are important promotion
not included in the screening test for GDM in Japan. Al- factors. These can be achieved by utilizing the maternal andthough 75 g OGTT 2-h plasma glucose and HbA1c values child health handbook and regular health checkups for chilat diagnosis had been reported as risk factors for developing dren, such as health checkups for infants. Writing “GDM”
type 2 diabetes mellitus in Japanese women (Kugishima et in the maternal and child health handbook by the medicalal., 2018), measurement of HbA1c is not required at the institution that diagnosed GDM allows sharing of informatime of diagnosis of GDM. A Swedish study (Ekelund et al., tion among medical professionals even after childbirth. It is2010) also reported that the HbA1c value at diagnosis was thought that women with a history of GDM can continue toan independent factor for developing type 2 diabetes melli- receive support from medical professionals, such as recomtus within 5 years postpartum, with an HbA1c level of ! mendations for postpartum OGTT, advice on lifestyle habits,
5.7% reported to increase the risk of developing postpartum and blood glucose measurements during regular checkups
type 2 diabetes mellitus by 4.8-fold. In the future, it should for their children.
be mandatory to measure HbA1c values at the time of GDM
diagnosis. Postpartum follow-up of GDM has become diffi- Acknowledgments
cult because the number of women with GDM has increased The authors would like to thank Dr. Kazuhide Ogita, Rinku
since the adoption of the IADPSG criteria. Therefore, we General Medical Center, and Ayu Iguchi, Assistant Profesbelieve that it is important to examine the risk of developing sor, St. Mary’s College, for supporting data collection. We
postpartum type 2 diabetes based on data at the time of thank all of the participants of this study.
GDM diagnosis.
Third, in the present study, we used OGTT 2-h plasma Author Contributions
glucose levels and HbA1c during pregnancy to classify pa- Study design: K.Y. and K.O.
tients according to their risk of developing type 2 diabetes Data Collection: K.Y.
mellitus. However, as the standard for the OGTT 2-h plasma Data analysis: K.Y. and K.O.
glucose level is 153 mg/dL or higher, our definition of the Manuscript writing: K.Y. and K.O.
OGTT 2-h plasma glucose level of <183 mg/dL as a “low- All authors have read and agreed to the published version ofrisk group” was limited. Several studies published in the lit- the manuscript.
erature have previously investigated the risk factors for thedevelopment of type 2 diabetes mellitus (Rayanagoudar et Declaration of Conflicting Interestsal., 2016; Kugishima et al., 2018), and if the risk classifica- The authors declare that there are no conflicts of interest.
tion is clarified in the future by scoring risk factors, then it
will be possible to conduct continuous follow-up according Ethical Approvalto the severity of the classification.
This research was approved by the ethical review board of
In conclusion, the low rate of postpartum OGTT among the Graduate School of Nursing Osaka Prefecture University
women with a history of GDM is a global issue. In the pre- (approval number 30-42).
sent study, 34.2% of women with a history of GDM did not (Osaka Prefecture University changed its name to Osaka
undergo a postpartum OGTT. There was no difference in the Metropolitan University in 2022.)
risk factors for developing type 2 diabetes mellitus between
women who had and had not undergone a postpartum Funding
OGTT, except for the preterm birth rate. In addition, 12.5% This research was supported by JSPS Grants-in-Aid for Sciof women with a history of GDM did not undergo a post- entific Research (KAKENHI) (grant number 17K17478).
partum OGTT despite being in the high-risk group for developing type 2 diabetes mellitus. For high-risk women with References
a history of GDM, the prevention of diabetes from the early American Diabetes Association Professional Practice Committee.
(2022). 15. Management of Diabetes in Pregnancy: Standards of
postpartum period and that of complications through early
6 of 8https://doi.org/10.53044/jinr.2023-0006
Medical Care in Diabetes-2022. Diabetes Care, 45(Suppl. 1), S
232-S243.
https://doi.org/10.2337/dc22-S015
Aroda, V. R., Christophi, C. A., Edelstein, S. L., Zhang, P., Herman,
W. H., Barrett-Connor, E., Delahanty, L. M., Montez, M. G.,
Ackermann, R. T., Zhuo, X., Knowler, W. C., Ratner, R. E., &Diabetes Prevention Program Research, G. (2015). The effect oflifestyle intervention and metformin on preventing or delaying
diabetes among women with and without gestational diabetes:
The Diabetes Prevention Program outcomes study 10-year followup. Journal of Clinical Endocrinology and Metabolism, 100(4),1646-1653.
https://doi.org/10.1210/jc.2014-3761
Bernstein, J. A., McCloskey, L., Gebel, C. M., Iverson, R. E., & LeeParritz, A. (2016). Lost opportunities to prevent early onset type2 diabetes mellitus after a pregnancy complicated by gestational
diabetes. BMJ Open Diabetes Res Care, 4(1), e000250.
https://doi.org/10.1136/bmjdrc-2016-000250
Bounds, F. L., Rojjanasrirat, W., & Martin, M. A. (2021). Team-based
approach to managing postpartum screening of women with gestational diabetes for type 2 diabetes. Journal of midwifery &women’s health, 66(1), 101-107.
https://doi.org/10.1111/jmwh.13202
Cabizuca, C. A., Rocha, P. S., Marques, J. V., Costa, T., Santos, A. S. N.,
Schroder, A. L., Mello, C. A. G., Sousa, H. D., Silva, E. S. G.,
Braga, F. O., Abi-Abib, R. C., & Gomes, M. B. (2018). Postpartum follow up of gestational diabetes in a Tertiary Care Center.
Diabetology and Metabolic Syndrome, 10, 2.
https://doi.org/10.1186/s13098-017-0303-4
Caleyachetty, R., Barber, T. M., Mohammed, N. I., Cappuccio, F. P.,
Hardy, R., Mathur, R., Banerjee, A., & Gill, P. (2021). Ethnicityspecific BMI cutoffs for obesity based on type 2 diabetes risk in
England: A population-based cohort study. The Lancet Diabetes &Endocrinology, 9(7), 419-426.
https://doi.org/10.1016/s2213-8587(21)00088-7
Carson, M. P., Frank, M. I., & Keely, E. (2013). Original research:
Postpartum testing rates among women with a history of gestational diabetes--systematic review. Primary Care Diabetes, 7(3),177-186.
https://doi.org/10.1016/j.pcd.2013.04.007
Cosson, E., Bihan, H., Vittaz, L., Khiter, C., Carbillon, L., Faghfouri,
F., Leboeuf, D., Dauphin, H., Lepagnol, A., Reach, G., & Valensi,
P. (2015). Improving postpartum glucose screening after gestational diabetes mellitus: A cohort study to evaluate the multicentre IMPACT initiative. Diabetic Medicine, 32(2), 189-197.
https://doi.org/10.1111/dme.12631
Dennison, R. A., Fox, R. A., Ward, R. J., Griffin, S. J., & UsherSmith, J. A. (2020). Women’s views on screening for Type 2 diabetes after gestational diabetes: A systematic review, qualitativesynthesis and recommendations for increasing uptake. Diabetic
Medicine, 37(1), 29-43.
https://doi.org/10.1111/dme.14081
Ekelund, M., Shaat, N., Almgren, P., Groop, L., & Berntorp, K.
(2010). Prediction of postpartum diabetes in women with gestational diabetes mellitus. Diabetologia, 53(3), 452-457.
https://doi.org/10.1007/s00125-009-1621-3
Feig, D. S., Berger, H., Donovan, L., Godbout, A., Kader, T., Keely,E., & Sanghera, R. (2018). Diabetes and pregnancy. Canadian
Journal of Diabetes, 42, S255-S282.

JINR 2024, 3(1), e2023-0006
https://doi.org/10.1016/j.jcjd.2017.10.038
Halperin, I. J., Sehgal, P., Lowe, J., Hladunewich, M., & Wong, B. M.
(2015). Increasing timely postpartum oral glucose tolerance testcompletion in women with gestational diabetes: A qualityimprovement initiative. Canadian Journal of Diabetes, 39(6),451-456.
https://doi.org/10.1016/j.jcjd.2015.06.004
Hamel, M. S., & Werner, E. F. (2017). Interventions to improve rate ofdiabetes testing postpartum in women with gestational diabetes
mellitus. Current Diabetes Reports, 17(2), 7.
https://doi.org/10.1007/s11892-017-0835-x
Huo, X., Gao, L., Guo, L., Xu, W., Wang, W., Zhi, X., Li, L., Ren, Y.,
Qi, X., Sun, Z., Li, W., Ji, Q., Ran, X., Su, B., Hao, C., Lu, J.,
Guo, X., Zhuo, H., Zhang, D., . . . Ji, L. (2016). Risk of nonfatal cardiovascular diseases in early-onset versus late-onset type2 diabetes in China: A cross-sectional study. Lancet Diabetes Endocrinol, 4(2), 115-124.
https://doi.org/10.1016/s2213-8587(15)00508-2
Inoue, H., Ishikawa, K., Takeda, K., Kobayashi, A., Kurita, K., Kumagai, J., Yokoh, H., & Yokote, K. (2018). Postpartum risk of diabetes and predictive factors for glucose intolerance in East Asian
women with gestational diabetes. Diabetes Research and Clinical
Practice, 140, 1-8.
https://doi.org/10.1016/j.diabres.2018.03.031
Jones, E. J., Hernandez, T. L., Edmonds, J. K., & Ferranti, E. P.
(2019). Continued disparities in postpartum follow-up and screening among women with gestational diabetes and hypertensive disorders of pregnancy. Journal of Perinatal & Neonatal Nursing, 33(2), 136-148.
https://doi.org/10.1097/jpn.0000000000000399
Kawasaki, M., Arata, N., Sakamoto, N., Osamura, A., Sato, S., Ogawa,Y., Yasuhi, I., Waguri, M., & Hiramatsu, Y. (2020). Risk factors
during the early postpartum period for type 2 diabetes mellitus in
women with gestational diabetes. Endocrine Journal, 67(4), 427437.
https://doi.org/10.1507/endocrj.ej19-0367
Kugishima, Y., Yasuhi, I., Yamashita, H., Sugimi, S., Umezaki, Y.,
Suga, S., Fukuda, M., & Kusuda, N. (2018). Risk factors associated with the development of postpartum diabetes in Japanesewomen with gestational diabetes. BMC Pregnancy Childbirth, 18(1), 19.
https://doi.org/10.1186/s12884-017-1654-4
Lee, A. J., Hiscock, R. J., Wein, P., Walker, S. P., & Permezel, M.
(2007). Gestational diabetes mellitus: Clinical predictors andlong-term risk of developing type 2 diabetes: A retrospective
cohort study using survival analysis. Diabetes Care, 30(4), 878883.
https://doi.org/10.2337/dc06-1816
Linnenkamp, U., Greiner, G. G., Haastert, B., Adamczewski, H., Kaltheuner, M., Weber, D., & Icks, A. (2022). Postpartum screeningof women with GDM in specialised practices: Data from12,991 women in the GestDiab register. Diabetic Medicine, 39(7),e14861.
https://doi.org/10.1111/dme.14861
Lowe, W. L., Scholtens, D. M., Lowe, L. P., Kuang, A., Nodzenski,M., Talbot, O., Catalano, P. M., Linder, B., Brickman, W. J.,
Clayton, P., Deerochanawong, C., Hamilton, J., Josefson, J. L.,
Lashley, M., Lawrence, J. M., Lebenthal, Y., Ma, R., Maresh, M.,
McCance, D., . . . Metzger, B. E. (2018). Association of Gesta-

7 of 8JINR 2024, 3(1), e2023-0006
tional Diabetes with maternal disorders of glucose metabolism
and childhood adiposity. JAMA, 320(10), 1005-1016.
https://doi.org/10.1001/jama.2018.11628
Masuko, N., Tanimura, K., Kojima, N., Imafuku, H., Deguchi, M.,
Okada, Y., Hirota, Y., Ogawa, W., & Yamada, H. (2022). Predictive factors for postpartum glucose intolerance in women withgestational diabetes mellitus. Journal of Obstetrics and Gynaecology Research, 48(3), 640-646.
https://doi.org/10.1111/jog.15155
Matsunaga, M., Horiuchi, S., Kataoka, Y., Igarashi, Y., Porter, S. E., &Fukui, T. (2021). Continuous interprofessional collaboration for
women with gestational diabetes mellitus: A cross-sectional survey in Japan. Japan Journal of Nursing Science, 18(4), e12438.
https://doi.org/10.1111/jjns.12438
Ministry of Health, Labour and Welfare. (2016). Kokumin kenko eiyo
chousa no kekka [Results of the 2016 national health and nutrition survey].
https://www.mhlw.go.jp/stf/houdou/0000177189.html
Ministry of Health, Labour and Welfare. (2017). Chiiki hoken kenko
zoushin jigyo houkoku no gaikyo [Report on regional publichealth services and health promotion services 2017].
https://www.mhlw.go.jp/toukei/saikin/hw/c-hoken/17/dl/gaikyo.pdf
Ministry of Health, Labour and Welfare (2020). Kokumin iryouhi no
gaikyo [Estimates of national medical care expenditure 2020].
https://www.mhlw.go.jp/toukei/saikin/hw/k-iryohi/20/dl/data.pdf
Morikawa, M., Sugiyama, T., Sagawa, N., Hiramatsu, Y., Ishikawa, H.,
Hamada, H., Kameda, T., Hara, E., Toda, S., & Minakami, H.
(2017). Perinatal mortality in Japanese women diagnosed withgestational diabetes mellitus and diabetes mellitus. Journal of Obstetrics and Gynaecology Research, 43(11), 1700-1707.
https://doi.org/10.1111/jog.13431
Pastore, I., Chiefari, E., Vero, R., & Brunetti, A. (2018). Postpartum
glucose intolerance: An updated overview. Endocrine, 59(3), 481494.
https://doi.org/10.1007/s12020-017-1388-0
Nishikawa, T., Ono, K., Hashimoto, S., Kinoshita, H., Watanabe, T.,
Araki, H., Otsu, K., Sakamoto, W., Harada, M., Toyonaga, T.,
Kawakami, S., Fukuda, J., Haga, Y., Kukidome, D., Takahashi, T., &Araki, E. (2018). One-hour oral glucose tolerance test plasma
glucose at gestational diabetes diagnosis is a common predictorof the need for insulin therapy in pregnancy and postpartum impaired glucose tolerance. Journal of Diabetes Investigation, 9(6),1370-1377.
https://doi.org/10.1111/jdi.12848
Nouhjah, S., Shahbazian, H., Amoori, N., Jahanfar, S., Shahbazian, N.,
Jahanshahi, A., & Cheraghian, B. (2017). Postpartum screening
practices, progression to abnormal glucose tolerance and its related risk factors in Asian women with a known history of gestational diabetes: A systematic review and meta-analysis. Diabetes
and Metabolic Syndrome, 11(Suppl. 2), s703-s712.
https://doi.org/10.1016/j.dsx.2017.05.002
Phaloprakarn, C., & Tangjitgamol, S. (2022). Glucose levels during
gestational diabetes pregnancy and the risk of developing postpar-

8 of 8https://doi.org/10.53044/jinr.2023-0006
tum diabetes or prediabetes. BMC Pregnancy and Childbirth, 22(1), 22.
https://doi.org/10.1186/s12884-021-04352-w
Rayanagoudar, G., Hashi, A. A., Zamora, J., Khan, K. S., Hitman,
G. A., & Thangaratinam, S. (2016). Quantification of the type 2
diabetes risk in women with gestational diabetes: A systematic review and meta-analysis of 95,750 women. Diabetologia, 59(7),1403-1411.
https://doi.org/10.1007/s00125-016-3927-2
Schwartz, N., Nachum, Z., & Green, M. S. (2015). The prevalence ofgestational diabetes mellitus recurrence--effect of ethnicity andparity: A metaanalysis. American Journal of Obstetrics and Gynecology, 213(3), 310-317.
https://doi.org/10.1016/j.ajog.2015.03.011
Seyama, R., Makino, S., Nojiri, S., Takeda, J., Suzuki, T., Maruyama,Y., Takeda, S., & Itakura, A. (2022). Retrospective study of therecurrence risk of preterm birth in Japan. Journal of MaternalFetal and Neonatal Medicine, 35(3), 515-519.
https://doi.org/10.1080/14767058.2020.1727435
Soffer, M. D., Factor, S. H., Rosenman, A., Levy, C., & Stone, J.
(2017). Improving postpartum glucose monitoring in women withgestational diabetes. Journal of Maternal-Fetal and Neonatal
Medicine, 30(24), 3014-3019.
https://doi.org/10.1080/14767058.2016.1271411
Spong, C. Y. (2007). Prediction and prevention of recurrent spontaneous preterm birth. Obstetrics and Gynecology, 110(2 Pt 1), 405415.
https://doi.org/10.1097/01.AOG.0000275287.08520.4a
Yamada, K., Ohashi, K. (2018). Osakafu ni okeru ninshin Tounyoubyo
gappei ninpu no byoushin renkei to sango foroappu taisei no
genjo [Referral system during pregnancy and follow-up systemafter childbirth for women with gestational diabetes mellitus in
Osaka Prefecture]. Japanese Journal of Maternal Health, 59(2),569-577.
Van Ryswyk, E. M., Middleton, P. F., Hague, W. M., & Crowther, C. A.
(2016). Women’s views on postpartum testing for type 2 diabetes
after gestational diabetes: Six month follow-up to the DIAMIND
randomised controlled trial. Primary Care Diabetes, 10(2), 91102.
https://doi.org/10.1016/j.pcd.2015.07.003
Vounzoulaki, E., Khunti, K., Abner, S. C., Tan, B. K., Davies, M. J., &Gillies, C. L. (2020). Progression to type 2 diabetes in womenwith a known history of gestational diabetes: Systematic review
and meta-analysis. BMJ, 369, m1361.
https://doi.org/10.1136/bmj.m1361
Zhou, B., Lu, Y., Hajifathalian, K., Bentham, J., Di Cesare, M., Danaei, G., Bixby, H., Cowan, M. J., Ali, M. K., Taddei, C., Lo, W. C.,
Reis-Santos, B., Stevens, G. A., Riley, L. M., Miranda, J. J., Bjerregaard, P., Rivera, J. A., Fouad, H. M., Ma, G., . . . Zuñiga
Cisneros, J. (2016). Worldwide trends in diabetes since 1980: A
pooled analysis of 751 population-based studies with 4·4 million
participants. The Lancet, 387(10027), 1513-1530.
https://doi.org/10.1016/s0140-6736(16)00618-8

https://doi.org/10.53044/jinr.2022-0006
https://www.jinr.jsnr.or.jp/

Brief Report

Current state of advance care planning for patients with hematologic
malignancies in Japan: A nationwide survey
Miki Fujimoto, MA, RN1 , Yoshiyasu Ito, MA, RN2 , and Yukihiro Sakaguchi, PhD3
1

Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing,Midwifery & Palliative Care, King’s College London, London, United Kingdom, 2College of Nursing Art andScience, University of Hyogo, Hyogo, Japan, and 3School of Human Welfare Studies, Kwansei Gakuin University,
Hyogo, Japan

Abstract
Advance care planning (ACP) has various potential benefits. However, patients with hematologic malignancies(HMs) have fewer chances of accessing ACP compared with patients with solid tumors. It has been reported that
one of the main factors is the characteristics of the disease, such as its complex and uncertain trajectories. This
study aims to clarify the actual conditions of ACP for patients with HMs in Japan. A nationwide, cross-sectional,
self-questionnaire was administered to 346 hematology nurses in government-designated cancer hospitals in Japan. Consequently, 209 valid questionnaires were returned (response rate: 58.5%). All respondents answered that
ACP is important in patients with HMs. However, approximately 80% experienced difficulties with ACP. The topics“Surrogate decision-makers,” “Understanding of their illness and prognosis,” and “Place of care” were identified as
the most difficult. Notably, respondents recognized that most ACP topics tended to be discussed with family members rather than with patients. Additionally, between 60% and 70% of nurses reported that “Improvement of healthcare professionals’ knowledge and skills” and “Education for healthcare professionals” were the challenges of ACP.
Further research to explore the reasons related to the current state of ACP is needed.
Keywords
advance care planning, decision making, end-of-life discussion, hematologic malignancies
JINR 2024, 3(1), e2022-0006

Introduction
Since 1981, cancer has been the leading cause of death inJapan (Ministry of Health, Labour and Welfare, 2018), andas such, Japanese authorities have pushed for palliative carefor cancer patients to maintain their quality of life (Ministryof Health, Labour and Welfare, 2018). However, patientswith hematologic malignancies (HMs) are less likely to access advance care planning (ACP), palliative care and otherrelated services and interventions, that would help maintainand improve their quality of life (El-Jawahri et al., 2020;

Suthumphong et al., 2021; Tricou et al., 2019). Comparedwith other cancers, HMs have unique characteristics, such ascomplex and unpredictable trajectories and continued intensive treatment even in the end-of-life stage (Gray et al.,2021; LeBlanc et al., 2015; Wedding, 2021). Moreover, hospital death is twice as likely to occur in patients with HMs
compared with patients with solid tumors (Howell et al.,2010; McCaughan et al., 2018).
ACP is defined in Japanese context as “an individual’s
thinking and discussing with his or her family and otherpeople close to them with the support as necessary of

Correspondence: M. Fujimoto. Email: miki.fujimoto@kcl.ac.uk
Received: May 21, 2022, Accepted: December 14, 2022, Published: February 23, 2024
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 6JINR 2024, 3(1), e2022-0006

healthcare providers who have established a trusting relationship with the individual concerning preparations for the
future.” (Miyashita et al., 2022). Some potential benefits of
ACP for cancer patients are reported. For instance, increased
communication of end-of-life wishes with a physician, concordance between preferences and medical care at the end oflife, and improvement of the mental well-being of the bereaved families. (Johnson et al., 2018; Paladino et al., 2019).
On the other hand, healthcare professionals have identified different kinds of barriers to the participation of patientsand healthcare providers in ACP, such as a lack of time andinsufficient staff (Barnes et al., 2007; Durall et al., 2012;
Houben et al., 2014), difficulty identifying when to have
conversations with patients and families (Barnes et al., 2007;
Durall et al., 2012), and a lack of communication skills(McCaughan et al., 2018; Prod’homme et al., 2018). Furthermore, healthcare providers have expressed various concerns about ACP, such as the possibility of diminishing thepatients’ motivation for treatment, especially if remission is
likely (Barnes et al., 2007; Gray et al., 2021; Prod’homme
et al., 2018; Wedding, 2021), and causing patient stress(Prod’homme et al., 2018).
In terms of ACP for patients with HMs, hematologists
have been reported to avoid ACP if there is even a remotepossibility of remission (Gray et al., 2021; Prod’homme etal., 2018; Wedding, 2021). Nurses and other healthcare professionals have also confronted difficulties in ACP (Kasuga& Uruno, 2008; McCaughan et al., 2018; Wedding, 2021).
However, ACP in patients with HMs is still unclear. Therefore, this study sought to clarify the current state of ACP in
the Japanese context.

https://doi.org/10.53044/jinr.2022-0006

Data were provided by National Cancer Centre Japan(National Cancer Centre Japan, 2019). Since there is a concern that the nurses who are passionate about ACP in theunit would be selected to answer the questionnaire, wechose the vice-head nurses with a minimum of 5 years’ experience as hematology nurses who work in governmentdesignated cancer hospitals in Japan to avoid selection bias.
Ethical Approval
This study was approved by the Human Research Ethics
Committee of Kwansei Gakuin University (No. 2019-17).

Results
Characteristics of the Respondents
A total of 216 participants responded, representing a 58.5%
response rate. However, we excluded data from 7 respondents (3%) due to missing data. In total, there were 209
valid responses (see Table 1).
Importance and Difficulty in ACP for Patients with HMs

Methods

Regarding the perceived importance of ACP, 209 (100%) of
respondents indicated that they viewed ACP as very important, important, or slightly important. No respondent impliedthat it was not very important, not important, or not at allimportant.
Furthermore, the distribution of ACP difficulty was as follows: 26 (12.5%) of the respondents indicated that it wasvery difficult; 69 (33.2%) indicated that it was difficult; 75(36.1%) indicated that it was slightly difficult; 24 (11.5%)
indicated that it was not very difficult; 12 (5.8%) indicatedthat it was not difficult; and 2 (1.0%) indicated that it was
not at all difficult.

Study Design

Difficult ACP Topics

A survey using a cross-sectional, self-administered questionnaire was conducted. The questionnaire items consist of
characteristics of the participant, the importance and difficulty of ACP for patients with HMs, difficult ACP topics,
actors who engage in conversations with each ACP topic,
documentation related to ACP, and challenges in ACP. The
items were assessed using a 4- or 6-point Likert scale: very
important, important, slightly important, not very important,
not important, and not at all important in the importancescale; and very difficult, difficult, slightly difficult, not very
difficult, not difficult, and not at all difficult in the difficulty
scale.

Table 2 shows that 60% to 70% of respondents answered
difficult or slightly difficult on the topics “Surrogate
decision-makers,” “Place of care,” and “Understanding of
their illness and prognosis.” Conversely, nearly half of them
reported that “Specific preferences for types of care or treatment” and “Individual concerns” were not difficult to address with patients.

Setting and Respondents
The surveys were delivered to 346 units that have patientswith HMs and one nurse for each unit. Finally 216 nurses
responded (a 58.5% response rate). It took place between
August and September of 2019.
2 of 6

Actors Who Engage in the Conversation of Each ACP Topic
All other topics, except for “Individual’s concerns” and “Important values or personal goals for care,” were discussedwith family members rather than with patients (See Table 3).
Moreover, almost 90% of nurses reported that physicians engage in conversations about “Understanding of their illness
and prognosis”, whereas “Important values or personal goals
for care” was reported as being discussed by less than 60%
of nurses.

https://doi.org/10.53044/jinr.2022-0006

JINR 2024, 3(1), e2022-0006

Table 1. Characteristics of the participants (n = 209).
n

%

Sex
Female
Male

201
8

96.2
3.8

StatusVice-head nurse
Staff
Certified Nurse a
Head nurse
Certified Nurse Specialist b
No response

136
46
27
8
6
3

65.1
22.0
12.9
2.9
1.4
3.8

Education
Nursing school
Junior college
University
Graduate school
Non-degree graduate nursing program
No response

137
32
29
7
3
1

65.6
15.3
13.9
3.3
1.4
0.5

Age, y
≤29
30–39
40–49
≥50
No response

12
49
91
46
11

5.7
23.4
43.5
22.0
5.3

Years of clinical experience, y
≥5
5–9
10–14
15–19
≤20

2
2
33
41
113

1.0
9.6
15.8
19.6
54.1

Years of clinical experience as a hematology nurse
1–3
17
4–6
66
7–9
63
≥10
63

8.1
31.6
30.1
30.1

VariablesaCertified Nurse (CN): a registered nurse who has a minimum of
5 years clinical experience and graduated from a special vocational school approved by the Japanese Nursing Association,
who engages in clinical practice, training, and consultation.
b
Certified Nurse Specialist (CNS): a registered nurse who has aminimum of 5 years clinical experience and completed a master’s degree; has various roles, such as clinical practice, consultation, coordination among health and social care professionals,
ethical management, education, and research.

Documentation Related to ACP
A total of 103 respondents (49.3%) did not use documentation to ensure the family’s and patient’s preferences for
medical care. For those nurses that reported using documentation to record ACP discussions, 63 (30.1%) reported thatthey updated documentation content as needed, yet 35(16.7%) have not updated documentation regularly. The

most common content of the document was “Individual’s
concerns.” Other contents included the patient’s symptoms,
family preferences, patient background, details of the carethat they received (see Table 4).
Challenges on ACP
Several challenges were reported by respondents, with themost common being “Improvement of healthcare professionals’ knowledge and skills” (73.7%) and “Cooperation withphysicians” (70.8%), whereas “Financial Support” was only
reported as a challenge by 23 (11%) respondents (see Table
5).

Discussion
To the best of our knowledge, this is the first study to clarify the current state of ACP for patients with HMs using anationwide survey in Japan, which is the strength of this research. First, responses were received from 216 participants,
representing a 60% response rate. This result, which was
higher than the 41.9% in a similar survey on general nursing
difficulties for patients with HMs (Furukawa, 2016), can besaid to indicate that nurses were aware of the importance of
ACP for patients with HMs.
The most significant finding is that all participants answered very important, important, and slightly important ona single scale of importance for ACP; more than 80% ofparticipants indicated very difficult, difficult, or slightly difficult on a single scale of difficulty for ACP. The difficulties
encountered with ACP for patients with HMs reported byhealthcare professionals in this study were similar to thosefound in previous research (Kasuga & Uruno, 2008;
McCaughan et al., 2018; Wedding, 2021). However, further
research is still required to better understand why these challenges occur and how they can be mitigated to better support professionals with the ACP for this group of patients.
The second important finding is that “Surrogate decisionmakers,” “Understanding of their illness and prognosis,” and“Place of care” were recognized as difficult ACP topics
when compared with others.
Discussions regarding “Surrogate decision-makers” are essential in ACP since family members tend to be required tomake decisions as surrogate decision-makers on behalf ofpatients who are unable to make their own decisions (Rietjens et al., 2017), placing a huge burden on families (Sanders et al., 2018). Family caregivers are often worried about
whether they would make the “right decision” for patients(Combes et al., 2021), which could be one reason why this
topic can be difficult to discuss; it is a common finding regardless of the type of disease (Combes et al., 2021).
The difficulties in discussing “Understanding of their illness and prognosis” and “Place of care” could be related tothe unique characteristics of HMs. Patients with HMs often
3 of 6JINR 2024, 3(1), e2022-0006

https://doi.org/10.53044/jinr.2022-0006

Table 2. Difficult ACP a topics (n = 209) b.
DifficultSlightlydifficult

Not reallydifficultNot
difficult

n

%

n

%

n

%

n

%

49
33
27
24
21
17

23.6
15.8
12.9
11.5
10.1
8.1

99
108
97
81
73
55

47.6
51.7
46.4
38.8
35.1
26.3

46
55
65
75
87
94

22.1
26.3
31.1
35.9
41.8
45.0

14
13
20
29
27
43

6.7
6.2
9.6
13.9
13.0
20.6

ACP topics
Surrogate decision-makers
Understanding of their illness and prognosis
Place of care
Important values or personal goals for care c
Particular preferences for types of care or treatment c
Individual’s concerns

Note: a Advance care planning; b Multiple answers allowed; c n = 208 due to missing values.

Table 3. Actors who engage in the conversation of each ACP a topic (n = 209) b.
Nurse
Actors who engage
Individual’s concerns
Place of care
Understanding of their illness and prognosis
Important values or personal goals for care
Particular preferences for types of care or treatment
Surrogate decision-makers

PhysicianPatient

FamilyOthers

n

%

n

%

n

%

n

%

n

%

119
189
189
183
174
141

95.7
92.2
91.3
88.4
84.5
68.4

143
168
182
120
180
142

68.4
80.4
87.1
57.4
86.1
67.9

177
162
151
173
134
111

84.7
77.5
72.2
82.8
64.1
53.1

147
175
162
130
147
143

70.3
83.7
77.5
62.2
70.3
68.4

36
55
23
25
15
17

17.2
26.3
11.0
12.0
7.2
8.1

Note: a Advance care planning; b Multiple answers allowed.

Table 4. Contents of documents related to ACP a (n = 209) b.

Table 5. Challenges on ACP a that nurses recognized (n = 209) b.

Contents of documentsn%Challenges on ACP

n%Individual’s concerns
Understanding of their illness and prognosis
Particular preferences for types of care or treatment
Important values or personal goals for care
Place of care
Surrogate decision-makers
Others

71
63
44
43
37
27
6

34.0
30.1
21.1
20.6
17.7
12.9
2.9

Improvement of healthcare professionals’ knowledge and skills
Cooperation with physicians
Secure personnel and time
Education for healthcare professionals
Reduction of healthcare professional burden
ACP at a healthy stage
Improvement of organizational system of care
Reduction of the psychological burden on healthcare professionals
Cooperation with Multidisciplinary teams
Increase staff motivation
Raising patient’s awareness
Cooperation with regional resource
Financial support
Others

154

73.7

148
146
131
112
110
92
91

70.8
69.9
62.7
53.6
52.6
44.0
43.5

82
79
77
36
23
3

39.2
37.8
36.8
17.2
11.0
1.4

Note: a Advance care planning; b Multiple answers allowed.

experience an unpredictable illness course that even healthcare providers cannot anticipate (Gray et al., 2021; LeBlanc
et al., 2015; Wedding, 2021), which can create difficulties
for patients. Indeed, more than 80% of patients with HMs
have a different understanding of their prognosis in comparison with that of their hematologists (Gray et al., 2021; LeBlanc et al., 2015). Moreover, patients with HMs tend tostay in hospitals and have intensive treatment until the endof-life stage (Cooper & Dains, 2021; El- Jawahri et al.,2020; Freeman et al., 2018). There are fewer opportunities
for them to choose their place of care, which could be whatmakes this topic more difficult to discuss.
Of note, in this study, there was a tendency for ACP topics to be discussed with family members rather than withpatients; however, the reasons for this were not investigated,
4 of 6

Note: a Advance care planning; b Multiple answers allowed.

therefore further research would be needed. Johnson et al.
(2016) claimed that ACP is a relational, family-centered, andsocial process rather than an isolated set of individual directives. Therefore, it can be stated that the responders werehttps://doi.org/10.53044/jinr.2022-0006

aware of the value of family involvement, which is a fundamental aspect of achieving patients’ preferences and wishes.
Concerning the challenges of ACP, between 60% and
70% of nurses recognized “Improvement of healthcare professionals’ knowledge and skills” and “Education for healthcare professionals” as two of the challenges. As ACP has
both benefits and risks (Johnson et al., 2016), healthcare
providers are concerned that the conversation might causestress in patients (Prod’homme et al., 2018), and finding thetiming to discuss it is difficult (Barnes et al., 2007; Durall etal., 2012). Importantly, a lack of communication skills is
one of the biggest barriers to ACP for healthcare professionals (McCaughan et al., 2018; Prod’homme et al., 2018).
Therefore, the majority of participants chose further training
regarding ACP to gain knowledge and skills regarding these
topics.
Regarding limitations, even though HMs encompass various kinds of diseases, such as leukemia, lymphoma, andmyeloma, these were classed together as “HMs” in thisstudy. Thus, it was not possible to reflect the detailed characteristics of each disease. Following that, since the target of
this study were vice-head nurses in government-designatedcancer hospitals in Japan, there might have been a bias in
the responses. Additionally, the current state of ACP was notcompared between HMs and solid tumors. However, the results of this study as a nationwide survey can be utilized todevelop a training program about ACP for patients with
HMs that would represent the training needs of nurses
across Japan. Finally, this survey was conducted before the
COVID-19 pandemic; hence, the situation might havechanged in light of the pandemic. Therefore, it would be
beneficial to conduct further research to compare the difficulties in ACP before and after the pandemic.
Acknowledgments
We are deeply grateful to all the nurses who have contributed to this research and JSPS KAKENHI Grant Number
17K04474. Special thanks go to the colleagues and professors at Kwansei Gakuin University.
Author Contributions
Miki Fujimoto conceived the project, conducted the survey,
and drafted the paper. Miki Fujimoto and Yoshiyasu Ito analyzed the data. Yoshiyasu Ito also provided feedback on subsequent drafts of the paper. Yukihiro Sakaguchi oversaw the
project and provided feedback at each step of the study. All
authors reviewed and approved the final manuscript.
Declaration of Conflicting Interests
We have no conflict of interest to disclose.
Ethical Approval
This study was approved by the Committee on Regulations

JINR 2024, 3(1), e2022-0006

for Behavioral Research with Human Participants [No.
2019-17].
Funding
Our work was funded by JSPS KAKENHI Grant Number
17K04474.
Informed Consent
Informed consent was obtained from all participants involved in this study.
References
Barnes, K., Jones, L., Tookman, A., & King, M. (2007). Acceptabilityof an advance care planning interview schedule: A focus groupstudy. Palliative Medicine, 21(1), 23-28.
https://doi.org/10.1177/0269216306073638
Combes, S., Gillett, K., Norton, C., & Nicholson, C. J. (2021). The
importance of living well now and relationships: A qualitative
study of the barriers and enablers to engaging frail elders withadvance care planning. Palliative Medicine, 35(6), 1137-1147.
https://doi.org/10.1177/02692163211013260
Cooper, A., & Dains, J. E. (2021). Advanced care planning and endof-life outcomes in hematopoietic stem cell transplant patients.
American Journal of Hospice and Palliative Medicine, 38(8),995-1003.
https://doi.org/10.1177/1049909120971566
Durall, A., Zurakowski, D., & Wolfe, J. (2012). Barriers to conducting
advance care discussions for children with life-threatening conditions. Pediatrics, 129(4), e975-982.
https://doi.org/10.1542/peds.2011-2695
El-Jawahri, A., Nelson, A. M., Gray, T. F., Lee, S. J., & LeBlanc, T.
W. (2020). Palliative and end-of-life care for patients with hematologic malignancies. Journal of Clinical Oncology, 38(9), 944953.
https://doi.org/10.1200/JCO.18.02386
Freeman, A. T., Wood, W. A., Fox, A., & Hanson, L. C. (2018). Access to palliative care consultation and advance care planning for
adults with high-risk leukemia. Journal of Palliative Medicine, 21(2), 225-228.
https://doi.org/10.1089/jpm.2017.0097
Furukawa, Y. (2016). Zouketukisyuyou kanzya no kango ni tazusawaru
kangosi no kea ni okeru konnankan syakudo no kaihatsu [Development of a difficulty scale in care for nurses to be engaged inhematological cancer nursing]. Palliative Care Research, 11, 265273.
https://doi.org/10.2512/jspm.11.265
Gray, T. F., Temel, J. S., & El-Jawahri, A. (2021). Illness and prognostic understanding in patients with hematologic malignancies.
Blood Reviews, 45, 100692.
https://doi.org/10.1016/j.blre.2020.100692
Howell, D. A., Roman, E., Cox, H., Smith, A. G., Patmore, R., Garry,
A. C., & Howard, M. R. (2010). Destined to die in hospital? Systematic review and meta-analysis of place of death in haematological malignancy. BMC Palliative Care, 9, 9.
https://doi.org/10.1186/1472-684X-9-9
Johnson, S., Butow, P., Bell, M., Detering, K., Clayton, J., Silvester,W., Kiely, B., Clarke, S., Vaccaro, L., Stockler, M., Beale, P.,
Fitzgerald, N., & Tattersall, M. (2018). A randomised controlled

5 of 6JINR 2024, 3(1), e2022-0006
trial of an advance care planning intervention for patients with incurable cancer. British Journal of Cancer, 119(10), 1182-1190.
https://doi.org/10.1038/s41416-018-0303-7
Johnson, S., Butow, P., Kerridge, I., & Tattersall, M. (2016). Advancecare planning for cancer patients: A systematic review of perceptions and experiences of patients, families, and healthcare providers. Psycho-oncology, 25(4), 362-386.
https://doi.org/10.1002/pon.3926
Kasuga, M., & Uruno, T. (2008). Emotions encountered by nurses
who experienced the death of patients: Through the nursing careof patients with hematological malignancies. Proceedings of The
Japan Society of Nursing: General nursing, 39, 386-388.
LeBlanc, T. W., O’Donnell, J. D., Crowley-Matoka, M., Rabow, M.
W., Smith, C. B., White, D. B., Tiver, G. A., Arnold, R. M., &Schenker, Y. (2015). Perceptions of palliative care among hematologic malignancy specialists: A mixed-methods study. Journalof Oncology Practice, 11(2), e230-238.
https://doi.org/10.1200/JOP.2014.001859
McCaughan, D., Roman, E., Smith, A. G., Garry, A., Johnson, M.,
Patmore, R., Howard, M., & Howell, D. A. (2018). Determinantsof hospital death in haematological cancers: Findings from aqualitative study. BMJ Supportive & Palliative Care, 8(1), 78-86.
https://doi.org/10.1136/bmjspcare-2016-001289
Ministry of Health, Labour and Welfare (2018). Gan taisaku kihon keikaku [The basic plan to promote cancer control programs]. Retrieved October 12 fromhttps://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkouk
yoku/0000196975.pdf
Miyashita, J., Shimizu, S., Shiraishi, R., Mori, M., Okawa, K., Aita,
K., Mitsuoka, S., Nishikawa, M., Kizawa, Y., Morita, T., Fukuhara, S., Ishibashi, Y., Shimada, C., Norisue, Y., Ogino, M.,
Higuchi, N., Yamagishi, A., Miura, Y., & Yamamoto, Y. (2022).
Culturally adapted consensus definition and action guideline: Japan’s advance care planning. Journal of Pain and Symptom Management, 64(6), 602-613.
https://doi.org/10.1016/j.jpainsymman.2022.09.005
National Cancer Center Japan. (2019). Cancer information service.
March 13, 2019, Retrieved fromhttps://hospdb.ganjoho.jp/kyotendb.nsf/xpKyotenSearchCancerRes
ult.xsp?g=g036&p=p01p02p03p04p05p06p07p08p09p10p11p12p1
3p14p19p15p20p16p17p18p21p22p23p24p25p26p27p28p29p30p3

6 of 6https://doi.org/10.53044/jinr.2022-0006
1p32p33p34p35p36p37p38p39p40p41p42p43p44p45p46p47
Paladino, J., Bernacki, R., Neville, B., Kavanagh, J., Miranda, S., Palmor, M., Lakin, J., Desai, M., Lamas, D., Sanders, J., Gass, J.,
Henrich, N., Lipsitz, S., Fromme, E., Gawande, A., & Block, S.
(2019). Evaluating an intervention to improve communication between oncology clinicians and patients with life-limiting cancer:
A cluster randomized clinical trial of the serious illness care program. JAMA Oncology. 5(6), 801-809.
https://doi.org/10.1001/jamaoncol.2019.0292
Prod’homme, C., Jacquemin, D., Touzet, L., Aubry, R., Daneault, S.,& Knoops, L. (2018). Barriers to end-of-life discussions among
hematologists: A qualitative study. Palliative Medicine, 32(5),1021-1029.
https://doi.org/10.1177/0269216318759862
Rietjens, J., A. C., Sudore, R. L., Connolly, M., van Delden, J. J.,
Drickamer, M. A., Droger, M., van der Heide, A., Heyland, D.
K., Houttekier, D., Janssen, D. J. A., Orsi, L., Payne, S., Seymour, J., Jox, R. J., & Korfage, I. J. (2017). Definition and recommendations for advance care planning: An international consensus supported by the European Association for Palliative Care.
The Lancet Oncology, 18(9), e543-e551.
https://doi.org/10.1016/s1470-2045(17)30582-x
Sanders, J. J., J.C., R., & Tulsky, J. A. (2018). Achieving goalconcordant care: A conceptual model and approach to measuringserious illness communication and its impact. Journal of Palliative Medicine, 21(S2), S17-S27.
https://doi.org/10.1089/jpm.2017.0459
Suthumphong, C., Tran, D. B., & Ruiz, M. (2021). Perceptions andmisperceptions of early palliative care interventions for patientswith hematologic malignancies undergoing bone marrow transplantation. Cureus, 13(3), e13876.
https://doi.org/10.7759/cureus.13876
Tricou, C., Munier, S., Phan-Hoang, N., Albarracin, D., PerceauChambard, E., & Filbet, M. (2019). Haematologists and palliative
care: A multicentric qualitative study. BMJ Supportive & Palliative Care.
https://doi.org/10.1136/bmjspcare-2018-001714
Wedding, U. (2021). Palliative care of patients with haematologicalmalignancies: Strategies to overcome difficulties via integrated
care. Lancet Healthy Longevity, 2(11), E746-E753.
https://doi.org/10.1016/S2666-7568(21)00213-0

https://doi.org/10.53044/jinr.2022-0035
https://www.jinr.jsnr.or.jp/

Brief Report

Learning outcomes from preventive home visits practicum in anundergraduate nursing program: A qualitative study
Aya Shinohara, MSN, RN1 , Ayako Ogata, PhD, RN, PHN2 , Takayuki Kageyama, PhD3 ,Joan K. Magilvy, PhD, RN, FAAN, FWAN4 , and Sachiyo Murashima, PhD, RN, PHN5
1

The Center for Nursing Education, Research and Collaboration, Oita University of Nursing and Health Sciences,
Oita, Japan, 2Department of Health Promotion, Japanese Red Cross Kyushu International College of Nursing,
Fukuoka, Japan, 3Department of Mental Health & Psychiatric Nursing, Oita University of Nursing and Health
Sciences, Oita, Japan, 4University of Colorado College of Nursing, Colorado, United State of America, and 5Oita
University of Nursing and Health Sciences, Oita, Japan

Abstract
Japan is a super-aging society, so nurses are expected to hold increasingly essential roles in both hospital- andcommunity-based settings in the future. To strengthen community-oriented geriatric and community health nursing
competencies among undergraduate nursing students, we implemented an undergraduate nursing practicum
called the Preventive Home Visits Practicum (PHVP). In the PHVP, students are grouped into teams of four (afreshman, sophomore, junior, and senior) before visiting healthy community-dwelling older adults to discuss life,
health, and activities of daily living. A qualitative descriptive focus group design was used to examine student
learning outcomes across 4 years of participation in the PHVP. The data obtained in focus group interviews were
descriptively analyzed. Students deepened their understanding of health and aging lives in an aging populationand developed interpersonal relationships and communication through the practicum across the 4-year period.
Additionally, we found that a team composed of students from all different grades achieved very effective learning
through interactions among team members. These findings suggest that nursing practicums that require nursing
students to visit community-dwelling older adults longitudinally, such as the PHVP, may have an important educational impact and may address the needs of the aging population.
Keywords
home visit practicum, community-dwelling older adults, nursing education, super-aging society, JapanJINR 2024, 3(1), e2022-0035

Introduction
Japan has long been known as a super-aging society. According to the Annual Report on Aging Society 2021 announced by the Cabinet Office of Japan, in 2020, the percentages of the population aged between 65 and 74 years,
and 75 years and over were 13.9% and 14.9%, respectively,
with the latter surpassing the population aged 65-74 years(Cabinet Office of Japan, 2021). The Japanese government
recently initiated a community-based integrated care systemthat was designed to support older adults in living their lives
in their own way in environments familiar to them even if
they require long-term care (Ministry of Health, Labour andWelfare of Japan, 2013). In the future, nurses are expected
to play an increasingly essential role in both hospital- andcommunity-based settings as the Japanese Nursing Associa-

Correspondence: A. Shinohara. Email: shinohara@oita-nhs.ac.jp
Received: October 13, 2022, Accepted: April 29, 2023, Advance Publication: November 21, 2023, Published: February 23, 2024
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 6JINR 2024, 3(1), e2022-0035

https://doi.org/10.53044/jinr.2022-0035

2017

2018

2019

2020

A collaborator
Mr. A

Age 70Age 71

Age 72

Age 73

SeniorStudent A

Student B

Student C

Student D

JuniorStudent B

Student C

Student D

Student E

Sophomore

Student C

Student D

Student E

Student F

FreshmanStudent D

Student E

Student F

Student G

Figure 1. An image of a collaborator and students in a team.
Students were grouped in teams of four (a freshman, sophomore, junior and senior), with
two faculty members for support. Teams are consolidated every year by replacing graduating seniors with freshmen.

tion (2017) declared that nursing services are in demand essentially everywhere, not only in hospitals.
In 2013, we developed an experimental practicum for theundergraduate nursing curriculum called the Preventive
Home Visits Practicum (PHVP). The purpose of the PHVP
was to strengthen community-oriented geriatric and community health nursing competencies among undergraduate nursing students. In the PHVP, small groups of undergraduate
students regularly visit healthy community-dwelling older
adults to discuss life, health, and activities of daily living togain a better understanding of their lives and health status.
After an initial 2-year trial period, in 2015, the PHVP was
expanded as a required yearly practicum for all undergraduate students.
In 2018, students who had participated in the PHVP in all
4 years of their undergraduate nursing program graduated.
We conducted focus group interviews with senior students to
examine learning outcomes across 4 years of participation in
the PHVP.
Description of the Preventive Home Visits Practicum(PHVP)
1．Overview
Students were grouped in teams of four (a freshman, sophomore, junior and senior), with two faculty members for support. Teams are consolidated every year by replacing graduating seniors with freshmen (Figure 1).
Each team makes monthly or bimonthly visits to an assigned community-dwelling older adult (these participants
are referred to as “collaborators”). Students and collaborators then discuss lifestyle and health, and blood pressure,weight, and grip strength are measured as needed. In consultation with their assigned faculty, the students provide advice regarding physical or cognitive exercises and diet topromote a healthy lifestyle. No medical treatment or clinicalcare is provided during the visits. Each visit takes approxi2 of 6

mately 1 h, and two members or more in a team visit together. Four visits or more in a year are necessary for a student. Therefore, the students in a team take turns to visit
their collaborator. The collaborators live in neighborhoods orvillages in the communities around the university, so students walk, drive, or take a taxi to visit their collaborator.
The students can observe the environment and services
nearby in transit.
Four main goals were identified to guide the students during their PHVP: 1) to understand health and living amongcommunity-dwelling older adults, 2) to contribute to the prevention of dysfunction by discussing appropriate health andwellness measures with them, 3) to comprehend community
systems to support home-dwelling older adults, and 4) tolearn teamwork with students of different academic grades
and generations. After each home visit, the students submit
a brief report to their team’s assigned faculty members. Faculty members then provide feedback to enlighten their perspectives or support their thinking and facilitate the students
in accomplishing their goals. An important role of the faculty members is to encourage the students to develop theirabilities and critical thinking skills during the home visits.
2．Collaborators and Visiting Area
We have administered the PHVP with the cooperation ofcommunity residents’ association leaders, officials, local
governments, and public health nurses in two areas near theuniversity, namely, areas A and B. As of December 2018,
the population of area A, a residential area developed in the
1970s, was 7,278, with 39.9% aged 65 years or over, andthat of area B, a mountainous rural region, was 4,315, with44.3% aged 65 years or over.
Older residents in these two areas near the university whowere aged 70 years or above were eligible to volunteer to bea collaborator in this practicum. Officials in each area initially suggested candidates as collaborators. Although collaborators are asked to commit to long-term participation,

https://doi.org/10.53044/jinr.2022-0035

JINR 2024, 3(1), e2022-0035

when necessary, local leaders may also assist in seeking replacement collaborators.

ethics review board (authorization No.: Educational research18-2).

Methods

Results

This study applied a qualitative descriptive design with focus group interviews to describe longitudinal experiences
and perceived outcomes for students who had completed the
4-year undergraduate nursing curriculum (Rabiee, 2004). We
recruited 79 seniors (10 males and 69 females) who hadparticipated in the PHVP throughout their undergraduate
education. Eight students who had applied for the study
were organized into two groups of four students each.
Audio-recorded focus group interviews were conducted by
the second author as a facilitator and the first author as anobserver on December 2018. The two researchers who led
the interviews have been managing the PHVP since 2018,
and they had previously participated in the practicum asteam faculty members assigned to three teams each.
All eight student participants provided written informed
consent to participate in the study after receiving an explanation of the study objectives, confidentiality, and ethicalconsiderations. Permission was also granted for the audio recording of the group interviews.

All participants were female. Seven participants were thesame age, and one participant was older. Three participants
visited a collaborator living in area A, and two participants
visited a collaborator living in area B. The remaining threevisited both areas as they were assigned multiple collaborators in the 4 years because of attrition.
We extracted 3 categories and 11 subcategories that describe student learning resulting from the PHVP experience.
We have illustrated the results using the description by astudent (students are identified as A to H) in Table 1.

Data Generation and Analysis
Each focus group session lasted for approximately 60 min.
The interviews consisted of a set of open-ended questions
matching the purposes of the study. The participants wereasked regarding a scene in which they felt their own growth
while visiting their collaborator and what experience camefor that growth. The same questions were given to eachgroup, but the interviewers allowed the participants to expand on their answers and discuss the questions with eachother. With consent from the participants, the interviews
were audio-recorded and transcribed for data collection purposes.
The focus group data were then subjected to qualitativedescriptive analysis. Students’ narratives were read and reread to identify the essential content. Similar ideas and underlying meanings were coded and analyzed further to develop subcategories. Subcategories were further grouped into
the three categories. These categories corresponded with theoriginal aim of the study. Thus, the quotations in the tableillustrated these findings. The findings were reviewed byother faculty members who were involved in managing the
PHVP to check whether the descriptions appeared consistent
with the students’ experiences. Bold italic font was used toindicate categories, and italic font was used to indicate subcategories.
Ethical Considerations
The study protocol was approved by the authors’ university

Health and Aging Lives in an Aging Population
The first category describes how students developed an understanding of the health and life experiences in an aging
population through their collaborators.
1．Observing Changes in the Environment
Students were able to identify changes from previous home
visits as they continuously visited the same collaborator’shome and developed knowledge year by year. Identifying
such changes helped the students gain confidence in observing the living environment.
2．Consideration for Support Tailored to Individual Living
As students gained knowledge and built up their experiences, they developed the perspective to see both the physical and mental health or life experience of their collaborators. Thus, students contemplated what support they could
offer regarding their collaborators’ conditions.
3．Comprehension of Living after Hospital Discharge
Some students experienced their collaborators’ hospitalization during the period of their continuous visits. Students
could then witness their collaborators’ physical and psychological changes after discharge, which allowed them to learn
how an illness or injury affected an older person’s life. This
perspective is not often possible solely from practice in an
in-patient setting, so these students develop a sense of patients’ posthospital life.
4．Differences in Lives and Perspectives of HealthSome students’ collaborators were replaced several times because of health issues or the need for family nursing care.
Although we had requested longitudinal participation fromthe collaborators, this was not always possible. However,students expressed their gratitude for all of their collaborators and the valuable experience that they had gained during
the 4 years. They felt that the more collaborators they had,the more knowledge and experience they gained.
5．Aging and Participation in Society
Because of their continuous visits, students observed thephysical and mental changes of their collaborators due to
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Table 1.

https://doi.org/10.53044/jinr.2022-0035

Categories of what students learned through the preventive home visits practicum (PHVP) across 4 years.

Categories

Health andaging lives
in an aging
population

Interactions
among teammembers

Interpersonal relationships andcommunication

Subcategories

Student descriptions

1. Observing changes
in the environment

I could find a changed picture on a hanging scroll and the growth of flowers and vegetables that mycollaborator had planted in her garden. I felt my own growth by noticing such changes. (Student B)

2. Consideration forsupport tailored toindividual living· I knew that my viewpoints of my collaborator changed after continuous home visits. I tried to understand my collaborator’s physical and mental health, and his life. (Student C)· I am now able to contemplate the person’s lives and consider support tailored to that person’s needs.
(Student H)

3. Comprehension ofliving after hospitaldischarge

My collaborator was hospitalized for lower back fracture. I think that I can imagine how the lives ofolder adults change after discharge because I learned about changes in her mind and way of life. (Student A)

4. Differences inlives and perspectivesof health· I was given the opportunity to learn about the lives and thoughts of the older people living in the community and what concerns they have about their lives through four years. (Student C)· I learned different lifestyles and various perspectives on health through each of my collaborators. I
believe that these experiences will help me in my career as a nurse. I really appreciated (this practicum). (Student E)

5. Aging and participation in society

As my collaborator grew older, I learned that his way to relate to society differed from before…Only
this practicum allowed us to learn that. (Student B)

1. Roles on a teamaccording to theirlevel in their nursing
educational program

The more I visited my collaborators with younger members, the more I began thinking about what myrole was on a team. (Student F)

2. Growth withinteractions among
team members

I knew (recognized) my development because I could do things that a senior student (had done) for us
before. (Student B)

3. Importance ofdiscussion with teammembers· I think that it was great experience to discuss what we could do with team members for our collaborator, especially the time she expressed heartache after her daughter had passed away. (Student F)· Sharing information about a collaborator allowed us to work together as a team. (Student H)

4. Self-confidence intheir nursing practice

My collaborator often told me that I was able to communicate well with him and measure blood pressure properly, although I could not do any of that before. At the end, he told me that I had grown into avery fine student. (Student C)

1. Enhancing communication skills

My collaborator often told us that she did not want to get older, but I did not know what to say to her atfirst. I gradually learned that listening closely while showing my understanding about her feelings wasenough for her. (Student A)

2. Interpersonal
relationships as acommunity member

My collaborator told me about nearby shops and gave me details about the surroundings. He also
asked me what I had learned at school. I think I learned how to talk to (community-) dwelling older
adults who were not (in an in-patient) nursing setting through this practicum. (Student G)

the aging process. Furthermore, they considered how suchchanges affected the participation of older adults in society.
Interactions among Team Members
The second category concerned student-to-student interactions as they served as members of multigrade level teams.
Although students participate in extracurricular activities
with others, they rarely work together on teams in clinicalcourses or settings.
1．Roles on a Team according to Their Level in Their Nursing Educational Program
Each student visited their collaborator with one or moreteam members from a different grade. They gradually became aware of what would be expected when they became
the senior member of a team. Therefore, leadership skills
developed naturally.
4 of 62．Growth with Interactions among Team Members
Students recognized their growth as they matured in the program and found that their skills had been nurtured by otherteam members. They understood that they had gained confidence through this process.
3．Importance of Discussion with Team Members
After each home visit, we encouraged the students to sharethe observations they had made with their team members
and to discuss what they had learned and thought regarding
the time spent with the collaborator. As a result, they acquired differing points of view from their team members.
4．Self-confidence in Their Nursing Practice
The collaborators were found to serve in a support role tofacilitate their students’ growth and improvement. Theirwords encouraged students and gave them confidence.

https://doi.org/10.53044/jinr.2022-0035

Interpersonal Relationships and Communication
A third category reflected building communication skills
through formed relationships. Interpersonal relationships
were stressed during the practicum team meetings and discussions. The group discussions strengthened the students’communication skills with peers, faculty, and collaborators.
1．Enhancing Communication Skills
Students described feeling too nervous to communicate with
their collaborator at first. However, over time, they learned
the importance of listening closely and empathizing. Subsequently, they became more comfortable and developed better
communication with their collaborator and other older people.
2．Interpersonal Relationships as a Community Member
Collaborators taught students a lot regarding their community and surroundings. Over the period of the visits, they
demonstrated that in their words, “their hearts went out tothese students.” In turn, this atmosphere encouraged students
to learn how to relate to community-dwelling older adults.

Discussion
In the present study, we verified that visits to communitydwelling older adults provided students with essential learning considered necessary for their future nursing practice. A
review by Hsieh and Chen (2018) reported that geriatric andlong-term care contents in undergraduate nursing curricula
can effectively enhance students’ nursing competence. In thepresent study, we found that collaborators’ physical andmental changes over continuous visits broadened students’views on aging and caring for older adults (Redfield et al.,2016). We assume that continuous visits across time deepened student knowledge of the aging process, health, andenvironment because they could witness changes and hear
regarding lived experiences and feelings from their collaborators.
Furthermore, in contrast to in-patient or acute care clinicalsetting practicums, older adults can take the lead in conversations in the PHVP. As described by Walton and Blossom(2013), students experience the welcoming presence andhospitality of older adults as they gradually engage with
their collaborator, gaining confidence along the way. As Reitmaier et al. (2015) concluded, a practicum involving
community-dwelling older adults as partners in student
learning enhanced intergenerational understanding. This intergenerational exchange in the PHVP helps students develop not only as nurses but also as human beings. The
wide range of topics that students discuss with their collaborators can lead them to reflect on their own lives and, as
mentioned by Eaton (2015), to provide motivation for their
nursing studies.
The present evaluation study revealed that interactions

JINR 2024, 3(1), e2022-0035

with other students in different grade levels in nursing education improved student learning and work effectiveness.
This finding is in agreement with the research reported byPålsson et al. (2017), where peer learning was found to be auseful method for improving nursing students’ self-efficacy.
Senior students could begin to serve as mentors on a team,which, in turn, might stimulate their motivation. We presume that interactions among team members have the same
effect as the findings reported by Gonzalez et al. (1999),
where collaborative alliances with faculty and registerednurse preceptors in home health enabled students to viewthe new practicum environment as a meaningful learning experience. As teamwork is an essential competency in healthcare, we believe that the PHVP and faculty mentoring canhave a positive influence on students’ later development as
graduate nurses working on multidisciplinary teams.
According to the results of previous research on the
PHVP conducted at the early stage of introduction, students
acquired multiple perspectives for understanding older
adults, such as wellness, prevention, community life, andteam practicums (Iwasaki et al., 2019). In the present study,
we observed enriched student learning and were able to describe ways in which students further developed their perspectives on community-dwelling older adults. The longterm perspective gained from graduating students who had
experienced the practicum over time clarifies the relationshipwith the achievements of the purposes of the practicum.
This study had two major limitations. First, as we onlyinterviewed a small number of students, our findings may
not fully reflect the learning that occurred through the
PHVP or its potential difficulties. Second, the students
might have been prompted to provide socially adequate responses because of the face-to-face nature of the interviews
conducted by the faculty. We propose further educational
evaluation research with larger sample sizes and different
designs to identify additional outcomes and possible pitfallsof the PHVP regarding nursing students, communitydwelling older adults, and undergraduate nursing education.
Despite this limitation, it should be noted that continuous
visits to community-dwelling older adults enabled students
to increase their knowledge and develop their perspectives.
It remains highly likely that the role of nursing will continue to expand in community settings, so nurse educators
must be prepared to take a leading role in the developmentof educational strategies.

Conclusion
The results of the present research suggest that visiting
community-dwelling older adults during a nursing practicum
may make an important educational impact on nursing students as future nurses. This study is a part of a series of investigations into the PHVP that may have implications for
5 of 6JINR 2024, 3(1), e2022-0035

improving undergraduate nursing education and equipping
future nurses to anticipate and address a super-aging society.
Author Contributions
Conceptualization, A.S., A.O., T.K., J.K.M, and S.M.; methodology, A.S. and A.O.; formal analysis, A.S. and A.O.; investigation, A.S. and A.O; data curation, A.S., A.O., andT.K; writing-original draft preparation, A.S.; writing-review
and editing, A.S., A.O., T.K., J.K.M, and S.M.; supervision,
T.K., J.K.M, and S.M.; funding acquisition, T.K. All authors
have read and agreed to the published version of the manuscript.
Declaration of Conflicting Interests
The authors declare that they have no competing interests.
Ethical Approval
The study protocol was approved by the Committee on Research Ethics and Safety of Oita University of Nursing andSciences. Authorization number: Educational research 18-2.
Funding
This study was supported by the research project fund from
Oita University of Nursing and Health Sciences.
References
Cabinet Office Japan. (2021). Annual report on the ageing society
2021. Retrieved fromhttps://www8.cao.go.jp/kourei/english/annualreport/2021/pdf/2021.
pdf (Last accessed January, 2023)
Eaton, J. (2015). The feasibility of ethnodrama as intervention to highlight late-life potential for nursing students and older adults. Gerontology & Geriatrics Education, 36(2), 204-222.
Gonzalez, L. O., Webb, M. S., Lowry, L. W., & Lengacher, C. A.
(1999). Baccalaureate nursing education and home health: A collaborative alliance. Nursingconnections, 12, 35-48.
Hsieh, P. L., & Chen, C. M. (2018). Nursing competence in geriatric/
long term care curriculum development for baccalaureate nursing

6 of 6https://doi.org/10.53044/jinr.2022-0035
programs: A systematic review. Journal of Professional Nursing,34, 400-411.
https://doi.org/10.1016/j.profnurs.2018.05.006
Iwasaki, R., Hirai, K., Kageyama, T., Satoh, T., Fukuda, H., Kai, H.,
Makino, K., Magilvy, K., & Murashima, S. (2019). Supporting
elder persons in rural Japanese communities through preventive
home visits by nursing students: A qualitative descriptive analysisof students’ reports. Public Health Nurse, 36, 557-563.
Japanese Nursing Association. (2017). Nihon kango kyokai statement[Statement by the Japanese Nursing Association.] Retrieved fromhttps://www.nurse.or.jp/home/about/tagline/index.html (Last accessed September, 2021) (in Japanese)
Ministry of Health, Labour and Welfare, Japan. (2013). Establishing acommunity-based integrated care system. Retrieved fromhttps://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-el
derly/dl/establish_e.pdf (Last accessed September, 2021)Pålssony, Y., Mårtensson, G., Swenne, C. L., Adel, E., & Engstrom,M. (2017). A peer learning intervention for nursing students inclinical practice education: A quasi-experimental study. Nurse
Education Today, 51, 81-87.
https://doi.org/10.1016/j.nedt.2017.01.011
Rabiee, F. (2004). Focus-group interview and data analysis. Proceedings of the Nutrition Society, 63(4), 655-660.
https://doi.org/10.1079/PNS2004399
Redfield, C. S., Mcguire, A. P., Lin, T. C., Orton, V. J., Aust, M., &Erickson, T. M. (2016). Shifts in attitudes, knowledge, and social
goals in nursing students following structured contact with
community-dwelling older adults. Journal of Nursing Education,
55, 569-573.
https://doi.org/10.3928/01484834-20160914-05
Reitmaier, A., Davies, S., Smith, L. R., Mangan-Danckwart, D.,
Hongerholt, K., & Klinkner, J. (2015). Discovering intergenerativity: An evaluation of learning partnerships between student nurses
and older adults. International Journal of Older People Nursing,10, 115-126.
https://doi.org/10.1111/opn.12061
Walton, J., & Blossom, H. (2013). The experience of nursing students
visiting older adults living in rural communities. Journal of Professional Nursing, 29, 240-251.
https://doi.org/10.1016/j.profnurs.2012.05.010

https://doi.org/10.53044/jinr.2023-0012
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Brief Report

The relationship between sense of coherence, occupational stress,
organizational climate, identity, and mental health of newly graduatednurses in a specified functional hospital (secondary publication)
Satoshi Ikeda, PhD, RN, PHN
Faculty of Medicine School of Nursing, Fukuoka University, Fukuoka, Japan

Abstract
Objectives: The purpose of this study is to examine the sense of coherence (SOC), occupational stress, organizational climate, and identity of new graduate nurses in a specified functional hospital to identify factors related tomental health. It will also identify the relationship between SOC and generalized resilience resources. Methods:
This study employed a self-completion questionnaire on SOC (29 items), an identity scale (20 items), a job content questionnaire (22 items), an organizational climate scale (12 items), and a general health questionnaire(GHQ; 12 items) among 105 new graduate nurses in specialized hospitals. Results: A multiple regression analysis
was performed with each subscale of the GHQ-12 and SOC-29 as dependent variables. The mental health of new
graduate nurses was found to be strongly associated with their SOC. Furthermore, the organizational environmentand basis of identity contributed to a sense of comprehensibility, which is a factor in SOC. A sense of manageability and meaningfulness is also related to the basis and establishment of identity. Conclusions: Increasing SOC
as a mental health measure for new graduate nurses is pivotal. Thus, creating an organizational environment may
strengthen SOC.
Keywordssense of coherence, mental health, occupational stress, organizational climate, new graduate nurses
JINR 2024, 3(1), e2023-0012

Introduction
New graduate nurses often face stressors such as reality
shock and transition shock (Al Awaisi et al., 2015; Labrague & McEnroe-Petitte, 2018), which can lead to mental
health problems and early turnover (Rudman et al., 2014).
Mental health problems are particularly serious for new
graduate nurses who join hospitals that provide highly ad-vanced medical care (Satoshi Ikeda, 2020). The effects ofstress on mental health are determined by an individual’s
stress tolerance and other factors. SOC (Antonovsky et al.,2001), the perception of coherence around an individual, hasbeen shown to positively impact an individual’s ability tocope with stress. Early adulthood, which applies to most
new graduate nurses, is a critical period in which job characteristics and the work environment play an important role

Correspondence: S. Ikeda. Email: ikedasatoshi@fukuoka-u.ac.jp
Note: This article is the secondary publication of an article previously published in the Journal of the Japan Society of Nursing Research. The English translation, for non-Japanese readers, is included here for reference purposes.
Ikeda, S. (2022). The relationship between sense of coherence, occupational stress, organizational climate, identity, and mental
health among new graduate nurses in specialized hospitals. Journal of Japan Society of Nursing Research, 45(4), 855-868. https://doi.org/10.15065/jjsnr.20211115168 [In Japanese]
Received: March 13, 2023, Accepted: May 16, 2023, Advance Publication: November 21, 2023, Published: February 23, 2024
Copyright Ⓒ 2024 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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SOC
Work-related factors· Comprehensibility· Manageability

Occupational stress· Job demands· Meaningfulness· Job control
Organizational climate
Mental health· Organizational environment· Tradition
Workplace support· Super visors Support· Coworker Supportsociodemographic
Identity· Basis of Identity· Establishment of identity
Personal related factors

Figure 1. Factors associated with mental health (conceptual framework).

GRRs : Generalized Resistance Resources
Occupational stress· Job demands· Job control
Organizational climate· Organizational environment

SOC· Tradition· Comprehensibility

Workplace support· Manageability· Super visors Support· Coworker Support· Meaningfulness

Identity· Basis of Identity· Establishment of identity

Age

Figure 2. Factors related to SOC (conceptual framework).

in the development of SOC (Antonovsky et al., 2001). Thus,
mental health interventions in nursing should address workplace and individual stressors and create healthy work environments that promote SOC (Langius et al., 1992).
Previous research on SOC among nurses has shown that itis strongly associated with mental health, including stress,
depression, burnout, and PTSD, including work-related andpersonal factors (Michele Masanotti et al., 2020). Only afew studies have examined the factors that influence eachdimension of SOC (comprehensibility, manageability, andmeaningfulness); however, it has been suggested that a communicative organizational climate, adequate workload, andopportunities for participation and career advancement in2 of 9crease SOC (Kretowicz & Bieniaszewski, 2015). Most existing studies on SOC have focused on nurses in general, with
only a handful focusing on new graduate nurses. A priorstudy has found that SOC in early adulthood, during which
nursing students graduate, is thought to be influenced by theidentity developed in childhood and adolescence (Antonovsky et al., 2001), and a favorable organizational climate may enhance SOC (Feldt et al., 2000). This study focuses on SOC, its relationship with mental health, and thefactors affecting SOC among new graduate nurses.
This study examined the relationship between workrelated factors, personal factors, SOC, and the mental healthof new graduate nurses in hospitals. To examine the rela-https://doi.org/10.53044/jinr.2023-0012

tionship between SOC and mental health, a model that included personal and work-related SOC as independent variables was constructed. The hypothesis for this study objective is that SOC is most strongly related to mental healthand that the higher the SOC, the better the mental health(Figure 1). The second objective was to determine the relationship between work-related and personal factors and SOC
development. The framework used was a salutogenesis
model (Antonovsky et al., 2001), which posits that generalized resistance resources (GRRs), such as individual identity,
occupational stress, organizational climate, and job support,
are related to SOC development. The hypothesis for thisstudy objective is that individual identity is strongly related
to SOC and that occupational stress, organizational climate,and job support also play a role in SOC development (Figure 2).

JINR 2024, 3(1), e2023-0012

Materials and Methods

reliability and validity by Kawakami and Fujigaki (1996). It
comprises 22 items scored on a 1-4 scale, measuring job demands, job control, supervisor support, and coworker support. Higher scores indicated greater job demands, job control, supervisor support, and coworker support.
The 12-Item Organizational Climate Scale (OCS-12)
The 12OCS-12 (Fukui et al., 2004) measures an organization’s climate and comprises two subscales: tradition and organizational environment. An organizational environment refers to a climate in which the rules and norms outlined in
the organization are clear and rational, and organizational
management is conducted with a high degree of staff participation. Higher scores indicate a higher level of tradition or amore favorable organizational environment.
Sociodemographic Factors
The six sociodemographic information items were sex, age,
basic nursing curriculum, hospital department, workplace,and night shifts.

Participants

Statistical Analysis

A convenience sample of 320 new graduate nurses from five
Japanese hospitals with specific functions was used. Survey
forms were sent to these facilities and distributed by nursing
managers who requested anonymous completion. The survey
instrument comprised 101 items and took 20-30 min tocomplete, and the completed survey form was returned. Data
was collected from October 2013 to November 2013.

Descriptive statistical tables were prepared for the sociodemographic information of the participants. The mean, standard deviation, minimum and maximum values, and Pearson’s correlation coefficients for each scale and subscale
were calculated. Cronbach’s alpha was calculated for the internal consistency of each scale, and only values greaterthan 0.6 were used in multiple regression analysis: (1) for
hierarchical multiple regression analysis with GHQ-12 as thedependent variable, with the total SOC score as the main independent variable and other factors such as sex, education,
work location, and identity as additional independent variables; and (2) for multiple regression analysis, each SOC-29
subscale was used as the dependent variable, considering
variables that showed significant correlation with thesubscales and the effect of age as an independent variable.
The IBM SPSS statistics software for Windows (version 24;
IBM Corp.) was used to conduct the statistical analyses. Statistical significance was set at p <.05.

Measurement Tools
The General Health Questionnaire-12 (GHQ-12)
The GHQ measures depression- and nervousness-related illnesses using a 12-item scale (Goldberg et al., 2013). Developed in the UK by Goldberg (1978), it uses the Likert
method (0-1-2-3) for scoring. The total score evaluates mental health, with higher scores indicating poorer mental
health.
Identity Scale
The identity scale, developed by Shimoyama (1992), measures one’s identity through two subscales: establishment ofidentity and basis of identity. The basis of identity reflects
insecurity and loneliness, whereas the establishment of identity expresses independence and confidence. The four-casemethod was used to ask the questions. The total score wasused as the score for each subscale. The reliability and validity of the scale were evaluated.
SOC-29The SOC-29 was developed by Antonovsky (1987/2001) andvalidated for reliability and validity in Japanese by Yamazaki(2001). It comprises three subscales: comprehensibility,
manageability, and meaningfulness. Scores were calculated
by adding the rate (1-7) of the responses to each item.
Job Content Questionnaire-22 (JCQ-22)
Developed by Karasek (1985), the JCQ-22 was evaluated for

Ethical Considerations
Approval was obtained from the Research Ethics Committeeof Fukuoka Prefectural University and the director of thecollaborating institution for the study using a survey form
(approval date: July 12, 2013, no approval number provided).

Results
Sociodemographic Factors
Data from 107 participants were collected (collection rate:
33.4%), out of which, 105 were included in the analysis
with a mean age of 22.9 ± 1.8 years; 102 (97.1%) were females, and 92 (87.6%) were college graduates. Table 1
3 of 9JINR 2024, 3(1), e2023-0012

https://doi.org/10.53044/jinr.2023-0012

Table 1. Participants’ sociodemographic factors (n = 105).
n

%

Male
Female

3
102

2.9
97.1

Basic Nursing CurriculumHigh School (Hygiene and Nursing)
Vocational school
University

4
9
92

3.8
8.6
87.6

Department

Internal medicine department
Surgical department
Mixed (Internal medicine/surgical)
Psychiatry department
Other departments

17
39
30
4
15

16.2
37.1
28.6
3.8
14.3

Workplace

Hospital ward
Other

99
6

94.3
5.7

Night shiftTwo-shiftThree-shift
No night shift

80
22
3

76.2
21.0
2.9

GenderAgeshows other sociodemographic factors.
Mean, Standard Deviation, Minimum and Maximum Values,
Pearson’s Correlation Coefficient, and Cronbach’s α for
Each Scale and Subscale
Table 2 shows the mean, standard deviation, minimum andmaximum scores, Pearson’s correlation coefficient and Cronbach’s α for each scale and subscale.
SOC-29, Scores for Comprehensibility, Manageability, andMeaningfulness
The SOC-29 mean score was 120.3 ± 6.5, with mean scoresof 40.2 ± 8.7 for comprehensibility, 44.1 ± 8.7 for manageability, and 36.4 ± 8.1 for meaningfulness.
Correlation between GHQ-12 and Each Scale
The GHQ-12 had strong negative correlations with SOC-29(−.68), manageability (−.63), meaningfulness (−.61), basis ofidentity (−.57), and comprehensibility (−.55), in order of increasing correlation coefficients (p <.001 for all).
SOC-29, Comprehensibility, Manageability, Meaningfulness,
and Correlations among the Scales
The strongest positive correlation with SOC-29 was found to
be with the basis of identity (r =.81, p <.001), followed by
the establishment of identity (r =.59, p <.001). For the SOC29 comprehensibility subscale, coworker support (r =.36, p<.001) and organizational environment (r =.34, p <.001) had
moderately positive correlations. Regarding manageability,
job control (r =.45, p <.001) and coworkers’ support (r=.42, p <.001) showed moderately positive correlations. For
4 of 9

M

SD

22.9

1.8

meaningfulness, job control (r =.49, p <.001), coworker support (r =.38, p <.001), and supervisor support (r =.31, p=.002) had moderately positive correlations with increasingcorrelation coefficients.
Cronbach’s α for Each Scale and Subscale
Cronbach’s α for job control was low (0.47), so it was excluded from the regression analysis. Organizational environment (0.67) and tradition (0.63) were acceptable as independent variables. All other variables had a Cronbach’s α
greater than 0.7.
Hierarchical Multiple Regression Analysis with the GHQ-12
as the Dependent Variable
A hierarchical multiple regression analysis was conducted to
examine the relationship between the GHQ-12 and various
independent variables, including those that showed a significant correlation with the GHQ-12. In Step 1, sociodemographic factors and significant variables were used, except for
SOC-29. In Step 2, the SOC-29 was added to the equation(forced entry method), resulting in a higher goodness of fit(adjusted R2 =.532). The results showed that SOC-29, establishment of identity, and three-night shifts (compared with
two-night shifts) were associated with the participants’ mental health. There was no multicollinearity, and the residuals
were normal (Durbin-Watson ratio = 2.092). Table 3 shows
more detailed results.
Multiple Regression Analysis with Comprehensibility, Manageability, and Meaningfulness as Dependent Variables
Table 4 shows the detailed results of a multiple regression

JINR 2024, 3(1), e2023-0012

.85
.83
.87
.92
.79
.82
.85
.71
.47
.92
.78
.67
.63
34.0
35.0
39.0
182.0
65.0
62.0
55.0
48.0
90.0
16.0
16.0
12.0
11.0

A multiple regression analysis was conducted, with comprehensibility as the dependent variable; and age and seven significant variables (Basis of Identity, Establishment of identity, Job demands, Supervisor support, Coworker support,
Organizational environment, and Tradition ) as independent
variables. Basis of identity (β =. 654, p <. 001) and organizational environment (β =.184, p =.014) were associatedwith comprehensibility. The fit of the regression equation
was satisfactory (R2 =.574, adjusted R2 =.539), no multicollinearity was observed, and the Durbin-Watson ratio was
1.924.

−.06

Factors Related to Manageability
A multiple regression analysis was conducted, with age andsix variables significantly correlated with manageability (Basis of Identity, Establishment of identity, Job demands, Supervisor support, Coworker support, and Organizational environment ) as independent variables. The results showedthat the basis (β =.584, p <.001) and establishment of identity (β =.164, p =.029) were associated with manageability,
and the goodness of fit was high (R2 =.630, adjusted R2=.603). No multicollinearity was found, and the DurbinWatson ratio was 2.076, indicating no issues with the residuals.

−.16.49***.31**.38***.22*−.10

Factors Related to Meaningfulness
A multiple regression analysis was conducted, with age andfive variables significantly correlated with meaningfulness(Basis of Identity, Establishment of identity, Supervisor support, Coworker support, and Organizational environment ) as
independent variables. The results showed that both the basis of identity (β =.422, p <.001) and the establishment ofidentity (β =.372, p <.001) were significantly related tomeaningfulness. The model had a high goodness of fit, withan R2 value of .591 and an adjusted R2 of .566. Additionally,
there was no evidence of multicollinearity among the independent variables. A Durbin-Watson ratio of 2.155 also confirmed the absence of unusual patterns in the residuals.

Discussion*p <.05, **p <.01, ***p <.001

1. GHQ-12
2. Basis of Identity
3. Establishment of identity
4. SOC-29
5. Comprehensibility
6. Manageability
7. Meaningfulness
8. Job demands
9. Job control
10. Supervisor support
11. Coworker support
12. Organizational environment
13. Tradition−.57***−.49*** .53***−.68*** .81***−.55*** .72***−.63*** .74***−.61*** .67***.35*** −.19*−.41*** .34***−.40*** .24*−.48*** .33**−.31** .20*
.34*** −.16

.59***.38***.54***.64***−.10.38***
.17
.24*
.21*
.03

.84***.95***.85***−.22*.46***.33**.44***.33**−.18.72***.49***
−.24*
.29**
.25*
.36***.34***−.21*.77***−.20*.45***.31**.42***
.30**
−.18

−.18
−.33**−.25*−.17.43***.39***.45***.23*−.34**.66***.33**−.51**.30**−.47**

22.3
4.9
4.5
6.5
8.7
8.7
8.1
5.1
8.1
2.4
2.1
1.5
1.5
20.0
22.8
25.9
120.3
40.2
44.1
36.4
38.8
69.4
12.7
12.6
10.8
8.4

4.0
11.0
11.0
76.0
21.0
25.0
14.0
24.0
48.0
4.0
7.0
6.0
6.0

SD
M
12
11
10
9
7

8

analysis. The dependent variables are comprehensibility,
manageability, and meaningfulness.
Factors Related to Comprehensibility

6
5
4
3
2
1

Table 2. Mean, standard deviation, minimum and maximum values, Pearson’s correlation coefficient, and Cronbach’s α for each scale and subscale.

min.

max.

Cronbach’s α

https://doi.org/10.53044/jinr.2023-0012

This study found that SOC, the establishment of identity,
and working three shifts are related to mental health, andthat mental health and SOC have a strong relationship. Identity is strongly related to SOC factors. Additionally, a strongorganizational environment is related to high levels of comprehensibility. These results support part of Antonovsky’s salutogenesis model (Antonovsky et al., 2001).
5 of 9JINR 2024, 3(1), e2023-0012

https://doi.org/10.53044/jinr.2023-0012

Table 3. Hierarchical multiple regression analysis with GHQ-12 as a dependent variable.
GHQ-12
Step 1

Step 2

β

VIF

β

VIF

Personal related factors

Gender*1
AgeHigh School (Hygiene and Nursing) *2
Vocational school*2
Internal medicine*3
Mixed (Internal medicine/surgical) *3
Psychiatry*3
Other department*3
Workplace*4
Three-shift*5
No night shift*5
Basis of Identity
Establishment of identity

.068
.048
.002
−.008
−.085
−.036
.019
−.121
.233*
.199*
−.140
−.315**−.236**

1.131
1.718
1.058
1.418
1.369
1.429
1.286
1.830
2.694
1.119
2.676
1.650
1.544

.080
.075
.024
.020
-.060
.025
.019
−.090
.195
.167*
−.134
−.093
−.179*

1.136
1.744
1.074
1.445
1.453
1.641
1.293
1.868
2.747
1.153
2.677
3.376
1.659

Work-related factors

Job demands
Supervisor support
Coworker support
Organizational environment
Tradition
SOC-29.163−.018−.199*
−.041
.081

1.453
2.185
2.044
1.401
1.969

.152
−.015
−.144
−.017
.086
−.348*

1.458
2.186
2.151
1.421
1.970
4.228

R2
Adjusted R2
Δadjusted R2.589***.503***.617***.532***.029*p <.05, **p <.01, ***p <.001
β: standard partial regression coefficients, R2: coefficient of determination, VIF: Variance Inflation Factor*1 Gender (0 = Male, 1 = Female)*2 Reference category is University*3 Reference category is Surgical*4 Workplace (Ward = 0, Other = 1)
*5 Reference category is two shifts

Table 4. Multiple regression analysis with comprehensibility, manageability, and meaningfulness as dependent variables.

Age
Basis of Identity
Establishment of identity
Job demands
Supervisor support
Coworker support
Organizational environment
Tradition
R2
Adjusted R2

Comprehensibility

Manageability

Meaningfulness

β

VIF

β

VIF

β

VIF

.082
.654***
−.025
−.046
−.092
.121
.184*
−.077

1.084
1.508
1.487
1.323
2.071
1.989
1.207
1.764

.098
.584***
.164*
−.001
.003
.165
.092

1.050
1.502
1.440
1.154
1.911
1.884
1.179

.074
.422***.372***

1.040
1.482
1.438

.070
.118
−.012

1.821
1.884
1.177

.574***.539***.630***.603***.591***.566****p <.05, ***p <.001
β: standard partial regression coefficients, R2 : coefficient of determination, VIF: Variance Inflation Factor

6 of 9https://doi.org/10.53044/jinr.2023-0012

Characteristics of the SOC of the Study Participants
The mean SOC-29 score (120.3 ± 6.5) of the study participants was lower than that of the general adult population but
close to the mean scores of junior college students and college students (Togari et al., 2008; Tsuno & Yamazaki,2007).
Factors Related to the Level of Mental Health
Mental health was associated with factors such as SOC, theestablishment of identity, and three shifts. The SOC showed
the strongest relationship with mental health, suggesting thata higher SOC could improve mental health. Although previous studies have shown a relationship between occupational
identity and mental health (Inaba et al., 2017), the establishment of identity in this study reflects the degree of selfinitiative and self-confidence and is not limited to occupational identity. Compared with two-shift work, three-shift
work is associated with higher cumulative fatigue and mental fatigue (Sato et al., 2002; Nakayama & Sato, 2004). In
addition, shift work with a strong sense of job strain leads
to sleep disturbance (Karhula et al., 2013). Shift work is an
important factor in the mental health of new graduate
nurses.
Factors Related to the Development of a Sense of Comprehensibility
This study suggests that the organizational environment andbasis of identity play a crucial role in the development of asense of comprehensibility in new graduate nurses. A stablesense of self and workplace with clear rules, goals, and a rational management style leads to higher comprehensibility.
Consistency and appropriate feedback from coworkers andmanagement are thus important for a sense of comprehensibility, and specific feedback on work and progress toward
goals and objectives set by the organization are key evaluation items (Antonovsky et al., 2001). The study also
showed a strong relationship between SOC and a good organizational environment, highlighting the significance ofthe relationship between SOC and a sense of comprehensibility.
Factors Related to the Development of a Sense of Manageability
These results suggest that the basis and establishment ofidentity are related to a sense of manageability. A balanced
workload and the use of GRRs, such as knowledge, skills,
and support from coworkers, can lead to a sense of manageability (Antonovsky et al., 2001). The degree of job control
may also play a role in the sense of manageability, as it allows employees to adjust their workload balance; however,
the relationship between job control and the sense of manageability needs further investigation.

JINR 2024, 3(1), e2023-0012

Factors Related to the Development of a Sense of Meaningfulness
The higher the basis and establishment of identity, thehigher the sense of meaningfulness. A prior study found that
only a sense of meaningfulness is related to identity (Dobeta, 2020), and Antonovsky’s salutogenesis model suggeststhat participation in decision-making is important for the development of a sense of meaningfulness (Antonovsky et al.,2001). Therefore, a work environment that allows employees
to participate in decision-making is believed to increase theirsense of meaningfulness. Job control has been suggested to
be associated with the development of meaningfulness(Takeuchi et al., 2009), but it could not be implemented inthis study. Further studies are needed to examine the relationship between a sense of meaningfulness and job control.
Limitations and Problems of the Study
This study has three main limitations: a small sample size, alimited target area, and outdated data. These limitations limit
the generalizability of the results. Additionally, as this was across-sectional study, the influence of the results could not
be accurately determined. Job control, an important factor inmental health and SOC, could not be used as an independent variable because of the low reliability of the scale. To
improve the results, it is thus necessary to increase the sample size, conduct longitudinal studies, and consider the number of questions and scale selections.

Conclusions
The SOC was strongly related to the mental health of new
graduate nurses working in hospitals with specific functions,and the factors related to the development of the SOC werelargely due to the individual identity that developed from infancy to adolescence, while a high organizational environment was related to the development of a sense of comprehensibility.
Acknowledgments
This study is a revised version of a master’s thesis submitted
to the Graduate School of Nursing, Fukuoka Prefectural
University. The authors express their gratitude to the hospital leaders and staff for allowing the study to be conducted
and to the new graduate nurses who participated in the survey. Furthermore, the authors acknowledge Michiko Matsueda’s guidance during this research.
Author Contributions
SI conceived the study, designed the study, collected thedata, analyzed and interpreted the data, drafted the manuscript, and critically revised important intellectual content.
7 of 9JINR 2024, 3(1), e2023-0012

Declaration of Conflicting Interests
There are no conflicts of interest related to this study.
Ethical Approval
This study was approved by the Ethics Review Committeeof Fukuoka Prefectural University [approval date: July 12,2013, without an individual approval number].
Informed Consent
Informed consent was obtained from all participants involved in this study.
References
Al Awaisi, H., Cooke, H., & Pryjmachuk, S. (2015). The experiencesof newly graduated nurses during their first year of practice in the
Sultanate of Oman: A case study. International Journal of Nursing Studies, 52(11), 1723-1734.
https://doi.org/10.1016/j.ijnurstu.2015.06.009
Antonovsky, A., Yamazaki, Y., & Yosii, K. (2001). Kenko no nazo otoku: Sutoresu taisho to kenko hoji no mekanizumu: Yuusindoukoubunsya.
Dobeta, Y. (2020). Daigakusei ni okeru shubiikkan kankaku to doitsusei tonokanren. Oyo Shinrigaku Kenkyu, 46(2), 167-175. Retrieved fromhttp://search.jamas.or.jp/link/ui/2021128232
Feldt, T., Kinnunen, U., & Mauno, S. (2000). A mediational model ofsense of coherence in the work context: A one-year follow-up
study. Journal of Organizational Behavior, 21(4), 461-476.
https://doi.org/10.1002/(SICI)1099-1379(200006)21:4<461::AID-J
OB11>3.0.CO;2-T
Fukui, R., Haratani, T., Tosima, Y., Shima, S., Takahasi, M., Nakata,A., Hirota, Y. (2004). Shokuba no soshiki fudo no sokutei:
Soshiki fudo shakudo 12 komoku ban (OCS-12) no shinraisei
to datosei. Sangyo Eisei Gaku Zasshi, 46(6), 213-222.
https://doi.org/10.1539/sangyoeisei.46.213
Goldberg, D. P., Nakagawa, T., & Daibou, I. (2013). Nihon ban GHQ:
Seishin kenko chosa hyo: tebiki (Zoho ban): Nihon bunka kagaku
sha.
Goldberg, D. P. (1978). Manual of the General Health Questionnaire.
NFER-Nelson, Windsor.
Ikeda, S. (2022). Tokuteikino byoin ni kimmu suru shinsotsu kangoshi
no shitoresu taishoryoku SOC, shokugyosei sutoresu, soshiki
fudo, aidenteitei oyobi seishin kenkodo no kanren. Nihon Kango
Kenkyu Gakkai Zasshi, 45(4), 855-868.
https://doi.org/10.15065/jjsnr.20211115168
Ikeda, S., & Matsueda, M. (2020). Tokuteikino byoin ni kimmu suru
shinsotsu kangoshi no aidenteitei, shokugyosei sutoresu, soshiki
fudo to seishin hoken kodo no kanren. Sangyo Ikadaigaku Zasshi,
42(3), 281-290.
Inaba, R., Inoue, M., & Hioki, A. (2017). Josei byoinc kangoshi nobanauto to shokugyoteki aidenteitei no kankei. Nihon Shokugyo
Saigai Igakukai Kaishi, 65(4), 160-165. Retrieved fromhttp://search.jamas.or.jp/link/ui/2017372081
Karasek, R. (1985). Job content instrument questionnaire and user’s
guide, version 1.1. Department of Industrial and Systems Engineering, University of Southern California, Los Angeles.
Karasek, R. (1985). Job content instrument questionnaire and user’s
guide, version 1.1. Department of Industrial and Systems Engi-

8 of 9https://doi.org/10.53044/jinr.2023-0012
neering, University of Southern California, Los Angeles.
Karhula, K., Härmä, M., Sallinen, M., Hublin, C., Virkkala, J., Kivimaki, M., Vahtera, J., & Puttonen, S. (2013). Job strain, sleep andalertness in shift working health care professionals: A field study.
Industrial Health, 51(4), 406-416.
https://doi.org/10.2486/indhealth.2013-0015
Kawakami, N., & Fujigaki, Y. (1996). Reliability and validity of theJapanese version of Job Content Questionnaire: Replication andextension in computer company employees. Industrial Health, 34(4), 295-306.
https://doi.org/10.2486/indhealth.34.295
Kretowicz, K., & Bieniaszewski, L. (2015). Determinants of sense ofcoherence among managerial nursing staff. Annals of Agriculturaland Environmental Medicine, 22(4), 713-717.
https://doi.org/10.5604/12321966.1185782
Labrague, L. J., & McEnroe-Petitte, D. M. (2018). Job stress in new
nurses during the transition period: An integrative review. International Nursing Review, 65(4), 491-504.
https://doi.org/10.1111/inr.12425
Langius, A., Björvell, H., & Antonovsky, A. (1992). The sense of coherence concept and its relation to personality traits in Swedish
samples. Scandinavian Journal of Caring Sciences, 6(3), 165-171.
https://doi.org/10.1111/j.1471-6712.1992.tb00146.x
Michele Masanotti, G., Paolucci, S., Abbafati, E., Serratore, C., &Caricato, M. (2020). Sense of coherence in nurses: A systematic
review. International Journal of Environmental Research andPublic Health, 17(6), 1861.
https://doi.org/10.3390/ijerph17061861
Nakayama, K., & Sato, K. (2004). Kangoshoku no kotai kimmu nokeitai to chikusekiteki hiro no kankei. Kango Kanri, 14(5), 408411.
Rudman, A., Gustavsson, P., & Hultell, D. (2014). A prospective studyof nurses’ intentions to leave the profession during their first five
years of practice in Sweden. International Journal of Nursing
Studies, 51(4), 612-624.
https://doi.org/10.1016/j.ijnurstu.2013.09.012
Sato, M., Yonezawa, H., Ishizu, M., Suga, K., & Ikemoto, N. (2002).
Kotai kimmu ni juji suru josei kango shi no chikuseki teki hiro to
shukanteki suimin kan to no kankei. Nihon Kango Iryo Gakkai
Zasshi, 4(1), 28-35.
Shimoyama, H. (1992). Daigakusei no moratorium no kaibunrui no
kenkyuu: Identity no hattatu tono kanren. Kyouiku Sinrigaku
Kenkyuu, 40(2), 121-129. Retrieved fromhttp://ci.nii.ac.jp/naid/110001892832/
Takeuchi, T., Togari, T., & Yamazaki, Y. (2009). Kangoshi no SOC to
shokuba no arikata: Ikiiki to shita kangoshi o sasaeru shokuba
yoin no kento. Kango Kenkyuu, 42(7), 517-526.
https://doi.org/10.11477/mf.1681100402
Togari, T., Yamazaki, Y., Takayama, T. S., Yamaki, C. K., &Nakayama, K. (2008). Follow-up study on the effects of sense ofcoherence on well-being after two years in Japanese university
undergraduate students. Personality and Individual Differences, 44(6), 1335-1347.
https://doi.org/10.1016/j.paid.2007.12.002
Tsuno, Y. S., & Yamazaki, Y. (2007). A comparative study of sense ofcoherence (SOC) and related psychosocial factors among urban
versus rural residents in Japan. Personality and Individual Differences, 43(3), 449-461.
https://doi.org/10.1016/j.paid.2006.12.014
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    JINR

Introducing JINR,
an English-language Open Access Journal !
Nowacceptingsubmissions

For details on guidelines for authors,please go to the JINR web site athttps://www.jinr.jsnr.or.jp/

Journal ofInternational
Nursing Research
Editor-in-Chief : Naohiro Hohashi, PhD, RN, PHN, FAAN
Online ISSN : 2436-1348
Print ISSN : 2436-3448
https://www.jinr.jsnr.or.jp/

The Japan Society of Nursing Research haslaunched publication of the English-language
Journal of International Nursing Research(JINR) in February 2022.
JINR welcomes submissions of unpublishedpapers on nursing and related topics,
including review articles, original research,
practice guidelines, technical reports andbrief reports.

About JINR : ● an international English-language journal

published by the Japan Society of Nursing Research● research topics covering a wide range of fields related to nursing science● upon acceptance, papers will be promptly available via open access● papers will also be registered in PubMed

as soon as the requirements are met in the future● no charge for publication if the first author holds membership in
the Japan Society of Nursing Research● secondary publication of articles published in

the Journal of Japan Society of Nursing Research can be consideredJapan Society of Nursing Research
Editor-in-Chief: Naohiro Hohashi, PhD, RN, PHN, FAAN
Mail contact for inquiries: jinr@kyorin.co.jp (JINR editorial office)List of Reviewers
The Editorial Committee members express their gratitude to the following individuals, who served as reviewers of manuscripts
for the Journal of International Nursing Research between April 2023 and March 2024.

Ebtsam Abou Hashish

Johanna Elizabeth Maree

Loretta Aller

Takeshi Matsubara

Ndaimani Augustine

Mitsunori Miyashita

Vishnu Bhat Ballambattu

Chizuru Nagata

Ellen Benjamin

Gojiro Nakagami

Yüksel CAN ÖZ

Atsuo Nakagawa

Jie ChenAyumi Nishigami

Vico Chiang

Junko Okada

Yi-Wen Chiu

Yuko Okamoto

Zoe Darwin

Graz· yna Puto

Caroline Davenport

Junko Saito

Tetsuya Fujii

Suzanne Schneider

Florinda Galinha de Sá

Michael Simon

Yoshie Hara

Masanori Tamaki

Yuta Hayashi

Hiroko Tanaka

T. Heather Herdman

Ozgur Tanriverdi

Toru Hifumi

Keiko Tasaki

Feifei Huang

Ai Tomotaki

Reiko Inoue

Sharon Tucker

Mikiko Ito

Mirinda Tyo

Kazue Iwase

Yusuke Umegaki

Yusuke Kanno

Munira Wells

Yuka Kanoya

Margareta Widarsson

Esmail Khodadadi

Anne Williams

Paolo Landa

Lisa Wolf

Samuel Lapkin

Xiaoyu Wu

Patrick Lavoie

Mitsuya Yamakita

Seung-Kyu Lim

Rika Yano

Kelsey Ludwig
Agnes Makhene