Volume 2│Number 2

August 2023

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

Shawn Yong-Shian Goh, BHSN, MN, PhD

Kieko Iida, PhD, RN, PHN

Kawasaki City College of Nursing,Japan

National University of Singapore, Singapore

Graduate School of Nursing, Chiba University, Japan

Polly Siu Ling Chan, RN, BHSc, MPHC,

Justina Yat-Wa Liu, RN, PhD

Yasuko Shimizu, PhD, RN, PHN

DHSc

School of Nursing, Hong Kong Polytechnic
University, Hong Kong SAR

Graduate School of Medicine, Osaka
University, Japan

Mayuko Tsujimura, PhD, RN, PHN

Yoshie Yokoyama, PhD, RN, PHN

Naoki Yoshinaga, PhD, RN, CPP, MSN

School of Nursing, Shiga University of
Medical Science, Japan

Graduate School of Nursing, Osaka City
University, Japan

School of Nursing, Faculty of Medicine,
University of Miyazaki, Japan

School of Nursing, Li Ka Shing Facultyof Medicine, The University of Hong
Kong, Hong Kong SAR

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.

Japan Society of Nursing Research
c/o Galileo, Inc., Center for Academic Societies
2-39-2-401, Higashi-Ikebukuro, Toshima-ku, Tokyo 170-0013 Japan
Online ISSN: 2436-1348
Print ISSN: 2436-3448
Copyright © 2023 by the Japan Society of Nursing Research (JSNR). All rights reserved. No portionof the contents may be reproduced in any form without written permission from the publisher.
Printed in Japan

Journal of International Nursing Research
Volume 2

Number 2

August 2023

Volume 2 Number 2 October 2023

Contents
Editorial
Improving the international presence of nursing research in Japan and expectations forthe development of Journal of International Nursing Research

e2023-0023

Midori Asano, PhD, RN, PHN

If you decline to conduct peer reviews, then don’t submit your paper

e2023-0025

Naohiro Hohashi, PhD, RN, PHN, FAAN

Review Article
Treatment engagement: A concept analysis

e2022-0012

Azusa Kudo, RN, PHN, MSN, Naoko Deguchi, RN, PHN, PhD , Tomoko Omiya, PHN, PhD, andTomoko Sankai, MD, PhD

Nursing care for people with concurrent heart failure and diabetes: A scoping review

e2022-0033

Yusuke Yamazaki, RN, BNS, Sumie Kuroda, RN, PhD, and Misaki Sawaoka, RN, MSN

Original Research
Typology of hunger sensation perception in patients with type 2 diabetes

e2022-0016

Mizuyo Nagamune, PhD, RN, Mayumi Okuwa, PhD, RN, Michiko Inagaki, PhD, RN, Keiko Tasaki,
PhD, RN, Tomomi Horiguchi, PhD, RN, PHN , Yuya Asada, PhD, RN, PHN, and Mai Kitagawa, PhD,
RN, PHN

Development of the prenatal positive experience scale for men in Japan:
A cross-sectional scale development study

e2022-0011

Yasuka Nakamura, PhD, Tomoka Oshikiri, BN, Yoko Takeishi, PhD, Moeka Aoki, BN, Nami Yashima,BN, Maiko Kawajiri, PhD, Mikako Yoshida, PhD, and Toyoko Yoshizawa, PhD

Development of a weight loss intervention by mothers for adults withsevere intellectual disabilities and autism

e2022-0003

Mitsuyo Nonaka, PhD, RN, PHN, and Satoko Yanagisawa, PhD, RN, PHN, MW

Cognitive behavioural therapy for mood and anxiety disorders deliveredby mental health nurses: Outcomes and predictors of response ina real-world outpatient care setting

e2022-0023

Hiroki Tanoue, RN, PhD, Yuta Hayashi, RN, PhD, Yuki Shikuri, RN, BSN, and Naoki Yoshinaga, RN,
PhD

Learning needs of family caregivers in the Japanese working generation
who care for community-dwelling people with dementia:
A qualitative research studye2021-0022

Sayori Sakanashi, PhD, RN, Kimie Fujita, PhD, RN, Midori Nishio, PhD, RN, Shinji Ouma, PhD, MD,
and Kumiko Ogata, PhD, RN

Nurse managers’ support during organizational change and nurses’organizational commitment: A cross-sectional study using nurses’ career stage
Chika Funakoshi, PhD, Keiko Kunie, PhD, Yukie Takemura, PhD, Kimie Takehara, PhD, and Naoko
Ichikawa, PhD

e2021-0025

Development of a medication-adherence assessment tool to assess andsupport medication self-management by older adults

e2021-0003

Kanako Sakane, PhD, Yuko Tsumoto, PhD, Yuta Kobayashi, PhD, Miki Fukuma, PhD, Mayumi
Miyamoto, PhD, and Hiromi Uchida, PhD

Association between family functioning, resilience, and psychosocial
burden among family members of patients in the intensive care unit:
A cross-sectional study

e2022-0032

Miyuki H Komachi, PhD RN PHN, and Kiyoko Kamibeppu, PhD RN PHN FAAN

Technical Report
A comparison of the ne particulate protection rate of face masks reused after washinge2022-0036

Kanna Okayama, RN, PHN, PhD, and Mitsue Arakawa, RN, PHN, PhD

Brief ReportFeasibility of two guidebooks for parents with mental illness and their children:
Healthcare professionals’ perspectives

e2022-0017

Rie Ueno, RN, PhD, Tytti Solantaus, MD, PhD, and Hirokazu Osada, PhD

Education
Current status of the JINR: From the editor-in-chiefe2023-0011

Naohiro Hohashi, PhD, RN, PHN, FAAN

Boosting the chances of getting your paper accepted in the Journal of International Nursing
Research: Understanding common reasons for paper rejection in international nursing
journals

e2023-0014

Naoki Yoshinaga, PhD, RN

Tips for papers’ acceptance from a peer review perspective

e2023-0017

Takiko Imai, PhD, RN, PHN

Some tips for writing a paper in English
Kiyoko Fukai, PhD, RN, PHN

e2023-0016

https://doi.org/10.53044/jinr.2023-0023
https://www.jinr.jsnr.or.jp/

Editorial

Improving the international presence of nursing research inJapan and expectations for the development of Journal ofInternational Nursing Research
Midori Asano, PhD, RN, PHN1, 2
President of Japan Society of Nursing Research, Tokyo, Japan and 2Professor & Vice Director of
Department of Integrated Health Sciences, Nagoya University Graduate school of Medicine,
Nagoya, Japan
1

With the publication of the Journal of International Nursing Research (JINR) Volume 2, Number 2, I am very proud to have theopportunity to say some words as the president of the Japan Society of Nursing Research. I am very happy that the first issue of
JINR, Volume 1, Number 1, was published in February 2022; Volume 2, Number 1 was published in February 2023, and now
Volume 2, Number 2 has been published smoothly. On behalf of all the members of the Japan Society of Nursing Research(JSNR), I would like to express my deepest gratitude to the editor-Chief Prof. Naohiro Hohashi and the editorial committee
members for their efforts.
So far, JINR has received many submissions that have exceeded our expectations. Volume 1, Number 1 contained two review
articles, two original research, and one technical report, and Volume 2, Number 1 contains two review articles, seven original
research, and one brief report. The research themes that have been published are diverse and suitable for the Japan Society of
Nursing Research as an umbrella society of nursing science.
As Prof. Kiyoko Fukai, the former president of JSNR, wrote in the preface to the first issue, “Nursing is a science that contributes to practice (applied science); therefore, papers written in Japanese are useful for busy practitioners. However, if details ofhigh-quality nursing research that contributes to practice can only be read in Japanese, it cannot be utilized as a new finding
shared by the entire world of the nursing academia because there are no borders in philosophy.” For most of us (nurses), writinga research paper in English is a bit of a hurdle and we may hesitate. However, by publishing papers in English, research papers
can have readers spread across the world. I do not think it is easy for most of us, but please continue to try it.
Finally, let us make JINR even more exciting, and take a new step in the history of JSNR!
JINR 2023, 2 (2), e2023-0023

Correspondence: M. Asano. Email: midoria@met.nagoya-u.ac.jp
Copyright Ⓒ 2023 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.2023-0025
https://www.jinr.jsnr.or.jp/

Editorial

If you decline to conduct peer reviews, then don’t submit yourpaper
Naohiro Hohashi, PhD, RN, PHN, FAAN1, 2
Editor-in-Chief, Journal of International Nursing Research, and 2Graduate School of Health
Sciences, Kobe University, Kobe, Japan1

I have often said, “If you publish one paper, you should review two papers by others, because more than two reviewers need tomake time to review your paper.” The Journal of International Nursing Research (JINR) has been struggling with problems
related to the time-consuming review process, due mainly to a shortage of reviewers. JINR is an international journal, and after
checking the content of submitted papers, it searches for researchers from around the world who are willing to undertake peer
reviews.
JINR has adopted the use of Reviewer Locator, an optional tool of ScholarOne Manuscripts that automatically generates a listof the most suitable reviewers. The Reviewer Locator displays a list of up to 30 candidates who may be suitable to review a submitted paper. The list displays the ORCID ID of the candidate, the DOI of the paper, and other information about the researcher.
The list also shows how many papers a researcher has published and how many papers they have reviewed. Some researchers
have published numerous papers but only engaged in a small number of peer reviews, which I believe is undercuts the principles
of academia.
Finally, I would like to report three updates for JINR. First, the Guidelines for Authors and Guidelines for Reviewers wererevised on May 29, 2023 to deal with the use of AI tools such as ChatGPT, so please check them carefully.
Second, the four winners of the Outstanding Reviewer Awards for 2023 have been selected. They are introduced on the JINR
website and in the print version of JINR. We hope that more of you will find the awards an incentive to undertake reviews.
Third, from the 2024 fiscal year, authors whose papers are published in JINR will be eligible for academic and incentive
awards. Details on this will be posted around June 2024.
We at JINR look forward, as always, to your submissions.
JINR 2023, 2 (2), e2023-0025

Correspondence: N. Hohashi. Email: naohiro@hohashi.org
Copyright Ⓒ 2023 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.2022-0012
https://www.jinr.jsnr.or.jp/

Review Article

Treatment engagement: A concept analysis
Azusa Kudo, RN, PHN, MSN1,2 , Naoko Deguchi, RN, PHN, PhD3 , Tomoko Omiya, PHN, PhD4 , andTomoko Sankai, MD, PhD4
1

Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan, 2Hasegawa
Hospital, Tokyo, Japan, 3Faculty of Education, University of Shizuoka, Shizuoka, Japan, and 4Faculty of Medicine,
University of Tsukuba, Tsukuba, Japan

Abstract
The concept of “treatment engagement” has been used in many research articles to describe the behavior andprocess by which patients engage in treatment and medication. However, the term “treatment engagement” isoften undefined and used ambiguously, with each researcher using the term, with a different, vague, or broad
meaning. Given that many studies have shown that treatment engagement is directly related to clinical outcomes,
the concept, should be defined more concretely. This study, therefore, aims to conduct a concept analysis of treatment engagement using Rodgers’ evolutionary method of concept analysis. The antecedents of the concept of“treatment engagement” consisted of three elements: individual (i.e., knowledge regarding the disease and treatment, attitudes toward disease and treatment, and acceptance of the disease), situational (i.e., negative experiences in the past and conditions and circumstances that allow patients to focus on treatment), and environmental(i.e., connection with providers, social support, and adaptive treatment system). The attributes of treatment engagement had two elements: behavioral (i.e., initiation of treatment, continuation of treatment, and adherence torecommendations in treatment) and psychosocial (i.e., attitudes that indicate value and expectations toward treatment, cooperation with peers, and collaboration between patient and providers). Consequences of treatment engagement were treatment retention, better clinical outcomes, and coping with disease and treatment. Through thisstudy, we developed the theoretical definition of treatment engagement as the process of initiating and continuing
treatment, and adhering to treatment recommendations, in cooperation with peers and in collaboration with supporters, accompanied by a positive attitude toward treatment.
Keywords
treatment engagement, concept analysis, nursing practice, patient engagement
JINR 2023, 2(2), e2022-0012

BackgroundIn various health care fields, some recommended treatments
are not initiated or, if initiated, a certain number of patients
drop out or show noncompliance (Catherine et al., 2013;
Colins et al., 2017). The nursing profession has a role toplay in providing community-based or patient-focused inter-

ventions to promote behavioral change related to treatmentcompliance. At the same time, there has been a paradigm
shift in health care from disease-centered to patient-centered
medicine (International Journal of Health Care Quality Assurance, 2002). Recent studies have shown a tendency forpatients to communicate better with health care professionals
and to refrain from problematic behaviors to prevent relapse

Correspondence: T. Sankai. Email: sankai_tomoko@md.tsukuba.ac.jp
Received: April 13, 2022, Accepted: September 6, 2022, Advance Publication: April 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 14JINR 2023, 2(2), e2022-0012

and enhance their quality of life, and actively participate intreatment and undergo new behavioral changes related totreatment and disease prevention (Brenner & Barnes, 2012;
Drieschner & Boomsma, 2008; Jochems, 2017). In otherwords, the perspective of “patient active participation intreatment” has become more important, including patientautonomy, self-determination, and shared decision making(Buckingham et al., 2016). Thus, in terms of treatment, attention is given not only to the behavioral aspects of the patient but also to the psychosocial aspects, both of which are
crucial (Buckingham et al., 2016). Instead of merely focusing on aspects of patient behavior, nursing professionals
must also contribute to the assessment and intervention in
the psychological aspects of the patients’ approach to treatment and the social aspects of the patients’ relationship withhealth care professionals and peers (Caplan & Whittemore,
2013; Claborn, et al., 2017). This concept, which encompasses patients’ behaviors and cognitions during treatment,is called “treatment engagement” (Buckingham et al., 2016).
It is an important concept because it has been shown to affect clinical outcomes (Stanley et al., 2018). Existing models
and theories, such as the health belief model, can show what
factors are related to a patient’s visit, but they cannot capture how patients participate in treatment. Therefore, we
now must consider the concept of “treatment engagement.”
In the scientific literature, the term “treatment engagement” first appeared in the mid-1980s and has been used increasingly since the 2010s. In the earlier publication, when
this term was first used, it referred to the connection between the patient and the health care providers in the context of suicide prevention (Adam, 1985). However, the term
is not explicitly defined in recent publications, and evenwhen it is, the definition varies from study to study. For instance, treatment engagement can refer to a variety of behaviors connected to treatment participation or compliancethroughout time (Anand et al., 2015), a proactive approachto therapy (Manuel, 2013), or even the therapeutic connection between health care providers (Collins et al., 2017). Additionally, even where treatment engagement refers to thesame behavioral aspect, some authors may use it to describe
initiating treatment (Colins et al., 2017), whereas others may
use it to describe continuing treatment (Catherine et al.,2013); hence, treatment engagement may carry different
meanings depending on the context in which it is used.
Clarifying the meaning of treatment engagement can contribute to the development of the concept itself and can provide a direction and foundation for future clinical practiceand research.
Therefore, the current study aims to identify the definitive
attributes, elucidate a more concrete definition of treatment
engagement, and develop the conceptual model of treatment
engagement.
2 of 14https://doi.org/10.53044/jinr.2022-0012

Methods
1. Concept Analysis
In this study, Rodger’s evolutionary method of concept
analysis (Rodgers & Knafl, 2000) was used. This method isbased on the philosophical foundation that concepts are
evolving things that change over time and circumstances,and by focusing on the nature of concepts and how they areused, the method reveals the properties that concepts possess(Rodgers & Knafl, 2000). It is also a method that is not easily influenced by the researcher’s preconceptions because of
the rigorous and systematic approach (Rodgers & Knafl,
2000). Treatment engagement may hold different meanings
or concepts depending on the time, context, and interpretation; therefore, Rodger’s evolutionary method of concept
analysis was selected as the most appropriate means ofanalysis.
Rodger’s evolutionary method of concept analysis isbased on the following steps (Rodgers & Knafl, 2000): (1)Identify the concept of interest and associated expressions(including surrogate terms). (2) Identify and select an appropriate realm (setting and sample) for data collection. (3)Collect data relevant to identify: attributes of the concept
and the contextual basis of the concept, including interdisciplinary, sociocultural, and temporal (antecedent and consequential occurrences) variations. (4) Analyze data regarding
the above characteristics of the concept. (5) Identify an exemplar of the concept, if appropriate. (6) Finally, identify
implications, hypotheses, and implications for further development of the concept. In this study, the concept analysis
was also conducted according to these procedures.
2. Data Collection
A literature search of articles written in English was conducted using the academic article databases PubMed, Medline, CINAHL, and PsychINFO. The keywords were (engag*[Title]) AND (treatment[Title]), and only Journal articles
published between 2010 and 2020 were included. A total of
1676 articles were retrieved, of which 671 remained after
duplicates were excluded. Unavailable articles and thosedealing with nonpatient treatment engagements (e.g., familyonly treatment engagements) were excluded, and finally, 485
articles were selected. It is recommended that 20% of theselected articles be included in the final analysis (Rodgers &Knafl, 2000); thus, from the 485 articles, 97 were randomly
selected using a random number table.
3. Data Analysis
Inductive analysis, which is a flexible method of identifying
and analyzing patterns(Braun &Victoria, 2006) within a data
set was performed. First, a spreadsheet was created to tabulate the data collected in the analysis. Next, each paper was
read carefully, identifying initial codes that were groupedhttps://doi.org/10.53044/jinr.2022-0012

into tentative categories. Terms that indicate the nature of
the concept of treatment engagement in the target literature
were designated as attributes, the terms that indicate events
that occur before the concept as antecedents, and the terms
that indicate events that occur as a result of the concept asconsequences. The categories and included codes were further discussed within the researchers with doctoral degrees
in nursing and experience in concept analysis. Furthermore,
the content of the analysis was reviewed and revised withthe supervision of experts in community health and publichealth nursing. Through the ongoing analysis, the contentsof each identified category were further clarified. Second,model cases were identified, and those that illustrate the defining attributes of treatment engagement were examinedfrom the results of inductive analysis. Finally, a conceptual
definition and a model of treatment engagement were created from the results of inductive analysis, establishing theoccurrence of the attribute in various contexts. Moreover, toensure reliability, research notes (describing the work process, decision making, interpretation, etc.) were prepared, anddetailed notes were kept for each analyzed paper.

Results
1. Domains of the Literature and Existing Definitions
Of the literature retrieved, the mental health domain was themost prevalent, comprising 61 articles, followed by the HIVrelated domain with 16, the lifestyle-related domain with 8,
and others with 11. There were 24 articles with explicit definitions of treatment engagement. For example, in the case ofalcohol and other drug use disorder, treatment engagement
was defined as having two or more alcohol and other drug
related services within 30 days after initiating treatment (orhospital discharge) (Binswanger et al., 2019). And elsewhere, treatment engagement was defined as a multidimensional construct that includes not only observable behavior
but also attitudes, relational aspects, and cognitions (Collins
et al., 2017b), and it was also defined smokers’ interest andinvolvement in both motivational and cessation treatments(Pipper et al., 2012).
2. Attributes
Attributes of a concept are those characteristics of the concept under analysis that have been repeatedly described in
the literature (Rodgers& Knafl, 2000). The attributes oftreatment engagement included, as behavioral elements, “Initiation of treatment,” “Continuation of treatment,” and “Adherence to recommendations in treatment” and, as psychosocial elements, “Attitudes that indicate value and expectations
toward treatment,” “Cooperation with peers,” and “Collaboration between the patient and providers” (Table 1).
1) Initiation of Treatment“Initiation of treatment” denoted the connection to medical

JINR 2023, 2(2), e2022-0012

care or the start of a specific treatment. An example of theconnection to medical care is gay men being tested for HIV
and other conditions (Anand et al., 2015). Examples of thestart of specific treatment are military veterans’ visits to outpatient posttraumatic stress disorder clinics (Stecker et al.,2016), the initiation of psychotherapy for veterans (Mott etal., 2014), and the initiation of medication for depressed
Hispanic patients (Sanchez et al., 2017).
2) Continuation of Treatment“Continuation of treatment” referred to multiple medical examinations and treatment-related behaviors. For example,
veterans’ use of mental health services more than a certain
number of times (Catherine et al., 2013), veterans’ participation in psychotherapy more than a certain number of times(Mott et al., 2014), smokers’ continued smoking cessation(Carpenter et al., 2020), and multiple insulin replacement ofpatients with diabetes (Goldman et al., 2018).
3) Adherence to Recommendations in Treatment“Adherence to recommendations in treatment” indicated adherence to recommended behaviors and instructions given
by health care providers. Examples include juveniles who
had used illegal drugs adhering to the instructions of healthcare providers (Abdel-Salam et al., 2014) and people of racial/ethnic minorities adhering to treatment plans (Aggarwal
et al., 2015).
4) Attitudes that Indicate Value and Expectations toward
Treatment“Attitudes that indicate value and expectations toward treatment” indicated giving meaning to treatment, agency intreatment, and assertiveness about treatment plans. Examples
include young people’s perceptions of the usefulness of theirtreatment from mental health services (Yeh et al., 2019), theconcentration on treatment among children with behavioral
disorders (Lindhelm et al., 2010), the retention of treatment
goals among individuals with eating disorders (Darcy et al.,2010), and self-advocacy among youth who use mental
health services regarding their treatment or life (Buckingham
et al., 2016).
5) Cooperation with Peers“Cooperation with peers” indicated providing mutual help
and support for those who are undergoing similar treatment.
For example, “Cooperation with peers” was observed in aperson with a personality disorder who supports other participants within a group treatment program (Clarke et al.,2014) or a substance abuser who receives support frompeers in the program (Goodson et al., 2019).
6) Collaboration between Patients and Providers“Collaboration between patients and providers” denotedbuilding trusting relationships between patients and providers and collaborating in treatment decision making. For example, “Collaboration between patients and provides” wasobserved in young people who used mental health services
and had an open relationship with their providers (Bucking3 of 14

JINR 2023, 2(2), e2022-0012

https://doi.org/10.53044/jinr.2022-0012

Table 1. Attributes of treatment engagement.
Characteristics

ExamplesReferences

Getting an HIV test (Anand et al., 2014)
Seeing a PTDS treatment facility (Stecker et al.,2010)
Initiating psychotherapy (Mott et al., 2014)
Initiating pharmacotherapy (Sanchez et al., 2017)

Aggarwal et al. 2015; Anand et al. 2015; Becker et al. 2020;Brenner et al. 2012; Carmlin et al. 2019; Catherine et al. 2013;
Chen et al. 2017; Collins et al. 2017a; Cowan et al. 2013; Delaney et al. 2013; Drew et al. 2016; Interian et al. 2013; Jin et al.
2019; Kraviz et al. 2013; Lancaster et al. 2019; Marques et al.
2011; McMurran et al. 2010; Mott et al. 2014; Pillai et al. 2016;
Roozen et al. 2010; Sampson et al. 2017; Santis et al. 2017;
Schoenfelder et al. 2017; Silva et al. 2020; Simeone et al. 2017;
Sirey et al. 2013; Skilbeck et al. 2020; Stecker et al. 2010, 2016;
Stein et al. 2014; Stubbe et al. 2016, 2019; Tkach et al. 2019;
Wilson et al. 2018, 2019; Woodhead et al. 2013

Continuation oftreatment

Utilization of mental health services above a certain number of times (Catherine et al., 2013)
Participation in psychotherapy more than a certain number of times (Mott et al., 2014)
Continuing medication (Solomon et al., 2020)
Continuing to quit smoking (Carpenter et al.,2020)
Multiple insulin replacement (Goldman et al.,2018)

Acevedo et al. 2012; Albertsa et al. 2018; Binswanger et al.
2019; Buckingham et al. 2016; Busch et al. 2017; Carpenter et
al. 2020; Catherine et al. 2013; Cheung et al. 2018; Claborn etal. 2017; Clarke et al. 2014; Delaney et al. 2013; Dillon et al.
2020; Drew et al. 2016; Garnick et al. 2013; Goldberg et al.
2020; Goldman et al. 2018; Gouse et al. 2016; Guerreo et al.
2013; Harris et al. 2010; Heffne et al. 2016; Ho et al. 2019;
Houtepen et al. 2020; Interian et al. 2013; Jin et al. 2019; Jonseet al. 2013a; Jonse et al. 2013b; Kelly et al. 2010; Kern et al.
2014; Kline-Simon et al. 2019; Kwan et al. 2010; McMurran etal. 2010; Monney et al. 2017; Mott et al. 2014; Moucheraud etal. 2020; Myers et al. 2017; Nan et al. 2020; Richwood et al.
2020; Rodriguez et al. 2020; Rutkowski et al. 2010; Schoenfelder et al. 2017; Shrestha et al. 2018; Skilbeck et al. 2020;
Solomon et al. 2020; Stubbe et al. 2016; Terzian et al. 2011;
Travaglinia et al. 2017; Urbanoski et al. 2018; Wild et al. 2016;
Woodhead et al. 2013; Woodhouse et al. 2013; Yeh et al. 2019

Adherence torecommendations intreatment

Adhering to staff instructions (Abdel-Salam et al.,2014)
Adhering to treatment plans through appointment
keeping and use of full treatment utilization (Aggarwal et al., 2015)

Abdel-Salam et al. 2014; Buckingham et al. 2016; Aggarwal etal. 2015; Clarke et al. 2014; Jeager et al. 2013

Attitudes that indicate
value and expectations
toward treatment

Perceived usefulness of treatment (Yeh et al,
2019)
Focused commitment to treatment (Lindhelm et al
2010)
Having a goal (Darcy et al., 2010)
Satisfaction with treatment (Becker et al., 2014)
Advocating for oneself (Buckingham et al., 2016)

Abdel-Salam et al. 2014; Becker et al. 2014; Buckingham et al.
2016; Collins et al. 2017b; Clarke et al. 2014; Darcy et al. 2010;
Dillon et al. 2020; Frost et al. 2018; George et al. 2016; Goodson et al. 2019; Hack et al. 2020; Lindhelm et al 2010; Lore etal. 2015; Manuel et al. 2013; Marshall et al. 2018; Pancow et al.
2012; Pipper et al. 2012; Wild et al. 2016; Yeh et al. 2019; Loreet al. 2015

Cooperation withpeers

Supporting and helping others in group therapy(Clarke et al., 2014)
Receiving support from peers in the program(Goodson et al., 2019)

Clarke et al. 2014; Goodson et al. 2019; Pankow et al. 2012;
Woodhead et al. 2013

Collaboration between
patients and providers

Having an open relationship with the provider(Buckingham et al., 2016)
Collaborating with patients and providers to develop a treatment plan (Aggarwal et al., 2018)

Aggarwal et al. 2015; Becker et al. 2014; Buckingham et al.
2016; Clarke et al. 2014; Clarkson et al. 2014; Collins et al.
2017b; George et al. 2016; Goodson et al. 2019; Kwan et al.
2010; Lore et al. 2015; Stacey et al. 2017; Yeh et al. 2019

<Behavioral elements>

Initiation of treatment<Psychosocial elements>

ham et al., 2018), and patients and providers collaborated ontreatment planning (Aggarwal et al., 2015).
3. Antecedents
Antecedents are preconditions that must exist before the occurrence of a concept (Rodgers & Knafl, 2000). The antece4 of 14

dents of treatment engagement were extracted as follows:
the individual elements of “Knowledge and attitudes about
the disease and treatment” and “Acceptance of the disease”;
the situational elements of “Negative experiences in thepast” and “Conditions and circumstances that allow one toconcentrate on treatment”; and the environmental elementshttps://doi.org/10.53044/jinr.2022-0012

of “Connection with providers,” “Social support,” and“Adapted treatment system” (Table 2).
1) Knowledge about Disease and Treatment“Knowledge about disease and treatment” referred to the patients’ knowledge regarding the disease itself, such as attention deficit hyperactivity disorder knowledge (Schoenfelder
et al., 2017), and treatment methods, such as knowledge regarding preventive treatment for AIDS (Monney et al.,2017).
2) Attitudes toward Disease and Treatment“Attitudes toward disease and treatment” represented a wide
range of factors, from negative attitudes, such as negative
feelings associated with the current situation and concerns
about the future, to positive attitudes, such as perceptions of
the need for and usefulness of treatment, and selfdetermination of treatment. For example, even among abusers of the same substance, one person’s treatment was motivated by her guilt and embarrassment over her continued
drug abuse (Wild et al., 2016), whereas another person engaged in treatment with a recognition that their illicit drug
use is uncontrollable and requires formal intervention (Dillon et al., 2020).
3) Acceptance of Disease“Acceptance of disease” indicated the outcome of reducing
self-stigma and establishing a self-concept, for example, acknowledging one’s own mental illness (Singh et al., 2013)
and integrating oneself with being a patient with HIV (Ho etal., 2013).
4) Negative Experiences in the Past
“Negative experiences in the past” referred to experiences offailure related to past treatment. For example, an alcoholic’s
past experience of failure to get sober or the experience oflosing a family member due to illegal drug use were antecedents of treatment engagement (Dillon et al., 2020). These
negative experiences in the past seemed to influence treatment engagement, as they led to the perception of not wanting to relapse and experience mental distress again (Dillon
et al., 2020).
5) “Conditions and Circumstances that Allow Patients to Focus on Treatment”“Condition and circumstances that allow patients to focus ontreatment” connotated that the patient is in a condition to receive treatment or to focus on treatment. For example,
women undergoing HIV treatment were more involved ifthey had milder menopausal symptoms (Solomon et al.,2020). Moreover, patients were more focused on treatment
when the well-being of family members supporting themwas better (Becker et al., 2020).
6) Connection with Providers“Connection with providers” indicated contact and a good
relationship between the party or family and the providers,such as outreach (Moucheraud et al., 2020) and increased
communication between patients and health care providers

JINR 2023, 2(2), e2022-0012(Jonse et al., 2013).
7) Social Support“Social support” referred to patients having support from thepeople and communities around them. For example, substance users and young people who use mental health services received support from family, friends, and community
members (Becker et al., 2020: Kelly et al., 2010).
8) Adaptive Treatment Systems“Adaptive treatment systems” implied a good treatment environment and treatment that is tailored to the needs of theparticipants; for example, accessibility of treatment facilities(Acevedo et al., 2012), and treatment content that is tailoredto the preferences of the participants (Kern et al., 2014).
4. Consequences
Consequences referred to situations that result from the attributes of a concept (Rodgers & Knafl, 2000). Three categories of consequences of treatment engagement were extracted: “Treatment retention,” “Better clinical outcomes,”and “Coping with disease and treatment” (Table 3).
1) Treatment Retention“Treatment retention” indicated the continuation of treatment
for a long time; for example, when substance users continued treatment for more than 90 days through treatment engagement (Abdel-Salam et al., 2014).
2) Better Clinical Outcomes“Better clinical outcomes” referred to health outcomes suchas improved symptoms, reduced problem behaviors, and improved quality of life. Examples include improved depressive symptoms in depressed patients (Skilbeck et al., 2020)
and reduced illicit drug use in substance users (Lore et al.,2015).
3) Coping with Disease and Treatment“Coping with disease and treatment” denoted the capacity to
see illness and treatment as a personal matter. For example,
it was used to refer to the introspection of patients with
hepatitis C through psychosocial support (Wild et al., 2015).
5. Conceptual Model of Treatment Engagement
Figure 1 shows the conceptual model of treatment engagement that was clarified in this study. Among the antecedents,
individual and environmental elements and attributes are
considered to influence each other. Among the attributes, behavioral and psychosocial elements also influence each other(Buckingham et al., 2016; Colins et al., 2017a). For example, Collins et al. (2017a) showed that people living withHIV could connect with other providers after “Initiation oftreatment,” and it facilitated engagement with new programs.
This means that among the antecedents, individual and environmental elements and attributes are considered to influence each other. Additionally, Buckingham et al. (2016)
showed that “Continuation of treatment” facilitates “Collaboration between patient and providers” and “Collabora5 of 14

JINR 2023, 2(2), e2022-0012

https://doi.org/10.53044/jinr.2022-0012

Table 2. Antecedents of treatment engagement.
Characteristics

ExamplesReferences

Knowledge about disease
and treatment

Knowledge of ADHD (Schoenfelder et al., 2017)
Information on preventive treatment for AIDS
(Monney et al., 2017)

Anand et al. 2015; Becker et al. 2020; Kraviz et al. 2013;
Monney et al. 2017; Richwood et al. 2020; Schoenfelder
et al. 2017; Sirey et al. 2013

Attitudes toward disease
and treatment

Guilt and shame about continuing to use illegal
drugs (Wild et al., 2016)
Health concerns (Woodhead et al., 2013)
Reduced concern about HIV medication (Jonse etal., 2013a)
Perception that drug use cannot be controlled byoneself and requires formal intervention (Dillon etal., 2020)
Patients can consider what is important for theirhealth and choose their preferred screening andtreatment options (Stacey et al., 2017)

Anand et al. 2015; Becker et al. 2020; Carpenter et al.
2020; Darcy et al. 2010; Dillon et al. 2020; George et al.
2016; Gouse et al. 2016; Ho et al. 2019; Houtepen et al.
2020; Jonse et al. 2013a, 2013b; Kern et al. 2014;
McMurran et al. 2010; Richwood et al. 2020; Singth et al.
2013; Stacey et al. 2017; Stecker et al. 2016; Wild et al.
2016; Woodhead et al. 2013

Acceptance of disease

Accepting compulsive hoarding syndrome as a mental illness (Singth et al., 2013)
Integrating oneself with being an HIV-positive
patient (Ho et al., 2013)

Becker et al. 2020; Buckingham et al. 2016; Hack et al.
2020; Ho et al. 2019; Moucheraud et al. 2020; Sampson etal. 2013; Singth et al. 2013; Schoenfelder et al. 2017

Negative experiences in
the past

Loss of family members due to substance use(Dillon et al., 2020)
Alcoholic’s experience of failure to get sober(Dillon et al., 2020)

Dillon et al. 2020; Woodhead et al. 2013

Conditions and circumstances that allow patients
to focus on treatment

Milder menopausal symptoms were more involvedin HIV treatment (Solomon et al., 2020)
Well-being of family (Becker et al., 2020)

Becker et al. 2020; McMurran et al. 2010; Solomon et al.
2020

Connecction with
providersOutreach (letters, face-to-face contact, phone calls)(Brenner et al., 2012)
Increased communication between patients andhealth care providers (Jonse et al., 2013a)
School and family connections (Becker et al., 2020)
Hospitals to assess patients at home after discharge
from emergency psychiatric facilities (Brenner et al.,2012)

Aggarwal et al. 2015; Becker et al. 2020; Brenner et al.
2012; Buckingham et al. 2016; Clarke et al. 2014a;
Delaney et al. 2013; George et al. 2016; Goldberg et al.
2020; Jonse et al. 2013a, 2013b; Moucheraud et al. 2020;
Nan et al. 2020; Singth et al. 2013; Stein et al. 2014; Yehet al. 2019Social support

Support from family and friends (Kelly et al., 2010)
Support from community members and better local
environment (Becker et al., 2020)

Becker et al. 2020; George et al. 2016; Jonse et al. 2013a;
Kelly et al. 2010; Monney et al. 2017

Adaptive treatment
systems

Accessibility (Acevedo et al., 2012)
Treatment adjusted to account for participant
preferences (Kern et al., 2014)
Use of social media (Knight et al., 2016)

Acevedo et al. 2012; Aggarwal et al. 2015; Becker et al.
2020; Busch et al. 2018; Collins et al. 2017a; Dillon et al.
2020; Goldman et al. 2018; Guerreo et al. 2013; Kern etal. 2014; Knight et al. 2016; Kwan et al. 2010; Lindhelm
et al 2010; Richwood et al. 2020; Silva et al. 2020; Singth
et al. 2013; Tkach et al. 2019

<Individual elements><Situational elements><Environmental elements>tion between patient and providers” or facilitates “Attitudes
that indicate value and expectations toward treatment”
among youth who have mental health problems. This meansthat behavioral and psychosocial elements also influenceeach other among the attributes. This conceptual model explains that the process described above eventually leads totreatment retention, better clinical outcomes, and, consequently, coping with the disease and treatment.
6 of 14

6. Exemplar
To illustrate the concept of treatment engagement, we identified a pertinent exemplar, drawing on qualitative studies by
Buckingham et al. (2016) and Colins et al. (2017a). The exemplar is a combined story created with reference to priorresearch to illustrate treatment engagement. Lucas (Alias)
was advised by his family to use mental health services tohttps://doi.org/10.53044/jinr.2022-0012

JINR 2023, 2(2), e2022-0012

Table 3. Consequences of treatment engagement.
Characteristic

ExamplesReferences

Treatment retention

Substance users stay in treatment for more than
90 days (Abdel-Salam et a., 2014)

Abdel-Salam et al. 2014; Clarkson et al. 2014; Collins et al.
2017a; Moucheraud et al. 2020

Better clinicaloutcomes

Improved depression in patients with depression(Skilbeck et al., 2020)
Reduced illegal drug use among substanceabusers (Gouse et al., 2016)
Enhanced quality of life for girls detained in jail
(Lore et al., 2015)

Brenner et al. 2012; Garnick et al. 2013; Gouse et al. 2016; Goodson et al. 2019; Harris et al. 2010; Kwan et al. 2010; Lindhelm et
al 2010; Lore et al. 2015; Nan et al. 2020; Simeone et al. 2017;
Skilbeck et al. 2020

Coping with disease
and treatment

Introspection of patients with hepatitis C throughpsychosocial support (Woodhouse et al., 2013)

Kraviz et al. 2013; Woodhouse et al. 2013

Antecedents<Individual elements>
・Knowledge about diseases
and treatment
・Attitudes toward disease andtreatment
・Acceptance of the disease<Situational elements>
・Negative experiences in thepast・Conditions and circumstances that allow patients tofocus on treatment<Environmental elements>
・Connection with providers
・Social support
・Adaptive treatment system

Attributes<Behavioral elements>
・Initiation of treatment
・Continuation of treatment
・Adherence torecommendations intreatment

Consequences
・Treatment retention
・Better clinicaloutcomes・Coping with disease
and treatment<Psychosocial elements>
・Attitudes that indicate value
and expectations toward
treatment
・Cooperation with peers
・Collaboration between patientand providers

Figure 1. Results of the concept analysis of treatment engagement.

treat his drug addiction. At first, he was reluctant to use
mental health services because he was concerned about what
others would think. However, he gradually developed attitudes that indicate value and expectations toward treatment,
wanting to change his situation and communicating hisneeds to his supporters. Additionally, he set goals for histreatment with his health care providers and shared his plans
with them. In this way, he continued his treatment for morethan 3 months while following the instructions of the medical staff and is now living independently in the community
without using illegal drugs.
7. Related Terms and Surrogate Terms
Related terms refer to concepts that are related in some way
to the target concept but do not share the same attributes(Rodgers & Knafl, 2000). As related terms for treatment engagement, “Adherence,” “Patient participation,” and “Patientengagement” were identified (Drew et al., 2016; Kern et al.,2014; Shrestha et al., 2017). “Adherence” is defined as “theextent to which a person’s behavior-taking medication, following a diet, and/or executing lifestyle changes correspondswith agreed recommendations from a health care provider”(WHO, 2003). “Adherence” is similar to treatment engagement in that it focuses on treatment behaviors such as medical examinations, taking medication, and self-management
and emphasizes the psychological aspect of a positive attitude toward treatment and relationships with health careproviders (WHO, 2003). Conversely, “Adherence” has astrong connotation of continuation of treatment behavior because it targets chronic diseases for which treatment is relatively long-term, whereas treatment engagement often targets
populations for which it is difficult to initiate treatment, and
it is about not only the continuation of treatment but also
the initiation of treatment. Hence, treatment engagement encompasses both continuation and initiation of treatment.
Therefore, although treatment engagement and adherence are
related, they are considered to be different concepts.
“Patient participation” is defined as a “patient’s rights and7 of 14JINR 2023, 2(2), e2022-0012

opportunities to influence and engage in the decision making about his care through a dialogue attuned to his preferences, potential and a combination of his experiential andthe professional’s expert knowledge” (Castro et al., 2016).
“Patient participation” is similar to treatment engagement inthat it emphasizes the psychological aspect of a positive attitude toward treatment and the relationship with health careproviders (Castro et al., 2016). Conversely, “Patient participation” does not include the behavioral elements of the patient among its attributes, whereas treatment engagement
differs in that it includes the behavioral elements of initiation or continuation of treatment. Additionally, although“Patient participation” focuses on decision making in treatment (Castro et al., 2016), treatment engagement is different
in that it focuses on receiving treatment. Therefore, althoughtreatment engagement and “Patient participation” are related,
they are considered to be distinct concepts.
“Patient engagement” is defined as “the desire and capability to actively choose to participate in care in a way
uniquely appropriate to the individual in cooperation with ahealthcare provider or institution for the purposes of maximizing outcomes or experiences of care.” (Higgins et al.,2016). “Patient engagement” is considered to be similar totreatment engagement in that it emphasizes the psychological aspect of a positive attitude toward treatment and the relationship with health care providers (Higgins et al., 2016).
Conversely, “Patient engagement,” like patient participation,
does not include patients’ behavioral elements among its attributes, whereas treatment engagement differs in that it includes the behavioral elements of initiation and continuationof treatment. Therefore, although treatment engagement and“Patient engagement” are related, they are considered to bedifferent concepts.
Additionally, a surrogate term refers to a semantic meansof expressing a concept in a language other than the one
chosen for analysis (Rodgers, 2000). Because treatment engagement was found to be a multidimensional and comprehensive concept, no adequate surrogate terms were identified.

Discussion
1. Theoretical Definition
In this study, we conducted a concept analysis of treatment
engagement using Rodger’s evolutionary method of concept
analysis (Rodgers & Knafl, 2000). Consequently, the attributes of treatment engagement were extracted as behavioral
elements, initiation of treatment, continuation of treatment,
and adherence to recommendations in treatment, and as psychosocial elements, attitudes that indicate value and expectations toward treatment, cooperation with peers, and collaboration between patients and providers. Based on these results, treatment engagement was defined as “the process of
8 of 14https://doi.org/10.53044/jinr.2022-0012

initiating and continuing treatment, and adhering to treatment recommendations, in cooperation with peers and incollaboration with supporters, accompanied by attitudes thatindicate value and expectations toward treatment,” This definition indicates that treatment engagement is a comprehensive and multidimensional concept that includes many elements.
2. Characteristics of the Concept
The six attributes of treatment engagement were divided into
two dimensions, namely, behavioral and psychosocial elements. Many of the previous studies analyzed targeted the
behavioral elements, and because these behavioral elements
are factors that directly affect clinical outcomes (Brenner etal., 2012; Colins et al., 2017), they are considered to be important for explaining treatment engagement.
Regarding the psychosocial elements of the attribute, “attitudes that indicate value and expectations toward treatment,” was extracted and bore similarities to the individual
element among the antecedents of “attitude toward disease
and treatment.” The difference between the two is that only
positive content was extracted for the attribute attitudes thatindicate value and expectations toward treatment, whereas acontent, both positive and negative, was extracted for the antecedent. Therefore, the characteristics of treatment engagement, in terms of patient attitudes toward treatment and disease, encompass both positive and negative attitudes in theprocess toward reaching a point of treatment engagement,
but when patients are engaged in treatment, the characteristics are accompanied by positive attitudes.
Additionally, studies by Buckingham et al. (2016) andColins et al. (2017) have shown that behavioral and psychosocial elements influence each other, and these elements are
considered to be dynamic and contextual in nature. Therefore, as indicated in the previous definition, treatment engagement may be a process rather than a state at a single
point in time. Given this, future studies should examine indetail the attributes as they relate to the process of treatment
engagement.
Furthermore, a unique aspect of the concept of treatment
engagement is that the behavioral component includes “initiation of treatment” and “continuation of treatment,” whichcarry meanings particular to different contexts. In the articles extracted for this study, only a few references used “initiation of treatment” and “continuation of treatment” together within their concept of “treatment engagement” (e.g.,Catherine et al., 2013), and most articles focused on one or
the other. In many articles, the context in which each element is used varies. For example, “initiation of treatment” is
an attribute of treatment engagement used in situations
where treatment is unlikely to be initiated, and “continuationof treatment” is used in situations where treatment is unlikely to be continued treatment engagement attribute used

https://doi.org/10.53044/jinr.2022-0012

in situations where treatment is difficult to continue. In otherwords, the fact that they have multiple attributes with different contexts of use also suggests that their meaning may not
be understood by the reader if they are just described astreatment engagement. Therefore, it was believed that treatment engagement should be explicitly defined, especially forstudies that are focused on such behavioral elements of theconcept.
3. Related Theories
Theories related to treatment engagement include those related to health behavior, such as the health belief model, thetheory of planned behavior, and empowerment theory (Dillon et al., 2020; Stecker et al., 2010). In the health belief
model and the theory of planned behavior, patients’ attitudes
toward disease and treatment are considered to be among
the factors that explain health behaviors such as willingness
to undertake medical examinations, which is consistent withthe results of this study. Additionally, empowerment theory
captures the concept of patients’ positive attitudes toward
treatment and their relationships with health care providers,which is consistent with the results of this study. However,these theories do not comprehensively explain the antecedents, attributes, and consequences of treatment engagement,
and the construction of a theory unique to the concept oftreatment engagement is required in the future.
4. Application to Clinical Practice and Further Research
Concept analysis clarifies the structure of a concept, which
in turn elucidates what antecedents are necessary to promote
the attributes that are the central properties of the concept.
Among the antecedents described in this study “building relationships between patients and health care providers” isthe foundation of treatment engagement, which promotes theachievement of patient goals and well-being (George et al.,2016). Nurses have a role to play in supporting treatment
engagement through health screenings, medical examinations, and outpatient settings (Whittemore, 2013). Therefore,
it was considered important for nurses to build a trusting relationship with patients and encourage them to build positive
attitudes and behaviors toward treatment collaboratively.
Although the qualitative contents of treatment engagement
were clarified and a theoretical definition of that was outlined in this study, this concept should be measurable forfurther research. Measuring the extent of this qualitative
content of treatment engagement will help to clarify its relationship with other concepts. This process is a necessary
part of testing theories or models of treatment engagement.
Developing the scale of treatment engagement will be also
useful for nursing practice, as it can serve as an indicatorfor evaluating treatment engagement in specific intervention
programs. There are several measures of treatment engagement that have been developed, including the Service En-

JINR 2023, 2(2), e2022-0012

gagement Scale (Tait et al., 2002), which measures engagement with community mental health services, and the Treatment Engagement Rating Scale (Drieschner & Boomsma,2008), which measures offender treatment engagement.
However, both of these are assessed by professionals. A
scale that incorporates subjective evaluations of treatment
engagement by the patients would be appropriate, because,in this study, we extracted attributes of treatment engagement that included the patients’ perspective, such as positive
attitudes toward treatment.
Additionally, most articles analyzed in this study focusedon the attributes and antecedents of treatment engagementand did not examine what might happen after treatment engagement was achieved. Thus, examining the consequencesof treatment engagement will contribute to the developmentof the concept in the future.
5. Limitations
This study was conducted using English-language articles
only, which may have restricted the scope of the literature
retrieved. There is a possibility of expanding the scope ofthe study beyond English language publications and deepening our understanding of the concept of treatment engagement as it applies to specific cultural contexts.
Moreover, it may be necessary to be careful in applying
these results in various fields because there was a significant
proportion of papers in the mental health field. This implies
that the final concept and model may be useful for such a
population.
Additionally, this study did not evaluate the quality ofeach article that was included in the final analysis. In the future, it may be beneficial to consider the quality of the collected literature to maintain the accuracy of the concept
analysis.

Conclusion
In this study, we conducted a conceptual analysis of treatment engagement. Consequently, six attributes, eight antecedents, and three consequences were extracted. Treatment engagement was defined as “the process of initiating and continuing treatment, and adhering to treatment recommendations, in cooperation with peers and in collaboration withsupporters, accompanied by attitudes that indicate value andexpectations toward treatment.” In clinical practice, ourdeepened understanding of the concept of treatment engagement suggests the important role that nurses and other
health care workers have in building trusting relationships
with patients and encouraging positive behavioral and psychosocial aspects of treatment.
Author Contributions
All authors have agreed on the final version and meet at
9 of 14JINR 2023, 2(2), e2022-0012

least one of the following criteria [recommended by the ICMJE (https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contribut
ors.html)]: substantial contributions to conception and design, acquisition of data, or analysis and interpretation of
data; drafting of the article; or critical revision of the ariticle
for important intellectual content.
Declaration of Conflicting Interests
The authors have no conflicts of interest that are directly
relevant to the content of this article.
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https://doi.org/10.53044/jinr.2022-0033
https://www.jinr.jsnr.or.jp/

Review Article

Nursing care for people with concurrent heart failure and diabetes: A
scoping review
Yusuke Yamazaki, RN, BNS1,2 , Sumie Kuroda, RN, PhD3 , and Misaki Sawaoka, RN, MSN3
1

Department of Nursing, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan, 2Programin Health and Welfare, Graduate School of Comprehensive Scientific Research, Prefectural University ofHiroshima, Mihara, Japan, and 3Nursing Course, Faculty of Health and Welfare, Department of Health andWelfare, Prefectural University of Hiroshima, Mihara, Japan

Abstract
There has been an increasing number of people with heart failure (HF) and with diabetes mellitus (DM). The number of people with concurrent HF and DM (HF-DM) is also expected to increase because of the strong relationship between both diseases. Several systematic reviews and meta-analyses have evaluated nursing care for each
HF and DM, but none have been retrieved on nursing care for people with HF-DM. This study reviewed and categorized the literature on nursing care for people with HF-DM and aimed to identify the scope of further researchthat is still required. A scoping review was conducted following the framework of Arksey and O’Malley (2005). A
broad range of keywords was used to systematically search the PubMed, MEDLINE, CINAHL, and Ichushi-Web
databases for topics on nursing care for people with HF-DM. A total of 957 articles were retrieved, and 11 papers
were ultimately accepted. Three of the 11 papers were randomized controlled trials (RCTs), which used integrated
program interventions for people with HF-DM to some efficacy. For the remaining papers, a qualitative synthesis of
the data identified six categories. Although a program integrating HF-DM presented a certain level of effectiveness,many of the nursing suggestions lacked specificity. Moreover, few RCTs have been conducted, which indicates theneed for further research. This study also indicated the importance of collecting practical knowledge from advanced nurse practitioners and developing guidelines on nursing assistance for HF-DM.
Keywords
diabetes mellitus, heart failure, nursing care, scoping review
JINR 2023, 2(2), e2022-0033

Worldwide, the number of people with diabetes mellitus(DM) is increasing every year. In 2021, 537 million people
were expected to have DM, and by 2045, the number is expected to increase to 784 million people (International Diabetes Federation, 2021). In Japan, the number of people
with DM is also increasing, with the number of “persons
strongly suspected of having DM” estimated at approximately 10 million (Ministry of Health, Labour and Welfare,2017). The number of people with heart failure (HF) is also

on the rise. The current 5.7 million people with HF in the
United States are projected to increase to more than 8 million by 2030, whereas prevalence is expected to increase by
46% (Virani et al., 2021). The number of people with HF in
Japan is similarly increasing and is estimated to reach 1.3
million by 2035 (Okura et al., 2008). The relationship between HF and DM is profound, with the incidence ofchronic HF in people with DM being twice as high in men
and five times higher in women than in people without DM

Correspondence: Y. Yamazaki. Email: yamazaki.y.119@gmail.com
Received: September 29, 2022, Accepted: March 26, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 13JINR 2023, 2(2), e2022-0033(Kannel et al., 1974). In an HF cohort study that includes
both HF with reduced ejection fraction and HF with preserved ejection fraction, the prevalence of DM was reported
to range from 10% to 47% (From et al., 2006; Shindler etal., 1996; Cleland et al., 2003; Dei Cas et al., 2014; Sandesara et al., 2018). The frequency of complications of DM
was 30.7% in Japan (Hamaguchi et al., 2009). In people
with DM, the prevalence of HF ranged from 9% to 22%,
which was four times higher than that in people without
DM (Nichols et al., 2004). Against the background of increasing figures for both HF and DM, those for HF-DM arealso expected to increase globally.
To prevent exacerbations of both HF and DM, self-care isnecessary, and people must maintain good glycemic control
to prevent exacerbations of HF (Kishimoto et al., 2014). The
American College of Cardiology (ACC) and American Heart
Association (AHA) HF stages define HF as the stage at risk
for HF, such as DM or ischemic heart disease. However, instages C and D, which are symptomatic HF, physical function is compromised and symptom management is required;doing self-care is even more important to prevent recurrence. DM requires management of a DM diet, DM medication, monitoring of blood glucose levels, daily physical activity, monitoring of hypoglycemic symptoms, and foot care
(Kerr et al., 2007). Additionally, HF requires following a
low-sodium diet, taking HF medications, performing and interpreting daily weight measurements, engaging in physicalactivity, and monitoring symptoms of dyspnea, fatigue, andedema (Heart Failure Society of America, 2010). Nevertheless, approximately half of the people with DM have inadequate glycemic control (Japan Diabetes Clinical Data Management Study Group, 2019) and low self-care adherence(Peyrot et al., 2005), which suggests difficulties in implementing self-care. Moreover, people with HF have a highrate of rehospitalization within a year after discharge, andinadequate self-care to prevent the worsening of symptoms
is a problem (Tsutsui et al., 2006). These indicate that thecurrent situation makes self-care challenging for people with
HF or DM alone. When both diseases are present, self-carebehaviors become more complex, especially competing recommendations for diet, medications, and symptom management (Cha et al.,2012). Furthermore, the presence of HF
may lead to a reduction in self-care priorities and capabilities for DM (Kerr et al., 2007). For these reasons, it is noteasy for people with HF-DM to balance the self-care behaviors of both diseases, and it is important to support peopleby viewing them as people with HF-DM. Nursing includes
the promotion of health, prevention of illness, and the careof ill, disabled, and dying people (International Council of
Nurses, 2023). Therefore, for those with complex self-carerequirements, nurses are the optimal self-care providers, andthe care they provide, nursing care, is important for people
with HF-DM.
2 of 13https://doi.org/10.53044/jinr.2022-0033

Several systematic reviews and meta-analyses have separately evaluated nursing care for people with HF and DM(Daly et al., 2017; Lambrinou et al., 2012; Niu et al., 2021;
Qiu et al., 2021; Rice et al., 2018; Son et al., 2020; Welchet al., 2010; Yu-Mei Chen et al., 2019). Nevertheless, nursing care for people with HF-DM is yet to be evaluated bystudies. The American Heart Association and the HF Societyof America summarizes the epidemiology, pathophysiology,
and impact of DM on HF outcomes in people with concurrent type 2 DM and HF and also reviews the evidence forpharmacotherapy, such as hypoglycemic agents, the effects
of exercise therapy, and the need for team-based care (Dunlay at al., 2019). However, it was not a focused analysis ofnursing care. Thus, this study reviewed and organized theexisting literature on nursing care for people with HF-DM
and aimed to identify the scope of further research that isstill required.

Methods
A scoping review was used as the research method. A scoping review adopts a broad view of the nature of the research
topic, integrates existing knowledge without being bound by
the research design, and maps differences and deficiencies inexisting research findings (Munn et al., 2018). This study
followed the framework of Arksey and O’Malley (2005),
which implements the following steps: 1) identifying the research question; 2) identifying relevant studies; 3) selecting
studies; 4) charting the data; 5) collating, summarizing, andreporting the results. We used the Population/Concept/Context (PCC) framework for this review. The PCC framework
is recommended by the Joanna Briggs Institute, which is developing guidance for scoping reviews, to identify the mainconcepts in our primary review questions (Joanna Briggs Institute, 2020). The framework was defined as follows: Population: people with HF-DM; Concept: nursing care; andContext: any hospital department, including outpatient, inpatient, and community. HF was defined as symptomatic HF,
that is, ACC/AHA HF stages C and D. Additionally, nursing
care was defined as care practiced by nurses for people.
Identifying the Research Question
Primary review questions were defined according to the
PCC framework that was set.
“What is effective nursing care and suggestions for people with HF-DM?”
Identifying Relevant Studies
To identify relevant studies, we searched the PubMed,
MEDLINE, and CINAHL (for European literature) andIchushi-Web (for Japanese literature), the latter of which is
updated by the nonprofit, nongovernment organization Japan
Association for Medical Abstracts. A literature search washttps://doi.org/10.53044/jinr.2022-0033

conducted on these databases on January 22, 2021. The following search formulas were used:a) PubMed/MEDLINE/CINAHL: “TI diabetes” AND (“TIHeart failure” OR “TI heart disease”) AND (“care” OR“nurse” OR “nursing”); andb) Ichushi-Web: “TI tonyobyo (diabetes)” AND {“TIshinfuzen (heart failure)” OR “TI shinzobyo (heart disease)”} AND {“kango (nurse or nursing)” OR “kea (care)”}.
Selecting Studies
In selecting studies in a scoping review, the adoption criteria
are set before the start of the study, and two reviewers independently decide whether to adopt the article. The same procedure was followed in this study. Based on the established
PCC framework, the inclusion criteria were a) describednursing care for people with HF-DM, b) research article,
and c) published in English or Japanese, regardless of thetype, quality, or location of the study (outpatient, ward,
community, etc.). The exclusion criteria were a) abstract notregistered in the database and b) article not available.
For the primary screening, two researchers independently
checked whether the retrieved articles met the criteria for inclusion based on the title and abstract of the article. The results of the two researchers were cross-checked, and if theiropinions differed, a third researcher was consulted to discuss
the results with the other two and decide whether to include
the article. In cases where no clear decision could be made,the article was included. In the secondary screening, the fulltext was obtained, and two researchers independently confirmed whether the inclusion criteria were met. If the two
researchers disagreed, the third researcher was again consulted to determine the final articles to be included.
Charting the Data
The data extracted were as follows: author, year of publication, country, purpose, study design, participants, sample
size, and major findings in the study. Additionally, descriptions and implications regarding effective nursing care forpeople with HF-DM were extracted from the sections corresponding to the results, discussion, and conclusions of theresearch article. For randomized controlled trials (RCTs), thedata extracted were the intervention content, eligibility criteria, exclusion criteria, outcome measures, and effect of theintervention. Two researchers independently confirmed thedata extraction, and in cases of disagreement, a third researcher was called in to discuss and decide on the data extracted.
Collating, Summarizing, and Reporting the Results
For RCTs, the extracted data were summarized. Additionally, we decided to examine the effectiveness of the RCTs
by critically evaluating them according to the Mixed Methods Appraisal Tool (MMAT, version 2018), which was de-

JINR 2023, 2(2), e2022-0033

veloped to critically appraise different study designs (Honget al., 2019). The MMAT allows for a critical appraisal
process in reviews of systematic mixed studies, by providing
methodological quality criteria for different study designs,
within a single tool.
For other studies, qualitative integration of the data was
performed. All the data obtained from the search results
were carefully read to extract statements on the implicationsof nursing care for people with HF-DM. The results of theextracted studies were categorized according to similarity.

Results
Identification of the Relevant Studies and Eligibility
Figure 1 shows the flow diagram of the article selection
process. In this study, 957 articles were retrieved: 352 fromMEDLINE, 442 from PubMed, 154 from CINAHL, andnine from Ichushi-Web. Of 485 valid papers, we excluded
472 duplicates to include a final total of 11 papers (Table1). Ten papers were published in English, whereas one waspublished in Japanese. The types of studies included ninequantitative studies, one qualitative study, and one mixed
study, of which three were RCTs. All participants were patients. Furthermore, nine of the 11 papers were published after 2014.
Data Charting and Reporting
Summarizing the RCTs
Of the three RCTs, the Reilly et al. (2015) study was a secondary analysis of the Dunbar et al. (2015) study; thus, twoof the studies actually implemented interventions. Two
screening questions obtained from the MMAT manual wereapplied to two RCTs, that is, “Are there clear research questions?” and “Do the collected data address the researchquestions?”; all of the RCTs satisfied the two screening
questions. Regarding MMAT scores, the Dunbar et al.
(2014) study was Yes (4/5) and Cannot tell (1/5), whereas
the Dunbar et al. (2015) study was Yes (4/5) and Cannot tell
(1/5).
The participants were people with HF-DM who were
either hospitalized or attending outpatient clinics. The interveners were trained nurses, and the interventions were notstand-alone but were delivered on multiple occasions on an
ongoing basis. The interventions were conducted with individual education and counseling, phone calls, with bothstudies further conducting home visits. The educational tools
were designed to integrate data on HF-DM and written at
the elementary school reading level. They also included information on the pathogenesis and interactions of HF-DM,
diet, activities, medications, oral care, foot care, smoking,and self-monitoring. Knowledge, self-efficacy, self-care behaviors, and quality of life (QOL) were the outcome measures used by Dunbar et al. (2014), whereas QOL, 6-minute
3 of 13

Included

Eligibility

Screening

Identification

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Records identified through database searching (N = 957)
MEDLINE (n = 352)
CINAHL (n = 154)
PubMed (n = 442)
Ichushi-Web (n = 9）
Records excluded as
duplicates(n = 472)
Records screened(n = 485)
Records excluded
based on title and abstract(n = 466)
Full-text articles assessed
for eligibility(n = 19)

Records includedin the final analysis(n = 11)Full-text articles excluded,with reasons(n = 8)1.
Nursing care notdescribed(n = 6)2.
Care of a single disease(n = 2)

Figure 1. Flow diagram of the study selection process.

walk test (6MWT), Community Healthy Activities Model
Program for Seniors were used by Dunbar et al. (2015). Alternatively, Reilly et al. (2015) used resource use and cost
determination and effectiveness measures. The effects of theintervention in the Dunbar et al. (2014) study were HF
knowledge at 30 days after intervention, improved HF selfcare maintenance at 30 days after intervention and sustained
to 90 days after intervention, improved self-care management at 90 days after intervention, improved DM selfefficacy at 30 and 90 days after intervention, improved selfreported general diet and exercise at 30 days after intervention, and improved foot care by 90 days after intervention.
However, no effects were observed on DM knowledge, DMspecific QOL, and HF self-efficacy. Moreover, the effects of
the intervention in the Dunbar et al. (2015) study included
greater improvements in HF total, physical, and emotional
QOL and general QOL. The effects of the interventions
were also observed in improved physical function, as measured by the 6MWT and self-reported physical activity. However, no effects on DM QOL were observed. The study by
Reilly et al. (2015) demonstrated dominance in loweringcosts without sacrificing quality-adjusted life years.
Qualitative Categorization and Nursing Suggestions for People with HF-DM
Six categories were generated by categorizing the descriptions of nursing suggestions for people with HF-DM extracted from eight studies (excluding RCTs) according tosimilarity (Table 2).
4 of 13Development of Education Guidelines that Integrate HF-DM
Management
The need to develop education guidelines that integrate HF
and DM management, rather than separate them, was mentioned.
A study examining the follow-up of people with HF-DM
found that DM management should be given the same importance as HF management due to the lack of professional
intervention for DM both during hospitalization and after
discharge (Wu et al., 2018). Conversely, the study also
found that people with HF-DM comorbidities who participated in the HF-only program had better DM self-care behaviors. This suggests that as people with HF age and develop more comorbidities, such as DM, an important strategy for improving the treatment of HF-DM is to consider
HF disease management (Ware et al., 2006). The need for
integrated interventions focusing on HF-DM was also described in a study that investigated self-care determinants inpeople with HF-DM (Aga et al., 2019) and in another that
identified predictors of DM self-care behavior (Ausili et al.,2016). Nevertheless, although the abovementioned studies
emphasized the need for integrated interventions for HFDM, they did not mention specific interventions.
In the aim to describe more specific nursing suggestions,the authors found that people with HF-DM had a significantly lower carbohydrate intake but a higher sodium intake
than people with HF alone and consequently proposed theneed to develop standardized dietary guidelines for people

To test an integrated self-care intervention
on outcomes of QOL, physical function,and physical activity in HF and DM

To conduct a prospective cost-effective
analysis of a randomized clinical biobehavioral trial focused on improving comorbid
self-care for people with HF-DM

USA

USA

USA

USA

ITA

Cha et al.,2012

Dunbar etal., 2014

Dunbar etal., 2015

Reilly etal., 2015

Ausili etal., 2016(3) To identify sociodemographic and clinical determinants of self-care maintenance,
self-care management, and self-careconfidence in patients with HF-DM(2) To determine whether the presence of
DM influences self-care maintenance,
self-care management, and self-careconfidence of HF patients; and(1) To compare self-care maintenance,
self-care management, and self-careconfidence of patients with HF-DM versus
patients with HF without DM;

To develop and test an integrated self-care
education and counseling program for its
short-term effects on self-care antecedents
and behaviors; to examine the feasibility ofsuch an integrated intervention

To explore the need for self-monitoring andself-care education in patients with HF-DM
by describing cognitive and affective
factors to provide guidance in developing
effective self-management education

To test the hypothesis that a focus on HF
care may be associated with inadequate
DM careUSA

Ware etal., 2006

PurposeCountry

Author (s)(Year)

Table 1. Studies included in the scoping review.

Secondary analysis of datafrom a multicentercross-sectional
study

Randomized
controlled trial(secondary
analysis of data)

Randomized
controlled trial

Randomized
controlled trial

Cross-sectional,
correlational
design(n = 1,192; with DM, n = 379)

Adults with a confirmed
diagnosis of HF

Same as S. Dunbar et al.
(2015)(n = 134; usual care, n = 64;
intervention, n = 70)

Patients with HF-DM (aged21–80 years)(n = 65; usual care, n = 19;
intervention, n = 46)

Patients with HF-DM (aged21–80 years)(n = 116; HF, n = 70; HF-DM,
n = 46)

NYHA Class II & III persons
with HF

Self-care was poor in patients with HF-DM. Statistically significant differences were
found in self-care maintenance, self-care management, and self-care confidence inpatients with HF with and without concurrent DM. The presence of diabetes did not
influence self-care maintenance, self-care management, or self-care confidence. Age,
number of medications, presence of a caregiver, family income, and self-care confidence
were determinants of self-care maintenance. Sex, number of medications, and self-careconfidence were significant determinants of self-care management. The number of
medications and cognitive function were determinants of self-care confidence.

The self-care intervention demonstrated dominance in lowering costs without sacrificing
quality-adjusted life years.

An integrated HF and DM self-care intervention improved perceived HF and general
QOL but not DM QOL. Improved physical functioning and self-reported physicalactivity (PA) were also observed with the integrated self-care intervention. Those who
received an integrated self-care intervention experienced greater improvements in HF
total, physical, and emotional QOL, and general QOL, but not DM QOL, when compared with a usual care attention control group. Additional effects observed included
improved physical function as measured by the 6-minute walk test and self-reported PA.

An integrated HF-DM self-care intervention was effective in improving essential components of self-care and had sustained (90 days) effects on selected self-care behaviors. The
data revealed that the integrated HF-DM self-care intervention conferred effects on HF
knowledge at 30 days, improved HF self-care maintenance at 30 days and sustained to 90
days, improved self-care management at 90 days, improved DM but not HF self-efficacy
at 30 and 90 days, improved self-reported general diet and exercise at 30 days, andimproved foot care by 90 days.

Patients with HF-DM were older, heavier, had more comorbidities, and took more daily
medications than HF patients. High self-efficacy on medication and low sodium diet wasreported in both groups with no significant difference. Although HF-DM patients took
more daily medications than HF, both groups exhibited high HF medication-taking
behaviors. The HF-DM patients consumed significantly lower total sugar than HF
patients, but clinically higher levels of sodium.

Ninety-five percent of patients had hemoglobin A1c levels measured within 12 months,
and 71% monitored their glucose at least once daily. Most patients received counselingregarding a diabetic diet and exercise, and approximately 80% reported receiving regulareye and foot examinations. The mean hemoglobin A1c level was 7.8% ± 1.9%. Patients inan HF disease management program demonstrated levels of diabetic care close to American Diabetes Associations’ goals.

Patients with DM enrolled inan HF disease management
programSingle-center,
prospective
observational
study(n = 78)

Major findings

Participants (n)Study design

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UK

USA

USA

JPN

USA

Wu et al.,2018

Aga etal., 2019

McCants
et al.,
2019

Yamazaki
et al.,
2019

Aga etal., 2020

To describe sociodemographic and clinicalcorrelates of DM self-efficacy in T2D
adults with comorbid HF

To clarify the experiences associated withthe care behaviors of patients with HF-DM
with poor glycemic control

To determine the impact of integrated casemanagement services versus treatment as
usual for patients diagnosed with HF-DM

To describe sociodemographic, clinical,
and psychosocial correlates of DM self-carebehaviors in adults with HF-DM(3) To explore patient experiences ofadmissions(2) To assess the use of an integrated careapproach for patients with HF-DM during
the index HF-related admission; and(1) To assess the differences in the numberof hospital readmissions between patientswith HF and patients with HF-DM;

PurposeCorrelational
design (secondary analysis ofdata)

A qualitative
study;
semi-structured
interviews

A retrospective,
descriptive, andcomparative
analysis

Cross-sectional,
correlational
design (Secondary analysis ofdata)

Mixed methods
approach

Study design

Same as F. B. Aga et al.
(2019)(n = 10)

Patients with HF-DM withpoor glycemic control(n = 68)

Patients diagnosed with
HF-DM

Patients with HF-DM (aged21–80 years; n = 180)(3) Patients with HF-DM who
had current or recent admissions (n = 14)(2) Both conditions of DM and
HF; ≥18 years old; with anejection fraction of <45% at
the index admission (n = 72);

(1) Patients with HF (n = 370;
with concurrent DM, n = 172);

Participants (n)Good self-rated health and the presence of an implantable cardioverter-defibrillator hadsignificant positive relationships with DM self-efficacy. Conversely, taking both oral
anti-glycemic medication and insulin, a history of depression, having a cardiac pacemaker, and taking digitalis were negatively correlated with DM self-efficacy. Patients ofAfrican American descent with HF-DM had significantly lower diabetes self-efficacy
scores compared with their White counterparts. A significant negative correlation was
found between LVEF and DM self-efficacy scores. Patients with HF-DM without
end-organ failure had significantly higher mean DM self-efficacy scores compared withthose with end-organ failure.

For the experiences associated with self-care behaviors, 14 categories were obtained,
including “struggling to balance the different and conflicting treatment behaviors ofdiabetes and heart failure,” “equating treatment behaviors of diabetes and heart failure,”“judging criteria for treatment behaviors based on changes in numerical values andsubjective symptoms,” and “priority for heart failure based on severe physical symptoms
and awareness of death.”

In the integrated case management group, 18.4% were readmitted, whereas 81.6% were
not. In the treatment as usual group, 52.6% were readmitted and 47.4% were not.
Integrated case management services were statistically significant in reducing readmission for the sample.

The number of comorbidities > 2 (p <.001), having more than a high school education (p<.05), and African American ethnicity (p <.05) predicted better exercise, SMBG, and footcare behaviors, respectively. The use of an aldosterone inhibitor (p <.05) predicted worse
exercise performance, higher Charlson Comorbidity Index scores (p <.01) worse SMBG,
and treatment with diet plus medication (p <.05). Dyslipidemia (p <.001) predicted worse
foot care.

Over a 12-month period, patients with HF-DM had more HF-related accident andemergency attendance episodes and hospital readmissions than patients with HF. We
reviewed 72 medical records, which met the inclusion criteria during admission. Most ofthem were reviewed by HF specialists, but less than one-third were reviewed by DM specialists. The interview respondents addressed the need for better integration and coordination of care.

Major findings

HF: heart failure; DM: diabetes mellitus; T2D: Type II diabetes; HF-DM: heart failure with diabetes mellitus; SMBG: self-monitoring blood glucose; LVEF: left ventricular ejection fraction.

Country

Author (s)(Year)

Table 1. Studies included in the scoping review (continued).

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with HF-DM (Cha et al., 2012). Additionally, Yamazaki etal. (2019) revealed the experience of HF-DM who try tofind commonalities and perform them in a simplified manner without distinguishing them rather than considering andexecuting self-care behaviors for both diseases individually.
They also recognized the need to help simplify self-care behaviors for both diseases by integrating self-monitoring toolsthat record the results of measurements, such as weight andblood glucose levels, and by focusing on the treatment
methods common to both diseases, such as diet and exercise.
Consideration for Contradictions and Conflicts Between HF
and DM Management
The need for consideration of the different and sometimes
conflicting management methods for HF-DM was identified.
Cha et al. (2012) found that people with HF-DM tended
to have a significantly lower carbohydrate intake but ahigher sodium intake than people with HF alone. Accordingly, they stated that nurse educators need to realize thisgap and assess people’s current knowledge, confidence,skills, and behaviors related to the requested treatment regimens for both conditions. They further suggested that strategies to solve problems and barriers should be included inself-management education. Yamazaki et al. (2019) described the self-care experience of people with HF-DM who
struggled to balance the conflicting self-care behaviors required to control HF and DM respective diseases. The study
also recommended the fact that people are required to undergo conflicting treatments and are easily confused in theirperception of their disease.
Individualized Approach
The need for an individualized approach, rather than a onesize-fits-all one, to people with HF-DM was recognized.
An investigation on the predictors of DM self-care behaviors in people with HF-DM suggests the importance of using the available resources for self-monitoring of blood glucose (SMBG) and tailoring DM self-care education to thepeople’s level of understanding, considering that higher education is associated with higher rates of SMBG implementation (Aga et al., 2019). Based on the self-care behavior experiences of people with HF-DM, Yamazaki et al. (2019)highlighted the need to understand how people deal with
HF-DM and what their current perceptions are of the “disease trajectory,” as well as to understand the disease phaseof the people through sufficient dialog. They also mentioned
the need to strengthen DM self-care support using numericalvalues and subjective symptoms, as well as to help people
take an interest in their own bodies.
Interventions Based on Appropriate Screening for Self-CareRisks
The need to intervene after screening people with HF-DM
for risks that may affect self-care was cited.
In a study investigating self-care among people with HF-

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DM, the determinants of self-care maintenance, self-caremanagement, and self-care confidence, each of which constitutes self-care in people with HF, were identified (Ausili etal., 2016). Age, number of medications, presence of acaregiver, family income, and self-care confidence were determinants of self-care maintenance. Gender, number of
medications, and self-care confidence were determinants ofself-care management. Number of medications and cognitive
function were determinants of self-care confidence. Thesefindings indicate that systematic assessment, especially assessment of self-care confidentiality, is important to identify
people at risk for inadequate self-care. The results further
showed that the rate of SMBG implementation decreased
with increasing comorbidity, suggesting that DM self-caremanagement becomes more complex with more comorbidities, which increase the psychological and economic burden
and predisposition to depression (Aga et al., 2019). Moreover, a study that investigated the relationship between DM
self-efficacy and health status revealed that DM self-efficacy
was higher in people with a higher self-evaluation of theirhealth status, suggesting that people with low health awareness need special support to increase their DM self-efficacy(Aga et al., 2020). The study also stated that depressive
symptoms should be regularly assessed and alleviated since
they are associated with DM self-efficacy.
Professional Cooperation and Collaboration Between HF
and DM Teams
For people with HF-DM, the respective teams for HF andDM should not only be involved with the people separately
but also need to cooperate and collaborate. Furthermore,
nurses need to coordinate between the two teams.
A study assessing the current status of people with HFDM after discharge from the hospital found that 69.4% of
people were followed up in the HF clinic after discharge,
but only 2.8% were referred to the DM clinic (Wu et al.,2018). The results also indicate that professionals from multidisciplinary teams need to take a coordinated and integrated approach to people with HF-DM. Furthermore, considering that people with HF-DM have self-care behavior
experiences that require support from others, including
healthcare providers, the paper described the need for nurses
to facilitate a multidisciplinary team collaboration that includes physicians, rehabilitators, and pharmacists and toserve as intermediaries to maintain good people-healthcare
provider relationships (Yamazaki et al., 2019). Furthermore,
the importance of case management was discussed based on
the results of an integrated case management service forpeople with HF-DM that reduced readmissions (McCants etal., 2019).
Development of Social Support and Resources
Besides direct support for people with HF-DM, social support and resources must also be developed.
Yamazaki et al. (2019) investigated the experiences asso7 of 13

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Table 2. Nursing suggestions for people with heart failure and diabetes.
Nursingsuggestions
Development of
Education
Guidelines that
Integrate HF-DM
Management

Descriptions
As the HF population ages and comorbidities such as diabetes become more prevalent, HF disease management should be considered an
important strategy to improve both cardiac and diabetic care. (Ware et al., 2006)
A future study should revisit these findings to explore the powers of specific and achievable objectives and to develop standardized
dietary guidelines for HF-DM patients. (Cha et al., 2012)
Finally, integrated methods and interventions, focusing both on heart failure and diabetes, should be tested to enhance self-care in thisunique and growing patient population. (Ausili et al., 2016)
The in-depth examination of inpatient care processes and the exploration of patients’ views on their admissions suggest diabetes
management should be considered as important as heart failure management during their admissions (Wu et al., 2018)
Nurses who are involved in caring for people with both heart failure and diabetes must provide them with sufficient education andsupport addressing both conditions, as well as liaising with other healthcare team members during their admission. (Wu et al., 2018)
Given the expected rise of T2D-HF in the foreseen future, increased research on self-care interventions that incorporate an integrated
approach will be vital for improving clinical outcomes in the management of complex and coexisting chronic conditions. (Aga et al.,2019)
It is effective to provide support to simplify treatment behaviors for both diseases, such as a single tool for self-monitoring to record
measured values and guidance that focuses on treatment methods such as diet and exercise that are common to both diseases. (Yamazaki
et al., 2019)

Consideration forContradictions
and Conflicts
Between HF andDM Management

Diabetes educators need to be aware of potential conflicts of treatment regimens to manage two chronic diseases. (Cha et al., 2012)

Individualized
Approach

Evaluating available resources, identifying barriers to self-care, and tailoring diabetes self-care education to the patient’s level ofunderstanding is essential for better management and preventing complications associated with T2D. (Aga et al., 2019)

The results of this study revealed that having both diabetes and heart failure, which have different self-care behaviors, causes not only asense of psychological burden but also a confusing experience in the perception of the illness. Confusion in the perception of illness maylead to incorrect self-care behavior, suggesting the importance of confirming the level of understanding of each self-care behavior.
(Yamazaki et al., 2019)

It may be effective to strengthen diabetes self-care support using numerical values and subjective symptoms, as well as approaches tohelp people take an interest in their own bodies. It may be effective to strengthen diabetes self-care support using numerical values andsubjective symptoms, as well as approaches to help people take an interest in their own bodies. (Yamazaki et al., 2019)
The process of how patients are dealing with chronic diseases such as diabetes and heart failure and how they are currently perceiving
the disease as an “illness trajectory” through sufficient dialog should be understood. Then, it would be effective to intervene on thatbasis. (Yamazaki et al., 2019)
Interventions
Based onAppropriate
Screening for
Self-Care Risks

We recommend that clinicians systematically evaluate these risk factors to identify patients at risk. Particularly, we recommend anevaluation of self-care confidence, because interventions aimed at improving confidence may be particularly effective in improving selfcare. (Ausili et al., 2016)
It is possible that each additional chronic illness may potentially complicate diabetes self-care management, increase psychological andfinancial burden, and have reduced motivation for performing diabetes self-care. Greater disease burden likely contributed to increased
depressive symptoms and lower perceived health status among our participants. (Aga et al., 2019)
Alleviating depressive symptoms could help to enhance patients’ confidence and attention and ultimately Improve diabetes self-efficacy.
Our findings also suggest that addressing treatment and comorbidity burden and alleviating depressive symptoms could help us to
Improve diabetes self-efficacy in adults with T2D and comorbid HF. (Aga et al., 2020)
Findings from this study indicate that lower perceived health status in particular may provide an opportunity to examine the person’s
confidence in performing self-care behaviors such as medication and dietary adherence essential for better health outcomes in T2D and
HF. Therefore, future interventions aimed at enhancing the self-efficacy of patients with T2D-HF should give special emphasis to thosewith lower perceived health status. (Aga et al., 2020)

Professional
Cooperation and
Collaboration
Between HF and
DM Teams

In future practice, healthcare professionals from all the relevant teams must take a collaborative and integrative approach for patientswith both heart failure and diabetes. (Wu et al., 2018)
This retrospective, descriptive, comparative analysis study confirms that case management services in comparison with treatment as usual for hospitalized individuals diagnosed with HF and diabetes are effective in reducing readmissions. (McCants et al., 2019)
Extending the length of stay for patients who are not medically ready for discharge should be considered because there is a cost difference, as there is evidence of readmission reduction. (McCants et al., 2019)
Nurses must coordinate collaboration between the multidisciplinary team, including doctors, rehabilitation, and pharmacists, and act asintermediaries to maintain good patient-provider relationships. (Yamazaki et al., 2019)

Development ofSocial Support
and Resources

8 of 13

For persons with T2D-HF without adequate social support, educational groups that promote observational learning and utilize positiverole models may be beneficial for improving participation and adherence to diabetes self-care and clinical outcomes. (Aga et al., 2019)
It is important to help create a supportive environment by checking the patient’s surroundings, including how they feel about supporting
others; whether they have support from family, friends, and others; and whether they are considering introducing care services. (Yamazaki et al., 2019)https://doi.org/10.53044/jinr.2022-0033

ciated with self-care behaviors of people with HF-DM andfound that although the people were prepared to manage
their disease by themselves without depending on others,
they also felt the need for support. The study described theimportance of support in assessing the people’s situations
and creating a supportive environment. The study assessed
how people felt about supporting others; whether they had
support from family, friends, and others around them; andwhether they were considering availing of nursing care services. Furthermore, for people without adequate social support, such as from family and friends who are successfully
managing DM, encouraging observational learning and education with positive role models can be effective (Aga et al.,2019).

Discussion
Only 11 articles on nursing care for people with HF-DM
were included for analysis. Of these, only one was published in Japan, making this scarcity of studies particularly
striking. Nevertheless, the rapid increase in the number of
research papers since 2014 indicates that the field of nursing
care for people with HF-DM is beginning to attract attention.
The present review suggests that RCTs with quality assessment by MMAT have shown that programs integrating
HF-DM have some effectiveness. These findings clearly indicate the importance of providing nursing interventions that
integrate HF-DM rather than nursing interventions for eachdisease. Notably, the educational tool was designed to integrate HF-DM data, and the intervention was delivered bytrained nurses. As mentioned earlier, self-care behaviors arecomplicated when both HF and DM are present. Furthermore, the management of both diseases can be conflicting.
Thus, education for each disease was not expected to solve
the problem. The current review has shown the effectivenessof using educational tools that integrate HF-DM data, andthe use of integrated educational tools may help address thecomplexity and conflict of self-care behaviors in people with
HF-DM. It is also important that the effectiveness of these
RCTs was produced by interventions by trained nurses.
However, it was suggested that nursing care for people with
HF-DM requires particular training, whereas the RCTs inthis review did not identify specific training content. Another future research question for effective nursing care for
HF-DM patients is what type of nurse education to provide.
One of the challenges is also the small number of RCTs.
Only three RCTs were retrieved in this review, all of whichwere conducted in the United States. Moreover, because thestudies were conducted by the same research group, the regions sampled were limited. As healthcare systems differ
around the world (Mossialos et al., 2016), programs tailoredto the healthcare systems of each country and region are

JINR 2023, 2(2), e2022-0033

necessary. Additionally, since various factors, such as poverty, education, race/ethnicity, age, and disability, may affectthe health literacy of individuals (Kutner M et al., 2006),
programs that match the health literacy issues of each country and region must be established. More studies on nursing
care, including qualitative studies, are needed for the development of a program for HF-DM and based on the results,
which is important to develop and evaluate programs. Moreover, to clarify the effectiveness of an integrated program for
HF-DM, conducting more RCTs and accumulating the results of these RCTs are essential in order to create a program that meets the challenges of healthcare systems andhealth literacy around the world. Furthermore, since no
RCTs evaluating people with HF-DM have been conductedin Japan, programs that are tailored to the Japanese healthcare system must urgently be developed, and more studies
on nursing care for people with HF-DM are needed.
The current review generated six categories of suggestions
for nursing care for people with HF-DM. The identificationof these suggestions for nursing care was very helpful in examining effective care for patients with HF-DM. Nevertheless, a challenge is the lack of specificity in these suggestions. “Development of education guidelines integrating HFDM management” only described the necessity of suchguidelines and did not provide specific directions for nursing
assistance, as was observed in several cases. The specificsuggestions presented were the need for standardized dietaryguidelines for HF-DM, unification of self-monitoring tools,
and common treatment methods for both diseases related todiet and exercise. Nonetheless, further research is required
to clarify specific nursing assistance, and guidelines that reflect the opinions of experts must be developed. “Interventions based on appropriate screening for self-care risks” indicated the need for the assessment of self-care confidence,
self-efficacy, and depressive symptoms. However, the contents of these screenings were inadequate and did not constitute a systematic risk assessment. Additionally, since selfcare risk may differ across countries and regions, more encompassing research on self-care risk in people with HFDM must be conducted, and a specific and systematic selfcare risk assessment index tailored to each country and region should be developed. “Professional cooperation andcollaboration between HF and DM teams” suggested that
team-based care for people with HF-DM requires collaboration between the HF and DM specialist teams rather than independent intervention. An important premise of the chroniccare model is team-based care, which usually includes physicians and advanced practice providers, nurses, pharmacists,
nutritionists, social workers, and community health workers(Proia et al., 2014). However, even in these respects, differences exist among national and regional healthcare systems,
and each may have its own challenges. Hence, a policy for
professional collaboration that is appropriate for each coun9 of 13

JINR 2023, 2(2), e2022-0033

try and region must be developed, and the impact of team
medicine practices on people’s outcomes should be investigated. Moreover, to determine how exactly HF-DM teams
should collaborate, as well as to establish the role of nurses
in initiating team medicine, further research is needed.
Another challenge is the lack of established guidelines fornursing assistance integrating HF-DM. In this review, six
categories were presented as suggestions for the nursing careof people with HF-DM. However, these suggestions were
not adequately reflected in the RCTs. The contents of thesenursing suggestions may be important factors in providing
appropriate care for people with HF-DM. Hence, specificnursing assistance guidelines for people with HF-DM thatincorporate these nursing suggestions should be developed.
Moreover, we believe that the practical knowledge possessedby nurses in the field of HF or DM can contribute to the development of these integrated nursing assistance guidelines
for people with HF-DM. Among other things, we believethat practical knowledge by advanced practice nurses who
have received advanced education in nursing care can contribute to these efforts. In the United States, the clinicalnurse specialist (CNS) certification is issued for advanced
practice nurses (National Association of Clinical Nurse Specialists, 2021). In Japan, similar certifications for advanced
practice nurses are also issued, such as Certified Nurse Specialist and Nurse Practitioner (Japan Association of Nursing
Programs in Universities, 2021). We believe that the nursing
practice of these advanced practitioners for people with HFDM should be refined. Therefore, we will not only compile
examples of advanced nursing practices but also conduct interviews with many advanced practice nurses to clarify the
structure and direction of their practice, which will facilitate
the development of assistance guidelines.

Limitations
This review investigated the implications of nursing care forpeople with HF-DM, clarified the scope of the study, andprovided baseline information for future research. Nevertheless, the results were derived from a small number of studies. Moreover, submission of this review was long a timefrom the date of the search (January 22, 2021). This may
not reflect the most recent situation, as the number of articles has been increasing since 2014. Furthermore, as characteristic of a scoping review, a quality assessment of the studies was not conducted. These attributes may thus limit thereliability of the study results.

Conclusion
A scoping review of effective nursing care for people andsuggestions for people with HF-DM found three articles on
integrated HF and DM self-care interventions in RCTs,
10 of 13https://doi.org/10.53044/jinr.2022-0033

which extracted and summarized content of the three articles
and found improvements in essential elements of self-caresuch as HF knowledge, self-care, QOL, DM self-efficacy,
physical function, self-reported physical activity, and demonstrated dominance in lowering costs without sacrificing
quality-adjusted life years but no improvement in DM QOL.
Additionally, six categories were generated by categorizing
the descriptions of nursing suggestions for people with HFDM extracted from eight studies (excluding RCTs): “Development of Education Guidelines that Integrate HF-DM Management,” “Consideration for Contradictions and Conflicts
Between HF and DM Management,” “Individualized Approach,” “Interventions Based on Appropriate Screening for
Self-Care Risks,” “Professional Cooperation and Collaboration Between HF and DM Teams,” and “Development ofSocial Support and Resources.” However, many of the suggestions lacked specificity and few RCTs have been conducted. It was suggested that more research should be conducted on nursing care for people with HF-DM in order todevelop programs and nursing assistance guidelines for themand to proceed with RCTs based on these guidelines.
Author Contributions
Yusuke Yamazaki designed the study, and Sumie Kuroda supervised the analysis and critically revised the work. Yusuke
Yamazaki and Misaki Sawaoka equally contributed to theliterature search and data analysis. Yusuke Yamazaki drafted
the article. All authors reviewed and accepted the final form.
Declaration of Conflicting Interests
The authors have conflicts of interest to declare.
Ethical Approval
This study is a scoping review and has not been approvedby an ethics committee because it does not involve experimentation with human subjects.
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Original Research

Typology of hunger sensation perception in patients with type 2 diabetes
Mizuyo Nagamune, PhD, RN1,2 , Mayumi Okuwa, PhD, RN3 , Michiko Inagaki, PhD, RN3 ,Keiko Tasaki, PhD, RN3 , Tomomi Horiguchi, PhD, RN, PHN3 , Yuya Asada, PhD, RN, PHN3 , andMai Kitagawa, PhD, RN, PHN3
1

School of Nursing, Kanazawa Medical University, Kahoku, Japan, 2Department of Chronic Care, Division of Health
Sciences, Graduate School of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa,
Japan, and 3Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa
University, Kanazawa, Japan

Abstract
Objective: This study is aimed to identify how patients with type 2 diabetes perceive hunger using a questionnaire based on the results of a previous study and characterize how they perceive hunger. Methods: First, wedrafted a 46-item questionnaire based on previous studies. Next, we subjected the draft questionnaire to exploratory factor analysis and assessed its reliability based on item validity and internal consistency. Finally, we confirmed the possibility of classification through hierarchical cluster analysis and determined whether the classified
types were related to HbA1c and body mass index, which are indicators of diabetes control. The inclusion criteria
involved participants who were 20 years of age or older, outpatients at a hospital or clinic, and diagnosed with
type 2 diabetes for at least 6 months. Results: The participants were 147 patients with type 2 diabetes, with amean age of 59.5 ± 12.7 years. We developed a 25-item, six-factor questionnaire to assess hunger perception inpatients with type 2 diabetes mellitus. Afterward, the construct was compared with previous studies. The cumulative contribution of the six factors was 53.7%, with a Cronbach’s alpha coefficient of reliability of 0.875 for the fullquestionnaire. A hierarchical cluster analysis based on the factor scores of the questionnaire showed that there
were two groups, namely, an “all factors high score group” and an “all factors low score group.” Notably, HbA1c
was significantly higher in the “all factors high score group.” Conclusions: In this study, a questionnaire based on
previous research allowed us to typify how patients with type 2 diabetes perceive hunger.
Keywords
diet therapy, factor analysis, hunger sensation, questionnaire, type 2 diabetes mellitus
JINR 2023, 2(2), e2022-0016

Introduction
In order to achieve treatment goals while maintaining effective behavioral management and psychological health, interventions, such as diabetes self-management education andsupport, are important (American Diabetes Association,2021). Good glycemic control requires self-management be-haviors, and theory-based self-management education is effective in improving HbA1c, self-efficacy, and diabetes
knowledge (Zhao et al., 2016). Nevertheless, reportedly, ittakes 2-8 months to change behavior after education. This isespecially the case with diet-related behaviors, which has a
low implementation rate of approximately 30% of 7 days
(Marinho et al., 2018; Alhaiti et al., 2020), and many pa-

Correspondence: M. Nagamune. Email: nmizuyo@kanazawa-med.ac.jp
Received: April 14, 2022, Accepted: November 16, 2022, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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tients struggle with diet management (Schmidt et al., 2020;
Polhuis et al., 2020). Particularly, according to studies, patients with type 2 diabetes often fail to take action, evenwhen they understand dietary knowledge (Willig et al.,2014). Moreover, notably, diet restricts dietary freedom andis most implicated in reduced quality of life (Shim et al.,2012).
These are reported difficulties in managing behavior andmaintaining psychological well-being, which patients withdiabetes must now continue to do for the rest of their lives.
In a previous study, patients with type 2 diabetes experienced challenges and exhaustion when attempting to adhere
to and continue with their diets, with a common theme of “I
understand the need, but I can’t do it.” That is, patients felt
hunger, which required the coping behavior of endurance. In
this context, the causes of difficulty in attempting to follow
a diet can be explained in two ways including “I don’t haveenough patience” and “the condition of diabetes is affectingme.” (Nagamune et al., 2020). Furthermore, based on theexperience developed through diabetes education and treatment, patients lived with the physical sensation of “notknowing” whether their hunger was “intolerable” or “affected by the pathophysiology of diabetes.” It was inferredthat the patients felt ambiguity in their own “physical sensation” of hunger because of their diabetes. Thus, we focusedon the feeling of hunger in patients with type 2 diabetes.
Hunger sensation, along with satiety, has been studied
since it relates to eating (Ogden et al., 2013; Pritchard et al.,2014; Rogers et al., 2016). Blood glucose levels and bloodconcentrations of free fatty acids stimulate the satiety andfeeding centers, which results in feelings of satiety and hunger. It is generally regulated by homeostatic and cognitive
mechanisms. Moreover, it is regulated by signals from thegastrointestinal tract and central nervous system (Davis,2018), particularly ghrelin, which is derived from the gastrointestinal tract and acts on the central nervous system topromote appetite and increase food intake and is involved inboth homeostatic feeding and preferences and nonhomeostatic feeding, including pleasure eating (Davis, 2018;
Howick et al., 2017). Ketone body formation increases hunger between meals and at night in compensated type 2 diabetes, whereas the lack of ketone body formation increases
daytime hunger in noncompensated type 2 diabetes (Cugini
et al., 1996). Additionally, insulin hypersecretion is associated with increased leptin levels, with higher leptin levels inhigh insulin resistance (Wauters et al., 2003) and lower
leptin levels in nonobese individuals with diabetes (Mohammadzadeh et al., 2013). Hence, endocrine metabolism andcircadian rhythms may affect diabetes mellitus. Furthermore,
hunger sensation is viewed as one of the internal senses thatmake us aware of body homeostases, such as pain, itchiness,thirst, and muscle and visceral sensations (Sherrington,
1906; Craig, 2003). Besides the aforementioned homeostatic
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and nonhomeostatic eating, hunger as an endogenous sensation varies widely among individuals because of multidimensional factors including genetic factors, health factors
such as obesity and eating habits, psychological andneurodevelopmental factors, psychological factors including
depression and eating disorders, and cognitive factors suchas the ability to consciously regulate eating and eating motivation. Nevertheless, measurement tools have been noted tolack validity (Stevenson et al., 2015). From the above, hunger and satiety have been studied from a physiological perspective. However, no studies on hunger in the context ofdiabetic recuperation exist.
Thus, the researchers focused on how patients with type 2
diabetes perceive hunger. Based on the results of previous
studies, it was hypothesized that the way patients with type2 diabetes perceive hunger is an evaluation of their own behavior and perceptions of their bodies, which occurs as patients receive diabetes education and build up their medicalcare. This study aimed to clarify how patients perceive hunger by typifying the feeling of hunger using a questionnaire
based on previous research.
By clarifying the feeling of hunger, which patients themselves express as “I do not know,” through a questionnairethat takes into account the patient’s medical treatment lifestyle, we thought it would be a way of finding new dietary
support for dietary therapy based on how patients perceive
hunger sensations.

Materials and Methods
Research Design
This study was a cross-sectional one that used an anonymous self-administered questionnaire method.
Study Participants
The study population involved patients who met the following criteria: aged 20 years or older, were attending a hospital or a clinic, and were diagnosed with type 2 diabetes forat least 6 months. The exclusion criteria were as follows:
unable to independently answer the self-administered questionnaire and highly obese based on a body mass index(BMI) of 35 kg/m2 or more (considered to be different inpathogenesis, treatment, and management from those withobesity based on a BMI of 25-35 kg/m2 or less, who often
have psychological and/or social problems) (Japan Society
for the Study of Obesity, 2016). Participants were recruitedwith the consensual assistance of medical personnel working
at the cooperating facilities.
Preparation of a Draft of the “Questionnaire for Perceptionof Hunger Sensation in Patients with Type 2 Diabetes”
To understand how patients with type 2 diabetes perceive
hunger sensation, we developed a 46-item draft question-

https://doi.org/10.53044/jinr.2022-0016

naire based on information from a previous study (Nagamune et al., 2020) in which patients were found to copewith hunger in their daily lives. The draft questionnaire included questions that included elements such as “it is because I do not have enough patience” and “it is because mydiabetes condition is affecting me,” which were the resultsof previous studies, as well as the perception, evaluation,and feelings about their own medical treatment behavior andtheir body with diabetes. To avoid simple “not think” and“think” responses, a 5-point Likert-type scale ranging from1 (never think) to 5 (always think) was chosen. We also
asked seven nursing experts in diabetes and five nurses, fortheir opinions on whether the items were appropriate for understanding how patients with type 2 diabetes perceived
hunger. Subsequently, we reexamined the appropriateness ofthe content and wordings of all items (Table 1).
Data Collection
Data were collected using a self-administered questionnairedeveloped by the researcher, with items including basic attributes, factors related to how hunger was perceived, andglycemic control indices. Participating facilities were recruited among hospitals and clinics with accreditation fromthe Council for the Promotion of Diabetes Control in Region A. Of these, three medical institutions agreed to cooperate in this study; the researcher or a medical worker at theinstitution explained the purpose of the study and the detailsof cooperation to the participants orally and in writing andthen distributed questionnaires to those who gave their consent. To collect the questionnaires, either the researcher directly visited the medical facilities to pick them up or thesurvey collaborators sent them in a return envelope to theresearcher. The data collection period lasted from July 2020
to June 2021.
Survey Items
The survey items included basic attributes, factors related tohow hunger was perceived, and diabetes control indices(HbA1c and BMI).
Basic Attributes
There were seven items in this section, with answer options
including fill-in-the-blank and choice selection (i.e., gender,
age, duration of illness, presence or absence of co-residents,
presence or absence of complications, treatment method, andpresence or absence of diabetes education experience).
Diabetes Control Indices
Based on test results from the day of the study explanation
or within the last month, the participants were asked towrite down their HbA1c levels. To ascertain their degree ofobesity, they were also asked to state their heights andweights to calculate BMI.

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Analysis Method
Statistical methods were used for analysis, with a significance level of p < .05. All analyses were performed using
The Statistical Package for the Social Sciences (SPSS) version 27.0 (IBM Corp, Armonk, NY).
Development of the “Questionnaire for Perception of Hunger Sensation in Patients with Type 2 Diabetes”
Item Analysis
The 46 items of the draft “Questionnaire on Perceived Hunger in Patients with Type 2 Diabetes” were checked for theceiling (mean + standard deviation [SD] > 5) and floor effects (mean − SD < 1) before analysis with item-total correlations (I-T analysis). Subsequently, items with low correlations (|rs| < 0.20) were discarded by item-total correlations(I-T analysis), and items inappropriate for factor analysis
were deleted (Streiner et al., 2015).
Extraction and Naming of Factors
We conducted an exploratory factor analysis (EFA) via theprincipal factor method (Costello et al., 2005) to understandthe indicators that characterized how patients with type 2
diabetes perceived hunger. Using Promax rotation, factor
analysis was performed. For each item, we compared thefactor loadings of each factor matrix; the factor structure
was constructed by assigning the item with the largest absolute value to the corresponding factor. The criterion for factor loadings was set at 0.4 or higher (Costello et al., 2005),
whereas the Kaiser-Meyer-Olkin (KMO) measures of sample
adequacy and Bartlett’s sphericity tests were used to determine the appropriateness of the factor analysis.
Confirmation of Construct
After extracting the factors, we calculated a Pearson’s
product-moment correlation coefficient for the correlation
coefficients of each factor. After adopting the factor structure, we compared the results with those obtained in previous research (Nagamune et al., 2020).
Examination of Internal Consistency
To calculate Cronbach’s alpha coefficients for the entire
questionnaire and each factor, we performed a reliability
analysis. Additionally, we generated standardized factor
scores (mean = 0, SD = 1) from the final factor solutions
and used these in subsequent analyses.
Cluster Analysis of the Participants
Based on the factor scores obtained for the “Questionnaire
for Perception of Hunger Sensation in Patients with Type 2
Diabetes,” the participants were classified through a hierarchical cluster analysis using the Ward method. This analysis
was conducted to identify similarities in the perception ofhunger among patients with type 2 diabetes (Mojena, 1977;
Blashfield, 1980). Furthermore, we performed a discriminant
analysis to confirm the validity of the cluster classification
by calculating the discriminant hitting rate of the discriminant function obtained from the data. Next, we compared
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Table 1. Questionnaire draft items and statistics.
Perception

Item

Mean

SD

Corrected
item-total
correlation

Awareness ofhunger

1. I feel hungry before meals.
2. I feel like I can eat even if I am not that hungry.
3. I feel hungry between meals.
4. I feel hungry when I see other people eating.
5. I feel hungry when I smell or see food.
6. I feel hungry after eating a meal.
7. This hunger is unique to patients with diabetes.
8. Only I feel this hunger.
9. I feel that my hunger has become stronger since I was diagnosed with diabetes mellitus.
10. I have to live with this feeling of hunger all my life.

3.6
3.7
3.0
2.2
2.6
1.9
2.0
2.1
2.0
2.6

1.1
1.0
1.1
0.9
1.1
1.0
0.9
1.0
0.9
1.2

.32**
.25**
.34**
.51**
.45**
―
.43**
.44**
.54**
.52**

Verbalization
approval

11. I may talk to a healthcare provider about hunger.
12. I may talk to my family about hunger.
13. I may talk to people other than medical professionals and family members about hunger.
14. I think people will listen to me seriously about my hunger.
15. This feeling of hunger is not my only problem.

3.0
3.1
3.0
2.5
2.6

1.3
1.3
1.3
1.0
1.1

.58**
.62**
.56**
.45**
.54**

Countermeasures andtolerance

16. Hunger can be suppressed without a strong will.
17. It is difficult to tolerate hunger, even in one’s own body.
18. Hunger does not have to be tolerated.
19. It is okay to eat a little to satisfy one’s body and feelings.
20. I can consult with medical professionals for advice and support.
21. I may talk to express my opinion about the family’s cooperation.

3.1
2.5
2.9
3.4
2.8
3.4

1.2
1.2
1.1
1.0
1.1
1.1

.10
.40**
.45**
.47**
.40**
.26**

Justification

22. Stress in diabetes is caused by this hunger.
23. One never gets used to the feeling of hunger in diabetes.
24. Blood glucose control does not work well due to diabetes.
25. Blood glucose control does not work well because of old age.
26. I get hungrier when my blood sugar is high.
27. I need not be driven by the state of my blood sugar control and my eating behavior.
28. It is my body, but I am having difficulty controlling my blood sugar.
29. I reflect on my life and acknowledge that my body is working hard enough.
30. I do not have to think that my hunger is because I am restricting myself with food.

2.2
2.6
3.1
2.8
2.3
3.0
3.3
2.9
2.9

1.0
1.0
1.1
1.0
1.0
1.0
1.1
1.0
0.9

.54**
.45**
.41**
.41**
.47**
<.01
.46**
<.01
.19*

Competence
evaluation

31. My efforts are not reflected in my weight and HbA1c.
32. When my blood glucose control is not good, I have to adjust my own diet.
33. If my healthcare provider suggests that I have a problem, I must take action to address it.
34. When the test results show that my blood sugar control is not good, the medical professional will say, “That is because you are eating too much,” and I will think that myself.
35. I am not able to resist eating just on my own.
36. My blood sugar control is not working because I am eating too much.
37. I am not able to control my diet as well as I used to.
38. I am less able to control my blood sugar than I used to be.
39. I am not as good at controlling my weight as I used to be.

2.5
3.9
4.1
4.0

1.0
0.8
0.7
0.8

.22**
.18*
.14
.38**

2.8
3.7
2.7
2.8
2.8

1.0
1.0
1.0
1.1
1.1

.47**
.36**
.33**
.40**
.37**

40. I do not feel hungry between meals.
41. I do not feel hungry from after dinner until bedtime.
42. I do not feel hungry at night (when sleeping).
43. I am able to have good blood sugar control.
44. I am able to control my weight.
45. I am able to manage my diabetes based on my doctor’s expectations.
46. I am able to manage my diabetes based on my family’s expectations.

3.2
3.4
3.9
2.7
2.8
2.6
2.6

1.0
1.0
1.1
1.0
1.0
1.0
1.0

<.01
<.01
<.01
−.22**−.27**−.18*<−.01

ResultNote. Items with |rs|<.20 were excluded. Floor effects excluded one item.
*p<.05 **p<.01
N = 147, SD = standard deviation.

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data for which normality was found by cluster using theStudent’s t-test and compared data for which normality was
not found by cluster using the Mann-Whitney U test.
Analysis of the Relationship between Clusters of Patientswith Type 2 Diabetes Classified by Hunger Perception Factors and Diabetes Control Indices
Cluster analysis was used in this study as a means of interpreting how patients with type 2 diabetes perceive hunger.
The Mann-Whitney U test was used for the relationship between clusters of participants classified based on hunger andHbA1c/BMI.
Ethical Approval
At each cooperating institution, the study procedures were
either conducted by a researcher or healthcare worker after
providing written explanations of the purpose to all participants. This study was conducted anonymously. All participants provided consent through the questionnaires. Additionally, we explained that there would be no disadvantage inmedical treatment due to nonparticipation. We carefully protected the privacy of all participants through anonymity andby strictly managing and storing their data. This study wasapproved by the Ethics Review Committee of his institution.

Results
Of the 200 questionnaires distributed, 175 were collected,
with a collection rate of 87.5%. The number of valid responses was 147, with a valid response rate of 84.0%. Besides the previously mentioned inclusion and exclusion criteria, we excluded questionnaires with missing values on thehunger perception section and those from respondents who
were taking immunosuppressive drugs. The effect of missing
values in deriving the results of the analysis was only present in one patient, who did not fill in HbA1c. Thus, missing values were treated as missing values.
Basic Attributes
Of the analyzed respondents, 104 were males (70.7%) and
43 were females (29.3%), and respondents were aged 20-85
years (mean of 59.5 ± 12.7 years). Table 2 lists other relevant items.
Development of the “Questionnaire for Perception of Hunger Sensation in Patients with Type 2 Diabetes”
Item Analysis (Table 1)
One item was deleted due to the floor effect, whereas 11
items were deleted due to I-T correlations below 0.2.
Examination of Construct Validity, Extraction, and Namingof Factors (Table 3)
Following the factor analysis, the KMO measure of sample
adequacy was 0.798, whereas Bartlett’s sphericity test
showed a significant probability of 0.000, indicating that it

JINR 2023, 2(2), e2022-0016

was proper to use the factor analysis. Initial eigenvalues of
1.000 or more were adopted and confirmed via the KaiserGuttman criteria and scree plots. In the second and subsequent factor analyses, items with factor loadings of less than
0.4 and items with factor loadings of 0.4 or more for two or
more factors for one item were deleted to discard items. Finally, the questionnaire had a 25-item, six-factor structure.
The cumulative contribution rate after rotation was 53.7%.
The first factor consisted of six items, including “competence evaluation” and “results” from the original proposal.
Most respondents assessed their own ability to manage
themselves and felt that self-management was challenging.
As such, this factor was named a “sense of lack of selfcontrol.” The second factor consisted of five items, including“verbalization approval” and “countermeasures and tolerance” from the original proposal. Most items were related to
discussions with others about hunger. As such, this factor
was named “verbal affirmations of hunger.” The third factor
consisted of five items, including “awareness of hunger” and“justification” from the original proposal. Most were basedon the sense of a relationship between diabetes and hunger
or that hunger had changed as a result of diabetes. As such,
this factor was named “acceptance of diabetes-specific hunger.” The fourth factor consisted of four items, including“awareness of hunger” and “justification” from the original
proposal. Most items were based on the feeling that one wasaware of a hunger situation. As such, this factor was named“hunger awareness.” The fifth factor consisted of two items,
including “justification” from the original proposal. Here,the reason for poor glycemic control is not one’s behavior
but one’s body. As such, this factor was named “feelingphysically dependent when blood sugar control is poor.” Finally, the sixth factor consisted of three items, including“countermeasures and tolerance” and “ability assessment”
from the original proposal. In response to hunger, participants felt that it was suitable to eat a little. As such, thisfactor was named “tolerance of food intake.”
Examination of Internal Consistency (Table 3)
The Cronbach’s alpha coefficient for the entire questionnaire
was 0.875. Table 3 shows the coefficients for each factor.
The factor analysis showed that five of the six factors had atleast three items, with factors containing three or more items
being stable and desirable (Costello et al., 2005). However,given the results of previous qualitative research (Costello etal., 2005), we believed that the two items from Factor 5
concerning physical sensation during poor glycemic control
should be retained.
Cluster Classification of Patients with Type 2 Diabetes According to the Six Factors of Hunger Perception (Figure 1,
Table 4)
We calculated factor scores based on the six factors of hunger perception in patients with type 2 diabetes, and respondents were classified via cluster analysis (Ward method).
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Table 2. Basic attributes.
n (%)
Sex

Male
Female104 (70.7)
43 (29.3)

20s
30s
40s
50s
60s
70s
80s

2 (1.4)5 (3.4)28 (19.0)
37 (25.2)
42 (28.6)
25 (17.0)
8 (5.4)

Less than 1 year
Less than 5 years
Less than 10 years
Less than 20 years
Less than 30 years
Less than 40 years
Less than 50 years

2 (1.4)31 (21.1)
29 (19.7)
54 (36.7)
19 (12.9)9 (6.1)3 (2.0)

Living alone
Living with family
Tablets
Insulin
GLP-1
Diet therapy only
Diabetic neuropathy
Diabetic retinopathy
Diabetic nephropathy
Periodontal disease
Vascular complication
Educated
Never educatedDo not know

146 (99.3)
147 (100)
21 (14.3)
126 (85.7)
137 (93.2)
35 (23.8)
5 (3.4)7 (4.8)10 (6.8)
12 (8.2)
4 (2.7)8 (5.4)7 (4.8)125 (85.0)
18 (12.2)
4 (2.7)Age (years)

Duration of disease (years)

HbA1c (%)
BMI (kg/m2)
Living situation
Treatment (Multiple answers)

Diabetic complication (Multiple answers)

Diabetes education

Mean ± SD

Range

59.5 ± 12.7

20–85

12.2 ± 9.3

0.7–457.4 ± 1.1
25.8 ± 3.9

5.7–12.2
18.5–34.4

Note. SD = standard deviation.

The number of groups was determined by referring to thedendrogram of the two groups that were most suitable forinterpretation. There were 38 and 109 individuals in clusters
A and B, respectively (Figure 1). The discriminant successrate (cross-confirmed) was 93.2%. To characterize the six
factors among the clusters, the factor scores were compared.
The data showing normality were tested using the Student’s
t-test, whereas data that did not show normality were tested
using the Mann-Whitney U test. The six-factor scores for
Cluster A were (Factors 1-6) 0.698, 0.241, 0.950, 0.972,
0.381, and 0.633, respectively. The six-factor scores for
Cluster B were (Factors 1-6) −0.243, −0.084, −0.331,−0.339, −0.133, and −0.221, respectively. Although the second factor, “verbal affirmations of hunger,” was not signifi6 of 12

cantly different between the two groups, the other factors
were significantly different (Table 4). As for the characteristics of the perception of hunger, Cluster A had high scoreson each factor and was thus named the “high score groupfor all factors.” By contrast, Cluster B had low scores oneach factor and was thus named the “low score group for all
factors.”
Characteristics of Diabetes Control in Patients with Type 2
Diabetes in Each Cluster (Table 5)
We analyzed the relationship between HbA1c and BMI withtwo clusters classified based on the six factors of hunger
perception.
HbA1c
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JINR 2023, 2(2), e2022-0016

Table 3. Factor loadings of the “questionnaire for perception of hunger sensation in type 2 diabetes patients”.
Factor

1

2

3

4

5

6

Factor 1: Sense of lack of self-control
43.*I am able to have good blood sugar control.
38. I am less able to control my blood sugar than I used to be.
39. I am not as good at controlling my weight as I used to be.
44. *I am able to control my weight.
37. I am not able to control my diet as well as I used to.
35. I am not able to resist eating just on my own.

.817
.791
.754
.726
.682
.442

.057
−.148
.050
.220
−.211
−.028

−.091
.059
.062
−.032
−.045
.245

.034
−.054
.011
−.034
.011
.075

.153
−.049
−.013
−.048
.020
−.015

−.205
.209
−.072
−.194
.251
.212

−.041
.073

.912
.883

−.045
.056

.070
−.067

.060
−.004

.070
.028

.093
−.065

.865
.454

.051
−.133

.025
.004

−.031
.062

−.019
.117

−.094

.405

.312

−.042

−.095

.108

−.064

−.075

.781

.162

−.024

.028

.163
−.082
.028
−.055

−.034
.041
.101
−.016

.683
.663
.558
.473

−.058
−.125
.105
−.108

−.079
−.013
−.005
.321

−.138
−.018
.016
.124

−.127
.130
.042
−.017

.005
.018
.071
−.076

−.079
−.126
.052
.160

.820
.654
.610
.512

−.002
−.130
.066
.091

.065
−.008
.015
−.080

.088

−.024

.070

.045

.834

−.125

−.019

0.072

−.128

−.037

.757

.140

−.027
−.098
.296

.030
.179
.140

.013
−.009
−.148

.049
−.024
−.030

.028
.004
−.019

.622
.600
.459

Cronbach’s α coefficient for each factor
Overall Cronbach’s α coefficient

.868

.852

.764
.734
.875

.763

.634

Factor correlations (r)

1
1.000

2
.250
1.000

3
.337
.236
1.000

5
.244
.084
.297
.175
1.000

6
.458
.275
.423
.345
.326
1.000

Factor 2: Verbal affirmation of hunger
12. I may talk to my family about hunger.
13. I may talk to people other than medical professionals andfamily members about hunger.
11. I may talk to a healthcare provider about hunger.
21. I may talk to express my opinion about the family’s cooperation.
14. I think people will listen to me seriously about my hunger.
Factor 3: Awareness of hunger
9. I feel that my hunger has become stronger since I was diagnosed with diabetes mellitus.
8. Only I feel this hunger.
7. This hunger is unique to patients with diabetes.
22. Stress in diabetes is caused by this hunger.
26. I get hungrier when my blood sugar is high.
Factor 4: Acceptance of diabetes-specific hunger
5. I feel hungry when I smell or see food.
1. I feel hungry before meals.
4. I feel hungry when I see other people eating.
3. I feel hungry between meals.
Factor 5: Feeling physically dependent when blood sugar control is poor
25. Blood glucose control does not work well because of oldage.
24. Blood glucose control does not work well due to diabetes.
Factor 6: Tolerance of food intake
19. It is okay to eat a little to satisfy one’s body and feelings.
18. Hunger does not have to be tolerated.
34. When the test results show that my blood sugar control is
not good, the medical professional will say, “That is because
you are eating too much,” and I will think that myself.

4
.305
.326
.422
1.000

Note. *Reverse-scored item.
N = 147, factor loading≧.40

7 of 12JINR 2023, 2(2), e2022-0016

https://doi.org/10.53044/jinr.2022-0016

1.200
0.950 0.972

1.000
0.800

0.698

0.633

Factor score

0.600
0.400

0.381
0.241

0.200
0.000
-0.084-0.200-0.133-0.221-0.243-0.400-0.331 -0.339-0.600All factors high score group

Cluster

All factors low score group■ Factor 1: Sense of lack of self-control■ Factor 2: Verbal affirmation of hunger■ Factor 3: Awareness of hunger■ Factor 4: Acceptance of diabetes-specific hunger■ Factor 5: Feeling physically dependent when blood sugar control is poor
■ Factor 6: Tolerance of food intake

Figure 1. Cluster classification of patients with type 2 diabetes according to the six factors of hunger perception.
Table 4. Statistics for each factor of hunger perception classified into two groups.
N = 147

Factor 1 “Sense of lack of self-control”
Factor 2 “Verbal affirmations of hunger”
Factor 3 “Acceptance of diabetes-specific hunger”
Factor 4 “Hunger awareness”
Factor 5 “Feeling physically dependent when blood
sugar control is poor”
Factor 6 “Tolerance of food intake within the group”

t

df

Z

p

95%CI

r

−5.83
−
−
−11.812−3.098

145
−
−
91.33
145

−
−1.695−7.322−−.000**.090.000**.000**.002*[−1.261, −0.623]−−[−1.531, −1.090][−8.41, −0.186]

.44
−.14
−.6
.78
.25

−

−

−5.384.000**−−.44

Note. SD = standard deviation.
*p<.05 **p<.001※Factor 1, 4, and 6: The Student’s t-test※Factor 2, 3, and 5: The Mann-Whitney U test

Table 5. Characteristics of diabetes control in patients with type 2 diabetes in each cluster.

HbA1c (%; mean ± SD)
BMI (kg/m2; mean ± SD)

NnAll factors highscore groupn

All factors lowscore group

Z

p

r

146
147

38
38

7.8 ± 1.1
26.2 ± 4.2

108
109

7.3 ± 1.1
25.6 ± 3.7−3.120−0.602.002*.547 (ns)

−.05
−.26

Note. Mann-Whitney U test; *p<.05; SD = standard deviation; BMI = body mass index.

group and 7.3% in the all-factor low score group, a significant difference (z = −3.120, p < .05, r = −.05). HbA1c wassignificantly higher in the high score group compared to thelow score group for all factors (Table 5).
8 of 12

BMI
This characteristic was 26.2 kg/m2 in the group with highscores for all factors and 25.6 kg/m2 in the group with lowscores for all factors, with no significant difference (z =https://doi.org/10.53044/jinr.2022-0016−0.602, p = .547, r = −.26) (Table 5).

Discussion“Questionnaire for Perception of Hunger Sensation in Patients with Type 2 Diabetes”
Content and face validity were ensured in the process ofdrafting the questionnaire. It used a six-factor, 25-item structure obtained through EFA. The Cronbach’s alpha coefficientof the sixth factor was 0.634, which is slightly low, but not
below 0.5 (Bujang et al., 2018), and the overall Cronbach’s
alpha coefficient was 0.875, which confirms the internalconsistency of the questionnaire as a single 25-item measure. Additionally, the cumulative contribution of the six factors after rotation was 53.7%.
Hara et al. (2011) found that a “sense of self-control” wasassociated with self-regulated eating behavior and HbA1clevels. Peyrot and Rubin (1994) divided internal control inpatients with diabetes into “autonomy” and “selfresponsibility” components, finding that autonomy was associated with positive outcomes and self-responsibility withnegative outcomes. Factor 1 thus indicates that patients havedifficulty protecting their autonomy and that they live withthe thought that they are unable to tolerate hunger in theirlives. Moreover, the contribution rate of the first factor,“sense of lack of self-control,” was 24.1%, indicating that it
is an important factor in the perception of hunger sensation.
In Factor 2, “verbal affirmations of hunger,” patients reported that having diabetes changed their relationships with
their surroundings and were frustrated with interventions regarding their food choices (Willig et al., 2014). Elements ofstigma for patients with diabetes include others being prejudiced against the patient’s food choices because of diabetes,
imposing excessive dietary restrictions when the patient does
not want them, and changing relationships with thosearound them because of diabetes (Browne et al., 2016). In
other research, patients were also hesitant to discuss hunger
and eating problems with their families or healthcare providers (Nagamune et al., 2020). Although the second factor inthis study did not capture the relationship with family members, surrounding others, or medical professionals, the patients’ ability to talk about their hunger and express theiropinions to others is related to their hunger. Nevertheless,the second factor could not be categorized as something thatall patients had, and thus, there were no significant differences between groups.
Factors 3, 4, and 5 consisted of “awareness of hunger”
and “justification,” which were original items. Posey (2006)
defined symptom perception as “the belief an individual has
about what a particular symptom means (cognitively andemotionally), the appraisal of the symptom based on pastand present knowledge and experience, and the response or
action of the individual based upon that meaning and ap-

JINR 2023, 2(2), e2022-0016

praisal.” This implies that patients make their own meaningsof diabetes and hunger, in which case they may perceive
hunger as a symptom of diabetes.
Finally, the sixth factor corresponds to items from a previous study, including “I physically feel that I cannot do it,
but I do not think the medical staff understands me” and“coping with passive endurance” (Nagamune et al., 2020).
As a novel contribution, the researchers reported that patients felt glycemic control was directly related to eating but
still tolerated eating to some extent.
Characteristics of Subjects Classified from the “Questionnaire for Perception of Hunger Sensation in Patients withType 2 Diabetes”
The “Questionnaire for Perception of Hunger Sensation in
Patients with Type 2 Diabetes” was used to divide the subjects into two groups. The all factors high score group had ahigher HbA1c than the all factors low score group, andthere was a significant difference between the two groups.
Comparing the two clusters, the all factors high score grouptended to have particularly high scores on Factor 3:“diabetes-specific hunger approval,” Factor 4: “hunger
awareness,” Factor 1: “Sense of lack of self-control,” andFactor 6: “Tolerance of food intake within the group.” Furthermore, the results of this study showed that the characteristics of each factor score of the clusters revealed that theideas “it is because I do not have enough patience” and “itis because my diabetes condition is affecting me” are notstronger in one and weaker in the other. Therefore, the perception of hunger in patients with type 2 diabetes should bebased on two concepts: “it is because I do not have enoughpatience” and “it is because my diabetes condition is affecting me.” Moreover, we believe that support is required tohelp patients feel that they are in control of themselves
while satisfying the sense that it is okay to eat.
Additionally, in this study, both groups scored low on
Factor 2: “verbal affirmations of hunger.” Relationships andcommunication with family, surroundings, and healthcare
providers have been shown to be related to motivation andself-management behaviors (Parkin et al., 2003; Heisler etal., 2003). Moreover, a previous study (Nagamune et al,2020) found that patients are hesitant to discuss hunger andeating with their families, people around them, and healthcare providers. Hence, we believe that the content of thesecond factor was not significantly different between the twogroups; the results in Figure 1 indicate that the participantsin this study tended to be less positive about verbalizing
their feelings and were “patient” about verbalizing their feelings regarding their bodies. Therefore, we believe that besides “helping patients feel in control while satisfying theirsense that it is safe to eat,” healthcare professionals, family
members, and others around them should start by “listening”
to the “hunger” that patients are feeling, rather than looking
9 of 12JINR 2023, 2(2), e2022-0016

for the cause of hunger.
Moreover, the present results confirmed that the all factors
high score group had higher HbA1c than the all factors lowscore group. Likewise, reportedly, the sense of self-care burden and behavioral changes associated with diabetes affectglycemic control (Roy et al., 2020). In summary, too highphysical sensations related to hunger may negatively impact
the ability to self-manage, which results in poor glycemic
control.
Considering the above, we believe that this study is novel
because it clarified the “feeling of hunger” as perceived bypatients. We believe that this research can be used to support
the self-management of diet therapy in terms of predicting
how patients feel about hunger and how they live their lives
under medical treatment according to how they perceive
hunger.
Limitations
The study had several limitations. First, given that this is across-sectional study that investigates the relationship between hunger and two specific diabetes control measures(HbA1c and BMI), whether changes in control measureswould result in changes in how hunger is perceived is unclear. Second, only patients with type 2 diabetes attending
hospitals and clinics as outpatients were involved. Therefore,
the study may not apply to patients with diabetes who are
hospitalized. Third, HbA1c may be lower in patients withnephropathy due to progressive anemia. Therefore, the study
may not apply to patients with diabetes who are hospitalized. Fourth, the age of the subjects was younger than the
average age for patients with diabetes in Japan in general,and few patients had complications.
This study should be retested to determine whether reliability can be ensured with different subjects.

Conclusion
In this study, it was investigated how patients with type 2
diabetes perceive hunger using a 25-item, six-factor structured questionnaire. Based on the six factors of hunger, participants were divided into two groups: the “all factors highscore group” with high scores on all items and the “all factors low score group” with low scores on all items. Additionally, the all factors high score group had significantly
higher HbA1c than the all factors low score group. The results of this study allowed the categorization of how patientswith type 2 diabetes perceive hunger.
Author Contributions
All authors contributed to the conception and design of thisstudy. Nagamune acquired and analyzed the data and drafted
the manuscript. Okuwa and Inagaki were major contributors
to the analysis and interpretation of the data. Okuwa, Ina10 of 12

https://doi.org/10.53044/jinr.2022-0016

gaki, Tasaki, Horiguchi, and Asada critically reviewed themanuscript and the entire research process. The final manuscript was read and approved by all authors.
Declaration of Conflicting Interests
We have no conflicts of interest to disclose.
Ethical Approval
Approval code issued by the Institutional Review Board:
967-2
The name of the institution that granted the approval:
Medical Ethics Committee of Kanazawa University
Funding
This study was part of a doctoral dissertation that was
funded by a Grant-in-Aid for Scientific Research (Support
for Starting Research Activities) (20K23144).
Informed Consent
All participants involved in this study provided informed
consent.
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Original Research

Development of the prenatal positive experience scale for men in Japan:
A cross-sectional scale development study
Yasuka Nakamura, PhD1 , Tomoka Oshikiri, BN1 , Yoko Takeishi, PhD1 , Moeka Aoki, BN2 ,Nami Yashima, BN2 , Maiko Kawajiri, PhD1 , Mikako Yoshida, PhD1 , and Toyoko Yoshizawa, PhD1
1

Women’s Health Nursing & Midwifery, Tohoku University Graduate School of Medicine, Sendai, Japan, andTohoku University Hospital, Sendai, Japan

2

Abstract
Objective: The aim of this study was to develop and validate a scale to measure the positive experiences of men
during their partner’s pregnancy. Methods: Scale items were developed in consultation with the literature. The
content and surface validity were assessed by experts and the public. Exploratory factor analysis, convergence validity, and internal consistency of the scale were analyzed. Data were collected using the Quality Marriage Index,
responsibility and happiness numerical rating scales, and Center for Epidemiologic Studies Depression Scale.
Multiple regression analysis was performed to identify relevant variables. Results: A total of 267 expectant fathers
were sampled. The final scale was composed of 28 items and 3 factors, namely, 1, increased awareness of becoming a father; 2, self-growth through becoming a father; and 3, comprising positive emotional responses topregnancy events. Cronbach’s alpha was .98 for the entire scale and ranged from .88 to .97 for the three factors.
Regarding convergent validity, a significant moderate positive correlation with other scales was found. Significantly
related variables included number of weeks pregnant, age of wife, positive emotional response at pregnancy announcement, and risk of depression. Conclusions: The 3 factors and 28-item Prenatal Positive Experience Scalefor Men were confirmed to have sufficient reliability and validity. More advanced gestational weeks, a younger
partner, positive emotional response at pregnancy announcement, and no risk of depression were associated withmore positive emotional experiences. On the basis of these results, nursing interventions promoting positive emotions should be provided for men during pregnancy.
Keywords
adoption, expectant fathers, experience, positive emotions, prenatal
JINR 2023, 2(2), e2022-0011

Introduction
The transition to parenthood requires physical, psychological, and social adaptation. During gestation, women undergo
physical changes, whereas men do not; thus, psychologicaland social adjustment is important for men during this period. In a systematic review of anxiety in men during pregnancy, the incidence of anxiety in men whose partner ispregnant increased from the time of conception to the timeof delivery, and the incidence was reported to be 3.4%-25%(Philpott et al., 2019). In other review articles, the prevalence of anxiety disorders in men whose partners are pregnant has been reported to range from 4.1% to 16% (Leachet al., 2016). A meta-analysis of prenatal depression in expectant fathers also reported a prevalence of paternal depression of approximately 10% (Cameron et al., 2016; Paul-

Correspondence: Y. Nakamura. Email: ynaka@tohoku.ac.jp
Received: April 7, 2022, Accepted: December 1, 2022, Advance Publication: April 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 9JINR 2023, 2(2), e2022-0011

son & Bazemore, 2010; Rao et al., 2020). In addition, highstress levels in men during pregnancy have been shown tohave an impact on mental health, including anxiety, depression, distress, and fatigue (Philpott et al., 2019). In a qualitative study of men’s psychological transition to fatherhoodfrom gestational age to the time of birth, the partner’s pregnancy was also described as the most demanding period interms of psychological reorganization of the self (Bäckström & Hertfelt Wahn, 2011; Genesoni & Tallandini,2009).
However, several studies have reported experiences withpositive emotions, such as increased feelings of being happy
because of a partner’s pregnancy, building a relationshipwith the fetus, and deepening attachment (Golian Tehrani etal., 2015; Poh et al., 2014). It is expected that the positive
emotions of men during pregnancy will have a positive impact on mothers and children.
The broaden-and-build theory (Fredrickson, 2001) expands thought-action repertoires, functions as antidotes forthe lingering effects of negative emotions, enhances psychological resiliency, and triggers upward spirals toward improved emotional well-being. Don et al. (2021) reported thatmen’s positive emotions during pregnancy increased their
postpartum marital satisfaction and perceptions of positive
support and decreased their perceptions of negative support,
indicating that positive emotions also have a positive impact
during the transition to parenthood. In summary, it is expected that positive emotions will help reduce negative emotions, such as anxiety, depression, and stress, in men during
pregnancy. It is also expected that such emotions have apositive effect during the child-rearing period. As a measureof men’s positive emotions during pregnancy, Don et al.
(2021) used the Profile of Mood States, but this scale assesses mood state at particular times and has limitations inassessing positive emotions specific to the pregnancy period.
A qualitative research study by Yashima et al. (2021) explored the positive emotions of men during pregnancy. This
study identified 10 related themes, namely, 1, the achievement of a role as a man; 2, the joy of pregnancy itself; 3,caring for pregnant wife; 4, an increasing interest in pregnancy, childbirth, and childcare; 5, valuing relationships andtime with wife; 6, the joy of becoming a father; 7, happy tofeel the presence of my child; 8, affirming visualizations ofchild or family; 9, positive recognition of changes related to
becoming a parent; and 10, gratitude for supportive environment. This qualitative research indicates that men have very
specific experiences related to pregnancy. It would be possible to evaluate men in transition to parenthood by assessing
whether these experiences are occurring in men during theirpartners’ pregnancy; however, there is no simple quantitative
measure that can be used to quantify these experiences.
This study aimed to develop and validate a scale to measure men’s experiences of positive emotions during their part2 of 9

https://doi.org/10.53044/jinr.2022-0011

ner’s pregnancy. In addition, we examined the factors associated with men’s experiences of positive emotions for antenatal childcare. We hypothesized that men who experience
positive emotions during pregnancy will experience bettermental health and participate in childcare and will eventually have a positive effect on mothers and children. If we
can evaluate men’s positive emotions during the pregnancy
period, we will be able to better provide psychosocial support to men, support the adoption of the fatherhood role,and encourage increased involvement from the antenatal period.

Material and Methods
Participants
The eligibility criteria for the participants were men over theage of 20 years and whose wife or partner is pregnant with
their first child. Men who previously had children (including
adopted children) were excluded from this study. The sample size required to verify the structural validity of the scale
was set to 300. This sample size was selected because it isfive times the number of scale items and more than 100
people are considered an appropriate sample size for scale
development (Mokkink et al., 2010). In addition to that criterion, the number of inappropriate responses, such as thesame number for all items, was estimated to be approximately 10%; thus, the number was set at 300.
Data Collection
Data collection was conducted in March 2018 by an online
research company (Cross Marketing Co., Ltd.). The researchcompany invited participants in the company’s database who
met the eligibility criteria to participate in the study via
email. Participants were invited to read the research information sheet, which outlined the research purpose and ethical considerations, on a web page, accept the contents, andthen proceed to the questions. Consent was obtained bypressing the research participation consent button. This
study was approved by the institutional review board of[name and reference number removed].
Measurements
Prenatal Positive Experience Scale for Men
This scale development study was conducted according to
the scale development procedure outlined by DeVellis et al.
(2016).
Determine what to measure: This scale measured men’s
experiences of positive emotions during pregnancy. Positive
emotions were defined in our study as experiences of joy
and happiness, comfort and enjoyment, self-growth and responsibility, and expectations and compassion, based on theemotions addressed in Fredrickso’s (1998) broaden-andbuild theory.

https://doi.org/10.53044/jinr.2022-0011

Generate an item pool: The draft of this scale has 57
items with 43 subcategories developed from the qualitative
research by Yashima et al. (2021), which results based oninterviews of positive experiences during wife’s pregnancy
conducted with a total of 9 men from 17 weeks gestation to
4 months postpartum with their first child, and 14 subcategories added from the literature review (Kamiike et al.,2018), which results derived from 41 Japanesel and Englich
literature aimed at identifying positive emotions and experiences of men during the pregnancy period.
Reviewed by experts and cognitive interviewing: These
items were evaluated in an expert meeting with three nursing specialists and two nursing students. Six men and four
women of reproductive age were included to strengthen thecontent and surface validity.
Determine the format for measurement: Responses to thescale were rated on a 6-point Likert scale, ranging from notapplicable or /not experienced at all (0) to very applicable(5). Higher scores indicated a more positive emotional experience.
Marital Satisfaction
The Quality Marriage Index (QMI), with six items, wasused to assess the quality of the marital relationship (Moroi,
1996; Norton, 1983). Responses were rated on a 4-point
Likert scale ranging from strongly disagree (0) to strongly
agree (4). The score range was 0-24 points, and the higher
the score, the more satisfactory was the marital relationship.
This scale was used to verify the concurrent validity of thescale developed in this study.
Responsibility and Happiness
Using the numerical rating scale (NRS), we measured theparticipant’s current sense of responsibility within his family
and current sense of happiness in his life. Responses wererated on a 10-point Likert scale ranging from not at all (0)to very much (10). This scale was used to verify the concurrent validity of the scale developed in this study.
Depression
The Center for Epidemiologic Studies Depression Scale(Radloff, 1977; Shima et al., 1985) was used to measure depression. This 20-item Likert scale measures the degree ofdepressive symptoms within the past week. The scale asks
participants to rate their mood based on items related to depressive symptoms. The items pertain to the mood of theparticipants and include depressive and physical symptoms,
interpersonal relationships, and positive emotions. Responses
were rated on a 4-point Likert scale ranging from rarely ornone of the time (<1 day) to most or all of the time (5-7days). The score range was 0-60 points. The scale has a cutoff score of !
16, which indicates greater symptoms of depression. A score of <16 indicates no risk of depression(Radloff, 1977; Shima et al., 1985).
Demographic Information
The following demographic details were sought: age, age of

JINR 2023, 2(2), e2022-0011

partner, number of weeks pregnant, employment status, individual annual income, annual family income, family structure, educational background, morning sickness, presence orabsence of infertility treatment, and emotional response topregnancy announcement.
Analysis
The analysis procedure was performed according to thescale development guidelines described below (DeVellis etal., 2016). The data were analyzed using SPSS ver. 26 (IBMSoftware Group, Chicago, IL, USA) (with p = .05).
Exploratory Factor Analysis
The ceiling and floor effects were analyzed for each item of
the Prenatal Positive Experience Scale for Men. Moreover,
exploratory factor analysis (maximum likelihood method,and Promax rotation) was performed to validate the scale.
The item exclusion criteria were items having a factor loading of <.400 and those with two or more factors having afactor loading of !.300. After item exclusion, the item
meanings and item-total correlation were confirmed among
the researchers. Items with duplicate contents were excluded. Finally, the researchers interpreted the meanings ofthe items and named the extracted factors.
Reliability Analysis
The internal consistency of the scale was calculated using
Cronbach’s α coefficient to test the interitem consistency.
Pearson’s Correlation Coefficient
Pearson’s correlation coefficient was used to analyze theconcurrent validity between the total score of the Prenatal
Positive Experience Scale for Men and QMI and happinessand responsibility NRS.
Multiple Regression of Related Factors
Multiple regression analysis was performed to investigate
the related factors in the Prenatal Positive Experience Scalefor Men. The total score of the scale was the dependent
variable. The independent variables included the number ofweeks of gestation, participant’s age, wife or partner’s age,emotional response to pregnancy announcement, infertility
treatment, and the risk of depression.

Results
Participants’ Characteristics
The characteristics of the subjects are shown in Table 1. Of
the 300 participants, 31 respondents had inappropriate responses, such as answering the same number for all items,
and 2 respondents reported that their partners were at <5weeks of gestation. These participants were excluded fromthe sample. A final total of 267 participants were includedin the analysis. The mean age of the participants was 38.1
years with a standard deviation of 8.2 years. The mean ageof the participants’ partners was 34.0 years with a standard
deviation of 5.5 years. Regarding the participants’ educa3 of 9

JINR 2023, 2(2), e2022-0011

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Table 1. Characteristics of the participants (n = 267).
Mean (SD)Age (years)
Male
Partner
Gestational week (weeks)

Education<16 years>16 years
Occupation
Yes
No
Annual income<4 million yen
4–8 million yen>8 million yen
No response
Pregnancy period
1st trimester (–12 weeks)
2nd trimester (13–27 weeks)
3rd trimester (28 weeks–)
Infertility treatment
No
Yes
Feelings at the pregnancy announcement
Very happy
Unexpected but happy
Unexpectedly surprised/confused
Nothing in particular
Risk of depression
YesNo

38.1 (8.2)
34.0 (5.5)
21.7 (9.9)
n

%

81
186

30.3
69.7

263
4

98.5
1.5

77
139
36
21

28.8
52.1
13.5
7.8

57
124
87

21.3
46.3
32.5

195
72

72.8
27.2

179
57
9
22

67.0
21.3
3.4
8.2

123
144

46.1
53.9

SD, standard deviation

tional and employment background, 186 (69.7%) participants were university graduates or above and 263 (98.5%)
were employed. Most participants (n=139, 52.1%) had an
average annual income of !
4 million yen to <8 million. The
average number of weeks of pregnancy for the participants’partners was 21.7 weeks. The ratio of first trimester of pregnancy (<13 weeks) was 57 (21.3%), second trimester ofpregnancy (13-28 weeks) was 124 (46.3%), and third trimester of pregnancy (!28 weeks) was 87 (32.5%). A total of
179 (67%) participants were very happy when they foundout that they were pregnant. Seventy-two (n=72, 27.3%) participants were on fertility treatment, and 123 (46.1%) participants were at risk of depression.
Exploratory Factor Analysis
First, the two items with ceiling and floor effects were excluded from the item analysis. An exploratory factor analysis (maximum likelihood method and Promax rotation) was
4 of 9performed on 55 items. Three factors were extracted and areshown in Table 2. Items were deleted in accordance with theexclusion criteria. After the exclusion, 32 items remained.
We confirmed the meaning and content of each item in anexpert meeting. During this process, we excluded four items
that had overlapping meanings and content. After this process, the final scale consisted of 28 items, which covered
three factors. The Kaiser-Meyer-Olkin measure was .969,
Bartlett’s spherical was p <.001, and the cumulative contribution rate was 76.3%.
The first factor, increased awareness of becoming a father,
consists of 13 items. This factor measures feelings of contentment related to having a baby, sense of family responsibility, and awareness of becoming a father. The second factor, self-growth through becoming a father, consists of 10
items. This factor measures positive emotions associatedwith life changes and the increased sense of social responsibility related to becoming a father. The third factor, comprising positive emotional responses to pregnancy events, consists of five items. This factor determines and measures thetype of positive reactions to events related to their partner’s
pregnancy, such as feeling the movement of the fetus,
healthcare checkups, childcare products, and childbirth.
Reliability Analysis
Cronbach’s α coefficient was .98, .97, .97, and .88 for theentire scale and the first, second, and third factors, respectively. These results indicate sufficient internal consistency.
Pearson’s Correlation Coefficient
Examining the concurrent validity, the correlation with thePrenatal Positive Experience Scale for Men was r =.477 (p<.001), for QMI; r =.419 (p <.001) for happiness NRS; andr=.516 (p <.001) for responsibility NRS. A significant, moderate positive correlation was found between these scales.
Multiple Regression
In Table 3, multiple regression demonstrated a significant
association between the Prenatal Positive Experience Scalefor Men and the number of weeks of pregnancy (β= .14, p= .019); the age of the wife (β =−.20, p = .008); positive
emotional response at pregnancy announcement (β =.246, p<.001); and risk of depression (β =−.18, p = .003) (adjusted
R2 = .143, p <.001). No significant correlation was observedin relation to infertility treatment, despite previous studies
noting a significant relationship.

Discussion
Validity and Reliability of the Prenatal Positive Experience
Scale for Men
In this study, we developed and validated the Prenatal Positive Experience Scale for Men. The developed scale con-

https://doi.org/10.53044/jinr.2022-0011

JINR 2023, 2(2), e2022-0011

Table 2. Exploratory factor analysis of the prenatal positive experience scale for men (n = 267).
Factor (factor loading)
No.

Item

Factor 1 [increased awareness as a father] (Cronbach’s alpha = . 97)
25 I am grateful to my pregnant partner.
3 I’m glad to know about my partner’s pregnancy.
5 I am looking forward to the birth of my child.
27 As my child is born, I feel more responsible for my family.
34 I am relieved that the baby my partner is carrying is fine.
36 I am happy to realize the existence of a baby in my partner’s stomach
35 I adore my baby.
23 I feel that my family ties are deepening, including with the baby that will be born.
37 I feel close to my baby.
22 I enjoy the time my partner and I have until childbirth.
20 I have a growing interest in childcare that stems from conversations with my partner.
16 I strive to maintain fetal health.
4 I am in awe of the mystery of life because of my partner’s pregnancy.
Factor 2 [self-growth by becoming a father] (Cronbach’s alpha = .97)
50 My view point has expanded since I became a parent.
48 By becoming a parent, I became more enthusiastic about my life.
46 Being a parent has increased my flexibility.
44 Being a parent has increased my inner strength.
47 Becoming a parent has increased my compassion for women and vulnerable people.
43 I enjoy becoming a father.
49 Being a parent has increased my sense of social responsibility.
55 I feel a connection with my parents because my partner is pregnant.
40 I enjoy imagining the specific characteristics of my baby.
52 I feel relieved by the information about pregnancy and the reaction of surrounding people.
Factor 3 [comprising positive emotional responses to pregnancy events] (Cronbach’s alpha = .88)
38 I enjoy feeling the baby respond to me when I touch my partner’s stomach
32 I enjoy feeling the fetal movement of my baby.
9 I’m glad that my partner’s morning sickness and dietary restrictions have been resolved.
6 There is a sense of relief with a release of pressure on the wife to get pregnant.
19 I think the performance of ultrasound machines and the functionality of childcare products
are amazing.

1

2

3

Communality

.987
.978
.923
.917
.858
.827
.814
.675
.666
.660
.615
.606
.560

.023
−.101
−.063
.144
−.100
−.030
.043
.218
.047
.165
.209
.206
.129

−.150
−.018
−.032
−.190
.142
.146
.098
.056
.246
.061
.082
.051
.153

.811
.793
.726
.801
.786
.831
.845
.791
.796
.692
.708
.649
.605

−.041
.037
−.069
−.061
.129
.073
.267
.113
.043
.012

.954
.938
.894
.877
.847
.790
.762
.662
.645
.594

−.051
−.090
.073
.062
−.070
.046
−.122
.091
.252
.226

.788
.812
.807
.772
.801
.772
.785
.669
.771
.617

−.228
.126
.077
.136
.238

.237
−.055
−.033
−.022
.077

.862
.834
.656
.610
.467

.790
.786
.471
.482
.492

-

.733
-

.702
.719

Interfactor correlations
Factor 1
Factor 2

Note. Exploratory factor analysis (maximum likelihood method, Promax rotation); Cronbach’s α (full scale) = .98, Kaiser–Meyer–Olkin, .969;
Bartlett’s spherical, p <.001; the cumulative contribution rate was 76.3%.

sisted of 28 items encompassing three factors: 1., increased
awareness of becoming a father; 2, self-growth through becoming a father; and 3, comprising positive emotional responses to pregnancy events. The reliability of the scale wasanalyzed using the internal consistency of the conceptualcomposition of each factor and the entire scale. The cutoff
for Cronbach’s α coefficient was set at .80. These results
confirm the reliability of each factor and the internal consistency of the concept of the Prenatal Positive Experience
Scale for Men (Polit-O’Hara & Beck, 2008). We examinedsurface validity through a review of the questions by experts
and the public during the drafting stage. Questions weremodified for clarity and readability. The validity of the construct was further determined by extracting the factors using
exploratory factor analysis and examining their meanings.
Concurrent validity was analyzed by finding the correlation between existing measuring tools and the newly developed scale. We noted that if there was a high positive correlation, the validity of each scale was strengthened (Burns &Grove, 2005). The QMI measured marital satisfaction(Moroi, 1996). We hypothesized a positive correlation between the QMI score and happiness related to pregnancy, as
marital satisfaction may impact men’s emotional response topregnancy announcement. In addition, we hypothesized that
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Table 3. Factors related to men’s prenatal positive experiences (n = 267).
β(Intercept)
Gestational week
Age
Partner’s age
Feelings at the pregnancy announcementa
Risk of depressionb
Infertility treatmentc

.135
.050
−.204
.246
−.176
.060

t
8.404
2.351
.656
−2.6854.045−3.020
1.024

p
.000
.019
.512
.008
.000
.003
.307

95.0% Confidence interval for
regression coefficient
Lower boundUpper bound

3.403
.003
−.014
−.075
.455
−.672
−.145

5.486
.029
.028
−.012
1.318
−.142
.458

Note. Multiple regression analysis, forced entry, was conducted.
Adjusted R-squared, .143; F-statistic, p < .001; Durbin–Watson = 1.917
a
0 = Unexpectedly surprised/confused, nothing in particular; 1 = Very happy, Unexpected but happyb
0 = <16 of CES-D score; 1 = >16 CES-D scorec
0 = no; 1 = yesβ, Standardized coefficient beta

the happiness NRS would be positively correlated as it
measures levels of happiness felt related to pregnancy andimagining the birth of the child. The sense of responsibility
NRS was also hypothesized to be positively correlated as it
measures the increased sense of responsibility for the family
and society. As expected, a significant positive correlation
was obtained with all these measures. Moreover, concurrent
validity was confirmed.
Factor Structure of the Prenatal Positive Experience Scalefor Men
The first step related to parental development is accepting
pregnancy and preparing to become a parent. Preparing forchanges in the parents’ relationships and lifestyle involves
imagining the birth of a child and becoming a parent (Galinsky, 1987). The first factor, increased awareness of becoming a father, includes items related to the man’s emotional
response to their partner’s pregnancy, physical experience ofthe child through the changes in their partner’s body, and interest in childcare. The first factor includes the experiencesof a man who is preparing to become a parent, as they
imagine becoming parents through their partner. In addition,
the first factor measures experiences unique to men, which
are different from the positive experiences of pregnant
women (Takeishi et al., 2011), such as feelings of gratitude
toward their partner and increased sense of responsibility toward their family.
The second factor, self-growth through becoming a father,measures the individual growth of men into fatherhood suchas increased flexibility, broadened horizons, deepened affection, awareness of the importance of social connections, andstepping into a parenting role. Previous research has reported that fathers’ experiences of self-growth related tochildcare are related to increased flexibility, deepened love
6 of 9for family, and broadened horizons. Our study notes that
self-growth begins from the pregnancy period. Kikoshi andTomari (2006) argue that the process of acquiring the role ofa father starts as an emotional response toward fatherhoodand then they form an image of fatherhood, which includes
increased responsibilities. Our study measured the formationof the image of fatherhood. We postulated that being awareof the connection with the surroundings and sense of social
responsibility are experiences related to pregnancy that are
unique to men who see high social status as a male role
(Watanabe, 2017).
The third factor, comprising positive emotional responses
to pregnancy events, includes physical experiences of pregnancy through feeling fetal movements and emotions (i.e.,
joy and relief) related to witnessing physical changes intheir partner associated with pregnancy. Men’s experiencesof pregnancy and fetal growth are moderated through theirpartner’s body. Seeing the physical changes in their partner’sbody, feeling the fetal movements, and seeing the fetus
through an ultrasound at a health checkup are important aspects of men’s experiences related to pregnancy. Our findings demonstrated that the process of buying, feeling, andpreparing childcare products promote positive feelings related to pregnancy. One study postulates that men have agood scientific understanding (Wakabayashi et al., 2006),
such as the performance of medical devices and the functionality of childcare products. This study states that men
systemize their understanding of pregnancy and childbirth.
Our scale recognized the experiences related to pregnancy
that are unique to men. With the development of medical
equipment, through ultrasound examinations, expectant parents can see the fetus clearly and realize its presence and its
growth early in the pregnancy. Yet, it may be difficult to answer all items of this scale early in the first trimester.

https://doi.org/10.53044/jinr.2022-0011

Variables Related to the Prenatal Positive Experience Scalefor Men
The Prenatal Positive Experience Scale for Men was significantly associated with the number of weeks of gestation,
partner’s age, emotional response to pregnancy announcement, and risk of depression. As the number of weeks ofgestation elapses, physical changes associated with pregnancy become more apparent and fetal movement can be
felt from the abdominal wall. These changes allow the father
to have a physical experience of the pregnancy, which assists them in stepping into a father’s role (Iwata & Mori,
2004). In this process, men may accumulate experiences thatare accompanied by positive emotions.
Our findings demonstrate that pregnancy is associatedwith fewer positive emotions if the man’s partner is older.
Previous research has demonstrated that advanced maternal
age pregnancy is at higher risk for complications, such as
miscarriage and preeclampsia (Hashimoto et al., 2003; Furukawa, 2016). As such, men with older partners may have increased anxiety surrounding the pregnancy, which may
lower their scores.
Some studies have stated that women who reported feeling “confused and perplexed” during pregnancy struggle totransition into motherhood compared with those who reported feeling “happy” during pregnancy (Kondo et al.,2005). Drawing on this research, we proposed that men who
report feelings of joy during pregnancy easily transition into
fatherhood. We also found that men at risk of depression reported having fewer positive experiences of pregnancy thanmen at no risk of depression. Consequently, our scale could
lead to early screening for the risk of depression by measuring positive emotions associated with their partner’s pregnancy (Watson et al., 1988).
Limitations and Future Research
One significant limitation of this study was that the participants were not representative of the broader Japanese population. The participants were older than the average age offirst-time fathers in Japan, which is 32.8 years. Considering
the university entrance rate is 56.6% for men in Japan (Ministry of Education, 2018), the participants in this study had ahigher degree of education. Our sample included many participants with high socioeconomic status. These participants
may have more positive emotional experiences than the general population because they have greater access to financial
and social resources. Therefore, future studies should include participants with high social risk, such as those belonging to low educational background and lower socioeconomic status. In addition, majority of the participants werein the second trimester of their partner’s pregnancy, and few
of the participants were in their first trimester. Although
there is a greater risk of pregnancy complications in the first

JINR 2023, 2(2), e2022-0011

trimester, such as imminent miscarriage, the midpregnancy
period is generally considered stable with minimal risk for
miscarriage. This may have resulted in higher scores for
positive emotions. In addition, some items are difficult toanswer immediately after the discovery of pregnancy andmay not be accurately assessed as early as the first trimester,and an assessment based on the number of weeks of gestation would be necessary.

Conclusions
In this study, we developed and validated the Prenatal Positive Experience Scale for Men. Therefore, 28 items belonging to three factors were extracted and named as the first(increased awareness of becoming a father), second (selfgrowth through becoming a father), and third (comprising
positive emotional responses to pregnancy events) factors.
This study demonstrated that the scale had sufficient reliability and validity. The Prenatal Positive Experience Scalefor Men allows for a quantitative evaluation of the positive
experiences of men during their partner’s pregnancy. This
scale could be used for developing psychosocial support for
expectant fathers and to encourage and strengthen their participation in postpartum childcare activities. This study is thefirst to develop and validate a quantitative scale on men’s
positive experiences during their partner’s pregnancy. Our
study demonstrated that positive experiences of men during
their partner’s pregnancy were associated with a young partner, a positive emotional response to pregnancy announcement, and experiencing the pregnancy progress. In the future, it is expected that this scale will be used to examine
the effects of interventions for men during pregnancy andthe relationship between postpartum participation in childcare and motivation to work.
Acknowledgments
The author would like to thank all the participants in thisstudy. This study was supported by a Grant-in-Aid for Scientific Research (B) 20H03993.
Author Contributions
YN, YT, and TY were involved in study conception and design; YN, YT, TO, MA, and NY were involved in data interpretation and analysis; and MK, MY, and TY contributed tothe interpretation of the results and critically reviewed themanuscript. All authors revised and approved the manuscript
to be published and agreed to be accountable for all aspectsof the work, ensuring that questions related to the accuracy
or integrity of any part of the work are appropriately investigated and resolved. They also critically revised the report.
Declaration of Conflicting Interests
The authors declare no conflict of interest associated with
7 of 9JINR 2023, 2(2), e2022-0011

this study.
Ethical Approval
Ethics Committee Tohoku University Graduate School of
Medicine (2018-1-821)
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Original Research

Development of a weight loss intervention by mothers for adults withsevere intellectual disabilities and autism
Mitsuyo Nonaka, PhD, RN, PHN1 , and Satoko Yanagisawa, PhD, RN, PHN, MW2
1

Department of Nursing, Faculty of Health and Science, Nagoya Women’s University, Nagoya, Japan, and 2Schoolof Nursing & Health, Aichi Prefectural University, Nagoya, Japan

Abstract
Objective: Obesity is highly prevalent among people with intellectual disabilities (ID) and autism. Programs to reduce obesity, however, are currently underexplored. Furthermore, people with severe ID and autism are highly dependent on their family members for a healthy lifestyle; therefore, behavioral changes within the family, especiallyin mothers, are necessary to reduce their obesity. This study aimed to develop a diet-centered obesity reduction
program by mothers that can cater to people with severe ID and autism. Methods: The study used an AB design,with A as the baseline and B as the intervention. An intervention based on “behavior analysis” and the “obesity acceptance process of mothers” was conducted with nine mothers and adults (age range: 20-46 years) with severe
ID and autism from different day centers. The primary outcomes were weight and waist circumference. The secondary outcomes were the occurrence of desirable maternal behavior, the scores of the children’s inflexible adherence to target foods, and target food intake. The outcomes were analyzed at the individual and group levels. Results: Seven adults lost weight, with five losing !3%. During the follow-up, six adults continued losing weight. The
rate for implementing behaviors related to at least one target food was approximately !80% for all mothers. The
adults’ resistance scores were generally low, and six people scored 0 points. The Friedman test revealed significant decreases in weight and waist circumference. Conclusions: The program effectively decreased the weight ofpeople with severe ID and autism through changes in maternal behavior. The children’s low resistance reinforced
maternal behavioral changes.
Keywords
obesity, intellectual disability, mother, behavior analysis, autism
JINR 2023, 2(2), e2022-0003

Introduction

more effective for people with mild or moderate ID.

What Is Already Known

What This Paper Adds

Obesity is highly prevalent among people with intellectual
disability (ID) and autism.
Weight loss programs for adults with ID focus on the
cognition and behavior of individuals with disabilities andtarget people with mild or moderate ID.
To date, studies on weight loss in this group have beenThis was the first weight loss program specifically for adults withsevere ID and autism and the first study aimed at their mothers.
The weight loss program reduced the body weight ofadults with severe ID and autism.
The dietary intervention of mothers modified the routine
diet of adult children with ID and autism.

Correspondence: M. Nonaka. Email: 1minonaka@gmail.com
Received: January 22, 2022, Accepted: December 9, 2022, Advance Publication: April 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 9JINR 2023, 2(2), e2022-0003

According to the American Psychiatric Association(APA), the prevalence of ID in the general population is approximately 1%. Severity levels for ID are classified as
mild, moderate, severe, and profound, and the prevalence ofsevere ID is approximately 6 per 1000 in the general population (APA, 2013). One of the mental and neurodevelopmental disorders that most commonly co-occur with ID is
autism (APA, 2013). Many studies have reported that thehigh prevalence of obesity in people with ID and autism
leads to premature mortality (George et al., 2011; Ha et al.,2010; Phillips et al., 2014). People with ID who live athome are more likely to be obese than those who live in institutions (Bhaumik et al., 2008). In Japan, approximately
90% of people with ID live with their families (Cabinet Office, 2019), and >60% of caregivers of people with disabilities are mothers (Kyosaren, 2010). Individuals with severe
ID require support in all daily living activities (APA, 2013).
Their mothers are often responsible for weight control
through diet and exercise. Many such mothers are very positive about supporting the components of healthy eating, suchas good food selection and regularity (George et al., 2011;
Sakuda et al., 2013). However, mothers of people with ID
also maintain close relationships with their children (Ueto,2012) and believe that eating is enjoyable for them (Arai etal., 2011; Nonaka et al., 2019). Many people with autism
demonstrate excessive adherence to routines and resistanceto change (APA, 2013), making it extremely difficult to provide dietary support to people with ID who also have autism(Tanabe et al., 2012). Among adolescents with developmental disabilities, adolescents with autism had the highest
prevalence of obesity in a national sample of the UnitedStates (Phillips et al., 2014).
Globally, the few intervention programs that address obesity among people with ID are limited in scope, targeting
only those with mild or moderate disabilities (Harris et al.,2018; Nonaka & Furuta, 2017). Previous study on weight
loss, including ones on individuals with severe ID living athome, suggested that existing interventions were likely to be
more effective for people with mild or moderate ID(Melville et al., 2011). To address obesity in people with severe ID and autism, the behavior of family members, especially mothers, needs to be changed; more specifically, interventions should be made in the psychologies of mothers ofpeople with severe ID and autism to address obesity in thisgroup. This study aimed to develop a diet-centered obesity
reduction program for children with severe ID and autism,
performed by their mothers. It aims to help health professionals, such as nurses, to instruct mothers to manage theirchildren’s weight without conflict and help mothers accompany their children to hospitals or elsewhere and use paidcarers. People with severe ID and autism would thus havemore opportunities to go out and for leisure activities, havebetter access to medical care, and be better equipped to pre2 of 9

https://doi.org/10.53044/jinr.2022-0003

vent lifestyle-related diseases and extend their healthy life
span.
The rest of the study is organized as follows. Section 2
provides an overview of the study design and method, Section 3 presents the results, and Section 4 discusses them andends with a conclusion.

Materials and Methods
Study Design
This study used an AB design, with A as the baseline and B
as the intervention, with follow-ups.
Participants
The inclusion criteria were certification of severe ID andautism; aged !
18 years, BMI !
25, and residing with family
at home. The exclusion criteria were certification of physicalor mental disability by Japanese law, receiving dietary guidance from experts within the last 6 months, and mother’s
age !75 years. The WHO defines BMI 30 as obese, but inJapan, BMI !
25 is considered obese because Japanese people are more likely to develop diseases with mild obesity
than Westerners (Japan Society for the Study of Obesity,
2000). The age of the mothers was also limited to !
75 years
to be more accurate in running and recording the program.
Individuals who met the criteria were recommended by day
center directors in Japan, and 10 pairs of mothers and children from 10 different day centers ultimately consented toparticipate. One dropped out; the remaining nine pairs remained until follow-up.
This study was conducted in accordance with the Helsinki
Declaration of 2013 (World Medical Association, 2013). The
purpose and methods of this study and the confidentiality of
personal information were explained orally and in writing to
all participating mothers, and written consent was obtained
from all mothers. These matters were also explained orally
and in writing to these mothers’ adult children with severe
ID and autism while they were with their mothers in waysthat were tailored to their abilities, and consent was obtainedin writing from the children or their mothers. This study
was approved by the Research Ethics Review Board of
Aichi Prefectural University (31aikendaigakujo dai1-7gou).
Intervention
The authors developed a diet-centered “Conflict-free Weightloss Program for Adults with Severe ID and autism” basedon the “obesity acceptance process of mothers” (Nonaka etal., 2019) and “behavior analysis.” According to the former,
mothers faced dietary and hyperkinetic issues caused bytheir children’s disabilities, owing to which they provided
them with scheduled meals―which included the same
foods, the same number of foods, and foods of the samecolor―to avoid conflict with their children, which conse-https://doi.org/10.53044/jinr.2022-0003

BeforeChild

AntecedentChild finishes
the meal.

MotherAntecedentChild finishes
the meal.

JINR 2023, 2(2), e2022-0003

Consequence
Mother serves
dessert.

Behaviour
Child waits.

Behaviour
Mother serves
dessert.

ConsequenceChild eats
dessert.

Child: Consequence of ‘mother serves dessert’ reinforces Behaviour of ‘child waits.’
Mother: Consequence of ‘child eats dessert’ reinforces Behaviour of ‘mother serves dessert.’
After
Child

AntecedentChild finishes
the meal.

MotherAntecedentChild finishes
the meal.

Consequence
Mother serves
tea.

Behaviour
Child waits.

Behaviour
Mother servestea.

ConsequenceChild isas usual.

Mother: Consequence of ‘child is as usual’ reinforces Behaviour of ‘mother serves tea.’

Figure 1. An example of the principle of reinforcement in behavioral analysis for mother and adult with severe
ID and autism.

quently led to obesity. Mothers worried about the adverse
effects of obesity and tried to assist their children in losing
weight, but such efforts were often abandoned. They resumed providing scheduled meals and accepted their children’s obesity because they were attached to their children
who had difficulty being independent. The key to the program was for mothers to avoid conflict with their children.
Figure 1 shows an example of the principles of reinforcement in behavioral analysis for mothers and their adult children with severe ID and autism. In “behavior analysis,” behavior is influenced by antecedents and consequences (ABCanalysis) (Cooper et al., 2007). Reinforcement is the mostimportant principle of behavioral analysis (Cooper et al.,2007); it is the process in which a behavior is strengthenedby the immediate consequences that reliably follow its occurrence (Miltenberger, 2015). The program was designed touse a “behavior analysis” framework to allow mothers who
were closely associated with their children to change their
behaviors, maintain changes in their behaviors through theconsequence “child is as usual,” and reduce their children’s
food intakes. Interventions were individually conducted onmothers by a researcher at day centers or participants’
homes. The intervention included two 70- to 90-min sessions aimed at changing mothers’ behaviors and daily records and 60-min monthly sessions for encouragement andadvice to help mothers maintain their good behaviors.
In Session 1, mothers were given a lecture on the “obesity acceptance process of mothers” (Nonaka et al., 2019) tohelp them objectively understand their experiences. They
then scored their children’s inflexible adherence to daily
routine foods and selected low-score target foods. During

Session 2, the mothers learned “behavior analysis.” By conducting an ABC analysis of their children’s behaviors when
they sought to obtain target foods, mothers realized that
their children’s behaviors were reinforced by the acquisitionof particular foods and that their own behaviors were reinforced by their children’s consumption of these foods. The
mothers decided how they could behave to reduce their children’s target food intakes and implemented these behaviors
at home. Further, they recorded their children’s resistancescores, weights, target food intakes, and whether they themselves implemented their plans to change their behaviors.
They submitted this information to a researcher at each session. The researcher highlighted any changes in the behaviors of the mothers and the children, confirmed whether they
had lost weight as planned, and guided mothers in how to
overcome barriers at monthly sessions. A researcher calledmothers twice a month to monitor whether they were experiencing difficulties and provide encouragement.
Measures
Data were collected from June 2019 to August 2020. The
primary outcomes were children’s weight and waist circumference, a convenient measure of visceral fat accumulation
leading to lifestyle-related diseases. They were measured
weekly during a 2-week baseline, monthly during the 4month intervention, and once 3 months after the intervention. Weight (kg) was measured using the HD-366 scale (Japan, Tokyo, Tanita), and waist circumference (cm) was
measured at the height of the navel of the standing participant. Secondary outcomes were target food intake, inflexible
adherence score (0 = as usual; 10 = occurrence of problem
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https://doi.org/10.53044/jinr.2022-0003

Table 1. Participants’ characteristics at baseline start.
Mothers

Adults with ID

Participants
Age

Age

Gender

BMI (kg/m2)

1
2
3
4
5
6
7
8
9

63
68
55
56
71
55
61
47
72

30
36
22
27
40
22
34
20
46

M
F
M
M
M
M
M
M
M

33.2
35.7
46.5
26.2
28.1
27.5
36.1
25.1
26.8

Average

60.9

30.8

31.7

BMI, body mass index
M, male; F, female
ID, intellectual disabilities

behavior), and occurrence of desirable maternal behavior. As
confounding factors, at baseline, intervention, and follow-up,
the children’s physical activity over 1 week was measured
using Active Style Pro HJA-750C (Japan, Kyoto, Omron
Healthcare) and their diet for 1 day was recorded by theirmothers. Additionally, as qualitative data, the researcher recorded the remarks of the mothers and the states of themothers and children during the sessions in field notes.
Data Analysis
For the primary outcomes, individual trends were first visually analyzed using line graphs. Collective data were analyzed using the Friedman test and multiple comparisons(Tukey’s test). The level of statistical significance was <5%,and statistical analysis was performed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, NY,
USA). For secondary data, weekly mean values were usedand visually analyzed using line graphs. Confounding factors were determined from dietary records, time by activity
intensity, average daily steps, steps per hour, and interviews
with mothers about changes in diets and physical activity.
Narrative data were used to explore factors for primary andsecondary outcomes.

Results
Table 1 presents the characteristics of the nine pairs of participating mothers and their adult children. At baseline, theaverage age of the mothers and children was 60.9 and 30.8
years, respectively, and the mean BMI of the children was
31.7 kg/m2.
Seven of the nine adult children experienced weight loss;
five and one of them lost !3% and >10% of their weight,
respectively. During the follow-up, six children continued tolose weight. All mothers were able to intervene for at least
4 of 9one target food, on average, approximately !
80% per week.
Even with their mothers’ interventions, the children did notresist much and were able to reduce their intake.
Results of Individuals
Figures 2.1, 2.2 show the individual results. Because of
space limitations, only six of the nine cases are explained indetail as follows.
P2: On weekdays, the child bought breakfast, supper,
snacks, and juice at a convenience store with their motherand consumed them alone. The child made coffee with milk
and lots of sugar every morning and drank cola and juice after their bath. The mother only served them holiday meals
and some drinks. The target foods were sugar, cola, andjuice. As the children always used both spoons in the container, the mother decided to reduce the amount of sugar
and the number of spoons and change to zero-calorie colaand juice. The mother’s implementation rate was 100% forsugar, but she could not stop the child from choosing hot
chocolate over cola and the regular-calorie juice. The child’s
inflexible adherence was 0. The child’s weight increased by
2.8% and sugar intake did not decrease. The confounding
factor was that holiday meals prepared by the mother increased.
P3: The mother said that her child’s weight had increased
from 14 to 15 kg over the last 3 to 4 years, with a similar
increase at baseline. She mentioned that the father liked tocook and served the food to the children. Target foods wererice and meat for breakfast; the mother decided to reducethese foods. Her implementation rates were >80%. The average daily intake per week was similar. The child’s inflexible
adherence was within 2. The child’s weight and waist circumference did not increase initially but slightly increased
thereafter. During the follow-up period, the child and his father consumed after-dinner snacks more frequently and the
COVID-19 pandemic prevented the child from going out
with helpers.
P5: The mother could not stop buying her favorite snacks,
so the target foods were four kinds of snacks that her childliked, dinner rice, breakfast fruits, and bread. In the firstmonth, however, she was warned by a family doctor that her
child might be hospitalized for diabetes. The mother thenstopped buying all snacks. She bought snacks only when
shopping with her child on holidays. The mother’s implementation rates were 100% for fruits and bread, 50%-100%
for rice, and 14%-100% for snacks. The child sometimes
sought snacks at home but did not become angry when hecould not find them. The inflexible adherence was 0. The
child’s weight loss was 13% at postintervention but 11.5%
at follow-up. The confounding factor did not change. The
mother said that she wanted to buy snacks but would refrain
postinterview.
P7: Target foods were rice and a main dish for dinner.

https://doi.org/10.53044/jinr.2022-0003

P

Target foods

JINR 2023, 2(2), e2022-0003

Mother’s implementation rate (%)

Score of inflexible adherence(0 = as usual; 10 = problem
behaviour occurrence)

BananaBananaConfounding factors
1

Banana: 1 → 1/2
Cold tofu: 75 g → 35 g
Apple: 1/4 × 3 → 1/6 × 3

No change of meals except
target foods and physicalactivity

2

Sugar in the container:
lots of → Less,
2 spoons → 1 spoon
Coke / Juice: → No calories
Follow-up period:
meals increased on holiday
Physical activity: no change

3 Breakfast rice: 210-250 g→ 150 gBreakfast meat: 128-258 g→ 100 g
Follow-up period: increased
midnight snack anddecreased physical activity

100
80
60
40
20
0
100
80
60
40
20
0

10
8
6
4
2
0

Cold tofu

Apple

Apple

(kg)
91
89
87
85

10
8
6
4
2
0

Coke

Body weight

10
8
6
4
2
0

50
40
30
20
10
0

10
8
6
4
2
0

Breakfast rice

Breakfast rice

(kg)
137
135
133
131

10
8
6
4
2
0

100
80
60
40
20
0

Breakfast meat

Breakfast meat

(cm)
136
134
132
BW +0.6% 130
Waist circumference

BW –0.1%

Body weight

10
8
6
4
2
0

100
80
60
40
20
0

(cm)
113
111
109
BW +2.8% 107
105
Waist circumference

Sugar

(g)

Juice

Juice
100
80
60
40
20
0

Cold tofu Apple

Banana

Sugar

Coke

105
103
101
Waist circumference

(g)
200
150
100
50
0

10
8
6
4
2
0

100
80
60
40
20
0

(cm)
109

BW –2.4% 107

Body weight

Sugar
100
80
60
40
20
0

Daily intake
(kg)
91
89
87
85

Cold tofu

10
8
6
4
2
0

100
80
60
40
20
0

Body weight /waist circumference

(g)
250
200
150
100
50
0
Breakfast rice

4 Bread rolls at 16:00:
5 → 3 on weekdays
Dinner main dish:2 servings → 80%
Dinner rice:heaping rice → 80%
Follow-up period:
60% of sports drinks
Physical activity: no change
5 Snacks: always available →4 kind of snacks → none
Dinner rice:150-210 g → 140 g
Breakfast Fruits → 1/2
Bread: 1 × 6-slice pack →1 × 8-slice packNo change of meals except
target foods and physicalactivity

16:00 bread

16:00 bread

100
80
60
40
20
0

10
8
6
4
2
0

Dinner main dishDinner main dish

10
8
6
4
2
0

100
80
60
40
20
0

Dinner rice

10
8
6
4
2
0

100
80
60
40
20
0

100
80
60
40
20
0
100
80
60
40
20
0
100
80
60
40
20
0

SnacksDinner rice

10
8
6
4
2
0

Fruits

1M 2M 3M 4M

Snacks

(kg)
84
80
76
72
68

Dinner rice

Waist circumference(%)

Dinner main
dish (%)

100
80
60
40
20
0

Dinnerrice (%)(cm)
100

BW –11.5% 96
BW –13.1% 92
88
84
Body weight Waist circumference

Fruits
(g)
180
160
140
120

Bread

10
8
6
4
2
0

F

92
90
88

(piece)5432
10
16:00 bread(pieces)

Dinner rice

10
8
6
4
2
0

Bread
100
80
60
40
20
0

(cm)

BW –6.6% 96
94
Body weight

10
8
6
4
2
0

Breakfast meat

(kg)
86
84
82
80
78

BL 1M 2M 3M 4M

F(%)

Dinner rice(g)

Fruits (%)

BL 1M 2M 3M 4M

100
80
60
40
20
0

F

Figure 2.1. Individual results.
Note. P, participant; BL, baseline; M, month; F, follow-up; BW, body weight.

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P

Target foods

https://doi.org/10.53044/jinr.2022-0003

Mother’s implementation rate (%)

Confounding factors
6

Sausage: at breakfast/dinner,
1 each → 1/2 each
Dinner rice: 120 g × 2 →100 g × 2 → 80 g × 2 or
noodles + rice 80 g × 2 →noodles + rice 50 g × 2
Saturday lunch: Yakisoba +noodles 2/3 + rice 80g × 2→ Yakisoba + noodles 2/3+ rice 50 g × 2
Decrease in side dishes andtreats availability
No change in physicalactivity

7

Dinner rice: 120 g-240 g →120-150 g
Dinner maindishes:
2 servings → 1 serving
Intervention period:
decrease in holiday snacks
Follow-up period:
breakfast decreased,
physical activity increased

8

Breakfast rice: 1 cup →0.7 cup (1 cup is 180 mL)
Snacks: 2 boxes →2 individually wrapped
Follow-up period: dinnerrice on days with manysnacks was reduced.
No change in physicalactivity

9

16:00 sugary drink: 1 cup
× 4 days/week → Tea
Soy milk after bath: 1 bottle→ NoneIntervention and follow-up
period: dinner rice on days
with many snacks was
reduced.
Physical activity:
significantly reduced in
4th month, decreased infollow-up period

Body weight /waist circumference

Score of inflexible adherence(0 = as usual; 10 = problem
behaviour occurrence)

Daily intake
Sausage(kg)

Sausage

100
80
60
40
20
0

Dinner rice

Lunch staple food73
71

Dinner rice

Dinner rice

Dinner main dish

100
80
60
40
20
0

Breakfast rice

16:00 sugary drink

0

Lunch
rice (g)Dinnerrice (g)(cm)

BW −6.9%

Body weight

Waist circumference

Dinner rice

Dinner main dish

(kg)
76
72
68
64

2M 3M 4M

F

120
116
112
108

(cm)

BW −7.2% 90
86
82
78

Body weight

Waist circumference

(cup)
1.2
0.8
0.4
0

(box)
2
1.5
1
0.5
0

Breakfast rice (cup) Snacks (box)

(kg)
64
60
56
52

16:00 sugary drink(cm)

BW −1.9% 92
88
84
80

Body weight

Soy milk after bathing

Waist circumference(kcal)
100
80
60
40
20
0

16:00 sugary drink

1M

Sausage(number)Snacks

10
8
6
4
2
0

100
80
60
40
20
0

0.5

106
102
98
94

Breakfast rice

10
8
6
4
2
0

Soy milk after bathing

1

(g)

10
8
6
4
2
0

100
80
60
40
20
0

(number)

180
160
140
120
100
80
60

10
8
6
4
2
0

Snacks

100
80
60
40
20
0

(g)
250
200
150
100
50
0

(kg)

Dinner main dish

10
8
6
4
2
0

100
80
60
40
20
0

Waist circumference

Lunch staple food

10
8
6
4
2
0

100
80
60
40
20
0

Body weight

Dinner rice

10
8
6
4
2
0

100
80
60
40
20
0

96
94
92
90

BW −4.0%

75

10
8
6
4
2
0

100
80
60
40
20
0

(cm)

77

10
8
6
4
2
0

BL

1M

2M 3M 4M

F

BL 1M

Soy milk after bathing

2M 3M 4M

F

Figure 2.2. Individual results.
Note. P, participant; BL, baseline; M, month; F, follow-up; BW, body weight.

The mother’s implementation rates were 80% for rice andapproximately !50% for main dishes, although sometimes
this rate was 30%. Inflexible adherence was 0. The childlost 6.9% of their weight, and intakes were reduced. The
confounding factors were that holiday snacks and breakfast
decreased and physical activity increased.
6 of 9

P8: Target foods were snacks and rice for breakfast. The
mother decided to reduce snacks from two boxes to two individually wrapped snacks and rice from one cup to 0.7
cups (one cup = 180 mL). The mother’s implementation
rates were 100% for rice and 30% for snacks, especiallyduring the follow-up, as the child’s parents and brotherhttps://doi.org/10.53044/jinr.2022-0003

JINR 2023, 2(2), e2022-0003

Table 2. Standardized body weight/standardized waist circumference friedman test.

1

Body weight*
Waist circumference*2

Baseline (n = 9)

Postintervention (n = 9)

Follow-up (n = 9)p1
10.978 (0.869–1.006)
0.965 (0.887–0.994)

0.960 (0.885–1.028)
0.960 (0.897–1.031)

.045
.013

*1 *2 The mean of the three baselines was set to 1, and the postintervention and follow-up values were divided by the baseline mean.
※Notation is shown by median (total range = minimum value − maximum value).

bought snacks. The inflexible adherence was low―0 forbreakfast and 2 for snacks in the second month. The child’s
weight reduced by 7.2%, and their intake of rice and snacks
was the same as the mother’s implementation. As a confounding factor, the mother reduced the quantity of riceserved at dinner on the day the child consumed manysnacks.
P9: The target foods included a sugary drink at 16:00 andsoy milk after a bath. At first, the child hated drinking tea at
16:00; hence, the mother served coffee with honey. However, a few days later, the child started drinking tea orwhipped green tea. The mother’s implementation rate was!
80%, and inflexible adherence was almost 0. Three months
later, the child’s weight decreased by 2 kg and their waist
circumference decreased by 1.5 cm. However, during thefourth month, the child’s day center closed because of
COVID-19; consequently, physical activity decreased drastically, weight increased, and the ultimate decrease in thechild’s weight was 1.9%.
Statistical Analysis of Primary Outcomes
As Table 2 shows, the standardized body weight (median[minimum-maximum]) with a baseline mean of 1 was 0.978(0.869-1.006) at postintervention and 0.960 (0.885-1.028) at
follow-up. The standardized waist circumference (median[minimum-maximum]) was 0.965 (0.887-0.994) at postintervention and 0.960 (0.897-1.031) at follow-up. Weight wassignificantly reduced from baseline at follow-up, and waist
circumference was significantly reduced from baseline at
postintervention and follow-up.
Mothers’ Remarks and the States of the Mothers and Children
Some children voluntarily weighed themselves at the sessions or at home. Some even mirrored their mothers’ expressions of happiness or disappointment with their weights. Because of severe ID, mothers usually had much less communication with their children, and therefore, some mothers
were pleased with this new communication. Certain mothers
recognized that their children either “accepted” or “did not
notice” that they were given inflexible adherence scores of
0. Reflecting on their behavior, some mothers reported thefollowing: “My child didn’t want them, but I bought them. I

was bad” (mother 8). “I thought deeply that my child was
satisfied with just this amount” (mother 1). “If I don’t give aside dish or snacks, my child won’t want it. It was weakening” (mother 7). “I was glad that the program was easy”(mother 9).

Discussion
This was the first weight loss program specifically for adults
with severe ID and autism and the first study aimed at theirmothers.
Effect of the Intervention on the Mothers
The results suggest that the program allowed the mothers tocontinuously intervene in and address their children’s obesity. The mothers’ implementation rates were approximately!80% for at least one target food. As is the case with thelarger public, interventions in balanced diets with limited
energy levels (Melville et al., 2011) and high-volume andlow-calorie foods (Saunders et al., 2011) are encouraged forpeople with intellectual or developmental disabilities. However, it may be difficult for mothers who believe that theirchildren’s enjoyment comes from meals to intervene in thediet of individuals with severe ID who themselves have difficulty understanding a healthy diet. In this program, target
food selections that did not conflict with children when intervening based on the “obesity acceptance process of mothers” (Nonaka et al., 2019) and an objective view of the children’s behaviors using the “behavior analysis” framework
appear to have modified the mothers’ behaviors. Additionally, postintervention, the mothers’ behaviors were reinforced and maintained by the fact that their “children wereas usual” and the achievement of weight loss. Mothers’ remarks such as “my child didn’t want them (target foods)”
and “I thought deeply that my child was satisfied with thisamount” also showed that this program was feasible formothers.
Effect of the Intervention on the Children
This study succeeded in reducing the children’s intakes of
the target foods selected by their mothers with little or noresistance from the children. Additionally, regarding the confounding factors, the children did not increase their levels of
7 of 9JINR 2023, 2(2), e2022-0003

food consumption, which contributed to their weight loss.
Other home-based weight loss programs for adults with ID
focus on the cognition and behavior of individuals with disabilities and target people with mild or moderate ID(Bergström et al., 2013; Martínez-Zaragoza et al., 2016; Pett
et al., 2013). To date, studies on weight loss in this group
have been more effective for people with mild or moderate
ID (Melville et al., 2011).
People with severe ID and autism frequently have obsessions with specific foods (APA, 2013) and highly regularized eating behaviors (George et al., 2011; Sakuda et al.,2013). “Conflict-free” food selection was an effective way
to encourage healthy dietary changes in individuals with severe ID and autism by working with their mothers. The program was also accepted by the children, as some of themvoluntarily tried to weigh themselves and seemed to “accept” or “not notice” that their mothers had intervened intheir diets. It is important to note here that if the target
foods that children accept are low in calories, they may lose
weight as a result of such repeated diets.
The results also suggest that individuals other than mothers who are familiar with the children benefit from weightloss. In individuals with mild to moderate ID and autism,however, the impact of their own meals is likely greater, so
their own interventions would be necessary, and thus, the effects of the program may be limited.
Factors Related to the Intervention EffectIf the child is relatively independent and the mother’s involvement in the diet is minimal, the program’s effect may
be limited, as was true in the case of P2. Additionally, thephysical activity of adults with severe ID can be affected bya lack of available support and whether their parents havethe time and physical strength to assist them (Arai et al.,2011; Spanos et al., 2013). Therefore, spending time at day
centers and going out with helpers are valuable physical activities for this group. If these activities are reduced, as was
the case with P3 and P9, the program’s effect may be diminished. Further, it may be difficult to maintain plans if
they significantly change the mother’s diet, as in the casesof P5 and P8.
Conclusions
The limitations of this study were its small sample size andadaptation of the AB design, given that using the ABA design would have been unethical. The results demonstrate thatthe program increased the mothers’ abilities to appropriatelyintervene in their children’s weight to help them lose weightwith little or no resistance from the children. The two sessions allowed mothers to appreciate their impact on theirchildren’s weight gain. The low resistance of the children
and application of praise reinforced good behavioral change
in the mothers. In future research, it will be necessary to in8 of 9

https://doi.org/10.53044/jinr.2022-0003

crease the number of cases and confirm the effectiveness ofthe program by including people with severe ID without
autism.
Author Contributions
Mitsuyo Nonaka designed and conducted the study, analyzed and interpreted the data, and prepared the manuscript.
Satoko Yanagisawa supervised the study process, designed
the study, interpreted the findings, and critically reviewed
the manuscript.
Declaration of Conflicting Interests
We have no conflicts of interest to disclose.
Ethical Approval
This study was approved by the Ethics Review Committeeof Aichi Prefectural University (31aikendaigakujo dai1-7
gou).
Funding
Our work was funded by the Japan Society for the Promotion of Science, Tokyo, Japan (KAKENHI Grant No. 19K
11154).
Informed Consent
Informed consent was obtained from all participants or theirmothers involved in this study.
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Original Research

Cognitive behavioural therapy for mood and anxiety disorders deliveredby mental health nurses: Outcomes and predictors of response ina real-world outpatient care setting
Hiroki Tanoue, RN, PhD1 , Yuta Hayashi, RN, PhD2 , Yuki Shikuri, RN, BSN3 , andNaoki Yoshinaga, RN, PhD1
1

School of Nursing, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan, 2Department of Nursing,
Graduate School of Health Sciences, Kobe University, Kobe, Japan, and 3Graduate School of Nursing Science,
University of Miyazaki, Miyazaki, Japan

Abstract
Objective: The need for mental health nurses (MHNs) to incorporate psychological techniques into their nursing
practice has been recognised worldwide. Further evidence from real-world settings is necessary to demonstratethat MNH-led cognitive behavioural therapy (CBT) is an effective approach that can be used in clinical practice.
This study aimed to explore the clinical effectiveness and predictors of MNH-led CBT for mood and anxiety disorders in routine outpatient care settings in Japan. Methods: This retrospective study collected data through a
medical record review of 69 participants who underwent MHN-led CBT between January 2015 and December
2019. Results: Participants who received MHN-led CBT demonstrated significant improvements in depressive/
anxiety symptoms, health-related quality of life and primary psychiatrists’ impressions of condition severity (all p <.001). At the end of therapy, more than half of the participants (56.5%) showed positive clinical significance (recovered/improved) based on cutoff points and reliable change indices of validated depression and anxiety measurement scores. Furthermore, an increase in the baseline anxiety score predicted lower odds of achieving positive
clinical significance (odds ratio = 0.87, 95% confidence interval = 0.79-0.96). Conclusions: Despite several limitations, mainly owing to its single-group retrospective design, this real-world evidence of MHN-led CBT bridges thegap between research and clinical practice, contributing to the widespread use of MHN-led CBT in mental healthservices worldwide.
Keywords
anxiety disorders, cognitive behavioural therapy, mood disorders, nurses, treatment outcome
JINR 2023, 2(2), e2022-0023

Introduction
Cognitive behavioural therapy (CBT) has been consistently
effective in treating mood and anxiety disorders (Butler etal., 2006; Hofmann et al., 2012; Wakefield et al., 2021). Although psychotherapy is preferred over medication by mostpatients, insufficient provision of such therapy is a major

problem in several countries (Kazdin & Blase, 2011;
McHugh et al., 2013). Efforts to improve mental healthservices worldwide have identified the need for mental
health nurses (MHNs) to incorporate evidence-based psychosocial interventions in their clinical practice (Hurley et al.,2020a; Hurley et al., 2020b; The Psychological Professions
Network, 2018).

Correspondence: N. Yoshinaga. Email: naoki-y@med.miyazaki-u.ac.jp
Received: July 21, 2022, Accepted: December 10, 2022, Advance Publication: April 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 8JINR 2023, 2(2), e2022-0023

Since nurses constitute the largest group of healthcare
professionals, the use of psychosocial intervention techniques by MHNs is expected to improve/expand mental
health services. MHNs play a vital role in the disseminationof CBT. In the UK, MHNs received systematic CBT training and primarily provided CBT to neurotic individuals.
These trained MHNs were as effective at delivering CBT asother professionals such as psychiatrists and psychologists(Bird et al., 1979). A follow-up study of British MHNs providing CBT further demonstrated a significant contribution
to mental health service provision, particularly in community care settings (Gournay et al., 2000). Several studies
have confirmed the efficacy of MHN-led CBT for various
mental disorders (Nance, 2012; Turkington et al., 2006). According to a report from the European Psychiatric Nurses(Horatio), most (90%) CBT therapists in the UK presently
have a background in psychiatric nursing (Horatio: European Psychiatric Nurses, 2012). Furthermore, CBT is thepsychological intervention technique most frequently administered by MHNs in outpatient settings (Ameel et al., 2019).
In Japan, CBT for mood disorders was included in the National Health Insurance in Financial Year (FY) 2010, marking an important milestone for Japanese mental health services, which are otherwise dominated by pharmacotherapy.
However, service users’ access to CBT in Japan is generally
suboptimal owing to the scarcity of CBT providers under
the health insurance scheme, which requires CBT to be only
provided by skilled and experienced psychiatrists (Ono,2011). Research has shown that psychological treatments,
predominantly CBT, for anxiety are more effective when
they are delivered by a psychiatrist or clinical psychologist
than when delivered by MHNs (Parker et al., 2021). However, to improve access to CBT in Japan, the subsequent FY
2016 revision of medical fees expanded the range of eligible
CBT providers to include MHNs. Therefore, further evidence from real-world outpatient care settings is necessary
to demonstrate that MHN-led CBT for mood and anxiety
disorders is an effective treatment that can be used in clinical practice. Our previous study reported the results of theroutine clinical outcomes of MHN-led CBT (Yoshinaga etal., 2022), but this study included a heterogeneous population that included all types of mental disorders; thus, realworld outcomes focusing on a more homogeneous population, especially common mental disorders (i.e. a range ofmood and anxiety disorders), are needed. Furthermore, it isessential to identify people who require an adapted treatment strategy and to specify the predictors of MHN-led
CBT responses.
Thus, this study aimed to analyse the clinical effectiveness of MHN-led CBT for mood and anxiety disorders inroutine outpatient care settings and investigate whether sociodemographic and clinical characteristics are predictive ofdifferential therapeutic responses to CBT. Accordingly, clini2 of 8

https://doi.org/10.53044/jinr.2022-0023

cal data were collected retrospectively from former patients,
in Japan, who had received MHN-led CBT for mood andanxiety disorders.

Materials and Methods
Study Design and Sample
This study employed a retrospective cohort design and included patients with mood and anxiety disorders referred to
MHNs for CBT at two psychiatric outpatient clinics in Japan. We retrospectively collected data through medical record reviews of former patients who had received individual
face-to-face CBT between January 2015 and December
2019. The Ethics Committee of the University of Miyazaki
reviewed and approved all aspects of this study (approval
number: O-0442) and waived the requirement to prospectively obtain informed consent from the participants due tothe retrospective nature of this study. In addition, we placed
posters/leaflets at the study institutions and their websites toinform participants that they could withdraw from the study
at any point.
The inclusion criteria for this study were as follows: (1)patients who had a primary diagnosis of mood or anxiety
disorders based on the 10th revision of the International
Classification of Diseases (ICD-10) or the 4th/5th editionsof the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV/DSM-5) and (2) those who had received individual face-to-face MHN-led CBT (at least one session) between January 2015 and December 2019. The diagnostic assessment/classification was conducted by their primary psychiatrist at the study institution.
A total of 121 patients were referred to MHNs for CBT
during the observation period, 52 of whom were excluded(31 did not meet the inclusion criteria for diagnoses, 12 did
not start CBT and 9 did not attend the initial assessment).
The remaining 69 participants with mood or anxiety disorders (n = 47 [68.1%] and 22 [31.9%], respectively) received
individual CBT of at least one session by an MHN (Figure
1).
Intervention
CBT was delivered by three MHNs (mean age = 34.7 years[SD = 2.1]) working at the study institution. On average,
they had clinical experience of 8.9 years (SD = 0.5) in psychiatric nursing and 4.9 years (SD = 1.5) in CBT. All
MHNs had completed a formal, multi-professional CBT
training programme in Japan (including onsite workshops
and online case supervision), which was organised by theCenter for the Development of Cognitive Behavior Therapy
Training.
Under routine clinical settings, CBT was conducted as astructured, individual face-to-face session containing components of CBT-related techniques. If available, therapists fol-

https://doi.org/10.53044/jinr.2022-0023

JINR 2023, 2(2), e2022-0023

Referred (n = 121)
Not assessed (n = 40)- Wrong population (n = 31)- Other reasons (n = 9)
Assessed (n = 81)

Received CBT (n = 69)● Completed the course of therapy (n = 55)● Dropped out (n = 14)- Not satisfied/comfortable with therapy (n = 4)
- Worsening symptoms (n = 2)
- Financial problems (n = 2)
- Schedule conflict (n = 2)
- Pregnancy (n = 1)
- Unknown (n = 3)

Not received CBT (n = 12)- Financial problems (n = 4)
- Schedule conflict (n = 2)
- Changed the treatment plan (n = 2)
- Lost contact (n = 2)
- Other reasons (n = 2)

Included in the intention-to-treat analysis (n = 69)

Figure 1. Flow of participants.
Abbreviations: ITT: intention to treat.

lowed standardised Japanese CBT protocols/manuals foreach disorder. Most sessions lasted approximately 40-60
min.
Outcomes
Depressive Symptoms (Patient Health Questionnaire-9 Item:
PHQ-9 [Self-rated])
The PHQ-9 was used to evaluate the severity of depressive
symptoms (Kroenke et al., 2001). It is a self-administeredquestionnaire comprising nine items that measure the frequency of depression symptoms (e.g. depressed mood, sleep
difficulties and feelings of worthlessness or guilt). Responders scored each item based on their experience over the previous 2 weeks, on a 4-point Likert-type scale. The total
score ranges from 0 to 27, the clinical cutoff for significant
depressive symptoms is !10 points, and a difference of !6points between assessments indicates a reliable change (reliable improvement/deterioration). The Japanese version of the
PHQ-9 is valid and reliable for use with Japanese university
students and primary care patients (Muramatsu et al., 2018;
Umegaki & Todo, 2017).
Anxiety Symptoms (Generalized Anxiety Disorder-7 Item:
GAD-7 [Self-rated])
The GAD-7 was used to evaluate the severity of anxiety
symptoms (Spitzer et al., 2006). It is a self-administeredquestionnaire comprising seven items that measure the frequency of generalised anxiety symptoms (e.g. feeling nervous, being unable to stop or control worrying and having

trouble relaxing). Responders scored each item based on
their experience over the previous 2 weeks, on a 4-point
Likert-type scale. The total score ranges from 0 to 21, and aclinical cutoff of !8 points and a difference of !5 points
between assessments indicate a reliable change. The Japanese version of the GAD-7 is valid and reliable for use withJapanese patients with depression or anxiety disorders (Doiet al., 2018).
Clinical Significance Based on the PHQ-9 and GAD-7
Scores (Primary Outcome)Participants were classified as recovered, improved, no reliable change (unproblematic or problematic) or deteriorated
based on the established cutoff points and reliable change
indices of the PHQ-9 and GAD-7 (Clark et al., 2018). Moredetails on how clinical significance was determined from theconjunction of these scales are as follows:
Recovered: Patients who improved reliably (PHQ-9 and/or GAD-7) and whose final observed scores (PHQ-9 andGAD-7) were below the cutoff point
Improved: Patients who improved reliably (PHQ-9 and/or
GAD-7) but whose final observed scores were above thecutoff point (PHQ-9 and/or GAD-7)
No reliable change (unproblematic): Patients who
showed no reliable change (PHQ-9 and/or GAD-7) andwhose final observed scores were below the cutoff point(PHQ-9 and GAD-7)
No reliable change (problematic): Patients who showedno reliable change (PHQ-9 and/or GAD-7) but whose
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last observed scores were above the cutoff point (PHQ-9
and/or GAD-7)
Deteriorated: Patients who reliably showed scorechanges in the opposite direction (PHQ-9 and/or GAD-7)
Health-related Quality of Life (EuroQol 5-dimension 5-level
Questionnaire: EQ-5D-5L [Self-rated])
The EQ-5D-5L was used to measure health-related subjective quality of life (QoL) (Herdman et al., 2011; van Hout etal., 2012). This questionnaire comprises five dimensions ofmobility, self-care, usual activities, pain/discomfort and anxiety/depression and is rated using five response options: 1(no) to 5 (extreme problems). These results were converted
into a single figure, that is, the health utility value. The
range is between 0 (dead) and 1 (full health), and a valueless than 0 represents a status worse than death. The Japanese version of the EQ-5D-5L is reliable for the general
population (Shiroiwa et al., 2016).
Clinicians’ Impressions of Condition Severity (ClinicalGlobal Impression of Severity: CGI-S [Clinician-rated])
The CGI-S was used by primary psychiatrists at the study
institutions to assess the severity of the clinician’s impressions of the patient’s condition (Busner & Targum, 2007).
The CGI-S is a single item that asks the clinician one question: ‘Considering your total clinical experience with thisparticular population, how mentally ill is the patient at thistime’? This question was rated on a 7-point Likert scaleranging from 1 (normal, not at all ill) to 7 (among the mostextremely ill patients). The rating is based on observed andreported symptoms, behaviour and function in the past 7
days.
Statistical Analysis
All statistical analyses were performed using JMP Pro version 15.2.0. The statistical significance threshold was set ata bilateral alpha level of 0.05. We compared the baseline
and endpoint scores (PHQ-9, GAD-7, EQ-5D and CGI-S)
using paired t-tests based on the intention-to-treat principle,
assuming that the missing values randomly occurred. We
calculated the Hedges’ g within-group effect sizes to determine the magnitude of the effect of MHN-led CBT. A
within-group effect size of 0.20-0.49 was considered small,
0.50-0.79 was medium, and !0.80 was large. Moreover, weevaluated the differences in the daily doses (mg/day) of concurrent psychotropic medications (imipramine-equivalentdose of antidepressants, diazepam-equivalent dose of anxiolytics and chlorpromazine-equivalent dose of antipsychotics) between the assessment points in the same manner.
Multivariate logistic regression models were used to examine the predictors of positive clinical significance status(recovered or improved) at the endpoint. First, we examinedthe crude (unadjusted) association between each factor andthe odds of positive clinical significance. Second, we examined the adjusted associations for possible confounders using
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multivariable logistic regression models with all factors included. Thirteen possible predictor variables were selected:(1) age (continuous), (2) sex (female or male), (3) marital
status (single or married), (4) employment (employed or unemployed), (5) primary diagnosis (mood or anxiety disorders), (6) duration of illness (continuous), (7) comorbidity(yes or no), (8) psychotropic medications (yes or no), (9)baseline PHQ-9 score (continuous), (10) baseline GAD-7
score (continuous), (11) baseline EQ-5D-5L score (continuous), (12) baseline CGI-S score (continuous) and (13) weeks
of treatment (continuous). The associations were presented
as odds ratios (ORs) with 95% confidence intervals (CIs).

Results
Baseline Sociodemographic and Clinical Characteristics
Among the 69 participants who received at least one sessionof CBT by an MHN, the mean age was 35.9 years (SD =10.8) and 31 participants (44.9%) were female. The mean
duration of the primary diagnosis of mood or anxiety disorders was 8.1 years (SD = 7.6) and 24 participants (34.8%)
had comorbid mental disorders. In addition, 52 participants(75.4%) received concurrent psychotropic medications (antidepressants, anxiolytics, or antipsychotics) at baseline. Table
1 shows the other baseline sociodemographic and clinicalcharacteristics.
Intervention Received
Among the 69 participants who underwent CBT, 55 (79.7%)
completed the course of treatment (dropout rate = 20.3%).
On average, 12.8 sessions (SD = 7.6) were conducted over
24.3 weeks (SD = 20.3).
As stated, 75.4% of the participants were prescribed psychotropic medications concurrently at baseline; however,throughout the observation period, there were no significant
differences in the average daily doses of concurrent psychotropic medications.
Outcomes
Regarding clinical significance based on PHQ-9 and GAD-7
scores (primary outcome), 27 participants (39.1%) were considered to have recovered and 12 (17.4%) improved (i.e. 39[56.5%] participants demonstrated positive clinical significance). The remaining 27 participants (39.1%) were judged
to have no reliable change (n = 13 [unproblematic] and 14[problematic]) and 3 (4.3%) had deteriorated (n = 3). In
terms of the difference in clinical significance between themood and anxiety disorder subgroups, 24 out of 46 (52.1%)
in the mood disorder subgroup and 15 out of 23 (65.2%) in
the anxiety disorder subgroup met the criteria for positive
clinical significance (see Tables S1, S2 for details).
Table 2 presents the results of other secondary outcome
measures (PHQ-9, GAD-7, EQ-5D-5L and CGI-S). Statisti-

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JINR 2023, 2(2), e2022-0023

Table 1. Baseline sociodemographic and clinical characteristics(n = 69).
Variable
Age, years, mean (SD)Sex, n (%)
FemaleMale
Marital status, n (%)
SingleNever married
Divorced
Total
MarriedMarriedLiving as married
Total
Employment status, n (%)
Employed or student Full time
Part time
Student
Total
Unemployed
Sick leave from work/school
Unemployed/homemaker
Total
Primary diagnosis, n (%)
Mood disorders
Major depressive disorder
Bipolar I/II disorder
Persistent depressive
disorder (dysthymia)
Total
Anxiety disorders
Social anxiety disorder
Generalised anxiety disorder
Agoraphobia
Total
Duration of primary diagnosis, years, mean (SD)
Comorbidity, yes, n (%)
Baseline concurrent psychotropic medications, yes, n(%)
Baseline antidepressant (imipramine equivalent),
mg/day, mean (SD)
Baseline anxiolytic (diazepam equivalent), mg/day,mean (SD)
Baseline antipsychotic (chlorpromazine equivalent),
mg/day, mean (SD)Value
35.9 (10.8)
31 (44.9)
38 (55.1)
40 (58.0)
4 (5.8)44 (63.8)
22 (31.9)
3 (4.3)25 (36.2)
17 (24.6)
9 (13.0)
6 (8.7)32 (46.4)
17 (24.6)
20 (30.0)37 (53.6)
39 (56.5)
7 (10.1)
1 (1.4)47 (68.1)
15 (21.7)
6 (8.7)
1 (1.4)22 (31.9)
8.1 (7.6)
24 (34.8)
52 (75.4)
43.6 (55.2)
7.9 (13.6)
10.3 (43.5)

cally significant improvements were also found in all secondary outcome measures (all p < .001). The within-group effect sizes for the PHQ-9, GAD-7 and CGI-S were large(Hedges’ g = 0.84, 0.90 and 0.91, respectively), and that for
EQ-5D-5L was medium (Hedges’ g = 0.52).
Predictors of Positive Clinical SignificanceAll potential predictors were entered into a logistic regression model with a positive clinical significance status (recovered or improved) at the endpoint as the outcome. Only thebaseline severity of anxiety symptoms (GAD-7) predicted
the likelihood of positive clinical significance, with an in-crease of one point in the baseline GAD-7 score predicting
lower odds of achieving positive clinical significance (OR =0.87, 95% CI = 0.79-0.96). None of the other predictors
were statistically significant. The area under the receiver operating characteristic curve was 0.74 (see Table S3).

Discussion
This study investigated the real-world clinical effectivenessof MHN-led CBT conducted in routine clinical settings formood and anxiety disorders, along with the baseline predictors of CBT outcomes. The results yielded three key findings. First, in routine care settings, MHN-led CBT for common mental disorders resulted in remarkable improvements
in all clinical outcome measures. Second, more than half ofthe participants either recovered or improved after receiving
CBT, with only a few participants who deteriorated or
dropped out. Third, CBT outcomes were affected by baseline anxiety symptoms in participants (less severe anxiety atbaseline was associated with better outcomes).
The key strength of our study is the high external validity
observed in the results based on real-world data derived
from routine clinical practice. As stated in the introduction,evidence from highly controlled efficacy studies (e.g. randomised controlled trials) often has low external validity.
Thus, the findings of this study using real-world data havesignificant implications for the dissemination of MHN-led
CBT in routine practice. Furthermore, a previous study indicated that CBT for anxiety disorders is more effective whenprovided by psychiatrists or clinical psychologists than whenprovided by MHNs (Parker et al., 2021). Despite this, interms of within-group effect size, our results were comparable to those of other studies in which mental health professionals other than MHNs delivered psychological interventions (including CBT) in a routine care setting. For example,
several previous studies investigated the effectiveness of psychotherapy delivered by clinical psychologists in routine
outpatient care, demonstrating within-group effect sizes of
0.42-1.34 on the severity of depression and anxiety symptoms (Cahill et al., 2010; Richards & Borglin, 2011; vonBrachel et al., 2019; Westbrook & Kirk, 2005). These wereclose to the effect sizes of MHN-led CBT on the severity ofdepression and anxiety symptoms observed in our study(Hedges’ g = 0.84-0.90). Similarly, the effect size of CBT
on QoL in our study (Hedges’ g = 0.52) was comparable tothe effect size reported in the previous meta-analysis basedon randomised controlled trials of CBT for depression andanxiety (Hedges’ g = 0.63) (Hofmann et al., 2017).
Furthermore, we found that less severe anxiety at baseline
was positively associated with better clinical outcomes, suggesting that MHN-led CBT may be more effective for mild
to moderate anxiety. These results are largely consistent withfindings from other studies that have investigated predictors
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https://doi.org/10.53044/jinr.2022-0023

Table 2. Changes in outcome measures (n = 69).
Mean (SD)

Depression (PHQ-9)
Anxiety (GAD-7)
Quality of life (EQ-5D-5L)
Clinician’s impressions of patients’condition severity (CGI-S)

Pre

Post

13.13 (5.84)
10.81 (5.43)
0.68 (0.12)
3.96 (0.92)

8.16 (5.90)
6.19 (4.71)
0.75 (0.15)
3.00 (1.19)tp

Effect size
g

7.90
6.23
−4.97
7.78

< .001*< .001*< .001*< .001*

0.84
0.90
0.52
0.91

Note. t and p values of paired t-test. *p < .01
Abbreviations: EQ-5D-5L, EuroQOL 5-dimensions 5-level; PHQ-9, Patient Health Questionnaire-9; GAD-7,
Generalized Anxiety Disorder-7; CGI-S, Clinical Global Impressions-severity of illnessof CBT outcomes in younger adults. The number of sessions, homework completion and baseline severity of depression and anxiety symptoms predicted treatment outcomes(Kampman et al., 2008). However, another study focusing
on older adults (Wetherell et al., 2005) reported that greaterbaseline severity of anxiety symptoms was positively associated with better clinical outcomes. This contradicts our findings, which may have been influenced by the young age ofthe participants. Further research is required for a detailed
examination of the relationship between symptom severity
and clinical outcomes among individuals with mood andanxiety disorders undergoing MHN-led CBT.
This study had some limitations. First, the most significant limitation was the lack of a control or comparisongroup. Therefore, we could not determine whether MHN-led
CBT itself or other nonspecific factors (e.g. natural timetrends) contributed to the considerable clinical effectivenessobserved in our study. This was an unavoidable limitation
because our study was conducted in a routine outpatientcare setting. Second, the sample size was relatively small
because the study was conducted at two sites within a limited geographical area. Third, only a small number of
MHNs provided CBT, primarily due to the limited numberof MHNs specifically trained in CBT in the country.
Overall, our findings demonstrate that MHN-led CBT canbe delivered with strong positive outcomes in routine clinical settings and will contribute to the spread of CBT worldwide. To disseminate CBT, evidence (e.g. clarification of
mechanisms of action, various targets and delivery methods,
cost-effectiveness and establishment of evidence in clinicalsettings) must be established. This is also recommended by
the guidelines, which require public administrative support.
It also requires training tailored to the therapist’s skill level(e.g. simple and flexible interventions that can be used inclinical practice and education for various professions),
along with ongoing evaluation and validation in routine
clinical practice (Holmes et al., 2018). Furthermore, the Japan Health Care Policy Institute recently released a proposal
outlining the requirements for further dissemination of CBT,
based on the concept of implementation science in Japan.
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These recommendations emphasise the need for public normalisation and awareness of mental health problems (including treatment) and the development of a delivery system (using information and communication technology and applications), as stigma against psychiatry persists in Japan (Japan
Health Policy NOW, 2021). In summary, our real-world evidence undoubtedly supports and encourages the use of
MHN-led CBT in mental health services, narrowing the gap
between clinical research and practice; however, Japanese
MHNs, researchers and policymakers also need to take additional measures to disseminate CBT across Japan.
Conclusions
In psychiatric outpatient routine care settings, CBT provided
by MHNs is effective for individuals with mood and anxiety
disorders to improve their depressive and anxiety symptoms,
QoL and clinicians’ impressions of condition severity. The
CBT response change was affected by baseline anxiety
symptoms in the participants. Our findings bridge theresearch-practice gap and will contribute to the widespreaduse of MHN-led CBT in routine clinical settings worldwide.
Acknowledgments
The authors are grateful to Dr. Hiromitsu Fukunaga (Fukunaga Internal Medicine and Neuropsychiatry Clinic) and Dr.
Kentaro Mizuno (Wakakusa Hospital) for coordinating thestudy, Dr. Daisuke Furushima for statistical advice, Editage(www.editage.com) for English language editing, andChieko Fujiyama for supporting data entry.
Author Contributions
HT and NY contributed to the conception and design of thisstudy. YH merged the dataset. HT analysed the data anddrafted the first manuscript. All authors collected and interpreted the data, critically revised the first manuscript for important intellectual content, and approved the final manuscript.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest.

https://doi.org/10.53044/jinr.2022-0023

Disclaimer
Naoki Yoshinaga is one of the Associate Editors of the Journal of International Nursing Research and is on the journal’s
Editorial Committee. He was not involved in the editorial
evaluation or decision to accept this article for publication.
Ethical Approval
This study was approved by the Ethics Committee of the
University of Miyazaki (O-0442).
Funding
This work was financially supported by JSPS KAKENHI(Grant Number: 17K17506 to HT) and The Mitsubishi
Foundation (Grant Number: 202030028 to HT). The funders/sponsors had no role in the acquisition or analysis of
the data or the content of this study.
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https://www.jinr.jsnr.or.jp/

Original Research

Learning needs of family caregivers in the Japanese working generation
who care for community-dwelling people with dementia: A qualitative
research study
Sayori Sakanashi, PhD, RN1 , Kimie Fujita, PhD, RN2 , Midori Nishio, PhD, RN3 ,Shinji Ouma, PhD, MD4 , and Kumiko Ogata, PhD, RN1
1

School of Nursing, Faculty of Medicine, Fukuoka University, Fukuoka, Japan, 2Department of Health Sciences,
Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan, 3Department of Nursing, Nishikyushu University,
Saga, Japan, and 4School of Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan

Abstract
Objective: This study investigated and described the learning needs experienced by family caregivers in theJapanese working generation who care for community-dwelling people with dementia (PWD). Methods: Thisqualitative descriptive study conducted semi-structured in-depth interviews to explore the learning needs experienced by the family caregivers of PWD. 18 family caregivers were recruited via purposive sampling (age range 3060 years) from two medical facilities, two self-help groups, and 10 prefectural-sponsored counseling facilities in Japan. The collected data were subjected to a qualitative content analysis. Then, the derived learning needs were independently reviewed by two nursing researchers with expertise in qualitative research and family nursing. The
Standards for Reporting Qualitative Research (SRQR) recommendations were followed. Results: Four main categories and 20 subcategories were derived to clarify the learning needs of family caregivers in the Japanese working generation who care for community-dwelling PWD. The four main categories included (a) increasing long-termcare literacy, (b) dispelling the negative images associated with dementia and long-term care, (c) working on longterm care as a unified team that handles issues concerning caregiving for dementia, and (d) promoting an activerole as a member of society. Conclusions: This study clarified specific learning needs that family caregivers in
the Japanese working generation experience when caring for community-dwelling PWD, thus, contributing to amore thorough understanding of the associated challenges. In addition, the structured list of learning needs
should aid health professionals when conducting assessments and planning interventions, especially when framing these issues from the cultural perspective.
Keywords
dementia, family caregiver, learning need, working generation, qualitative research
JINR 2023, 2(2), e2021-0022

Introduction
There are approximately 50 million people with dementia(PWD) worldwide, with current numbers expected to be
more than tripled by 2050 (World Health Organization,2020). This constitutes a serious international health problem, as the behavioral and psychological symptoms of dementia (BPSD) affect interpersonal relationships and theability to perform activities of daily living; even more problematically, the various issues stemming from COVID-19

Correspondence: S. Sakanashi. Email: sakanashi@adm.fukuoka-u.ac.jp
Received: October 6, 2021, Accepted: December 14, 2022, Advance Publication: April 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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have increased neuropsychiatric symptoms in many PWD.
Thus, this highlights the urgent need for interventions to improve support for caregivers (Wei et al., 2022).
In Japan, the number of PWD is expected to exceed sevenmillion by 2025 (Ministry of Health, Labour and Welfare,2019). Japanese tradition entails that families are responsible
for caregiving duties. To date, official reports show that approximately 54% of family caregivers with communitydwelling people are below 60-years-old in Japan (Statistics
Bureau of Japan, 2019). The situation in Japan is continually worsening, with 99,000 individuals quitting their jobs
due to long-term care needs on an annual basis (Ministry ofInternal Affairs and Communications, 2018).
Dementia care makes it especially difficult to balance
work requirements. Reports have shown that social isolation
due to turn over leads to other problems, such as the abandonment of care and elder abuse (Leung et al., 2017). While
the Japanese long-term insurance system assists people withthese types of care needs (Iwagami & Tamiya, 2019), cognitive symptoms have become more difficult to manage due toissues, such as the COVID-19 pandemic and certain lifestyle
restraints, including restrictions on going out and service usage and communication with others (Ministry of Health, Labor and Welfare, 2021). In summary, the current conditions
have increased the burden of long-term care, thus making
the problem more serious.
Research shows that individuals who care for PWD withhigh long-term care needs are especially hindered in theirwork due to heavy caregiving burdens (Gordon et al., 2012;
Fujihara et al., 2019). Further, individuals in the working
generation are more likely to develop depression because
they must work and provide care without help from family
members or formal services (Juratovac & Zauszniewski,
2014; Eguchi & Wada, 2018). Moreover, family caregivers
in the working generation are greatly affected by the burdens associated with long-term care.
Despite these issues, caregivers may benefit by employing
some helpful strategies. For example, Baharudin et al.
(2019) reported that pre-planned care positively influenced
the relationship between BPSD and caregiver burden. In addition, research shows that caregivers undergoing educational programs/courses feel more confident about dementia
care because they help reduce stress and dissolve feelings ofconcern and promote empathy and understanding. (Klimova
et al., 2019). In this regard, family caregivers in the working
generation may balance their work and care duties by learning more about the caregiving process itself. This should becomplemented by dementia education programs, which arefacilitated through goal setting (Resciniti et al., 2020). Assessing the learning needs of trainees is an essential elementof effective teaching and is becoming increasingly formalized as a part of continuing professional development(McKimm & Swanwick, 2009). Grant (2002) reported that
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https://doi.org/10.53044/jinr.2021-0022

published classifications of learning needs include felt needs
and expressed needs. Hence, these needs must be identified
to understand learning needs. Furthermore, Watanabe (2002)
reported that “apparent learning needs” that appear inlearner’s words and actions, such as “I want to learn,” do
not adequately reflect their true learning needs. Ergo, shehighlighted the need to focus on “in apparent learningneeds,” such as “feelings about learning” and “important
things,” that the learners themselves were not aware of anddid not verbalize. In other words, clarifying learning needs
is necessary for designing an educational program for family
caregivers in the Japanese working generation who care forcommunity-dwelling PWD. However, education on dementia
care tends to focus on formal caregivers (Resciniti et al.,2020). While a previous study described the learning needsof individuals who care for PWD (Yoon & Kim, 2019), it
did not focus on the needs of individuals in the working
generation. Dilworth-Anderson et al. (2020) critiqued thecurrent frameworks on education for caregivers and foundthem limiting; he called for reworking the framework to include diversity, inclusivity, and intersectionality. The generallack of evidence in this area highlights the need to clarify
specific learning needs and support strategies for thesecaregivers, especially considering the rapid rate of population aging in Japan. This study aims to understand the learning needs of family caregivers in the Japanese working generation who provide care to community-dwelling PWD andbuild support to balance work and long-term care with peaceof mind. Sakanashi and Fujita (2017) reported that empowering caregivers provides them continuous physical andmental stability and confidence in caregiving. Hence, thisstudy’s theoretical perspective is empowerment. Therefore,
this study conducted interviews with diverse family caregivers of PWD from the working generation in Japan, revealing
and describing relevant learning needs based on their direct
experiences. The results may help develop an additional dimension for empowerment―the empowerment of caregivers
through their knowledge and experiences. Here we define
the working generation in Japan as individuals between 30
and 60 years of age who have work experience and are currently responsible for work duties.

Materials and Methods
Study Design
This study employed a qualitative descriptive design (Sandelowski, 2000) to gain a rich understanding of learning needs
that pertain to family caregivers in the Japanese working
generation who provide care to community-dwelling PWD.
The learning needs in this study were defined as including both of the following: apparent learning needs that family caregivers in the Japanese working generation who carefor community-dwelling PWD felt and expressed, and inap-

https://doi.org/10.53044/jinr.2021-0022

parent learning needs that they themselves were not awareof and did not verbalize through their caregiving experience.
Reporting follows the Standards for Reporting Qualitative
Research (SRQR; O’Brien et al., 2014).
Population and Sample
To include a wide range of caregivers, we recruited 18 family caregivers of PWD through two medical facilities, two
self-help groups, and 10 prefectural-sponsored counselingfacilities in Japan. The inclusion criteria were family
caregivers of PWD, aged between 30 and 60 years of age
and ability to speak fluent Japanese. We used purposive
sampling (Sandelowski, 2000) to recruit a wider range of
caregivers (e.g., men and women, husbands and wives, sonsand daughters), caregiving durations, and types of dementia
diagnoses. This ensured robust sample representativenessacross study sites. Long-term participation in the field andassiduous observation yield reliable information (Flick,2011). Thus, before conducting the interviews, we participated in the self-help groups to develop relationships withpotential participants.
We provided each medical facility, self-help group, andprefectural-sponsored counseling facility with adequate information regarding the study purpose and procedures. Following this, we provided all participants with the relevant
information and obtained their informed consent.
Data Collection
We collected data through semi-structured interviews withall 18 participants between January 2019 and February
2020. To identify their apparent and inapparent needs, we
asked caregivers what difficulties they faced when caring fora family member with dementia, how they dealt with them,and what they were careful about and valued when caring
for their families. We also asked what they wished to learn
about caring for a family member with dementia.
We also collected demographic characteristics, including
gender, age, employment status during caregiving, relationship with the PWD, family cohabitation status, dementia
type, duration of caregiving, and level of caregiving. The interviews were conducted in the one-on-one semi-structured
format and held in comfortable, safe environments―suchthat all participants were encouraged to engage both openly
and freely. After obtaining their respective consent, theaudio from each interview session was digitally recorded.
Meanwhile, we documented their expressions and movements in the field notes. The interviews ranged from 45 to
150 minutes (M = 91.2 min). Signed consent forms cannot
be linked with interview content and informant names wereneither requested nor recorded.
AnalysisInterviews were transcribed anonymously by an independent

JINR 2023, 2(2), e2021-0022

professional. We employed the qualitative content analysis
method (Elo & Kyngäs, 2008) after transcribing the interviews verbatim. During the first phase, the first author familiarized with the data and led the initial analysis. The
author repeatedly read each interview transcript, identified
the participant’s learning needs, and recorded codes. At thisstage, the codes were documented onto coding sheets, whichwere then used to generate subcategories. Following thisopen coding process, the subcategory lists were grouped under higher-order codes. First, each subcategory was named
using content-characteristic words. Then, subcategories withsimilar contents and incidents were grouped. During the second phase, another researcher read through the transcripts
and verified the data categorizations. During the third phase,the results of both analyses were discussed to develop thelearning needs. Finally, two nursing researchers with expertise in both qualitative research and family nursing and who
were not otherwise involved in this study double-checked
the analysis to ensure rigor.
Ethical Considerations
This study was approved by the ethical review board at auniversity affiliated with one of the authors. All participants
were informed of the study purpose and procedures, potential for publication, and confidentiality of their data. All participants were informed regarding their right to refuse participation and provided their written informed consent prior
to interview engagement.

Results
Participant Characteristics
Table 1 shows relevant characteristics of the 18 participants.
Their mean age was 52.0 years (range of 31-60 years); 14
were women, 8 were full-time workers, 12 were daughtersof the care recipient, 11 cared for patients with Alzheimer, 8of the care recipients required extensive caregiving, and 8
reported caregiving durations >10 years.
Category Descriptions
Table 2 shows a list of learning needs extracted during theanalysis, including four main categories and 20 subcategories. Specific examples from participants’ responses are included below to illustrate some subcategories. Case identifiers are denoted by “[Mr./Ms., family caregiver].”
Main Category: (a) Increasing Long-term Care Literacy
This main category―investigated through seven subcategories―reflects that caregivers must collect/utilize appropriate
information and locate the various tools/networks designed
to support them in providing long-term care.
Prior to caring for PWD, the interviewees did not believethat either dementia or long-term care was relevant to theirlives. Therefore, “Understanding that care is not a problem
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https://doi.org/10.53044/jinr.2021-0022

Table 1. Demographic characteristics of the caregivers of people with dementia (n = 18).

No.

Age

Sex

Employment
status during
caregiving

Relationship withthe person withdementia

Sex ofAge ofpersonperson with
withdementia
dementia

A
B
C
D
E
G
H
I
J
K
L
M
N
O
P
Q
R
S

Late 40s
Early 50s
Early 60s
Early 30s
Early 50s
Late 50s
Late 50s
Late 50s
Early 50s
Early 60s
Late 30s
Late 30s
Early 50s
Late 50s
Late 50s
Late 50s
Early 50s
Late 50s

FemaleFemaleFemaleFemaleFemaleFemaleFemaleFemaleFemaleMale
Male
FemaleFemaleMale
Male
FemaleFemaleFemaleFull-time worker
RetiredPart-time worker
Full-time worker
Part-time worker
Full-time worker
Full-time worker
Full-time worker
Full-time worker
RetiredRetiredFull-time worker
Part-time worker
RetiredFull-time worker
RetiredRetiredRetiredDaughter
Daughter-in-law
SpouseDaughter
Daughter
Daughter
Daughter
Daughter
Daughter
Son
Son
Daughter
Daughter
Son
Son
Daughter
Daughter
Daughter

Male
FemaleMale
Male
FemaleFemaleFemaleFemaleFemaleMale
Male
FemaleFemaleMale
FemaleMale
Male
FemaleLate 70s
Early 80s
Late 60s
Late 60s
Late 70s
Late 80s
Early 80s
Late 80s
Late 70s
Early 90s
Early 70s
Late 70s
Early 80s
Early 90s
Late 80s
Late 80s
Late 70s
Late 80s

Type of dementia

Caregiving
required

Duration ofcaregiving(years)Dementia with Lewy bodies
Alzheimer’s disease
Young onset dementia
Young onset dementia
Alzheimer’s disease
Alzheimer’s disease
Alzheimer’s disease
Alzheimer’s disease
Alzheimer’s disease
Alzheimer’s disease
Dementia with Lewy bodies
Frontotemporal dementia
Frontotemporal dementia
Alzheimer’s disease
Alzheimer’s disease
Vascular dementia
Vascular dementia
Alzheimer’s disease

Extensive
Mild
Extensive
Extensive
Extensive
Mild
Extensive
Moderate
Mild
Extensive
Moderate
Moderate
Moderate
Dead
Extensive
Dead
Dead
Moderate

8
2.5
10
10
10
2
12
5
3
5
0.9
14
6
12
17
5
2.5
8

Table 2. Learning needs of family caregivers in the Japanese working generation who care for community-dwelling
people with dementia.
Main Category

Subcategory

Increasing long-term care
literacy

Understanding that care is not a problem for others but is a problem for me
Understanding that learning by myself is a shortcut to solving problems
Understanding the correct treatment and communication methods
Choosing quality services that match the personalities of people with dementia
Using social services that make full use of knowledge and information
Learning how to control my emotions
Understanding how to anticipate and act

Dispelling the negative
images associated withdementia and long-term care

Understanding that various treatments and courses exist for dementia
Understanding the people with dementia who suffer from difficulties in daily and social life
Understanding that dementia is only an illness

Working on long-term careas a unified team that
handles issues concerning
caregiving for dementia

Sharing long-term care life with the entire family
Acquiring the help of trusted specialists
Selecting an appropriate consultant according to the content
Understanding the benefits of long-term care for your family
Understanding that each family member has different thoughts and perceptions

Promoting an active role asa member of society

Understanding the responsibility of playing an active role as a member of society
Establishing one’s own life to maintain a balance between work and long-term care
Supporting changes in the image of dementia and the long-term care society
Promoting and disseminating useful information about dementia and long-term care
Increasing family involvement to improve the nature of care and the welfare service systemfor others but is a problem for me” was necessary. Additionally, they also did not know who to talk to―or where to obtain information from―when suddenly confronted with theneed to provide care. Therefore, “Understanding that learn4 of 10

ing by myself is a shortcut to solving problems,” “Understanding the correct treatment and communication methods,”“Choosing quality services that match the personalities ofpeople with dementia,” “Utilizing social services that makehttps://doi.org/10.53044/jinr.2021-0022

full use of knowledge and information,” “Learning how tocontrol my emotions,” and “Understanding how to anticipate
and act” were also crucial. Below are the characteristic subcategories and specific examples.
(1) Understanding that “Care Is Not a Problem for Others
but a Problem for Me”
This subcategory indicates family caregivers recognizing
their caregiving responsibilities. Mr. K had an active careerin the metropolitan area and lived a fulfilling life with hiswife. He was willing to take care of his parents if they required it but was actually not prepared for the work. Being
unable to cope, Mr. K lost his employment and home:
Before I started caring, I had a vague feeling that I[would have] to go back to my parents’ house and take careof them someday. However, I don’t think I fully understoodthat caregiving was my problem. So, I did not know what toprepare, I did not prepare for anything [Mr. K, family
caregiver].
(2) Utilizing Social Services that Fully Utilize Knowledge
and Information
This subcategory refers to obtaining knowledge and information about caregiving to receive effective support. Mrs.
C’s husband developed young-onset dementia. Childcare is aunique challenge for family caregivers with young-onset dementia. While working part-time, she raised three children, acollege student and a high school student. She was initiallyworried about the situation but learned that she could receive her disability pension with the help of a self-helpgroup’s supporters. Since then, she has received a lot of information on her own:
I did not understand anything at first. However, I realizedthat it is important to always go to the city hall and look for
useful information. It is necessary to talk to various people
and get information for yourself [by asking questions suchas] “What is that?” There is no support unless you study or
ask people. It is both mental and economically important[Mrs. C, family caregiver].
Main Category: (b) Dispelling the Negative Images Associated with Dementia and Long-term Care
This main category―investigated through three subcategories―indicates that caregivers perceive the care recipient asa self-respecting person.
The interviewees did not initially understand that thetreatments, processes, and reasons for the illness’ onset differ on a case-to-case basis. Thus, “Understanding that there
are various treatments and courses for dementia” was necessary. Further, they were prejudiced against dementia andheld negative perceptions of PWD due to the belief that interpersonal engagement was a difficult or vulnerable process. As such, “Understanding the people with dementia who
suffer from difficulties in daily and social life” and “Understanding that dementia is only an illness” were necessary.
Below are the characteristic subcategories and specific ex-

JINR 2023, 2(2), e2021-0022

amples.
(1) Understanding the PWD who Suffer from Difficulties in
Daily and Social Life
This subcategory refers to understanding the behavioral context of PWD. Mrs. M was tasked with caring for her
mother. In this context, she cohabitated with her mother,husband, and children, which meant she was also responsible for childcare. She expressed that this arrangement wasarduous because she did not have an amicable relationshipwith her mother prior to moving her into the household.
Moreover, she did not know how to solve this problem. She
did not fully understand how her mother felt about this for along time:
Looking back on those days, I can see that my motherwas having a hard time. She thinks her mother noticed that
her abilities were declining, and she felt that her daily life
was not going well [Mrs. M, family caregiver].
(2) Understanding that Dementia Is Only an Illness
This subcategory represented the caregivers’ understandingof dementia as a common illness. Upon learning that her
husband had developed young-onset dementia, Mrs. C was
saddened that there was a PWD in her family. When her
husband was admitted to psychiatric care, she was shocked
to find that the hospital was “really like a prison” and choseto hide the situation from others. With the help of her supporters, she could eventually admit that her husband had dementia:
I could not accept that my family had a dementia case.
First, I wondered why this problem happened only in myhouse. However, after understanding dementia, I started
talking frankly about my husband. My husband is not in jail.
My husband is not doing anything wrong. Dementia is oneof the most common illnesses, [like] cancer [Mrs. C, family
caregiver].
Main Category: (c) Working on Long-term Care as a Unified Team Handling Issues Concerning Caregiving for Dementia
This main category―investigated through five subcategories―indicates that the caregiver works to form a team comprising all possible helpers to handle the surrounding issues.
The interviewees took great responsibility in their careduties but experienced difficulty when they were the only
ones providing the care. Therefore, “Sharing long-term carelife with the whole family,” “Acquiring the help of trusted
specialists,” “Selecting an appropriate consultant according
to the content,” and “Understanding the benefits of longterm care for your family” were necessary. To effectively
utilize the family’s power, “Understanding that each family
member has different thoughts and perceptions” was necessary. Below are the characteristic subcategories and specificexamples.
(1) Sharing Long-term Care Life with the Whole Family
This subcategory refers to sharing caregiving roles regarding
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PWD with their families. Mr. L once held a long-term carejob but retired and devoted himself to caring for his mother.
This was largely due to an assertion made by his father (i.e.,“neighbors say that Mr. L does not take care of his family
but only takes care of others”). There were also influencesfrom other family members; it may be a characteristic ofJapanese culture to decide who will be in charge of longterm care according to the opinions of neighbors.
My younger brother often says, “I want you to live yourown life, so you don’t have to worry too much about ourmom.” I wanted to prioritize my mother’s care, but I began
to think I had to make my own life plan [Mr. L, family
caregiver].
(2) Understanding that Each Family Member Has Different
Thoughts and Perceptions
This subcategory demonstrates the recognition and affirmative acceptance of the differences in family members’ opinions. Mrs. A had numerous experiences abroad and optimally utilized these in her work, but she was called upon by
her mother. At the time of the interview, she provided herfather with care and helped run his business. She had anolder brother and younger sister; however, each had theirown families and were rarely involved in long-term care duties. She once asked her brother to take care of her father,but he declined (i.e., “it was hard because I did not knowwhat my father was saying. You should leave it to the experts”). Her siblings often disregarded responsibility:
They just say, “you are doing your best.” I want them tohelp with my father’s care. So, I am angry with them. I
learned that even within the same family there are different
ways of thinking about caregiving [Mrs. A, family
caregiver].
Main Category: (d) Promoting an Active Role as a Memberof Society
This main category―investigated through five subcategories―demonstrates the establishment of social roles in both
work and the community, specifically aimed at improving
the circumstances surrounding dementia.
The interviewees had difficulty balancing their work andlong-term care duties, thus changing or quitting their jobs.
Thus, “Understanding the responsibility of playing an activerole as a member of society” and “Establishing one’s own
life to maintain a balance between work and long-term care”
were important. They noticed some existing social problems
related to dementia care but could not find workable solutions. Therefore, “Supporting changes in the images of dementia and the long-term care society,” “Promoting and disseminating useful information about dementia and long-termcare,” and “Increasing family involvement to improve thenature of care and the welfare service system” were necessary. -Below are the characteristic subcategories and specificexamples.
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https://doi.org/10.53044/jinr.2021-0022(1) Establishing One’s Own Life to Maintain a Balance Between Work and Long-term Care
This subcategory indicates having a social life with proper
management of work and caregiving. After being tasked
with caring for his father, Mr. K resigned from his position
at a major company, divorced his wife, and returned to hishometown. He took care of his father alone because he had
no other family members to help him; it may be a characteristic of male caregivers that Mr. K tried to take care of himself without relying on familiar people such as his wife.
I lost my work and career. No one needs me now, even if
I have worked for a big company in the past. This is frustrating and sad...However, since I have gained experience in
caregiving, I may be able to work on a new caregiving job
while balancing my own caregiving for parents [Mr. K, family caregiver].
(2) Supporting Changes in the Images of Dementia and theLong-term Care Society
This subcategory represents the attempt to address dementia
and caregiving issues. Mrs. M majored in sociology while
attending college and was therefore highly interested in social issues. She actively exchanged views with her classmates about long-term care:
I think it tends to be reported that there are many problems in long-term care facilities. However, the problem wasonly with 10%, and the remaining 90% were good. We needto know the truth about the problems in long-term care facilities [Mrs. M, family caregiver].

Discussion
This study examined learning needs in caregiving based on
the experiences of individuals in the working generation in
Japan who also provided care to community-dwelling PWD.
The learning needs derived from the analysis were arranged
into four main categories: (a) increasing long-term care literacy, (b) dispelling the negative images associated with dementia and long-term care, (c) working on long-term care asa unified team that handles issues concerning caregiving fordementia, and (d) promoting an active role as a member ofsociety.
Dementia care research has strong cultural characteristics(Samson et al., 2016; Tuomola et al., 2016) and requires
culturally related conceptual models and theoretical perspectives (Dilworth-Anderson et al., 2020). This study discusses
dementia care based on the perspective of empowerment
among family caregivers of community-dwelling PWD in
Japan by Sakanashi and Fujita (2020); this is regarded as an
excellent practice in dementia care and helps with understanding the essence of dementia care, caring for oneself as
well as for the person with dementia, and having peers withshared support activities.
Increasing long-term care literacy extracted in this study

https://doi.org/10.53044/jinr.2021-0022

shows that Japanese working generation caregivers cangreatly benefit from preparing before engaging in long-termcare. While those in the working generation tend to bephysically healthier and more active than older caregivers(Chiao et al., 2015), they are also more often confronted
with a greater variety of challenges, both in society and at
home. Owing to time limitations, they must quickly learn
how to obtain useful resources and information, especiallyby availing flexible services that are easy to use. Some interviewees had actually quit their jobs or divorced theirspouses to focus on providing long-term care, which indicates that collecting information once the process has already begun may be too late. In other words, working families who have not yet experienced long-term care must adequately prepare themselves by increasing their long-termcare literacy prior to the actual caregiving. While a previous
study offered some learning needs of family caregivers of
PWD (Yoon & Kim, 2019), these suggestions pertained to awide variety of caregiver ages and were solely focused onlong-term care. “Increasing long-term care literacy” maypromote excellent practice in dementia care (Sakanashi &Fujita, 2020) for individuals in the working generation who
can prepare themselves prior to caregiving engagement. This
also constitutes a new perspective on the issue.
Alzheimer’s Disease International (2019) is working to resolve an issue wherein over 35% of family caregivers worldwide hide the presence of dementia in their families. According to a survey of urban communities in Japan, approximately half of the family caregivers were embarrassed tohave PWD in their families (Aihara et al., 2016). Younger
people’s tendency to exhibit negative attitudes toward dementia has also been reported (Chang & Hsu, 2020). This
indicates widespread prejudice against people with disabilities in the working generation that must be addressed bothin Japan and abroad. “Dispelling the negative images associated with dementia and long-term care” found in this study
refers to a biased perception of dementia that family
caregivers must work to replace with positive judgments andevaluations. This is similar to Yoon and Kim’s (2019) suggestion that caregivers must be “able to talk optimistically.”
Chang and Hsu (2020) reported a link between negative perceptions of dementia and knowledge. In other words, a poor
understanding of dementia precipitates negative emotions.
Contrarily, Aihara et al. (2016) suggested that increasing theability to obtain and use information improves attitudes. The
need for educating the younger generation about PWD has
also been suggested (Chang & Hsu, 2020). In summary,both this study and the current literature demonstrate the importance of acquiring knowledge and information aboutcaregiving for the working generation. Hence, “increasing
long-term care literacy” may lead to “dispelling the negative
images associated with dementia and long-term care,” which
may be related. Furthermore, this may aid empowerment

JINR 2023, 2(2), e2021-0022

through understanding the essence of dementia care (Sakanashi & Fujita, 2020).
Japanese families are traditionally expected to fulfill
caregiving responsibilities in cases when older adult family
members require care (Kumagai & Ishii-Kuntz, 2016). However, since kinship networks have recently begun transforming, caregivers may find that gaining help and understanding
from other family members is difficult. Indeed, the modern
decline in family functions increases the burden placed on
caregivers, especially for the adult children of parents thatneed care (Chiao et al., 2015). For family caregivers to be
empowered, long-term care requires active cooperation with
one’s immediate surroundings and society in general (Sakanashi & Fujita, 2017). Here, “working on long-term care asa unified team that handles issues concerning caregiving fordementia” reflects a situation wherein members of the working generation who also provide care to PWD must take theinitiative to form a care team. This may enable caring for
oneself as well as for the person with dementia (Sakanashi & Fujita, 2020). Several studies have reported that dementia care exhibits a significant cultural impact (Samson
et al., 2016). Therefore, this learning need may be especially
important for Japanese caregivers due to the substantial influence of family culture in Japan.
Yoon and Kim (2019) suggested some learning needs that
focus on the relationship between PWD and their caregivers
or what it means for self-development through caregiving in
caregivers from results, including data of older caregivers.
However, several Japanese working individuals spend a large
amount of time at work, where they also establish social
roles and identities (Funashima & Mochizuki, 2017). In
other words, they play social roles and find value throughtheir work. This makes caregiving even more difficult for
those in the working generation, who must establish a balance between their existing purposes in life and the value ofself-development found by providing long-term care. According to Resciniti et al. (2020), providing these individuals
with educational materials that describe the cultural relevance of long-term care is important. Here, “promoting anactive role as a member of society” will help family caregivers in the working generation understand that their new social roles constitute respectable positions in society. This
may lead to care for oneself as well as for the person withdementia (Sakanashi & Fujita, 2020).
Thus, a link may exist between “increasing long-term care
literacy” and “dispelling the negative images associated withdementia and long-term care.” Hence, “increasing long-termcare literacy” may lead to an understanding of the essenceof dementia care and, thereby, improve dementia care.
Therefore, “increasing long-term care literacy” was hypothesized to influence empowerment among the family caregivers of community-dwelling PWD in Japan.
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Implications
The learning needs developed in this study offer a usefulperspective for health professionals in Japan, particularly inthe context of structured learning support and relevant interventions. This perspective may also be helpful for professionals in countries with similar family cultural values andworking conditions. Notably, the task of increasing longterm care literacy prior to beginning caregiving may positively affect other learning needs and should, therefore, receive greater attention in practice. Here, critical support may
also be provided to caregivers based on their level of understanding. This should include educational programs provided
by healthcare professionals. For example, family caregivers
who begin providing assistance during the early stages oflong-term care and have lower understanding of the relevant
learning needs typically require immediate help, which may
prompt health professionals to proactively offer support andstrategical advice. Meanwhile, individuals in the working
generation may be unable to afford learning programs or
may be less interested in their engagement prior to beginning caregiving, especially when they do not fully understand the learning needs. In such cases, health professionals
may actively provide support that is focused on increasing
their interest in matters related to caregiving.
In summary, these findings have important implications indementia care research, from both the Japanese cultural perspective and for members of the working generation. However, continued research is needed to construct and verify
educational programs that are tailored to fit different levelsof understanding regarding the learning needs.
Study Limitations
This study has some limitations. First, the results may havebeen affected by sampling bias, as participants were limited
to family caregivers in one Japanese prefecture. Second,some perspectives may not have been represented in the
study sample. Future studies should, therefore, conduct interventions to assess the validity of the learning needs in
different environments.

https://doi.org/10.53044/jinr.2021-0022

a member of society. These findings may also be pertinent
in other countries with similar social cultures and working
habits. Finally, the structured nature of the learning needs
offers a useful perspective for health professionals when
conducting assessments and prescribing interventions that reflect specific cultural characteristics and the needs of theworking generation.
Acknowledgments
We thank all the family caregivers of PWD who participatedin this study, as well as the staff members at all cooperating
institutions. This study was a part of a larger research project funded by Grants-in-Aid for Scientific Research (KAKENHI) from the Japan Society for Promotion of Science(Grant Number JP 18K10563) from 2018 to 2021.
Author Contributions
S. S. contributed to the study conception and design, datacollection, data analysis and interpretation, and manuscript
drafting. K. F. contributed to the study conception, data
analysis and interpretation, and critical revision of the manuscript for intellectual content. M. N. contributed to the datacollection, data analysis, and interpretation processes. S. O.
contributed to the data collection process. K. O. contributed
to the data analysis and interpretation processes. All authors
read and approved of the final manuscript.
Declaration of Conflicting Interests
The authors declare no conflicts of interest with respect tothe research, authorship, and/or publication of this article.
Ethical Approval
This study was approved by the ethical review board of
Fukuoka University, Japan (ID Number 2018M081).
Funding
This study was a part of a research project funded by
Grants-in-Aid for Scientific Research (KAKENHI) from theJapan Society for Promotion of Science [grant number JP 18
K10563] from 2018-2021.

Conclusion

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caregiving for dementia, and (d) promoting an active role as

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

Original Research

Nurse managers’ support during organizational change and nurses’organizational commitment: A cross-sectional study using nurses’ career
stage
Chika Funakoshi, PhD1 , Keiko Kunie, PhD2 , Yukie Takemura, PhD1 , Kimie Takehara, PhD3 , andNaoko Ichikawa, PhD1
1

Department of Nursing Administration, The University of Tokyo, Tokyo, Japan, 2Department of Nursing
Administration, School of Nursing, Tokyo Women’s Medical University, Tokyo, Japan, and 3Department of Nursing,
Nagoya University, Nagoya, Japan

Abstract
Objective: Hospital organizational changes are known to deteriorate nurses’ organizational commitment, and the
support of frontline nurse managers is crucial in preventing this deterioration. However, the effects of the practicalsupport provided by frontline nurse managers at different subordinate career stages during organizational change
are yet to be determined. Thus, in this study, we aim to clarify the associations between nurses’ organizational
commitment and the two types of frontline nurse manager support (i.e., preparation for organizational change andpersonal counseling) based on subordinate nurses’ years of experience. Methods: This cross-sectional study was
conducted among nurses using a self-report survey method. Hierarchical multiple regression analyses were conducted, with organizational commitment as the dependent variable. Results: Responses from 1,603 nurses at 63
hospitals were analyzed. As per our findings, both types of frontline nurse managers’ practical support were foundto positively and significantly affect nurses’ organizational commitment. The association of these two types of frontline nurse manager support with organizational commitment based on years of nursing experience was deemed
insignificant. However, the results of a subgroup analysis per career stage based on years of experience showedthat organizational commitment for nurses with more than 20 years of experience was not associated with preparation for organizational change. Conclusions: Both types of practical support provided by frontline nurse managers during organizational change are important to retain nurses’ organizational commitment. However, the effectiveness of each type of support may differ according to the nurses’ career stage. For expert nurses, personalcounseling was found to be more important than preparation.
Keywords
affective organizational commitment, frontline nurse manager support, hospital nurse, organizational change
JINR 2023, 2(2), e2021-0025

Introduction
Hospital organizational changes have emerged as an issue
affecting the healthcare industry globally. Organizationalchange is defined as the process by which organizations re-design their structure or culture to increase their effectiveness (Jones, 2013). “Change scale” refers to the degree ofchange required to reach the desired outcome (Al-Haddad &Kotnour, 2015). Hospital organizational changes often range
from hospital level (e.g., mergers) to unit level (e.g., func-

Correspondence: Y. Takemura. Email: takemuray@g.ecc.u-tokyo.ac.jp
Received: October 12, 2021, Accepted: February 1, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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tional, clinical specialty, or number of beds). Various scalesof hospital organizational change occur worldwide due tothe ever-changing social conditions (Malach & Baumol,
2010), making the phenomenon a global healthcare issue.
The deterioration of affective organizational commitment
is one of the effects of such organizational change amongnurses (Jensen & Sørensen, 2017; Keane et al., 2016). Somemeta-analyses have shown that affective organizational commitment has strong positive correlations with organizational
citizenship behavior and negative correlations with stressand turnover (Bowling et al., 2015; Cetin et al., 2015;
Guzeller & Celiker, 2019). Nurses with low affective organizational commitment are noted to quit, show poor performance, or fail to implement patient safety measures (Al-Zamel
et al., 2020; Baird et al., 2019; Liu et al., 2020). Thus,
maintaining nurses’ affective organizational commitment via
nursing management is essential for hospital organizations
as well as for individual nurses.
As per systematic reviews of organizational change, thepsychological outcomes of employees, including nurses, arefound to be largely related to supervisor support (De Jong etal., 2016; Oreg et al., 2011). Although not organizationalchange, longitudinal studies of nurses required to adapt to
new tasks, for example, during an infection outbreak or entering the workforce, have reported higher affective organizational commitment and lower emotional exhaustion
among nurses who have received support in the past
(Church & Yarbrough, 2018; Maunder et al., 2006). Thus,
supervisor support received by nurses during organizationalchange may subsequently affect their affective organizational
commitment. Notably, frontline nurse managers play a majorrole in addressing and preventing the decline of nurses’ affective organizational commitment (Asiri et al., 2016), as
they are in charge of managing the day-to-day activities inwork units and providing direct support to subordinates(Sullivan, 2017). The support of supervisors, especially,
frontline nurse managers, during organizational change may
enhance nurses’ affective organizational commitment at thetime of the survey. However, how frontline nurse managers’
support affect nurses’ affective organizational commitment
has not been clarified. Moreover, there remains limited research on the types of practical support frontline nurse managers should provide during organizational change.
Effective types of support can be found among the success factors of organizational change, as identified by Kotter(1996). He noted that training is a major success factor thatmanagers should provide, particularly when new technicalskills, social skills, or behaviors are needed for new work
arrangements (Kotter, 1996). In another study, nurses expressed concerns regarding their insufficient knowledge ofcaring for new patients and the difficulties of cooperatingwith new colleagues before a unit merger (SalminenTuomaala et al., 2017). Thus, having the opportunity to pre2 of 9

https://doi.org/10.53044/jinr.2021-0025

pare for organizational change by receiving frontline nurse
managers’ practical support may be key to nurses continuing
to provide quality care. Another type of support that frontline nurse managers can provide during organizationalchange is personal counseling, which is an aspect of individualized consideration, according to transformational leadership theory (Bass et al., 2003). Individualized consideration describes the leader’s provision of personal attention,coaching, and support to followers (Bass, 1999), and it has
been found to be associated with nurses’ affective organizational commitment (Top et al., 2015; Weng et al., 2010) as
they have different skills, techniques, and career plans. Additionally, the roles, skills, and activities required by unitcharacteristics and clinical specialties differ (Cooper et al.,2019; Kilpatrick et al., 2013; Kramer et al., 2013). Previous
studies have reported that during organizational change,
nurses commonly perceive role conflicts, role ambiguity, andcareer stagnation (Blythe et al., 2001; Cummings & Estabrooks, 2003). Nurses’ reactions to organizational change
can vary; thus, personal counseling, including providing explanations and rationales that consider nurses’ individual
situations, can help them design resilient career paths while
fulfilling their professional aspirations.
Although frontline nurse managers should provide nurses
with opportunities for preparation and personal counseling,
the relationships between these two types of support as they
relate to nurses’ affective organizational commitment are yet
to be clarified. Intervention requirements may differ depending on nurses’ years of experience. Benner (1984) statedthat nurses go through stages from novice to expert, depending on their experience, and they require different types of
support at each stage. Clarifying the differences in the association between these two types of support and nurses’ affective organizational commitment according to their yearsof experience will enable frontline nurse managers to provide support that is suited to the characteristics of thenurses. These differences will enable frontline nurse managers to support nurses efficiently during organizationalchange. However, these differences have not been wellinvestigated.
Thus, this study aims to reveal the associations and thestrengths thereof between frontline nurse managers’ practicalsupport during organizational change and nurses’ affective
organizational commitment based on years of experience.

Materials and Methods
DesignA cross-sectional study using anonymous self-report questionnaires was conducted between June and September
2017.

https://doi.org/10.53044/jinr.2021-0025

Hypotheses
In this study, we evaluated the following two hypotheses:
H1: Among nurses, frontline nurse managers’ practicalsupport (i.e., preparation for organizational change and personal counseling) is positively related to nurses’ affective organizational commitment.
H2: Among nurses, years of nursing experience moderates
the positive relationship between frontline nurse managers’
practical support (i.e., preparation for organizational change
and personal counseling) and nurses’ affective organizational
commitment.
Participants
Although several types of organizational changes may havedifferent effects on nurses’ affective organizational commitment, previous studies have used several change types as theselection criteria and analyzed subjects who experienced
these changes according to the situation in each country(Bernstrøm & Kjekshus, 2015; Brown et al., 2006; Montour
et al., 2009). As an organizational change that occurs due tochanges in inpatient characteristics and care practices, in thisstudy, hospital organizational changes were defined as anyof the following changes implemented for managerial reasons: change in function (e.g., a unit that changes from being an acute general unit to a long-term care unit); change
in clinical field specialty (e.g., a unit that changes from being a gastroenterology unit to a mixed unit with both gastroenterology and gastrointestinal surgeries); or change in thenumber of beds (e.g., increase or decrease in the number ofbeds per unit).
The targeted hospitals were those in Japan with more than
200 beds and units that had changed in the year before thesurvey date. Specialized psychiatric hospitals and facilities
for disabled persons were excluded.
Inclusion/Exclusion Criteria
The participant inclusion criteria were as follows: nurses,
midwives, and licensed practical nurses who had experienced organizational change, apart from frontline nursing
managers.
The participant exclusion criteria were as follows: nurses
who had endured a long-term absence and had joined thehospital after the organizational change.
Data Collection
Randomly selected hospitals throughout Japan were sent a
written request to participate in this study, as there is noavailable list that enumerates hospitals that have underwent
organizational changes. Directors of nursing in the selected
hospitals were notified of the study’s criteria, and if their
hospital met these criteria, they were asked to pledge a commitment to participate. Prior to conducting this study, the

JINR 2023, 2(2), e2021-0025

sample size was estimated using G*Power 3.1 (Faul et al.,2007). We used a priori power analysis for multiple regression with a moderate effect size of .15, a power of .95, and
α =.05, which yielded a minimum total sample size requirement of 153. We then divided the nurses into four groups(i.e., advanced beginner, competent, proficient, and expert)
according to their years of experience, which refers to thestages of nurse proficiency excluding nursing students, as
proposed by Benner (1984). Therefore, our total sample size
was 612 (4 groups × 153 nurses). In some countries, careerladder systems for nurses have been created based on Benner’s theory (Pertiwi & Hariyati, 2019). As the approximate
number of years separating career stages varies from study
to study, we referred to prior studies to reconcile the differences (Chatchumni et al., 2016; Farčić et al., 2020; Leeet al., 2021; Mortensen et al., 2019); we were able to determine that the thresholds of the nursing experience year
should be 3, 8, and 20 years. A follow-on discussion withexperts has confirmed this structure. To ensure the required
sample size, 1,000 hospitals with 200 or more beds wererandomly selected from a database of all Japanese hospitals
developed by Wellness Co. Ltd. (2011). Then, the directorsof nursing who agreed to participate in this study distributed
the questionnaire to the participants who met the inclusion
criteria through their frontline nurse managers. The participants were given approximately 2 weeks to complete thequestionnaire, seal it in the provided envelope, and drop it
in a collection box. The collection box was then returned tothe authors unopened.
Instruments
Information on affective organizational commitment, frontline nurse manager support, and demographic data was collected from the nurse participants. Organizational information was collected from frontline nurse managers.
Affective organizational commitment was measured using
a 7-point Likert-type scale ranging from 1 (“strongly disagree”) to 7 (“strongly agree”). The total scores ranged from
6 to 42. In this current study, the alpha coefficient was .87.
The measurement applied a subscale of the Japanese versionof the Three-Dimensional Organizational Commitment Scale(Takahashi, 1997), which was originally developed by Allenand Meyer (1990). The Japanese version is valid, reliable,
and satisfactory. Organizational commitment consists of affective, continuance, and normative commitments, which areconceptually separate ideas. The use of the subscale wasauthorized by Allen and Meyer (1990). The subscale has
been commonly used with nurses. Participants were asked
about their affective organizational commitment at the timeof the survey.
Frontline nurse managers’ support during organizationalchange was assessed using two subscales, namely, preparation for organizational change and personal counseling. The
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authors explored items based on themes from practice reports and interviews with directors of nursing regarding theorganizational change process. To assess preparation for organizational change, the questionnaire sought informationfrom nurses on whether they had received sufficient opportunity to prepare. This subscale consisted of six items as follows: (1) sharing of emotions, (2) learning specific medical
knowledge, (3) practicing new medical skills, (4) a tour ofthe other units inside or outside the hospital, (5) the opportunity to discuss operations with nurses, and (6) the opportunity to discuss operations with other medical professionals.
Regarding the sharing of emotions in the above subscale, arecent study reported that shared emotions among staff during restructuring efforts affected their change implementation behavior (Kanitz et al., 2022). Therefore, shared emotions were regarded as the first step in preparing for organizational change. A sample item read as follows: “Were you
given the opportunity to practice the nursing care required
after the organizational change?” Each item was rated using
a 6-point Likert-type scale, ranging from 0 (“no preparation”) to 5 (“sufficient preparation”). The total scores ranged
from 0 to 30. A subscale consisting of five items was used
to assess personal counseling: (1) explanation of organizational change, (2) answering questions about organizationalchange, (3) role change, (4) expectation, and (5) career
meaningfulness. One sample item read “Did you receive an
explanation about what the organizational change means foryour career?” Each item was rated using a 6-point Likerttype scale, ranging from 0 (“no explanation”) to 5 (“sufficient explanation”). The total scores ranged from 0 to 25.
The face validity of the two subscales was confirmed via
cognitive interviews with four graduate students and two
hospital nurses who had experienced organizational change.
A single factor with a loading of 0.6 or greater was confirmed for all questions from each scale using factor analysis. Reliability was affirmed by alpha coefficients: .92 for
preparation for organizational change and .91 for personalcounseling.
Organizational information included hospital size, hospitalfounder (public or private), type of organizational change,
and the date when the organizational change was conducted.
The demographic variables of the nurses included age, sex,
qualification (i.e., registered nurse, midwife, or licensed assistant nurse), years of nursing experience, employment
status (full- or part-time), educational background (i.e., nursing school, junior college, university, or graduate school),and position (i.e., staff, chief nurse, or assistant frontline
nurse manager).
Ethical Considerations
This study was approved by the Research Ethics Committeeof the Graduate School of Medicine at the University of Tokyo (No.11583). The authors requested that the frontline
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nurse managers ensure that nurses participated on their own
volition and return the collection box to the authors without
opening it.
Statistical Analysis
Descriptive analyses of all variables were first conducted;
thereafter, the authors conducted hierarchical multiple regression from Steps 1 to 3 using the forced-entry method toverify Hypothesis 1. The authors entered the control variables (those with p < .2 in the bivariate analyses for sex,
marital status, years of nursing experience, qualification,
educational background, position, hospital founder, hospitalsize, and change in clinical field specialty) in Step 1. Frontline nurse managers’ support was handled in Step 2.
To verify Hypothesis 2, the authors entered the interaction
term of frontline nurse manager support and years of nursing experience in Step 3.
Moreover, we conducted subgroup analyses using hierarchical multiple regression using the forced-entry method bycareer stage, with reference to Benner’s theory (1984). The
processes in Steps 1 and 2 were then repeated. Group 1 (advanced beginner) included nurses with less than 3 years ofexperience, and Group 2 (competent) included nurses with
between 3 and 8 years of experience. Group 3 (proficient)nurses had between 8 and 20 years of experience. Lastly,
Group 4 (expert) had nurses with more than 20 years of experience. To avoid multicollinearity, correlations between all
variables and variance inflation factors were checked. As
age was strongly correlated with experience (r = .91), theauthors selected years of nursing experience as the control
variable. The statistical significance was set to p < .05. To
analyze the data, the authors used IBM SPSS Statistics
ver.24.0 for Windows.

Results
In total, 199 out of 1,000 hospitals have restructured units inthe previous 2 years. Directors of nursing from 80 of these
hospitals accepted our request to participate in this study.
The number of questionnaires distributed to nurses was
3,998, of which 2,622 from 80 hospitals (176 units) werereturned. Ultimately, 1,603 responses (120 units) were analyzed. Those with blank answers (n = 58), no organizational
information from frontline nurse managers (n = 175), exclusion criteria (n = 606), or missing data for any analyzed
variables (n = 180) were excluded.
Characteristics of Nurses
The characteristics of the nurses are shown in Table 1. The
nurses’ mean age ± standard deviation was 34.4 ± 9.9 years,
and the mean for years of nursing experience was 11.4 ±9.2 years. Most nurses were female (91.6%), registerednurses (95.1%), and full-time workers (96.9%). Most partici-

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JINR 2023, 2(2), e2021-0025

pants were full-time, licensed nursing staff. The nurses’ average affective organizational commitment score was 21.5 ±6.5.
Associations of Frontline Nurse Managers’ Support and Affective Organizational Commitment
Model 2 in Table 2 show the associations between frontline

nurse managers’ support and affective organizational commitment. In Step 2, the two types of frontline nurse managers’ support (i.e., preparation for organizational change
and personal counseling) were found to be positively andsignificantly related to affective organizational commitment(β = .150, p < .001; β = .180, p < .001). Thus, Hypothesis 1
was supported.
Differences in Associations by Nurses’ Years of Experience

Table 1. Characteristics of nurses.

Participants (N = 1,603)
Age (years)
Sex
FemaleQualification
Registered nurse
MidwifeLicensed assistant nurse
Nursing experience
Years of nursing experience
Employment status
Full-time
Educational backgroundNursing school and junior college
University and beyond
Position
Staff
Chief nurse or assistant frontline nurse manager

n (%)
Mean ± SD
34.4 ± 9.9
1,468(91.6)

1,524
53
26

(95.1)(3.3)(1.6)

11.4 ± 9.2
1,553(96.9)

1,267
336(79.0)(21.0)

1,431
172(89.3)(10.7)

Note. SD : standard deviation.

Model 3 in Table 2 presents the interaction term of eachfrontline nurse managers’ support (i.e., preparation for organizational change and personal counseling), and years of
nursing experience was deemed insignificant (β = −.036, p =.186; β = .017, p = .539). Thus, Hypothesis 2 was not supported.
Moreover, Table 3 presents the results of the subgroup
analyses. For Group 1 (advanced beginners) in Step 2, bothtypes of frontline nurse managers’ support were positively
and significantly related to affective organizational commitment. Preparation for organizational change (β = .225, p =.001) showed a sharper slope than that of personal counseling (β = .162, p = .015). Meanwhile, in Group 2 (competentnurses) in Step 2, both types of frontline nurse managers’
support were found to be positively and significantly related
to affective organizational commitment. Personal counseling(β = .173, p = .001) showed a slightly sharper slope thanthat of preparation for organizational change (β = .158, p =.004). Regarding Group 3 (proficient nurses) in Step 2, bothtypes of frontline nurse managers’ support were found to bepositively and significantly related to affective organizational

Table 2. Hierarchical multiple regression analysis for affective organizational commitment.
(N = 1,603)
Mean ± SD
Step 2: Frontline nurse managers’ support
Preparation for organizational change
Personal counseling
Step 3: Interaction effects
Preparation a) × Years of experience b)
Personal counseling × Years of experience b)
R2
Adjusted R2
ΔR2

13.2 ± 6.8
13.3 ± 5.3

Model 2Model 3

β

p

β

p

.150
.180

<.001
<.001

.148
.181

<.001
<.001

−.036
.017

.186
.539

.167
.160
.083

.168
.160
.001

Note.
Preparation for organizational change; b)Years of nursing experience
SD : standard deviation; β : standardized partial regression coefficient.
R2: determined coefficient.
Although each β is not shown in the table, sex, marital status, years of nursing experience, qualification,
education background, position, hospital founder, hospital size, and change of clinical field specialty
were entered as control variables in Step 1.
ΔR2 represents the amount of change from R2 when only the control variables were entered.

a)

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https://doi.org/10.53044/jinr.2021-0025

Table 3. Subgroup analyses using hierarchical multiple regression analysis by career stage.
Career stage (Years of nursing experience)Group 1
Advanced beginners<3 years(n = 287)

Group 2Competent nurses
3 years ≤, <8 years(n = 465)

Group 3
Proficient nurses
8 years ≤, <20 years(n = 530)

Group 4
Expert nurses
20 years ≤(n = 321)

β

p

β

p

β

p

β

p

Step2: Frontline nurse managers’ support
Preparation for organizational change
Personal counseling

.225
.162

.001
.015

.158
.173

.004
.001

.119
.178

.015
< .001

.062
.243

.332
< .001

R2
Adjusted R2
ΔR2

.177
.141
.111

.103
.077
.082

.157
.135
.067

.177
.142
.074

Note.
β : standardized partial regression coefficient.
R2: determined coefficient.
Although each β is not shown in the table, sex, marital status, years of nursing experience, qualification, education background, position, hospital founder, hospital size, and change of clinical field specialty were entered as control variables in Step 1.
ΔR2 represents the amount of change from R2 when only the control variables were entered.

commitment. Personal counseling (β = .178, p < .001)
showed a sharper slope than that of preparation for organizational change (β = .119, p = .015). Regarding Group 4(expert nurses) in Step 2, only personal counseling was
found to be significantly and positively related to affective
organizational commitment (β = .243, p < .001).

Discussion
The nurses’ average affective organizational commitment
score in this study was 21.5. Previous studies of hospitalnurses reported scores ranging from 24.1 to 30.1 (including
studies that converted mean scores to total scores; e.g., Asiri
et al., 2016; Neves et al., 2016; Santos et al., 2016). In thisstudy, the affective organizational commitment of nurses
who experienced organizational change is noted to be lower
than that reported in the studies mentioned above. This indicates that the organizational change has caused deteriorationof nurses’ affective organizational commitment.
Associations of Frontline Nurse Managers’ Support and Affective Organizational Commitment
This study showed significant positive associations between
the two types of frontline nurse managers’ practical support(i.e., preparation for organizational change and personalcounseling) and nurses’ affective organizational commitment. A previous review indicated that the perception oftraining related to organizational change can influence employees’ well-being (De Jong et al., 2016). This findingaligns with the results of the current study for nurses who
experienced organizational change; however, preparation fororganizational change included not only skill acquisition but
6 of 9also discussion of operations. The current study showed thatcomprehensive preparation, which includes clinical skills
training and discussions of unit operations provided by frontline nurse managers, may be related to higher levels of affective organizational commitment among hospital nurses.
Regarding personal counseling, a previous review showedthat a supportive process of manager communication was related to employee outcomes (Oreg et al., 2011); however,
the effect of explanations on the individual-level impact oforganizational change was not verified. In this current study,
it was shown that personal counseling provided by frontline
nurse managers may be related to higher levels of affective
organizational commitment in nurses. Previous studies reported that individualized considerations were related tonurses’ affective organizational commitment (Top et al.,2015; Weng et al., 2010). On the other hand, previous studies have also reported that this association was not present(Kodama et al., 2016). One possible reason for these inconsistent results is that the effect of individualized considerations on affective organizational commitment may differ depending on nurse attributes and hospital organizational contexts. In the context of hospital organizational change, personal counseling may be important for nurses’ affective organizational commitment. As discussed, frontline nurse managers who provide both types of support will likely enable
nurses to strengthen their affective organizational commitment.
Differences in Associations by Nurses’ Years of Experience
The interaction effect showed that the two types of frontline
nurse managers’ practical support on nurses’ affective organizational commitment did not vary by nurses’ years of expe-https://doi.org/10.53044/jinr.2021-0025

rience. Therefore, preparation for organizational change andpersonal counseling provided by frontline nurse managers
may be vital to enhancing nurses’ affective organizational
commitment at all levels of experience.
Although preparation for organizational change wasdeemed insignificant, there was a reversal of the coefficients.
Moreover, according to the results of the subgroup analysis,
for Group 4 (expert nurses), preparation for organizationalchange was not significant for nurses’ affective organizational commitment, unlike the other groups. In previous
studies, late-career nurses expressed that they wanted to contribute to a better work environment in their unit or to patient care by taking advantage of their own roles, careers,and experiences (Price et al., 2018). Based on these findings, the results of this current study can be interpreted asfollows: For Group 4 (expert nurses), personal counselingmay be more important than preparation for organizationalchange as they have already mastered general nursing skills
and played important roles in their organization.
These results demonstrate that frontline nurse managers
during organizational change should provide opportunities
for preparation and personal counseling to nurses. All nurses
require these two types of practical support from nurse managers. Notably, expert nurses benefit more from personalcounseling than from preparation.
Strengths and Limitations
This study has two major strengths. First, two types of practical support (i.e., preparation for organizational change andpersonal counseling) provided by frontline nurse managers
during organizational change were shown to be significant
in maintaining nurses’ affective organizational commitment.
Preparation for organizational change added opportunities todiscuss the new operations, and personal counseling included explanations that considered nurses’ career paths.
This study was able to identify the specific types of practical support that frontline nurse managers should provide tonurses during organizational change. Second, the effectiveness of each instance of support may depend on a nurse’s
career stage. The results demonstrate the importance of considering differences in career stage while providing support
to nurses during organizational change.
This study also has several limitations. First, it used across-sectional design; thus, the observed associations
among the variables might not be causal. Second, there wasa common method bias, as this study used self-reported data
and targeted units that had been changed between 1 monthand 1 year prior to this study. Therefore, the study results
were not completely controlled for post-organizationalchange effects. Third, this study targeted medium-sized orlarger hospitals. Therefore, further examinations in small
hospitals may be necessary. Fourth, the number of participants was larger than the required sample size, which could

JINR 2023, 2(2), e2021-0025

result in overinterpretation. Fifth, there might be a bias toward favorable responses as only the nurses who had received information from frontline nurse managers could
complete the questions with all analyzed variables. Sixth,
the number of organizational changes experienced by all
nurses was not controlled. Seventh, 20 years of nursing experience is not a clear delimiter for “expertise,” although anexpert nurse was defined as having 20 years of experiencein this study. Further research is thus needed to determine
whether there is an interaction between years of nursing experience and frontline nurse managers’ support. For example, because a nurse’s career is not limited to years of experience, additional indicators should be considered in futurestudies.
Implications for PracticeIn this study, we were able to identify two important typesof practical support from frontline nurse managers tostrengthen nurses’ affective organizational commitment. Thatis, frontline nurse managers should provide preparation fororganizational change and personal counseling to nurses. All
nurses require these types of practical support from frontline
nurse managers. Moreover, expert nurses are found to benefit more from personal counseling.
Conclusions
Two types of practical support, preparation for organizational change and personal counseling, provided by frontline
nurse managers during organizational change were found to
be positively related to nurses’ affective organizational commitment. Furthermore, there may be differences in thestrengths of these associations based on the nurses’ career
stages. Frontline nurse managers should provide support tounit nurses by prioritizing different types of intervention depending on nurses’ career stages.
Acknowledgments
We express our sincerest gratitude to all the directors of
nursing, frontline nurse managers, and nursing staff who
participated in this study. We would also like to express our
deep appreciation to Dr. Hiromi Sanada of the University ofTokyo for the insightful advice provided. We also thank Dr.
Naotaka Watanabe of Aichi Shukutoku University for giving
us permission to use the Japanese version of the ThreeDimensional Organizational Commitment Scale.
Author Contributions
C.F, K.K, Y.T, and K.T contributed to the conception anddesign of this study. C.F and K.K performed the statisticalanalysis. C.F, K.K, and Y.T drafted the manuscript. C.F,
K.K, Y.T, K.T, and N.I contributed to the data interpretation.
K.K, Y.T, K.T, and N.I critically reviewed the manuscriptand supervised the whole study process. All authors read
7 of 9JINR 2023, 2(2), e2021-0025

and approved the final manuscript.
Declaration of Conflicting Interests
The authors declare no conflicts of interest.
Ethical Approval
This study was approved by the Research Ethics Committeeof the Graduate School of Medicine, the University of Tokyo (no. 11583).
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Original Research

Development of a medication-adherence assessment tool to assess andsupport medication self-management by older adults
Kanako Sakane, PhD1 , Yuko Tsumoto, PhD1 , Yuta Kobayashi, PhD1 , Miki Fukuma, PhD1 ,Mayumi Miyamoto, PhD1 , and Hiromi Uchida, PhD2
1

Shimane University, School of Nursing, Faculty of Medicine, Izumo, Japan, and 2Tenri Health Care University,
Tenri, Japan

Abstract
Objective: To develop a medication-adherence assessment tool for nurses to acquire greater understanding ofautonomous medication self-management by older adults. Methods: This study was based on an exploratory sequential study design using a qualitative inductive study and pretest results from which we created a draft
medication-adherence assessment tool containing 74 items. Then, to verify reliability and validity, questionnaires
were sent to nurses with three or more years of clinical experience in randomly selected acute care hospitals or inhome-visit nursing stations. The research was conducted with the approval of the Shimane University Nursing Research Ethics Review Committee. Results: From a total of 747 responses and following an item analysis, 40 items
were selected and exploratory factor analysis was performed. From this, we prepared a “medication-adherence assessment tool for older adults” consisting of 40 items and 6 factors. The six factors were the following: 1) active
participation in their treatment, 2) stable medication compliance, 3) medication behavior and stable lifestyle, 4)
health control ability with continuous medication, 5) inhibitors of medication self-management, and 6) capability of
medication record management. This assessment tool was proven to show internal consistency based on Cronbach’s α coefficient, criterion-related validity, and constructive concept validity. Conclusions: The “medicationadherence assessment tool for older adults” allows nurses to systematically assess the status of autonomous selfmanagement of medication by older adults from a medication-adherence perspective.
Keywords
medication-adherence, medication self-management, older adults, assessment tools
JINR 2023, 2(2), e2021-0003

Introduction
Noncommunicable diseases (NCDs), also known as chronic
diseases, have a long duration and are the result of a combination of genetic, physiological, environmental, and behavioral factors (WHO, 2021). NCDs are the number-one causeof death and are a common health issue worldwide. Continuous medication therapy plays an important role in controlling the pathology of such NCDs, and older adults tend

to suffer from multiple diseases, including NCDs, as theyage (Salive, 2013). There is a strong correlation between thenumber of diagnosed diseases and the number of medications prescribed (Suzuki et al., 2006), with a mean numberof 6.9 ± 4.7 medications used by patients at admission and
6.8 ± 4.3 at discharge (Tomita et al., 2018). Thus, older
adults are particularly likely to be prescribed multiple medications for treatment.
The greater the number of prescription medications is, theCorrespondence: K. Sakane. Email: k-sakane@med.shimane-u.ac.jp
Received: June 9, 2021, Accepted: February 3, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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greater is the challenge to the patient for self-managementof such medications. When multiple episodes of forgetfulness or intentional avoidance accumulate, the amounts ofunused prescription medication increase. The reported average compliance rates for self-managing patients are 26.4%
for ages 65 to 74 years and 23.7% for ages 75 years andover, and the average numbers of days of unused medication
are 8.5 days for the former group and 8.7 days for the latter(Omotani et al., 2020). The older the patient is, the greater
is the difficulty self-managing medications for timing andappropriate dosage.
The degree of compliance with prescription medications
is associated with the risk of developing cardiovascular disease (Krousel-Wood et al., 2015), risk of death from asthma(Suissa et al., 2003), and worsening of Parkinson’s disease
symptoms (Kulkarni et al., 2008). Furthermore, noncompliance by self-managing patients is reportedly related with readmission events (Tuppin et al., 2010) and health-related
quality of life (Holt et al., 2010). Thus, prolonged improper
medication self-management by older adults not only has anegative effect on pathological control of target diseases but
also hinders smooth continuity of daily life.
Polypharmacy, cognitive decline, and health literacy areassociated with the medication self-management capabilitiesof older adults (Yap et al., 2016), as are various physicalfactors such as decreased visual acuity, deafness, decreased
swallowing function, and trembling of fingers. Inherent
emotions of older adults (Nakamura et al., 2016), such as
distrust of medication and different perceptions of medication compared to those of healthcare professionals, may also
prevent older adults from proper self-management. To effectively support medication self-administration by older adults,
healthcare professionals must evaluate medication selfmanagement programs from various angles.
Compliance with a healthcare professional’s directive has
traditionally been used as a factor when evaluating medication self-management. However, there has recently been ashift from medical-staff-centered medical care to patientcentered medical care, and the concept of adherence has
been adopted. Adherence includes the patient’s consent to ahealthcare professional’s recommendations, collaborationand partnership between the healthcare professional and thepatient, and the patient making autonomous decisions. It is aconcept of a collaborative model for the patient and medical
staff.
The measurement index of medication-adherence for older
adults established in previous studies is the eight-item
Morisky Medication-Adherence Scale (MMAS-8) (Morisky
et al., 2008; Krousel-Wood et al., 2009). In addition, theMedication Possession Ratio and the proportion of days
covered are used. These metrics are limited to the evaluationof forgetting and self-interrupting of medication, suggestingthat they are used synonymously with compliance (Sakane,
2 of 9https://doi.org/10.53044/jinr.2021-0003

2019).
A tool with which to objectively evaluate medicationadherence by an older adult from the viewpoint of collaboration with and autonomy from healthcare professionals is
still lacking. Thus, the results of the current support efforts
for medication self-management may not effectively lead tohelpful or positive patient outcomes. The aim of this study
is to develop such a medication-adherence assessment toolfor nurses, who play a central role in supporting medication
self-management, to assess the autonomous medication selfmanagement status of older adults.
Definitions of Terms
1. Medication-adherence
On the basis of the definition presented by the WHO(2003), supplemented by the results of a conceptual analysisof adherence by Cohen (2009), Medication-adherence is defined as “Patients build partnership-based collaborative relationships with healthcare professionals, actively participate
in treatment policy decisions, agree to the treatment policies
and support recommended by healthcare professionals, andapply desirable medication and health behaviors.”
2. Medication Self-management
Medication self-management in this study is defined as “Theactivity in which older adults who require continuous medication therapy continue to take medication based on the prescribed usage of medications and manage their effects.”

Materials and Methods
1. Research Design
This study was an exploratory sequential study design forthe development of metrics by mixed methods research(Creswell & Creswell, 2018). The study was conducted fromMay 2018 to July 2020.
2. Preparation of the Draft of the Medication-adherence Assessment Tool for Older Adults
We first conducted a qualitative inductive study to explore
the content of medication-adherence for older adults. Eighteen people participated in the study, including six nurses,
six pharmacists, four doctors, and two patients who had
been hospitalized and had been taking medication. The
nurses, pharmacists, and doctors were selected from bothacute care hospitals and community healthcare institutions.
To supplement the nurses’ assessment perspectives, wesought input from pharmacologists for a pharmacologicalperspective as to what was necessary for maintaining andimproving medication-adherence (Sakane, 2020). From this,adherence by older adults was classified into 88 items and 6
categories. Finally, the content was further supplemented
from literature on medication-induced older adults’ syndrome. Ultimately, we prepared a draft of 91 items for thehttps://doi.org/10.53044/jinr.2021-0003

medication-adherence assessment tool.
3. Pilot Study
To confirm the structure of the draft assessment tool and establish the validity of its content, a pilot study was conducted on nurses with more than 3 years of clinical experience at acute care hospitals and home-visit nursing stations.
Responses covering 38 active patient cases were obtained
and included opinions on the items regarding their difficulty
for use in evaluations, difficulty of answering, and possible
overlapping of items. Following the discussions and examination of the opinions of the doctors, pharmacists, andnurses, 19 items were deleted, wording and expressions
were appropriately adjusted, and a reordering of the questions was conducted to facilitate answering. With the structure and content validity of the assessment tool confirmed, afinal draft questionnaire composed of 74 items for the
medication-adherence assessment tool for older adults was
prepared.
4. Questionnaire Survey and Path Analysis
Participants
We requested research cooperation from 500 randomly selected acute care hospitals with more than 200 beds and 500
randomly selected home-visit nursing stations nationwide inJapan. Acute care hospitals diagnose and treat older patients,
initiate medication self-management, and change prescriptions. Therefore, it is necessary to provide individualized
and timely support by nurses for medication selfmanagement by older patients. In addition, home-visit nursing stations must provide ongoing nursing support, andtherefore, they were selected as study sites. Questionnaires
were sent to 3,377 nurses who had more than 3 years ofclinical experience and who were working in the medical institutions that had agreed to participate in this study.
Extraction of Sample Size
Our sample size was based on the generally accepted concept that approximately 5 to 10 times as many respondents
as the number of samples are necessary (Burns & Grove,2007). In addition, the number of hospital nurses and homevisiting nurses was calculated and stratified by the ratio of
the age composition of nurses in Japan. To minimize any
bias in the scale of regions and hospitals, the number of facilities approached for research cooperation was stratified
according to the scale of regions and hospitals.
Data Collection
A request document for cooperation in the survey was sent
to the nursing managers of the randomly selected acute care
hospitals and home-visit nursing stations. Request documents and questionnaires were distributed to the nurses
working at each institution with the consent of the nursing
manager. Collection was by individual mailing.

JINR 2023, 2(2), e2021-0003

Survey Contents
The questionnaire asked the participants to answer question
items regarding one case of an older adult for which thenurse was currently providing some type of selfmanagement support, including monitoring self-managementof medication, checking the remaining number of dosages,
setting prescription medications, and providing guidance forself-management. Of these reported cases, those of older
adults (65 years old and over) diagnosed with dementia andthose with obvious problems in daily life due to cognitive
decline were excluded.
The items in the questionnaire covered the individual attributes of the participant as well as those of older adult patients as recalled by the participant, the characteristics ofparticular medication self-management, the 12 revised
medication-adherence scales used for chronic disease patients in Japan (Ueno, 2018), and the 74 prepared
medication-adherence assessment tool draft items. In the explanation portion of the questionnaire, we also asked forparticipant opinions as to the feasibility of the use of the assessment tool relative to the current medication status of theolder adult.
The assessment tool questionnaire answer format was a
five-step rating scale as well as “not applicable” and “unknown.”
Data Analysis
Statistical software SPSS ver. 22 and covariance structure
analysis software Amos ver. 19 were used for data analysis.
1) Descriptive statistics were calculated for all items, andthe average score and standard deviation of each item
were calculated.
2) Selection of question items: As item analysis, (1) the
calculation of the change in the α coefficient wheneach question item is excluded, (2) the confirmation of
the ceiling effect/floor effect, (3) item-overall (I-T)
correlation analysis, (4) G-P analysis, (5) the calculation of the interitem correlation coefficient, and (6) exploratory factor analysis.
3) Examination of reliability: Cronbach’s α coefficient
was calculated to confirm the internal consistency ofthis assessment tool.
4) Examination of criterion-related validity: As coexistence validity, the correlation with this assessment tool
was calculated using the revised medication-adherence
scale of Ueno (2018) as an external criterion.
5) Examination of construct validity: A confirmatory factor analysis was performed on the assumption that thefactors extracted by the exploratory factor analysis
were influenced by higher-order factors (dose adherence for the older adults).
Ethical Considerations
The research was conducted with the approval from the Shimane University Nursing Research Ethics Review Commit3 of 9

JINR 2023, 2(2), e2021-0003

tee (Notification No. 344). All nurses who met the conditions at the medical institution from which research permission had been obtained were considered potential participants, and the participants were asked to read the information provided regarding the research purpose, method, benefits/disadvantages associated with research cooperation, themeans or protection of privacy, and the publication of theresults. The participants were also asked to acknowledge
that they freely agreed to cooperate and to provide certain
personal information. The completion and submission of thequestionnaire by the responder/participant was considered asconsent for the study.

https://doi.org/10.53044/jinr.2021-0003

Table 1. Demographics of the older adults reported by thesurvey participants (n = 737).
Demographics

n

%

Sex

Male
FemaleUnknown

271
449
17

57.8%
60.9%
2.3%

Age (years)

65-74
75-84
≥85
Unknown

206
329
164
38

28.0%
44.6%
22.3%
5.2%

Main disease

Digestive disease
Cardiovascular disease
Musculoskeletal disorder
CancerRespiratory disease
Cranial nerve disease
Endocrine disease
OthersUnknown

140
115
107
71
68
61
35
107
33

19.0%
15.6%
14.5%
9.6%
9.2%
8.3%
4.7%
14.5%
4.5%

Medical history

Yes
No
Unknown

663
68
6

90.0%
9.2%
0.8%

Previous disease2)

Cardiovascular disease
Digestive disease
Endocrine disease
Musculoskeletal disorder
Respiratory disease

310
176
124
122
101

42.1%
23.9%
16.8%
16.6%
13.7%

Results
General research cooperation permission was obtained from40 randomly selected acute care hospitals and 36 home-visit
nursing stations nationwide, and a total of 737 questionnaires (recovery rate of 21.8%) were returned with responses.
1. Participant Demographics
The average number of years of nursing experience of theparticipants was 15.0 ± 9.3 years, and 85.3% worked for
acute care hospitals and 13.4% for home-visit nursing stations.
2. Demographics of the Older Adults in Participants’ Responses
Table 1 shows the demographics of the older adults who
were the subjects of the participants’ responses. The older
adults’ age ranges were 65-75 years (28.0%), 75-85 years(44.6%), and 85+ years (22.3%). Their main current illnesses were digestive illnesses, followed by cardiovasculardisease. Ninety percent had medical histories, with cardiovascular disease being the most common, followed by gastrointestinal disease. The average number of medications
taken daily was 6.8 ± 3.6, each taken at an average of 3.1 ±1.0 times/day. Of the reported cases, 37.7% fully selfmanaged their prescription medications and 40.7% selfmanaged with the support from others.
3. Selection of Question Items by Item Analysis
Examination of Changes in α Coefficient when Each Question Item was Excluded
The α coefficient of the entire assessment tool composed of
74 items was .976. We confirmed the α coefficient wheneach question item was excluded. There was no item thatthreatened the internal integrity of the assessment tool.
Confirmation of Ceiling Effect and Floor Effect
There were no items that had a floor effect. There was one
item that caused a ceiling effect, but this bias may havebeen influenced by the response results of acute care hospi4 of 9

Number of medications taken1)

6.8 ± 3.6

Number of doses per day1)

3.1 ± 1.0

Medication
self-management
statusSelf-management
Self-management withsupport from others
Management by others
Unknown

278
300

37.7%
40.7%

142
17

19.3%
2.3%

Note.
1) Mean ± SD
2) Disease prevalence

tal nurses, who accounted for more than 80% of all respondents. Therefore, the Mann-Whitney U test was performedon the response results from both the hospital nurses andhome-visiting nurses for this item, and as a significant difference was found in the response results, the item was included.
Calculation of the Ratio of Not Applicable/No Answer
Percentages were calculated for each item having a “not applicable” response or no answer, and items having 10% ormore of such responses were deleted.
I-T Correlation Analysis
The correlation coefficient between each question item andthe total score of the assessment tool ranged from −.103 to.760. There were six question items showing a correlation

https://doi.org/10.53044/jinr.2021-0003

coefficient of .3 or less. These were removed because oflack of consistency.
G-P Analysis
The average of the total score of the assessment tool was
220.6 points, which was divided into an upper group and alower group, and the t-test was performed based on thescore of each question item. As a result, the significanceprobability was .05 or more for three items, indicating thatthese three should be deleted. However, they had alreadybeen removed following the I-T correlation analysis.
Calculation of Correlation Coefficient between Items
The interitem correlation coefficient for 74 items ranged
from −.178 to .891. Principal component analysis was performed for each of the six categories determined at thequalitative research stage. For a combination of question
items with an interitem correlation coefficient of .7 or more,
the item with a higher factor loading was adopted and theother was excluded. As a result, 21 items were deleted, andof these, 3 had a high percentage of nonapplicable andnonanswered items and had already been targeted for deletion.
Exploratory Factor Analysis
As a result of the item analysis, 40 items were ultimately
selected. Of the 737 returned questionnaires, 545 subjects
answered all 40 items. We next tested whether the data fromthe 545 questionnaires were suitable for factor analysis. The
sample validity of Kaiser-Meyer-Olkin was .959 and thesphericity test of Bartlett was p < .01, confirming that thedata were in fact suitable. Factor analysis was then performed using the pro max rotation by the generalized leastsquares method. Factors were extracted with an eigenvalueof 1 or more and a factor loading of .3 or more as setting
criteria. As a result, the 40 items and 6 factors were extracted. The cumulative contribution rate was 55.45%, thecommonality was .436 to .822, and the interfactor correlation coefficient was .204 to .693.
The six factors were interpreted and labeled as follows.
The first factor (18 items) was interpreted as showing an attitude of actively participating in treatment through collaboration with healthcare professionals and in autonomous
medication self-management and was defined as “active participation in their treatment.” The second factor (five items)
was interpreted as indicating that medication can be taken
according to prescribed dosages and the administration instructions of the prescription medications and was defined as“stable medication compliance.” The third factor (six items)
was interpreted as indicating that the actions in basic daily
life associated with the physical taking of the medications
are stable, defined as “medication behavior and stable lifestyle.” The fourth factor (four items) indicated that symptoms and distress can be controlled by continuous medication self-management and was defined as “health control
ability with continuous medication.” The fifth factor (fourJINR 2023, 2(2), e2021-0003

items) indicated whether the patient has cognitive, physical,
and sensory functions necessary to continue medication selfmanagement and was labeled “inhibitors of medication selfmanagement.” The sixth factor (three items) was interpreted
as indicating records generally and records related to medication can be managed and was defined as “capability of
medication record management.” The assessment tool using
the selected 40 items and 6 factors was named “medicationadherence assessment tool for older adults” (Table 2).
Score Status of the Medication-adherence Assessment Tool
for Older Adults
The total scores of this assessment tool ranged from 49 to
198 points, with an average of 123.8 ± 31.6 points (Figure1). In the Kolmogorov-Smirnov test, the significance probability was .042. In the response distribution, the number
and percentage of respondents for each option were calculated for each question item. As a result, all question items
were answered using all of the options.
4. Reliability and Validity of the Assessment Tool
Reliability
Cronbach’s alpha, which represents the internal consistencyof the scale, was .960 for the entire assessment tool. The
Cronbach’s alpha coefficient for each factor ranged from.725 to .950.
Criteria-related Validity
Using the revised medication-adherence scale (Ueno, 2018)
for patients with chronic diseases as an external standard,
the total score of the assessment tool and the correlation coefficient with each factor were calculated. The correlation
coefficients were all significant, ranging from .126 to .605.
Construct Validity
A confirmatory factor analysis was performed using the
medication-adherence of the older adults as a secondary factor and the six factors extracted by exploratory factor analysis as primary factors (Figure 2). As a result, all path coefficients were significant. The path coefficient from the secondary factor, medication-adherence to the primary factor, was.53 to .91, and the path coefficient from the primary factor
to the observed variable was .49 to .88. The goodness of fit
between the model and the data was GFI = .825, AGFI =.805, CFI = .887, and RMSEA = .060.

Discussion
1. Data Adequacy
The normality of the total score of the assessment tool was
slightly less than .05 in the Kolmogorov-Smirnov test, but
the histogram generally had a bell shape (Figure 1), and as
the number of data is large, we elected to treat it as a normal distribution. When there is a large quantity of data,
overdetection is likely to occur and tends to be significant(Orikasa, 2017). It is possible that overdetection occurred
5 of 9JINR 2023, 2(2), e2021-0003

https://doi.org/10.53044/jinr.2021-0003

Table 2. Exploratory factor analysis of the medication-adherence assessment tool for older adults (n = 545).
Factor/item
Factor 1: active participation in their treatment
q50 Asks medical staff about the effects of their medication
q47 Actively talks to medical staff about their physical condition and the effects of theprescribed medicine
q63 Stays aware of medical examination values and symptoms of the diseaseq48 Searches for diseases and medicine on their own
q59 Ability to talk about their prescribed medicine when consulting another hospital
q37 Knowledge of the effect of forgetting to take a medicine
q46 Ability to explain the details of ordinary self-medication
q66 Feeling the effectiveness of the medicine
q45 Try to listen to the medical staff’s explanation carefully
q44 Read and understood the instructions regarding the appropriate doseq57 Ability to consult about the disease and medicine
q42 Aware of medicines running out or of insufficiency before the next prescription day
q33 Knowledge of the side effects of the prescribed medicine
q65 Having the will to appropriately take medicines by themselves
q32 Knowledge of the effects of the prescribed medicine
q29 Ability to contrive methods for continuing medication on their own
q61 Understand the explanation by medical staff
q69 Aware of healthy habits such as diet and exercise

Factor loading
Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6
.875
.856

−.035
−.102

−.016
.087

.031
−.063

−.027
−.011

−.087
−.069

.830
.828
.743
.742
.720
.715
.710
.705
.694
.668
.641
.635
.594
.554
.541
.351

−.157
−.033
−.098
−.140
.081
.032
.138
.079
−.026
−.009
−.014
.032
.101
.185
.202
.042

.106
−.232
−.058
−.028
.153
−.085
.106
−.129
.139
−.043
.039
.099
.071
−.040
.144
−.144

.019
−.063
.053
.008
−.082
.162
.007
−.032
.117
.062
−.196
.101
−.078
−.041
.143
.251

−.056
.066
−.055
.131
−.005
−.049
−.084
−.033
−.038
.059
.182
−.012
.103
−.043
−.156
.116

−.018
.030
.104
.026
−.006
−.091
−.151
.092
−.083
.080
.128
−.057
.023
.161
−.081
.080

Factor 2: stable medication compliance
q13 No self-judgment or no self-adjustment of prescribed medicine
q12 At minimum, medicine was taken in the morning and evening.
q14 Ability to manage medicines for a day
q18 The numbers of prescribed days and remaining medicines are almost in accord
q11 Capable of following instructions and advice for lifestyle

−.094
−.041
.143
−.043
.120

1.011
.797
.654
.585
.538

−.100
−.009
.046
.061
.185

−.099
.017
.014
.093
−.052

−.005
−.018
.027
−.095
.104

.000
.005
−.011
.111
−.048

Factor 3: medication behavior and stable lifestyle
q22 No problems swallowing medicine
q21 No spillage of medicine
q20 No problems opening and taking out the medicine
q7 Eats meals 3 times every day
q8 Has financially stable life
q9 Properly dressed when consulting the hospital or visited by medical staff

−.079
−.003
.134
−.170
−.022
.034

−.022
.021
−.066
.101
−.067
.200

.899
.826
.708
.354
.338
.313

−.054
−.038
−.059
.152
.077
.089

−.018
.005
.049
.087
.259
.090

.005
.041
.106
.075
.102
.032

Factor 4: health control ability with continuous medication
q71 Pain is well-controlled in daily life
q70 Stability in biochemical values and condition related to the diseaseq72 Medication management method and patient’s ability match
q73 Daily-life schedule and medication schedule match

−.044
.020
.126
.085

−.097
−.064
.157
.040

−.075
.043
−.030
.023

.882
.658
.590
.575

.095
.063
−.031
−.036

.006
.037
.027
.058

Factor 5: inhibitors of medication self-management
q5 No decline in ADL or cognition ability compared with that in the pastq6 No problems for transportation and ADL to consult hospitals/clinics
q2 No problems for medication management because of cognitive decline
q3 No problems for medication management due to visual impairment

−.014
.089
.042
−.085

−.012
−.096
.342
−.009

.059
−.015
−.039
.302

.047
.039
.018
.053

.801
.702
.617
.527

−.049
.036
−.082
−.124

Factor 6: capability of medication record management
q26 No problem storing or bringing a medicine notebook
q27 Attaches printed prescription lists to medicine notebook
q28 Regularly records physical condition and administered medicines in a medical
record book or a medicine notebook

−.025
−.021
.421

.025
.008
.035

.155
.095
−.204

.033
.117
−.140

.012
−.136
.093

.772
.724
.435

Cronbach’s α coefficient

.950

.862

.824

.809

.825

.725

Cumulative contribution ratio
Note. Shading for factor loading of .30 or more

6 of 939.49% 45.84% 48.69% 51.47% 53.61% 55.45%

https://doi.org/10.53044/jinr.2021-0003

JINR 2023, 2(2), e2021-0003

here as there were large amounts of data used in this analysis. In the reaction distribution, there were no items withlow discriminating power, and it was confirmed that thescores of the items of the assessment tool ranged from low

to high.
Therefore, we believe that the data of this study are generally appropriate data for use in the examination of reliability and validity.
2. Reliability and Validity of the Assessment Tool
Generally, for the internal consistency of the measurement
tools, Cronbach’s alpha of >.7 is appropriate and >.80 is extremely desirable (Polit & Beck, 2010). Here, the Cronbach’s alpha of the entire assessment tool was .960, indicating internal consistency of the assessment tool. The correlation coefficient between the medication-adherence scale by
Ueno (2018), an external criterion in the criterion-related validity examination, and the total score of the assessment
tools, and the score of each factor were all calculated. A
moderately significant correlation between the total score of
the assessment tool and the total score of the external standard scale was confirmed with a correlation coefficient of.605 (p < .01). A significant correlation was confirmed between this assessment tool and the total score of the external
criteria, each factor of the assessment tool, and the corresponding subscale of the external criteria, indicating criteriarelated validity.
Regarding the validity of the construct, higher-order factor

40

30

20

10

0

50.0

75.0

100.0

125.0

150.0

175.0

200.0

Figure 1. Total score of the assessment tool (n = 545).
Note. The horizontal axis indicates the total score, and the verticalaxis indicates the number of subjects.

e20

e21

e22

e23 e24e25

e26 e27

e28

e29

e30

e31

e32

e33

e34

e35

q50

q47

q63

q48 q59

q37

q46 q66

q45

q44

q57

q42 q33

q65

q32.80 .75.74.66.67 .70 .81 .71 .76.68 .77 .74 .68

Factor 1
active participationin their treatment

.81

e38

e39

e40

q29 q61q69 q26

q27

q28

.74

.88

.71 .49.75 .73 .68

d1

e36

e37

.55

Factor 6
capability of
medication record
management.53

Older adultmedication adherence
.73

.91

d2
.75

Factor 2
stable medication
compliance.75

d3.81 .63 .78

.84

.73

Factor 3:
medication behavior
and stable lifestyle.72 .81 .76

Factor 4
health control ability
with continuous
medicationd4.51 .55 .64

.72

d5

.69 .77 .69

Factor 5
inhibitors of medication
self-management.77 .65 .86 .66

q13

q12

q14

q18 q11

q22

q21 q20

q7

q8

q9

q71 q70

q72

q73

q5

e1

e2

e3

e4

e6

e7

e9

e10

e11

e12

e14

e15

e16 e17

e5

e8

d6

e13

q6

q2

q3

e18 e19

All path coefficients are p<.01
X2 = 2162.14 (p<.001)
GFI = 0.825, AGFI = 0.805, CFI = 0.887
RMSEA = 0.060

Figure 2. Confirmatory factor analysis results of the assessment tool.
Note. White circle = secondary factors; gray circles = six factors extracted by exploratory factor analysis, primary factor; (q) =observed variable; (d, e) = error variable; arrows = causal relationship, path coefficients are shown next to the arrows.

7 of 9JINR 2023, 2(2), e2021-0003

analysis was performed with the medication-adherence ofthe older adults as the secondary factor and the six factors
extracted by exploratory factor analysis as the primary factor. The results indicated permissible conformance (GFI:.923; AGFI: .893; CFI: .927; and RMSEA: .066), and thetool displayed great construct validity. Therefore, it was confirmed that the medication-adherence of older adults in thisstudy explained the six factors obtained by the exploratory
factor analysis, and the validity of the construct was confirmed.
The above analyses established the content validity, reliability, criteria-related validity, and construct validity of the“medication-adherence assessment tool.”
3. Clinical Applicability of the Assessment Tool
This assessment tool may be used to evaluate the attitude ofolder adults toward autonomously maintaining medication
self-management while continuing their disease control anddaily life through medication and to provide an assessment
from a viewpoint based on the definition of medicationadherence.
High assessment scores for older adults are an indicationof the presence of the necessary judgment, execution ability,
and attitude for continued medication self-management, andthus, self-management and support may be continued as it
is. The event of low scores indicates a need for adjustmentsin the support for self-management. Until now, it has beendifficult to predict medication-adherence by older adults, andevaluation for self-management ability was left to nurses’
experiences (Sakane, 2020). With this newly developed assessment tool, it is possible to identify changes in an older
adult’s medication self-management abilities and to provide
the support determined necessary for maintaining and improving medication-adherence.
Further, the items of this assessment tool include evaluations of collaboration with healthcare professionals, autonomous attitude to participate in medication and treatment, andthe status of continuous medication control, so the score will
not change significantly from day to day. Assessments may
be conducted at regularly scheduled times (for example, during an initial interview), as well as when prescriptions
change or the condition of the patient changes, among others. Rather than comparisons between patients, an individual
patient’s situation may be assessed, compared to prior assessments over intervals of time, and adjustments to support
may be made accordingly.
The assessment tool may also serve as a tool for sharingof useful patient data and may contribute to the promotionof multidisciplinary collaboration and collaboration in thecomprehensive community care system.
4. Study Limitation
The assessment tool developed in this study assesses
8 of 9https://doi.org/10.53044/jinr.2021-0003

medication-adherence, focusing on autonomy in medication
self-management. Therefore, it is difficult to use this tool for
older adults who have been diagnosed with dementia or who
need support in all aspects of their lives due to cognitive decline.

Conclusion
To verify the reliability and validity of a medicationadherence assessment tool for older adults, we conducted asurvey on nurses at acute care hospitals and home-visit nursing stations nationwide and received 747 responses. Itemand exploratory factor analysis showed that a reliable andvalid “medication-adherence assessment tool for older
adults” incorporating 40 items and 6 subfactors could beconstructed.
Our results indicated that this medication-adherence assessment tool may be used by home-care and hospital acutecare nurses for evaluating the autonomous self-management
status of older adult patients and may aid in the implementation of appropriate support.
Acknowledgments
We wish to express our sincere gratitude to all participants
and the managers of each medical institution for their cooperation in the field survey, interview survey, and preliminary
survey in the process of this research.
Author Contributions
Kanako Sakane, Yuko Tsumoto, Yuta Kobayashi, and Hiromi
Uchida contributed to the study design. Kanako Sakane was
responsible for data collection, data analysis, and interpretation of the results. Yuko Tsumoto, Yuta Kobayashi, and Miki
Fukuma contributed to critically revising the methods andstatistics section of the manuscript. Kanako Sakane, Yuko
Tsumoto, Miki Fukuma, and Mayumi Miyamoto contributed
to drafting and critically revising the entire study. All
authors read and approved the final version of the manuscript.
Declaration of Conflicting Interests
There are no conflicts of interest in this study.
Ethical Approval
Study number: 344
The Shimane University Institutional Committee on Ethics
Funding
This work was supported by JSPS KAKENHI Grant Number JP19K19497.
Note
A portion of this research was presented at ICN Congresshttps://doi.org/10.53044/jinr.2021-0003

2021. This research is a partial addition of a doctoral dissertation from Shimane University Graduate School.
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https://www.jinr.jsnr.or.jp/

Original Research

Association between family functioning, resilience, and psychosocial
burden among family members of patients in the intensive care unit:
A cross-sectional study
Miyuki H Komachi, PhD RN PHN1 , and Kiyoko Kamibeppu, PhD RN PHN FAAN2
1

Faculty of Nursing, Musashino University, Tokyo, Japan, and 2Master’s & Doctoral Programs in Family Nursing,
Graduate School of Health and Welfare Sciences, International University of Health and Welfare, Tokyo, Japan

Abstract
Objective: Families of patients in the intensive care unit (ICU) often experience severe stress, and understanding
their experience is important for maintaining family functioning. This study aimed to determine the characteristics
and factors associated with family functioning in families of patients admitted to the ICU. Methods: This crosssectional study recruited all family members (N = 144) of patients admitted to the ICU at two teaching and advanced treatment hospitals, 77 (53.5%) of whom completed a questionnaire. Family members provided the demographic and clinical characteristics of the patients and completed the Family Relation Index (FRI), the Impact ofEvent Scale-Revised, the Center for Epidemiologic Studies Depression Scale, the State-Trait Anxiety Inventory(STAI) Form X, the Connor-Davidson Resilience Scale (CD-RISC), and the Social Support Questionnaire. Results: Ten (13.0%) and 37 (48.1%) family members had the “hostile” and “sullen” family functioning type, respectively. Multiple regression analysis revealed the presence of a significant negative relationship between the FRI
and the STAI-state (B = −0.057, β = −0.36; p = .001) that the participants had experienced a stressful event within
the previous month (B = −1.201, β = −0.276, p = .009), and that the participants’ CD-RISC scores were correlatedwith family functioning (B = 0.021, β = 0.176, p = .049). Moreover, this model explained 23.9% of the variance intotal FRI scores with regard to family functioning. Conclusions: In total, 61% of the family members had poorfamily functioning and required support. Among the family members of patients in the ICU, anxiety was associatedwith poor family functioning, whereas resilience was associated with good family functioning.
Keywords
family functioning, intensive care unit, post-intensive care syndrome-family
JINR 2023, 2(2), e2022-0032

Introduction
Most patients admitted to the intensive care unit (ICU) areunable to communicate for a variety of reasons, including
heavy sedation, a state of delirium, and connection to a ventilator (McAdam & Puntillo, 2009). Therefore, families ofsuch patients often experience severe stress due to having to
make decisions on behalf of the patient when the risk to thepatient’s life is high (White et al., 2007). To act as proxydecision-makers for the patient, family members must listen
to explanations about the patient’s therapeutic options andprognosis from healthcare providers. Some family members
may also experience a degree of mental shock after witnessing a loved one in the ICU in a severe condition and/or connected to medical apparatuses, especially in comparison withthe patient’s usual condition (White et al., 2007). Experienc-

Correspondence: M H. Komachi. Email: miyukomachi@gmail.com
Received: September 24, 2022, Accepted: March 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 11JINR 2023, 2(2), e2022-0032

ing severe mental stress in the initial period after a patient’s
admission to the ICU has been reported to be among themost predictive factors for the development of posttraumaticstress disorder (PTSD) among family members (Harvey &Bryant, 1999).
Given this background, family members of patients in the
ICU may be prone to developing a type of psychologicalstress called post-intensive care syndrome-family (PICS-F)(Davidson, Jones, & Bienvenu, 2012). PICS-F comprises a
set of symptoms such as anxiety, depression, PTSD, andposttraumatic stress symptoms (PTSSs).
Since PICS-F was named, it has been widely accepted in
the research community for describing the psychiatric symptoms that occur in family members after a patient is admitted to the ICU (Hoo et al., 2022; Inoue et al., 2019). Regarding the prevalence of PICS-F in patients’ spouses or cohabitants, exploratory studies for investigating the factorsthat affect PICS-F have been performed, as have intervention studies to reduce PICS-F (Cairns et al., 2019; Naaktgeboren et al., 2022; Shirasaki et al., 2022). Nevertheless,those studies have involved only spouses or cohabitants.
Since PICS-F can affect the functioning of entire families,
factors that ease the burden should also be identified.
Studies that aim to gain an understanding of the functioning of the entire family and elucidate the relationship between family functioning and psychological symptoms havebeen conducted in Europe, the United States, Australia, andTaiwan since the 1990s. Among such efforts, we identified
six quantitative studies that used family functioning scales in
the ICU, including the Feetham Family Functioning Survey;
versions II, III, and IV of the Family Adaptability and Cohesion Evaluation Scale; the Family Assessment Device; andthe Family Environment Scale (FES) (Ballantyne, Benzies, & Trute, 2013; Finello, Dellemos, & Chan, 1998; Klassen et al., 2004; Vance, Pan, Malcolm, & Brandon, 2020;
Youngbult & Lauzon, 1995; Youngbult & Shiao, 1993). Allof the participants in those studies were family members ofchildren admitted to the neonatal intensive care unit (NICU)
or pediatric intensive care unit (PICU). Four of the studies
were cross-sectional, and two were longitudinal.
One of the two longitudinal studies elucidated the relationship between family functioning and negative psychological symptoms, and the other examined the relationshipbetween family functioning and psychological states, including positive ones, with self-efficacy as the independent variable (Vance, Pan, Malcolm, & Brandon, 2020; Youngbult &Shiao, 1993). Vance et al. (2020) examined the relationships
between family functioning, psychological symptoms, andself-efficacy. The study participants were 67 mothers of infants who had a severe medical condition and were admitted
to the PICU or intensive care nursery. Measurements were
performed at three time points. The relationships between
family functioning, psychological well-being, and parenting
2 of 11https://doi.org10.53044/jinr.2022-0032

self-efficacy were examined, with the results showing thatmaternal self-efficacy increased significantly over time. If
family functioning was poor at the first time point, maternal
self-efficacy was low at all time points.
Few previous studies of families of patients admitted toan adult ICU that used these family functioning scales haveexamined the direct relationship between family functioning
and positive psychological states among family members ofa patient admitted to an adult ICU. Moreover, few previous
studies have elucidated the characteristics of family functioning using family functioning scales. Komachi and Kamibeppu (2018) previously conducted a cross-sectional study
focused on the resilience of families with severe stress suchas PTSSs in early ICU admission. The results indicated thathigh PTSSs were associated with low resilience, and thus,
early support concentrating on resilience during admission
to the ICU was believed to reduce the psychological symptoms of family members. To maintain a good psychiatriccondition among family members, the functioning of thewhole family should also be understood. Consequently, toclarify the relationship between the functioning and psychiatric condition of the entire family, in the present study, asecondary analysis was carried out using data from the previous study regarding family functioning, psychiatric conditions, social support, and demographic characteristics (Komachi & Kamibeppu, 2018).
Therefore, the present study aimed to examine the characteristics of family functioning among families of patients after admission to an adult ICU, as well as positive psychological states and other psychosocial factors in family members that affect family functioning.

Materials and Methods
Study Design and ParticipantsThis cross-sectional study was conducted in an urban areaof Japan at two teaching and advanced treatment hospitals
with medical/surgical (35 beds) and emergency ICUs (eight
beds: four each in the emergency ICU and coronary careunit). The inclusion criteria for patients were as follows: 1)planned admission to the ICU after surgery; 2) unplanned
immediate admission to the ICU after a flare-up in the patient’s condition while in the general ward; and 3) unplanned admission to the ICU after treatment in the emergency room. The exclusion criterion was living alone. The
inclusion criteria for family members were as follows: 1)
being a close relative to the patient (e.g., spouse, child, parent, or sibling), 2) provision of consent to be surveyed by aphysician or member of the ICU staff, 3) age over 20 years,
and 4) ability to communicate in Japanese. The exclusion
criterion was being a caregiver for multiple family members.
We recruited potential participants from November 2010
to March 2011 and collected data from electronic medical

https://doi.org10.53044/jinr.2022-0032

records through April 2011. We then conducted a secondary
analysis of the present study in 2020. Consent to collect patient information from electronic medical records and a family questionnaire survey was obtained from the physicians,
managing nurses, and nursing staff who were treating andcaring for patients who had been admitted to medical/surgical ICUs within each facility. After explaining the study
aims and methods to the staff, we requested a list of patientsand family members who met the inclusion criteria and thenvisited each family member in the medical/surgical ICU. We
asked all family members to complete and return the questionnaire by mail within 24 h to protect their anonymity andalleviate any pressure associated with completing the questionnaire in front of us. After obtaining consent from theparticipants, information regarding the patients was collectedfrom electronic medical records by the investigators.

JINR 2023, 2(2), e2022-0032

Data were collected as described previously (Komachi &Kamibeppu, 2018). The Family Relationship Index (FRI),
Impact Event Scale-Revised (IES-R), State-Trait Anxiety Inventory (STAI), Center for Epidemiologic Studies Depression Scale (CES-D), Connor-Davidson Resilience Scale(CD-RISC), Social Support Questionnaire (SSQ), and itemson the participants’ demographics were used to estimate
family functioning, psychiatric symptoms, resilience, social
support, and the characteristics of the participants in the present study. The previous study used participants’ demographics, IES-R, and CD-RISC data (Komachi & Kamibeppu, 2018).

and Blosh (2002) to determine the characteristics of thefamily functioning of the study participants. For categorizing
families by type, a scoring system has been established inwhich families are classified according to five types of functioning and designated depending on the main characteristics
of each type. Two of the five types indicate that a family exhibits good family functioning: the “cooperative type” and“conflict resolution type.” Cooperative families have thecharacteristics of high cohesiveness, good expressiveness,
and absence of conflict. The conflict resolution type has thecharacteristics of moderate conflict, as well as high cohesiveness and above-average expressiveness. Two other types
represent dysfunctional families. The first is the “hostile
type,” and the second is the “sullen type.” The hostile familyis the most dysfunctional, characterized by high conflict andlow cohesiveness, but low expressiveness. The sullen type ischaracterized by muted anger and high rates of depression
among members. Sullen families are characterized by reduced cohesiveness, mild-to-moderate conflict, and poor expressiveness. The final type is an intermediate type between
dysfunctional families and families that function well; it istherefore referred to as the “intermediate type.” This type ischaracterized by moderate cohesiveness, as well as highrates of psychosocial morbidity.
The FRI score for each type is as follows: 12 points forthe cooperative type, 10-11 points for the conflict resolution
type, 0-4 points for the hostile type, 5-7 points for the sullen
type, and 8-9 points for the intermediate type, respectively.
Cronbach’s α coefficients in this study were 0.67 for expressiveness and cohesion and 0.73 for conflict resolution.

Family Relationship Index (FRI)

Impact of Event Scale-Revised (IES-R)

The FRI is a scale derived from the short form of the FES(Moos & Moos, 1975) that measures the perceptions of family members regarding family functioning. The FRI has beenused for members of families such as those of patients withadvanced cancer, head injuries, and somatization disorderand those of patients with cancer receiving palliative care
(Kissane & Blosh, 2002; Laratta et al., 2021; Nissen et al.,2016; Obimakinde, Ladipo, & Irabor, 2015). It is composedof 12 dichotomous (true/false) items categorized into the following three subscales (four items per subscale): cohesion,
which captures the overall sense of family togetherness andthe willingness toward family time; expressiveness, whichmeasures the capacity of family members to express their
feelings to each other; and conflict resolution, which measures the ability of the family to resolve disagreements
among one another. The score for each subscale ranges from0 to 4, with higher scores indicating better family functioning. Additionally, the FRI can be used for screening to identify families at risk of family dysfunction and categorize
families according to the type of family functioning.
The present study adopted the classification of Kissane

We used the Impact of Event Scale-Revised (IES-R) to assess PTSS in the families of patients admitted to the ICU(Weiss, 1997; Asukai et al., 2002). The IES-R has been usedin numerous studies and is considered a reliable measure of
PTSD in Japanese subjects (Asukai et al., 2002). To categorize PTSS, the items on the IES-R comprise three dimensions (eight intrusion items, eight avoidance items, and six
hyperarousal items), as described in the DSM-IV (Weiss,
1997), that consist of 22 statements rated on a five-point
scale (0-4) in terms of the response to a specific stressful
life event in the past week. All PTSS and total scores on the
IES-R were calculated. Cronbach’s α coefficient for the
IES-R in the present study was 0.96. Cronbach’s α coefficients were 0.94, 0.76, and 0.87 for the three IES-R
subscales of intrusion, avoidance, and hyperarousal, respectively.

Data Collection

State-Trait Anxiety Inventory (STAI)
We used the State-Trait Anxiety Inventory (STAI) Form X
to measure the anxiety in the family members of patients
admitted to the ICU. The original STAI was developed by
3 of 11JINR 2023, 2(2), e2022-0032

Spielberger et al. (1970), and the Japanese version by
Nakazato and Mizuguchi (1982). The reliability and validityof these scales have been confirmed. The STAI is a selfrated tool composed of two scales that measure state andtrait anxiety symptoms using 20 items rated on a scale from
1 to 4 (1 = “almost never” to 4 = “almost always”). The total score ranges from 20 to 80, and a score !40 is considered to indicate “high anxiety.” In the present study, the total
score was measured. Cronbach’s α coefficients for state andtrait anxiety were 0.89 and 0.91, respectively.
Center for Epidemiologic Studies Depression Scale (CES-D)
We used the Center for Epidemiologic Studies Depression
Scale (CES-D) to measure depression in the families of patients admitted to the ICU. The CES-D is a self-rated scale
composed of 20 items that was developed to assess depression symptoms based on a four-point scale. The original
CES-D was developed by Radloff (1977), and the Japaneseversion by Shima et al. (1985). The total score ranges from0 to 60, with a cutoff value of 15/16. The higher the score,
the worse the depression symptoms. Cronbach’s α coefficient for the CES-D is 0.89.
Connor-Davidson Resilience Scale (CD-RISC)
To assess resilience, we used the CD-RISC, for which the
responder rates the question on a five-point scale (0-4) andthe scores range from 0 to 100, with higher scores indicating a higher level of resilience (Connor & Davidson, 2003).
For the purposes of the present study, we measured the total
score. The CD-RISC has demonstrated excellent reliability
and validity in clinical trials and various settings, including
medical facilities (Sottile, Mealer, & Moss, 2016). Cronbach’s α coefficient for the CD-RISC in the present study
was 0.87.
Social Support Questionnaire (SSQ)
We used the SSQ to measure satisfaction among families ofpatients admitted to the ICU. The SSQ is a reliable, valid,
and convenient index of social support that was developedby Sarason et al. (1983). Two versions of the SSQ, a 27item version and an abbreviated six-item version, have beenfound to have high internal consistency, validity, and testretest reliability (Sarason et al., 1983). In the present study,
the six-item instrument developed by Furukara et al. (1999)
was used to measure satisfaction with social networks. The
SSQ asks about the number of people in the respondent’s
support network and his or her satisfaction with it. The satisfaction score is calculated based on a six-point Likert-type
scale (from 0 = very dissatisfied to 5 = very satisfied). Theinternal consistency value for the satisfaction score in thepresent study was 0.94.

4 of 11https://doi.org10.53044/jinr.2022-0032

Statistical Analysis
To determine the characteristics of family functioning, thetype classifications of Kissane and Blosh (2002) were used
to classify the families into five types according to functioning. For each type, means and standard deviations (SDs)were calculated for the following measures of psychosocial
factors, and a one-way analysis of variance was performed:
IES-R, CES-D, STAI-state, STAI-trait, CD-RISC, and SSQ(satisfaction). Multiple comparisons were adjusted using the
Bonferroni method.
To examine the relationship between the FRI score andeach variable, the correlation with the FRI score was examined when the independent variable was a continuous variable, and the mean FRI scores for the individual responses
were compared when the independent variable was not acontinuous variable. An exploratory analysis of the related
factors for the FRI score and each variable was then performed. With the FRI score as the dependent variable, variables for which a correlation (r !.2) or difference (p < .1)
was seen were checked for multicollinearity and selected as
explanatory variables. Moreover, a multiple regression analysis was performed using the forced entry method.
We also calculated variance inflation factors (VIFs) for
the final models to examine multicollinearity. The VIFs of
all variables in the final models ranged from 1.02 to 1.18.
After constructing a multiple regression model, we performed a residual analysis, and the residuals were found to
be normally distributed. All statistical analyses were conducted using SPSS 25.0 (SPSS, Chicago, IL, USA), withstatistical significance set at p < .05.
Ethical Considerations
This study was approved by all relevant ethics committees.
Written informed consent was obtained from all participants
after they received written and oral explanations of the study
aims and were assured that their anonymity would be preserved and their condition and treatment would be prioritized. They were also informed that their participation in the
study was voluntary and that withdrawing at any time would
not affect their care.

Results
Overview of the Participants
The characteristics of the participants, shown in Figure 1,
were the same as those in a previous study (Komachi &Kamibeppu, 2018). Table 1 shows the demographic characteristics of the family members of the patients in the ICU(family members = 68% female, mean age of 54.6 years;
patients = 32.5% female, mean age of 64.1 years). Three ofthe participants had a history of mental disorders. Acuteischemic heart disease was the most common causative dis-https://doi.org10.53044/jinr.2022-0032

Family members of patients in the ICU (N = 144)

Did not meet the inclusion criteria (n = 33)

Met the inclusion criteria (n = 111)

Refused to participate (n = 12)

Agreed to participate and was sent a questionnaire (n = 99)

JINR 2023, 2(2), e2022-0032

Multiple Regression Analysis of Major Factors Associatedwith Family Functioning
Four variables for which significant trends were seen in theunivariate analysis were used as independent variables in themultiple regression analysis (Table 4). The STAI-state scores(B = −0.057, β = −0.36; p = .001), experience of a stressful
event within the previous month (B = −1.201, β = −0.276, p= .009), and CD-RISC scores (B = 0.021, β = 0.176, p =.049) were significantly correlated with the FRI scores. The
results of the multiple regression analysis showed that family functioning explained 23.9% of the variance in the total
FRI scores in this model. No associations were found between family functioning and experiencing the loss of afamily member.

Discussion
Status of Family Functioning
Did not return the questionnaire (n = 16)

Returned the questionnaire (n = 83)

Excluded because of incomplete
responses (n = 6)

Family members analyzed in the present study (n = 77)

Figure 1. Flowchart summarizing the recruitment of participants in the present study. ICU, intensive care unit.

ease among the patients in the ICU (Table 1). Table 2 shows
the findings regarding the prevalence of family functioning
based on the FRI.
Relationship between Family Functioning Type and Psychosocial Factors
Family functioning was classified into three types. Ten(13.0%) family members had the hostile family functioning
type, and 37 (48.1%) had the sullen type (Table 3). The remaining 29 family members (37.7%) had the intermediate
type. There were no cooperative or conflict resolution types.
The examination of differences in the mean scores for the
scales related to psychosocial factors according to the typeof family functioning showed that the CD-RISC score wassignificantly associated with family functioning type (F (2,73) = 2.99, p < .0). Significant differences were found between the hostile and sullen types and between the hostileand intermediate types.

The family functioning of the families of patients admitted
to the ICU was measured in this study using the FRI. The
mean score was 6.8 (SD = 1.2). By contrast, the mean FRI
score in a previous study on the family functioning of outpatients with somatic symptom disorder was 5.92 (SD =2.85), which was lower than that observed in the present
study (Obimakinde, Ladipo, & Irabor, 2015). Patients withsomatic symptom disorder often experience abuse or a lackof affection from caregivers during childhood (Stuart &Noyes, 1999). Families with such experiences have a highlikelihood of chronic family dysfunction. For the participants in the present study, the illnesses that resulted in admission to the ICU, such as myocardial infarction, were unlikely to be related to the factors that worsened family functioning. Consequently, the difference in mean scores was attributed to differences in the family backgrounds of the patients affected by illness. Conversely, the mean FRI score
ranged from 7.97 to 10.3 points for patients with advanced
cancer and was 9.4 (SD = 2.4) for patients with a head injury (Laratta et al., 2021; Nissen et al., 2016), which wereboth higher than the result of 6.8 (SD = 1.2) in the present
study. The patients with advanced cancer were receiving
outpatient treatment, and the patients with a head injury
were undergoing rehabilitation. Therefore, the condition of
the patients was relatively stable. By contrast, the patients inthe present study had only recently been admitted to the
ICU, and their condition was therefore unstable. The differences in the mean FRI scores were therefore linked to differences in the conditions of the patients.
Scores of the Family Functioning Types
To determine the characteristics of family functioning
among the participants, the type classifications of Kissane
and Blosh (2002) were adopted, and the families were clas5 of 11

JINR 2023, 2(2), e2022-0032

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Table 1. Characteristics of the patients and their family members (n = 77).
Characteristics of the participantsAge (years)

Number of household members, including patients in the ICU

≤45
46–55
56–65
≥66
≤2
3
≤4

n

%

Mean

SD

MedianRange

p value

16
24
23
14
30
30
17

20.78
31.17
29.87
18.18
38.96
38.96
22.08

54.61

11.93

57.1

20–72

.718b

2.86

1.09

3.94

1–7

.418b

.53a

Sex
Female
Male

53
24

68.83
31.17
.544c

Education level
Junior high school
High school
Technical school
Junior college
University

9
49
4
5
10

11.69
63.64
5.19
6.49
12.99
.444a

Marital status
MarriedNot married.994c

Relationship to patient
SpouseChildparentSibling/Other

39
23
6
9

50.65
29.87
7.79
11.69
.224c

Household income (million JPY)

Participants with a history of mental disorders
Family has a member with a history of mental illness
Experienced a loss of a family member
Experienced a loss of a close relative
Experienced a stressful event within the previous
month
Encountered a traumatic event in the past<3
3.01–55.01–7
7.01–15
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

sified according to family functioning type. Thirteen percentof the families (10 people) in this study were classified as
the hostile type. In a previous study that classified the functioning of families of patients with cancer, 6% of the families were classified as the hostile type during the palliative
care period, and this proportion increased to approximately
12% early in the period after the patient’s death, which wascomparable to the proportion seen in the present study (Kissane & Blosh, 2002). The timing of the survey in the present study was soon after the patient had been admitted to
6 of 11

20
21
26
7
3
74
2
75
69
8
43
34
25
52
4
73

25.97
27.27
33.77
9.09
3.9
96.1
2.6
97.4
89.6
10.39
55.84
44.16
32.47
67.53
5.19
94.8

.422a
.311a
.048a
.763a
.011a
.208a

the ICU, which is a period of rapid changes in the patient’s
condition and invasive treatments, all of which place aheavy mental and physical burden on the family. The mental
and physical burden is also believed to be heavy during theperiod immediately after a patient dies, and stressful events
related to the patient that the family encounters during thisperiod explain the comparable proportions of families classified as the hostile type.
The results of this study showed that the family functioning type of 48% of the families was the sullen type. Kissane

https://doi.org10.53044/jinr.2022-0032

JINR 2023, 2(2), e2022-0032

Table 1. Characteristics of the patients and their family members (n = 77) (continued).
n

%

Mean

SD

MedianRange

p value

≤55
56–65
66–75
≥76
1–10
11–20
≥21
≤24
25–48
49–96
≥97
0
1–24
25–48
≥49

14
23
28
12
28
29
20
18
25
12
22
48
11
8
10

18.18
29.87
36.36
15.58
36.36
37.66
25.97
23.38
32.47
15.58
28.57
62.34
14.29
10.39
12.99

64.06

13.78

67.0

20–86

.351b

14.4

8.83

13.0

1–40

.07b

84.56

84.95

48.0

12–491

.197b

59.14

76.62

37.5

3–360

.188b

Female
Male
Yes
Yes
Yes
Yes
Yes
Yes

25
52
25
23
29
4
17
2
25
12

32.5
67.5
32.47
29.87
53.7
7.0
31.5
4.0
46.3
22.2

Patient characteristics
Age (years)

APACHE II score

Duration of ICU stay (h)Duration of mechanical ventilation (h)Sex
Use of cardiac stimulants or vasopressors
Use of sedatives
Use of mechanical ventilator support
Use of artificial heart-lung machine
Use of blood transfusion
Use of hemodialysis
Number with complications
Admitted to ICU in the pastPrimary causative diseases among patients in the ICU

.386a
.937a
.386a
.302a
.199a
.487a
.82a
.976a
.775a

n

Hepato-biliary-pancreatic cancers
Esophageal cancer or other alimentary canal cancer
Lung cancer
Other underlying causes of cancer
Cancer recurrence
Acute ischemic heart disease
Valvular heart disease
Arterial and peripheral arterial occlusive disease
Heart failure
Irregular heartbeat
Septic shock
Hemorrhagic shock
High-energy trauma injuries
Cardiac arrest caused by respiratory failure
Other

8
9
6
6
9
10
5
9
5
1
3
2
1
1
2

Total

77

APACHE II, Acute Physiology and Chronic Health Evaluation II; ICU, intensive care unit; SD, standard deviation.
paired t test, bPearson’s correlation coefficient, cone-way analysis of variance.

aand Blosh (2002) found that this type of family functioning
was exhibited by 9% of the families of patients with cancer
receiving palliative care and approximately 18% of families
soon after the death of the patient. Additionally, the proportion was higher than that immediately after the death of apatient with cancer. Sullen-type families have been describedas guardedly expressing candid emotions and exhibiting
rigid attitudes. In the period immediately after the death of apatient with cancer, many families report having foreseen
the patient’s death since the palliative care stage and haveaccepted changes in the patient’s condition with time. Conversely, families at the stage early after admission to the
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Table 2. Psychosocial characteristics of the respondents (n = 77).

FRI
IES-R
Total score
Re-experience
Avoidance
Arousal
STAI-trait
STAI-state
CES-D
CD-RISC
SSQ (satisfaction)

n

Mean

SD

MedianRange

Pearson’s correlation
coefficient

75
77
77
77
77
77
77
77
76
73

8.0
18.1
7.7
6
4.4
44.4
47.9
15.9
57.6
4.0

1.8
17.1
7.3
5.7
4.9
10.8
12.6
11.2
17.8
1.8

8.0
11
6
4
3
42
48
13.0
58.0
4.7

4–12
0–56
0–32
0–21
0–20
23–75
22–77
0–54
17–1000–6.0

0.771a0.496a0.002a0.759a0.038a0.24aFRI, Family Relationship Index; IES-R, Impact Event Scale-Revised; STAI, Spielberger’sState–Trait Anxiety Inventory; CES-D, Center for Epidemiological Studies Depression
Scale; CD-RISC, Connor–Davidson Resilience Scale; FRI, Family Relationship Index; SSQ,
Social Support Questionnaire; SD, standard deviation.

Table 3. Relationship between family functioning type and psychosocial factors (n = 77).
Hostile typen = 10(13.0%)

Sullen typen = 37(48.0%)

Intermediatetypen = 30(38.9%)

F(2, 73)

p

Mean

SD

Mean

SD

Mean

SD

IES-R
CES-D
STAI-state
STAI-trait

24.4
16.8
53.5
54.1

18.2
8.1
21.6
9.8
*

15.0
11.9
58.3
53.2

15.0
10.7
11.2
12.9

18.6
15.0
55.6
54.6

18.9
9.5
12.3
10.4

1.2
1.2
0.6
0.1

.2
.2
.5
.8

CD-RISC

45.7

17.0

59.4

19.7

60.4

13.4

2.9

.0

SSQ (satisfaction)

3.8

1.6

*
4.0

1.5

4.0

2.0

0.1

.9

IES-R, Impact Event Scale-Revised; CES-D, Center for Epidemiological Studies Depression
Scale; STAI, Spielberger’s State–Trait Anxiety Inventory; CD-RISC, Connor–Davidson Resilience Scale; SSQ, Social Support Questionnaire; *p < .05; SD, standard deviation.

ICU are psychologically traumatized immediately after encountering the appearance and condition of a patient who
has drastically changed from before admission and cannot
accept the patient’s condition (White et al., 2007). The differences in the proportions of families with sullen-type family functioning were therefore related to differences in theevents leading to the patient’s condition at the time of thesurvey.
Factors Associated with the Functioning (FRI) of Families
of Patients Admitted to the ICU
An examination of the factors associated with family functioning showed a relation between severe anxiety in the family and poor family functioning. In a comparative investigation of the psychological symptoms and family functioning
8 of 11of immigrant mothers of premature infants admitted to the
NICU and mothers who were born and raised in that region,
Ballantyne et al. (2013) found that negative psychologicalsymptoms such as maternal stress and depression became
more pronounced as family functioning worsened. Although
this finding is similar to that of the present study, the negative psychological symptom in the study by Ballantyne et al.
(2013) was depression, whereas it was anxiety in the present
study; therefore, the types of psychological symptoms differed, as did the patients. The participants in the study byBallantyne et al. (2013) were mothers of premature infants,
whereas those in the present study were the family membersof patients admitted to the ICU. Although the patients werein similar environments, the types of psychological symptoms associated with family functioning may also have dif-https://doi.org10.53044/jinr.2022-0032

JINR 2023, 2(2), e2022-0032

Table 4. Results of multiple regression analysis of major factors associated with family functioning (n = 77).
Bβtp value

STAI-state score
CD-RISC score
Participant experienced a loss of a family membera
Participant experienced a stressful event within the previous monthb–0.0570.021–1.014–1.201–0.36
0.176–0.145–0.276–3.5341.694–1.412–2.677

.001
.049
.162
.009

R2
Adjusted R2

0.28
0.239**p < .05
Experiencing the loss of a family member was categorized into two groups for analysis: yes = 1 or no = 0.
bParticipants experiencing a stressful event within the previous month were categorized into two groups for analysis:
yes = 1 or no = 0.
STAI, Spielberger’s State–Trait Anxiety Inventory; CD-RISC, Connor–Davidson Resilience Scale.
afered if the backgrounds and attributes of the patients andsubjects had differed. Consequently, it will be necessary in
the future to accumulate further findings related to patients
admitted to the ICU and their families.
The results of the multiple regression analysis revealed
that resilience was associated with stable family functioning.
In a study that examined the causal relationship between
self-efficacy and family functioning in mothers of infants
who received medical treatment in the NICU, Vance et al.
(2020) found that if family functioning was poor when thepatient was admitted to the NICU, the mother’s selfconfidence was continuously low through 3 months after
NICU discharge. Because a healthy family environment fosters a positive psychological state in mothers, the investigators emphasized the importance of family support. The results of the study by Vance et al. (2020) were similar to
those of the present study; however, the present study determined only the correlations between family functioning andpositive psychological states, and the results therefore suggest only the possibility that family resilience is associatedwith family functioning. It will be necessary in the future to
elucidate the causal relationship between family resilienceand family functioning.
It has been shown that family functioning may be poor if
families of patients admitted to the ICU have encountered a
stressful life event in the previous month. Baseline data in acohort study of medical university students who responded
to the spread of infection of the 2019 novel coronavirus
showed that those who had encountered a stressful life event
during the previous year tended to experience severe psychological distress, but the psychological distress tended tobe mild if the student’s family functioning was good (Li etal., 2021). Although the causal relationship between encountering a stressful life event within the previous year andfamily functioning was not examined in the present study,
the results were similar to those of the previous study. To
clarify the association between family functioning andstressful life events, further longitudinal studies are needed.

Finally, as a clinical implementation of the current study,
the results of this study will serve as basic data for building
support for the families of patients admitted to the ICU. The
family function status, risk factors, and recovery factors ofpatients admitted to the ICU were clarified based on scientific evidence. This information will be useful information
for ICU staff to support families.
Limitations
This study had several limitations. First, we targeted family
members of patients who had been admitted or transferred
to a medical/surgical or emergency ICU in only two teaching and advanced treatment hospitals, so many of the participating family members may have done so because of thelocation, thereby leading to the possibility of a selection bias
regarding family status. Hence, the findings may not necessarily apply to family members of patients admitted to the
ICU after being transferred from another hospital. Second,
as a self-administered questionnaire was used in the present
study, the findings could be underestimated or overestimated. Third, the self-administered questionnaire used inthis study was developed to evaluate family functioning, resilience, and psychosocial burden. Therefore, although theparticipants were asked to complete the questionnaire within
24 h of their family member being admitted to the ICU, wecannot rule out the possibility of recall bias because thefamily members were likely under a great deal of stresswhen completing the questionnaire. Finally, the changes recently proposed regarding the diagnosis of PTSD in the
DSM-5 were not considered (American Psychiatric Association, 2013). The three symptom clusters in the DSM-IV-TR
were expanded to four symptom clusters in DSM-5 andshould be considered when interpreting the results of thepresent study.

Conclusion
None of the types of family functioning seen in the partici9 of 11

JINR 2023, 2(2), e2022-0032

pants in this study were types that would give the impression that the family members were happy. Sixty percent of
the families had poor family functioning and required support. The patient’s admission to the ICU was a psychologically severe event for the family members. Anxiety was highin this period, and family functioning was vulnerable if thefamily encountered stressful events within the past month.
Conversely, family members with high resilience had goodfamily functioning. These findings indicate that support for
the family as a whole is needed, so interventions that specifically focus on the resilience of family members may beeffective.
Acknowledgments
We appreciate the contributions of the family members who
participated in the research.
Author Contributions
MK conceived the study, collected the data, performed thedata analysis, and drafted the manuscript. KK helped design
the study, assisted with the data interpretation, and criticallyrevised the manuscript. All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The authors have no conflicts of interest to declare.
Ethical Approval
This study was approved by the ethics committees of the
Graduate School of Medicine of the University of Tokyo.
The approval code is 3080.
Funding
This study was supported by the Japan Society for the Promotion of Science KAKENHI (grant No. 19K19579).
Informed Consent
Obtained.
Data Availability Statement
Several reasons prevent the sharing of the data set. First, theresearch ethics committee that reviewed the study did not
approve the sharing of data. Furthermore, consent to sharedata was not obtained from the participants. At the time ofsubmission, it was unclear whether it is possible to prepare
anonymized data that can be shared.
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Technical Report

A comparison of the fine particulate protection rate of face masks reused
after washing
Kanna Okayama, RN, PHN, PhD1 , and Mitsue Arakawa, RN, PHN, PhD2
1

School of Nursing, Faculty of Nursing, Kansai University of Social Welfare, Hyogo, Japan, and 2School of Nursing,
Faculty of Nursing, Tottori College of Nursing, Tottori, Japan

Abstract
Objective: At the start of the coronavirus disease 2019 (COVID-19) pandemic, the Centers for Disease Control
and Prevention and the World Health Organization recommended the use of face masks in public places to prevent the spread of COVID-19. Several mask types flooded the market with little information regarding their effectiveness. This study aimed to clarify the change in the fine particle protection rate (FPPR) of face masks reused
after washing in an experimental study and to propose a method for reusing face masks that is suitable for nonmedical personnel. Technical Report: The FPPR was measured using a mask-fitting tester after one participant
wore the new masks and after 5, 10, 15, 20, 25, and 30 washes. The dimensions of the masks were measured todetermine whether shrinkage occurred after washing. The surgical mask had the highest FPPR, followed by thecloth, gauze, polyester, and polyurethane masks. Furthermore, all five mask types maintained the same FPPRs as
those of new masks, even after washing 30 times. An interesting observation was that the FPPR of the surgicalmask was higher even after the 30th wash, and therefore, it was more effective than the FPPRs of the other four
face masks when they were new. Conclusions: Surgical masks were the most effective, even though all five
types could be reused after 30 washes. The FPPR of the surgical masks showed better performance after 30
washes than the FPPRs of the other four types when they were new. These findings may start the discussion forthe possibility to reuse face masks.
Keywords
COVID-19, droplet infection, face mask, fine particles, reuse
JINR 2023, 2(2), e2022-0036

Introduction
To prevent infectious diseases, it is important to block theirtransmission routes. In particular, respiratory infections forwhich no cure has been established must be prevented by
wearing a face mask. Recently, wearing a face mask has
been recommended by the Centers for Disease Control andPrevention (CDC) and the World Health Organization(WHO) guidelines as an effective measure to block thedroplet route of transmission of the coronavirus disease2019 (COVID-19) that has caused a pandemic (CDC, 2021;
WHO, 2021).
Various types of face masks, including N95 and surgicalmasks, prevent the spread of infectious droplets/viral aerosols, thereby blocking the route of infection (Li et al.,2020). If infected persons wear cotton or surgical masks, thespread of the virus can be reduced by 60%-80%. Even if
only noninfected persons wear masks, cotton masks reduce
viral inhalation by 20%-40%, whereas surgical masks reduce
inhalation by approximately 50% (Ueki et al., 2020).

Correspondence: K. Okayama. Email: okayama@kusw.ac.jp
Received: October 12, 2022, Accepted: December 27, 2022, Advance Publication: April 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 5JINR 2023, 2(2), e2022-0036

https://doi.org/10.53044/jinr.2022-0036

During the 2009 influenza pandemic and in 2020, at thestart of the COVID-19 pandemic, the demand for surgicalmasks exceeded the supply, creating a worldwide situationin which it was difficult to obtain surgical masks. Gauze
masks are highly permeable to bacteria as they let moist air
pass through, and wearing gauze masks in medical settings
has not been recommended for infection control. Even so, inJapan, gauze masks were distributed to Japanese people as acountermeasure when there was a shortage of surgicalmasks. Concurrently, the demand for face masks made ofmaterials such as polyester and polyurethane increased, but
their ability to prevent infection remains unknown. Consequently, the reuse of face masks has been proposed as a crisis management response during the pandemic (CDC, 2020).
In fact, 34.5%-48.7% of people reportedly reuse surgicalmasks, whereas 48.4% dispose of them immediately afteruse. This clearly shows that face masks are being reused(Lee et al., 2021; Machida et al., 2020). However, although
there are reports focusing on the reuse of N95 masks, few
reports have assessed the reuse of surgical masks (Zorko etal., 2020), which are generally considered disposable.
This study aimed to clarify the change in the fine particle
protection rate (FPPR) of face masks reused after washingand to propose a method for reusing face masks that is suitable for people other than medical personnel. If a reusemethod can be proposed, it may contribute to solving theshortage of face masks in the medical field during a pandemic.

then washed using tap water at room temperature in a Panasonic (Osaka, Japan) household washing machine, which
was set to the normal course (9 min/wash, rinse twice, 6
min/dehydration). We added approximately 28 mL ofsurfactant-based liquid laundry detergent (AttackⓇ: Company
K), approximately 20 mL of hydrogen peroxide-based liquid
oxygen bleach (WidehaiterⓇ: Company K), and approximately 30 mL of surfactant-based fabric softener (HummingⓇ: Company K) in 33 L of tap water. Masks wereplaced in a laundry net and washed with other items, andthen, they were hung to dry. Washing was performed 30
times for each mask.

Technical Report

The performance of the face mask was evaluated by calculating the leakage rate as the FPPR. The Kruskal-Wallis test
and multiple comparisons were used to compare the FPPRs
for each type of brand-new face mask, and the Friedman
test was used to compare the FPPRs for the number of
washes. The Wilcoxon signed rank test was used to compare
the facemask sizes. Descriptive data were expressed as median (first quartile, third quartile) for continuous variables.
In this study, a two-tailed p-value (p = .05) was considered
statistically significant. Statistical analyses were performed
using Bell Curve for Excel (SSRI, Tokyo, Japan).
FPPR % was calculated as follows: 100 − Number of particles inside the mask/Number of particles outside the mask
× 100.

Mask Types
In this study, five types of masks were used: surgical masks,gauze masks, pleated cloth masks (cloth mask), polyestermasks, and polyurethane masks. Regarding the surgicalmask (Company K), the material of the mask body and filter
was polypropylene nonwoven fabric, and the size was approximately 145 × 95 mm. The material of the gauze mask
(Company S) consisted of a 12-layer structure made of
100% cotton, and the size was approximately 135 × 95 mm.
The cloth mask (Company S) was made of 100% cotton,
and the size was approximately 195 × 100 mm. The sizes ofthe masks were approximately 160 × 120 mm for the polyester mask (Company C) and 140 × 120 mm for the polyurethane mask (Company A). Ten of each type of mask
were used for the experiment.
Research Period
The research period was from October 2020 to December
2021.
Washing Method
The face mask was worn by one participant once a day and
2 of 5Fine Particle Measurement Method
One participant wore a face mask before and after washing
5, 10, 15, 20, 25, and 30 times. The number of fine particles
inside and outside the face mask, as well as the leakage rate,
was measured using the Labor Research Institute maskfitting tester MT-05 U (SIBATA, Saitama, Japan). The target
particle size was !
0.3 μm, including microdroplets (Lee etal., 2008). Measurements were made using sodium chloride
aerosol particles. After the participant confirmed that the N
95 masks could collect more than 95% of particles sized!
0.3 μm, measurements were taken for each mask. Before
testing, the researchers and the participant visually checked
each mask for damage and contamination. The experiments
were repeated three times.
Data Analysis

Ethical Considerations
This study was conducted according to the principles of the
Declaration of Helsinki. The protocol was approved by the
Ethical Committee of the Tottori College of Nursing (No.
2020-9). Written informed consent was obtained from one
participant.

https://doi.org/10.53044/jinr.2022-0036

JINR 2023, 2(2), e2022-0036

Results

Discussion
In this study, we determined the FPPRs of five types of facemasks reused through a specific washing method. The surgical, cloth, gauze, polyester, and polyurethane masks main-

**

**

** **

80
**
FPPR (%)

Figure 1 shows a comparison of the FPPRs of the five typesof new face masks. When the FPPR of the surgical masks(79.3% [67.3, 83.5]) was compared with the FPPRs of theother masks, significantly lower rates were observed withthe cloth, gauze, polyester, and polyurethane masks. Further,
the FPPR of the cloth masks was similar to that of thegauze masks, and that of the polyester masks was similar tothat of the polyurethane masks. The FPPR of the polyurethane mask was the lowest relative to the other four masks.
Figure 2 shows the FPPRs of the five types of face masks
according to the number of washes.
Surgical mask: The FPPR of the surgical mask showed adecline from 79.3% (67.3, 83.5) for new products to 61.9%(60.8, 65.1) after 30 washes. There was no significant difference across washes.
Cloth mask: Although the FPPR of the cloth mask was
lower after the 30th wash (44.4% [42.9, 51.0]) than that of
the new product (58.6% [43.5, 61.5]) with FPPRs of 51.3%(49.2, 53.6) and 55.3% (53.8, 59.4) for the 10th and 20th
washes, respectively, there was no significant trend observed
across washes.
Gauze mask: The FPPR of the gauze mask also showedno particular trend nor significance when the new productand different washing stages were compared.
Polyester mask: The FPPR of the polyester mask decreased when the new product and each stage of the subsequent washings were compared: 36.3% (18.2, 38.0) for new
products and 35.7% (34.6, 38.7), 34.6% (34.3, 36.0), and32.2% (27.4, 34.4) for the 10th, 20th, and 30th washes, respectively. These differences were not significant acrosswashes.
Polyurethane mask: The FPPR of the polyurethane mask
also showed no particular trend nor significance when the
new product and different washing stages were compared,
revealing values of 34.3% (32.1, 36.8) for new products and33.1% (32.3, 37.5), 36.0% (33.1, 36.8), and 33.7% (31.7,34.1) for the 10th, 20th, and 30th washes, respectively.
Table 1 shows the morphological changes in the five
types of face masks following washing. Regarding the sizeof the surgical masks before washing and after 30 washes,
the vertical length was shortened. The width and verticallength of the cloth masks were both shortened. The widthsof the gauze and polyurethane masks were reduced. However, there was no change in the size or shape of the polyester mask.

100

60

**
**

*

40
20
0

l

ca

i
rg
Su

h

ot

Cl

e

uz

Ga

ter

P

e

an

es

y
ol

u

ly

Po

th
re

Figure 1. A comparison of the fine particle protection rates ofthe five types of new face masks.
FPPR indicates the fine particle protection rate. Data are presented as FPPRs ( ) and medians ( ). Ten of each type of mask
were used for the experiment (n = 10). * p < .05, ** p < .01.

tained the same FPPRs as those of new masks, even after
washing 30 times. Furthermore, we compared the FPPRs of
the five types of face masks when they were brand new. The
surgical mask had the highest FPPR, followed by the cloth,gauze, polyester, and polyurethane masks. An interesting observation was that the FPPR of the surgical mask, even after
the 30th wash, was higher and, therefore, more effective
than the FPPRs of the other four face masks when new. Although it was reported that the filtration efficiency of surgical masks decreased to 41.9%-66.4% after the 10th wash ina washing machine (Everts et al., 2022), the washingmethod using the laundry net was expected to maintain the
FPPR at a similar level to that of new masks after the 30th
wash. The target particle size of this study was !0.3 μm,
which was smaller than that of droplet particles. Therefore,
the FPPRs can be presumed to be higher if the particle sizeis !
5 μm (Shakya et al., 2017). The FPPRs of the new surgical and cloth masks used in this study were higher thanthose identified in a previous report (Ueki et al., 2020),
which indicated that these masks protected against virus inhalation by 47% and 17%, respectively. This may be due tothe differences in the experimental methods (i.e., in this experiment, a participant actually wore the mask and tested it)
and in the efficacy of the masks themselves. Although thesurgical mask had the highest FPPR, this rate tended to decrease as the number of washings increased. Consideringthat friction during washing and wearing affects the expansion of the pore size and decreases the density of the fibers,
it may be necessary to consider using surgical masks fromother manufacturers for comparison (Wibisono et al., 2020).
The washing method used in this study is effective for laun3 of 5

JINR 2023, 2(2), e2022-0036

https://doi.org/10.53044/jinr.2022-0036(a) Surgical mask(c) Gauze mask(b) Cloth mask

80

80

60
40

60
40

20

20

0

0

New 5

10 15 20 25 30
Washing times

FPPR (%)

100

FPPR (%)

100

80

FPPR (%)

100

New 5

0

10 15 20 25 30
Washing times(d) Polyester mask

New 5

10 15 20 25 30
Washing times(e) Polyurethane mask

80

80

FPPR (%)

100

FPPR (%)

40
20

100
60
40

60
40
20

20
0

60

New 5

0

10 15 20 25 30
Washing times

New 5

10 15 20 25 30
Washing times

Figure 2. Fine particle protection rates of the five types of face masks according to the number of washes.
FPPR indicates the fine particle protection rate. Data are presented as FPPRs ( ) and medians ( ). Ten of each type of mask wereused for the experiment (n = 10).

Table 1. Morphological changes in five types of face masks following washing.
Face mask

Surgical (n = 10)
Cloth (n = 10)
Gauze (n = 10)
Polyester (n = 10)
Polyurethane (n = 10)Size of the mask after 30 washes (mm)Median (first quartile, third quartile)

widthverticalwidthverticalwidthverticalwidthverticalwidthvertical

146.0 (145.0, 146.0)
93.0 (93.0, 94.0)
178.5 (176.0, 189.8)
95.5 (94.0, 99.0)
123.5 (122.0, 124.0)
94.0 (93.0, 95.0)
167.0 (166.0, 167.0)
119.0 (118.0, 119.0)
154.0 (153.0, 154.8)
119.0 (119.0, 119.0)

Difference from a newface mask (mm)p -value

0
−2.0
−14.5
−8.5
−10.5
−1.0
+1.0
+1.0
−1.0
0

.950
.006*
.015*
.009*
.002*
.160
.580
.110
.025*
N/A†)

* p < .05. †: N/A denotes not available.

dering dirty textiles and fabrics in medical facilities and issafe for the skin (Christian et al., 1983). In the former research regarding hospital healthcare workers, the risk of infection was reduced following the use of masks washed in
the hospital laundry in an automatic washing machine compared to following their self-washing (Maclntyre et al.,2020). In the same way, our results suggest that the machine
washing of masks may be effective.
Until now, the general view was that surgical masks aredisposable. Even in the remaining four types of face masks,
very few reports have discussed changes in their FPPR or
4 of 5morphology when reused. Our results suggest that surgicalmasks are the most effective for infection control, although
all five types of face masks can be reused up to 30 times
during pandemics of emerging and re-emerging infectious
diseases. Moreover, because the cloth and gauze masks
shrink significantly with an increasing number of washings,
their reuse must be avoided once they can no longer coverboth the nose and mouth.
Surgical masks were the most effective, even though all
five types could be reused after 30 washes. The FPPR of thesurgical masks showed better performance after 30 washes

https://doi.org/10.53044/jinr.2022-0036

than the FPPRs of the other four types when new. Our findings may refute the notion that masks are not reusable andpropose a method for reusing face masks that is suitable fornonmedical personnel. Face masks for surgeons were introduced in the 1960s as disposable face masks, and their use
spread across the world (Matuschek et al., 2020). As such,the history of face masks is surprisingly recent, and scientific discussions regarding their efficacy are still ongoing. In
the future, it will be necessary to consider the FPPR whendifferent types of face masks (with different threedimensional structures) are considered for reuse and to know
the actual amount of droplet dispersion of reused facemasks.
Author Contributions
Kanna Okayama and Mitsue Arakawa contributed to theconception, design, and perform of this study; Kanna
Okayama drafted the manuscript and supervised the wholestudy process; and Mitsue Arakawa critically reviewed themanuscript. All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest.
Ethical Approval
This research was approved by the Ethical Committee of the
Tottori College of Nursing (No. 2020-9).
Funding
This work was supported by JSPS KAKENHI Grant Number JP20K23182.
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Everts, R. J., Ghusaini, S. A., Telfar-Barnard, L., Barclay, E., Tan, S.,
Jekel, S., Jennings, L., Choi, D. H., Hilson, D., & Gibson, B.
(2022). Liquid-immersion reprocessing effects on filtration efficiency of ‘single-use’ commercial medical face masks. Annals ofWork Exposures and Health, 66(2), 246-259.
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Leung, H. P., & Pun, A. L. (2021). Reuse of face masks among

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adults in Hong Kong during the COVID-19 pandemic. BMC Public Health, 21(1), 1267.
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Li, T., Liu, Y., Li, M., Qian, X., & Dai, S. Y. (2020). Mask or nomask for COVID-19: A public health and market study. PLOS
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Machida, M., Nakamura, I., Saito, R., Nakaya, T., Hanibuchi, T., Takamiya, T., Odagiri,Y., Fukushima, N., Kikuchi, H., Amagasa, S.,
Kojima, T., Watanabe, H., & Inoue, S. (2020). Incorrect use offace masks during the current COVID-19 pandemic among thegeneral public in Japan. International Journal Environmental Research and Public Health, 17(18), 6484.
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Maclntyre, C. R., Dung, T. C., Chughtai, A. A., Seale, H., & Rahman,
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W. T., Lichtenberg, A., Tamaskovics, B., Djiepmo-Njanang, F. J.,
Budach, W., Corradini, S., Haussinger, D., Feldt, T., Jensen, B.,
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Zorko, D. J., Gertsman, S., O’Hearn, K., Timmerman, N., Ambu-Ali,
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https://doi.org/10.1016/j.jhin.2020.07.007

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Brief ReportFeasibility of two guidebooks for parents with mental illness and theirchildren: Healthcare professionals’ perspectives
Rie Ueno, RN, PhD1 , Tytti Solantaus, MD, PhD2 , and Hirokazu Osada, PhD3
1

Department of Mental Health and Psychiatric Nursing, Faculty of Makuhari Human Care, Tohto University, Chiba,
Japan, 2Finnish Institute for Health and Welfare, Department of Public Health and Welfare, Helsinki, Finland, and3
Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan

Abstract
In this study, we aim to examine the feasibility of two guidebooks in Japanese healthcare services, which aimed
to support parenting and child well-being in families with parental mental health illness. We sought and explored
professionals’ perspectives on the translated versions of the Finnish guidebooks, one for parents with mental illness and the other for children. 55 professionals providing support to parents and/or their dependent children
were included in this study. Participants were asked to read the guidebooks and completed a self-report questionnaire as regards the necessity/helpfulness and utilization of the guidebooks. Berelson’s content analysis method
was utilized to analyze the participants’ free description responses. As per our findings, around 70%-85% of theparticipants see the guidebooks necessary and helpful for family members and professionals. These guidebooks
were assessed to provide parents and children emotional support, helping them to understand each other, andguide parents in finding ways to address their children’s issues. Similarly, the guidebooks were seen to help professionals understand these families, in terms of how to support them and explain parental illnesses to children.
Approximately 90%-95% of the participants shared that they would use these guidebooks, but half of them said
that they would use them only to a certain extent. Many had worries about how and with whom to utilize them.
Guidebooks are recommended for use in clinical training. In conclusion, this study suggests that guidebooks arefeasible in Japan as resources in clinical practice and for training professionals to support families. They are likely
to promote awareness of families and children with parental mental illness among professionals and within families.
Keywords
children, feasibility, guidebooks, healthcare professionals, parental mental illness
JINR 2023, 2(2), e2022-0017

Introduction
Approximately 10% to 45% of clients using adult mental
health services are parents of children aged under 18 years
old (Maybery & Reupert, 2018). While intergenerationaltransfer of mental illness is a well-documented phenomenon(Rasic, Hajek, Alda, & Uher, 2014), prevention of childproblems is also found to be productive (Siegenthaler, Munder, & Egger, 2012). It is evident that giving support tofamilies and children is both possible and crucial.
All parents are known to face difficulties on a day-to-day
basis in terms of raising their children; however, parents
who suffer from mental illness have to endure more as theymust also cope with their own symptoms (Solantaus, Reu-

Correspondence: R. Ueno. Email: rie.ueno@tohto.ac.jp
Received: April 25, 2022, Accepted: August 9, 2022, Advance Publication: April 7, 2023, Published: August 25, 2023
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 10JINR 2023, 2(2), e2022-0017

pert, & Maybery, 2015). Mothers who suffer from mental
illness have emphasized how important their children are in
their lives, but they often experience difficulties caring forthem (Ueno & Kamibeppu, 2008; Ueno & Kamibeppu,
2012; Wahl et al., 2017). The most common issues facing
children of parents with mental illness are as follows: “theneed for knowledge/understanding,” “worries about parents’
well-being/wish for relief,” and “the need for normality/
stigma reduction” (Wahl et al., 2017). Thus, it is essential
for professionals to understand the situation of both parents
and children to be able to support families in living as gooda life as possible.
However, lacking appropriate knowledge and skills haveremained to be the barriers that impede professionals from
helping clients with parenting and child-related issues inadult mental health and other services (Maybery & Reupert,
2006; Leonard, Linden, & Grant, 2020). Similarly, in Japan,
many professionals have found it difficult to support parents
because their practice is often limited to their personal experiences in their careers (Ueno & Osada, 2018).
Despite evidence-based preventative interventions (Solantaus & Toikka, 2006) for parents and their families, these interventions often require extensive training and resources;
hence, it is often a challenge to provide them to all clients
who are parents. It is thus evident that developing various
resources to support parents and their families is urgent.
Finland has been active in developing resources to help
support parents and their families; in fact, the country haslaunched a nationwide program (the Effective Child & Family Programme) in 2001 (Solantaus & Toikka, 2006). Solantaus wrote guidebooks for parents with mental illnesses andfor their children (Solantaus & Ringbom, 2002, 2005). They
have been utilized in various services in Finland; additionally, they have been translated into 12 languages (Solantaus & Ueno, 2016a; Solantaus & Ueno, 2016b) and used inthese respective countries. These guidebooks are commonly
utilized, as professionals find them useful to support parents
who suffer from any mental illness and their families; however, the feasibility of the guidebooks has never been examined in any country.
As such guidebooks have not been used in Japan for parents with mental illness, it was considered necessary to shedlight on professionals’ experiences and willingness to accept
the guidebooks in their clinical work, i.e., before using themwith their clients. Thus, in this study, we examined professionals’ perspectives concerning the necessity, helpfulness,and utilization of the translated versions of Solantaus’s two
guidebooks: one for parents (“parent guidebook” hereafter)
and the other for older children and adolescents (“youth
guidebook” hereafter). Furthermore, in this study, we havelaid down some suggestions on how to promote the use ofsuch guidebooks in order to develop an effective practical
approach for parents and/or children.
2 of 10

https://doi.org/10.53044/jinr.2022-0017

Methods
The Two Guidebooks
How Can I Help my Children? A Guide to Parents Who
Have Mental Health Problems
This guidebook is known to not only provide information
and understanding for family members and professionals on
how children might experience their parents’ symptomatic
behaviors but also answer questions that parents often have.
A very important topic discussed in this guidebook is whatparents can do for their children in relation to their symptoms. This illustrated guidebook contains 21 pages (Solantaus & Ringbom, 2002).
What’s Up with Our Parents? A Handbook for Older Children and Adolescents Whose Mother or Father Has Mental
Health Problems
This guidebook explains, in an age-appropriate way, what
mental disorders and their symptoms and treatment. Children’s possible experiences of emotions which can range
from worry, anxiety, and being scared to anger and shame
are discussed in this guidebook. Youth are encouraged to initiate a discussion with the parents on issues that trouble
them. The importance of a trusted adult and the meaning of
one’s own social life are emphasized. This illustrated guidebook contains 34 pages (Solantaus & Ringbom, 2005).
The Japanese Versions of the Two Guidebooks
The first author has obtained permission from Solantaus totranslate and publish the two guidebooks in Japan. The firstauthor has carefully translated the guidebooks into Japaneseand then requested comments from the third author, a childpsychiatrist, and an academic manager from The Finnish Institute in Japan. As agreed with Solantaus, some adaptations
were made due to differences between the healthcare services and customs of Japan and Finland. Ringbom, the illustrator, and Sandman, the graphic designer, of the original
guidebooks were involved in producing the Japanese guidebooks in the same style as the originals (Solantaus & Ueno,
2016a; Solantaus & Ueno, 2016b).
ParticipantsThis study was approved by the ethics committees of thefirst author’s university at the time of the study. Informed
consent was obtained from all participants by returning thecompleted questionnaire. We recruited the participants
through the managers of the six institutions in the Kanto
area in 2014: children and family support centers (29.1%),
psychiatric hospitals (25.4%), community health centers(14.6%), public health centers (14.6%), mental health andwelfare centers (12.7%), and child consultation centers(3.6%). We mailed explanatory statements regarding thisstudy to 206 institutional managers with the Japanese versions of the guidebooks, an anonymous self-report questionnaire, and a return envelope. We asked the institutional man-https://doi.org/10.53044/jinr.2022-0017

JINR 2023, 2(2), e2022-0017

Table 1. Perceived necessity, helpfulness, and utilization of the guidebooks (n = 55).
Yes

Answers
Questions
Do you think that the guidebook is necessary?
Do you think that the guidebook is helpful?
Do you think that you would utilize the guidebook in your facility?

Not very much

No

Parent*Youth**

Parent*Youth**

Parent*Youth**

44 (81.5%)
38 (70.4%)
25 (47.2%)

46 (83.6%)
42 (76.4%)
26 (50.0%)

10 (18.5%)
16 (29.5%)
25 (47.2%)

9 (16.4%)
12 (21.8%)
21 (40.4%)

0 (0%)
0 (0%)
3 (5.7%)0 (0%)
1 (1.9%)5 (9.6%)Note.
Because some participants did not respond to all questions, the total number of participants (n) varied.
*A guidebook for parents: “How can I help my children? A guide to parents who have mental health problems”**A guidebook for youth: “What’s up with our parents? A handbook for older children and adolescents whose mother or father has
mental health problems”

agers to select one professional from their institutions toparticipate in this study. The collection rate was 27.7% (57/206), with one respondent from each facility. Two responses
were excluded because fewer than half of the questions wereanswered. Finally, 55 participants were included in the data
analyses.
Data Collection
Participants read the two guidebooks, completed a selfreport questionnaire anonymously, and then sent it to thefirst author. This study used a cross-sectional research design.
Questionnaire
We asked the following three questions: “Do you think thatthe parent/youth version of the guidebook is necessary?,”“Do you think that the parent/youth version of the guidebook is helpful?,” and “Do you think that you would utilize
the parent/youth version of the guidebook in your facility?”
In each question, the participants were asked to choose from“Yes,” “Not very much,” and “No,” followed by an openended question (“Why do you think so?”) that will be answered in a free-response space. Additionally, we asked theparticipants about their profession and workplace.

Results
Participants’ Professions
Approximately half of the participants (49.1%) were publichealth nurses, 16.4% were clinical psychologists, 14.5%
were social workers, 10.9% were psychiatric nurses, and9.1% were doctors.
Perceived necessity, helpfulness, and utilization of the guidebooks
For each guidebook, over 80% of the participants have answered that the guidebook was necessary. Almost threequarters of the participants (70.4% for the parent, 76.4% for
the youth) have answered that the guidebook was deemed
helpful. Approximately half of the participants (47.2%/50%)
answered “Yes,” indicating that they would utilize the parent/youth guidebook, whereas 47.2%/40.4% answered “Notvery much” (Table 1).
Healthcare Professionals’ Free Description of the Necessity/
Helpfulness and Utilization of the Guidebooks
Due to the similar free responses to the necessity and helpfulness questions, we have opted to analyze the data by
combining them.

Data Analyses

Reasons the guidebook is necessary/helpful

Berelson’s content analysis method was utilized to analyze
the participants’ free description feedback in response toeach question regarding the guidebooks (Berelson, 1957). As
per the content analysis, the first author read the entire description and regarded one sentence with a specific type ofcontent as a unit for analysis. The first author classified each
unit of analysis based on similarities and then grouped theminto categories. Then, the first author and the third author,
who is also a mental health professional/researcher, discussed all the data, including the raw data, units of analysis,
and categories, several times before reaching an agreement,
which ensured the reliability of the results.

In total, 33 of the 44 participants who answered that theparent guidebook was necessary provided valid data. Moreover, 27 of the 38 who answered that the guidebook was
helpful provided valid data. Only valid data were includedin this analysis (the same hereinafter). The participants’feedback was divided into 61 units of analysis; then, thesewere grouped into 13 categories according to their similarities.
In total, 32 of the 46 participants who answered that theyouth guidebook is necessary provided valid data. Meanwhile, 27 of the 42 participants who answered that theyouth guidebook was helpful were able to provide valid
data. The participants’ feedback was divided into 59 units ofanalysis and thereafter grouped into 13 categories (Table 2).
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Table 2. Reasons the guidebook is necessary/helpful.
Parent guidebook (n = 60)
Units ofanalysis

Category
numberCategory

Example of units of analysis

1

Providing specific and helpful content
for parents in the context of parenting
and mental illness•Parents can understand what is necessary for their children, what the children struggle with,and how they should engage with their children.
•The guidebook describes what parents should consider and can do when they are parenting.

14

2

Providing parents with emotional
support•The guidebook encourages parents to adopt self-acceptance.
•It is important for parents to know that there are parents who have the same difficulties andworries, and parents can think about what they can do.

10 16.4%

3

Rich in content•The guidebook is rich in content.
•The guidebook answers many questions.

5

8.2%

4

Concrete content•The guidebook contains concrete content, such as what parents can do for their children.
•The guidebook is helpful because it describes to the point of parents’ and children’s feelings.

5

8.2%

5

Allows parents to understand theirmental illness and behaviors•Parents can understand their mental illness and treatment well.
•It is needed for parents to understand and accept their mental illness.

5

8.2%

6

Need for something like this guidebook•The guidebook is needed.

4

6.6%

7

Necessary to consider parents’ conditions and needs•It would be necessary to assess parents using the guidebook because some parents mightexperience anxiety, of which they are unaware.

4

6.6%

8

Easy to understand•The guidebook is easy to understand.

3

4.9%

9

Few or no similar guidebooks available•There are few similar guidebooks available.

3

4.9%

10

Makes it easy for professionals to
discuss parenting with the parents•The guidebook makes it easier for professionals to discuss the topics covered with parents.

3

4.9%

11

Learning about parent care resources for•The guidebook can be a resource for professionals to understand parents and support them.
professionals

2

3.3%

12

Parent care resources for professionals•It could be utilized for professionals who support parenting, such as public health nurses,
psychologists, and child and family supporters, depending on the situation.

2

3.3%

13

Giving children relief•Children will be relieved to know that there is a guidebook containing general information
about mental illness that helps them understand their parents’ situation.

1

1.6%

23%

Youth guidebook (n = 59)
Category
numberCategory

Example of units of analysis

Units ofanalysis1

Acquiring knowledge and learning how •Children can come to know whom to consult and how to acquire knowledge of their
to cope with their concerns and difficul- parents’ mental illness.
ties•The guidebook explains what children can do and what they cannot/should not do.

12 20.3%

2

Helps professionals to explain theirparents’ illness/situation to children•The guidebook itself can provide a chance to have a conversation what covered in theguidebook.
•(The guidebook is necessary) Because it is difficult to tell their parents’ illness/situation tochildren in words.

9 15.3%

3

Helps children to understand theirparents’ illness/situation and theirrelationships with their parents•Children can understand their parents’ mental illness/situation.
•Children can understand their relationships with their parents.

9 15.3%

4

Providing children with emotional
support•Children can positively accept their feelings by reading the guidebook.
•Children can keep on living without blaming themselves.

6 10.2%

5

Necessary to consider children’s age and•It would be necessary to consider the children’s age.
situation

4

6.8%

6

Learning about parent/child careresources for professionals•I will utilize the guidebook to help professionals to understand parents and as a learning
resource for professionals.

3

5.1%

7

Concrete content•It is easy to understand because the explanations are concrete.

3

5.1%

8

Focus on children’s needs and perspectives•The guidebook is written from children’s perspectives and considers their feelings.
•The guidebook explains what children want to know.

3

5.1%

9

Need for something like this guidebook•The guidebook is needed.

3

5.1%

10

Rich in content•The guidebook is rich in content.

2

3.4%

11

Supports children when direct help isunavailable•Children can read the guidebook repeatedly when professionals often cannot directly support
them.

2

3.4%

12

Necessary to follow-up with children
after reading it•Follow-up might be necessary after children have read the guidebook.

2

3.4%

13

Few similar guidebooks available•There are few opportunities for children to acquire necessary knowledge like this; there arefew similar guidebooks or websites in Japan.

1

1.7%

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Table 3. Reasons the guidebook is necessary/helpful “not very much”.
Parent guidebook (n = 22)
Category
numberCategory

Units ofanalysis

Example of units of analysis

1Long text•The content is good; however, the text seems to be too long forparents.

7

25.9%

2

Small print•The print is small for parents.

6

22.2%

3

Necessary to consider parents’ condition•The guidebook can be utilized according to the condition of theparents (degree of stability of illness).
•There may be many parents who cannot read (or will not try toread) the guidebook.

6

22.2%

4

Translation/explanation is difficult to understand•The translation/explanation seem to be difficult to understand.

4

14.8%

5

Unfamiliar illustrations for Japan•The illustrations are unfamiliar in Japan.

2

7.4%

6

Not concrete in some of its advice for children•It would have been better had the guidebook adopted more specific advice for the children because it has several abstract parts.

1

3.7%

7

Content seems unsuitable•The purpose of the guidebook is good; however, the content does
not seem to be very suitable.

1

3.7%

Youth guidebook (n = 17)
Units ofanalysis

Category
numberCategory

1

Necessary to consider children’s age and situation•It cannot be utilized by children in lower elementary school.

6

24%

2

Long text•The text is long.

5

20%

3

Small print•The print is small.

4

16%

4

Explanation is difficult for children•The explanation is difficult for children.

4

16%

5

Unfamiliar illustrations for Japan•The illustrations are unfamiliar in Japan.

3

12%

6

Unfriendly font

•The font is unfriendly.

1

4%

7

No phonetic guides on Kanji*•There are no phonetic guides on Kanji*.

1

4%

8

Content seems unsuitable•The purpose of the guidebook is good; however, the content does
not seem to be very suitable.

1

4%

Example of units of analysis*Note.
The Japanese language uses three different types of characters: Hira-kana, Kata-kana, and Kanji. Hira-kana and Kata-kana are syllables, while eachKanji has specific phonetics and meanings. It is sometimes difficult for (young) Japanese children to read Kanji without phonetic guides.

Reasons the guidebook is necessary/helpful “not very much”
Eight of the ten participants who answered that the parent
guidebook was not necessary have provided valid data.
Meanwhile, 14 of the 16 participants who answered that theguidebook was not helpful very much provided valid data.
The participant’ feedback was divided into 27 units ofanalysis and then grouped into 7 categories.
Eight of the nine participants who answered that theyouth guidebook is not necessary provided valid answers.
Moreover, 9 of the 12 participants who responded that theyouth guidebook was not very helpful provided valid data.
The participant’ feedback was divided into 25 units ofanalysis and then grouped into 8 categories (Table 3).

not necessary/helpful, one participant responded that theyouth guidebook is not necessary/helpful because “It is possible that children might be more anxious if the guidebook
is utilized with unsuitable children.”
Reasons participants would utilize the guidebook
As per our findings, 21 of the 25 participants who answeredthat they would utilize the parent guidebook were able toprovide valid data. The participants’ feedback was divided
into 24 units of analysis and then grouped into 9 categories.
Also, 21 of the 26 participants who answered that theywould utilize the youth guidebook provided valid data. The
participants’ feedback was divided into 22 units of analysis
and then grouped into 11 categories (Table 4).

Reasons the youth guidebook is not necessary/helpful
While no participant answered that the parent guidebook is
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Table 4. Reasons participants would utilize the guidebook.
Parent guidebook (n = 21)
Category
numberCategory

Example of units of analysis

1

Learning about parent care resources for professionals•The guidebook could be utilized for professional workshops to better understandparents and methods of supporting them.
•It is necessary to share the guidebook with coworkers.

8

33.3%

2

Parent care resources for professionals•It would be possible to share with parents’ situation and concerns by reading theguidebook with them.

4

16.7%

3

Discussing the time required toutilize and how to utilize theguidebook•It would be necessary to discuss how to utilize the guidebook.

3

12.5%

4

Necessary to consider parents’ situation•I would like to utilize the guidebook to consider parents’ situations, relationships
with their children, and individual situations.

3

12.5%

5

Distributing the guidebook to parents•I would like to distribute the guidebook to parents.

2

8.3%

6

For parents’ families•Some parents who participate in return-to-work rehabilitation programs are worried about how to explain their mental illness to their families.

1

4.2%

7

Keeping guidebook in the outpatient area

•I would like to keep the guidebook in the outpatient area, where the parents canfreely read it.

1

4.2%

8

Mental health awareness•To raise awareness in people around persons with mental illness or those without
knowledge of mental illness.

1

4.2%

9

Concrete content•The guidebook is helpful because it describes the parents’ and children’s feelings.

1

4.2%

Units ofanalysis

Youth guidebook (n = 21)
Units ofanalysis

Category
numberCategory

1

Discussing the time required andhow to utilize the guidebook•I would like to utilize the guidebook if I have an opportunity.

5

22.7%

2

Learning resource for professionals•The guidebook could be utilized as a learning resource for professionals.

3

13.6%

3

Necessary to consider children’s
age and situation•I would like to utilize the guidebook in the consultation setting for children after
considering their age and situation.

3

13.6%

4

Distributing guidebook to children
and/or parents•I would like to distribute it to children because consultations with children are
rare.

2

9.1%

5

Concrete/important content•The content of the guidebook is important and is what we want to tell the children.

2

9.1%

6

For understanding themselves/
their parents and family situation•Children can understand themselves and what is happening in their families.

2

9.1%

7

Keeping the guidebook in theoutpatient area

•I would like to keep the guidebook in the outpatient area, where the parents canfreely read it.

1

4.5%

8

Mental health awareness•I would like to utilize the guidebook to help those people without knowledge ofmental illness learn about mental illness.

1

4.5%

9

Short versions are better•It would be better were there a short version of the guidebook.

1

4.5%

10

Tips for utilization are better•It would better if there were tips for utilization depending on children’s age.

1

4.5%

11

Helps professionals to explain
their parents’ illness/situation tochildren•It could be utilized for professionals to have conversations with children because
the guidebook covers necessary content and the illustrations describe the text.

1

4.5%

Example of units of analysis

Reasons participants would utilize the guidebook “not verymuch”
In total, 23 of the 25 participants, who answered that they
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would not utilize the parent guidebook very much, provided
valid data. The participants’ feedback was divided into 32
units of analysis and then grouped into 15 categories.
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JINR 2023, 2(2), e2022-0017

Table 5. Reasons participants would utilize the guidebook “not very much”.
Parent guidebook (n = 23)
Category
numberCategory

1

Translation/explanation is difficult to understand•The explanation is difficult to understand.

4

12.5%

2

Long text•The content is good; however, the text is somewhat long.

3

9.4%

3

Few or no opportunities to utilize the guidebook•There are few opportunities to utilize this guidebook when interacting with parents.

3

9.4%

4

Unfamiliar illustrations for Japan•The illustrations are unfamiliar in Japan.

2

6.3%

5

Necessary for parents to be aware of their illness

The content of this guidebook requires that parents be aware of theirillnesses.

2

6.3%

6

Small print•The print is small.

2

6.3%

7

Difficult for professionals to read it with parents•It is difficult for professionals to read the guidebook with parents.

2

6.3%

8

Necessary to discuss how to utilize the guidebook•I do not understand how to utilize the guidebook, at what time tointroduce it, or what form of meeting to adopt.

2

6.3%

9

Seems better utilized by other institutions•It would be easy to utilize at educational institutions.

2

6.3%

10

Short versions are better•It would be better if there is a short version of the guidebook.

2

6.3%

11

Partial utilization•If partially utilized, the guidebook can be utilized more frequently.

2

6.3%

12

Necessary to consider parents’ condition•Reading the guidebook would make persons with mental illness betired and confront their illness too directly, although it may be helpful for professionals.

2

6.3%

13

Learning about parent care resources for professionals•I will share the guidebook with coworkers.

2

6.3%

14

Difficult for professionals to address the topic•Currently, it is difficult to address the topics of this guidebook in thetreatment of parents.

1

3.1%

15

Unsuitable for Japanese culture•I would love to utilize the guidebook if it were more suitable forJapanese culture.

1

3.1%

Units ofanalysis

Example of units of analysis

Youth guidebook (n = 18)
Category
numberCategory

Example of units of analysis

Units of analysis

1

No opportunities to utilize the guidebook•There seem to be no opportunities to utilize the guidebook.

4

18.2%

2

Necessary to consider children’s age and characteristics•It would be necessary to consider the children’s age.

3

13.6%

3

Necessary to discuss how to utilize the guidebook•I do not know how to utilize the guidebook.

3

13.6%

4

Long text•The text is long.

2

9.1%

5

Difficult content•The content is difficult.

2

9.1%

6

Necessary to have a relationship with the children•I feel that maintaining a continuous relationship with the children isnecessary.

2

9.1%

7

Seems better utilized by other institutions•The guidebook is appropriate at medical institutions.
•The guidebook would be easy to utilize at educational institutions.

2

9.1%

8

Unfamiliar illustrations for Japan•The illustrations are unfamiliar in Japan.

1

4.5%

9

Necessary to carefully consider whether approach is appropriate for children at institutions
supporting parents•I think that medical institutions treating parents with mental illnesses
should carefully consider whether a direct approach with children issuitable.

1

4.5%

10

Unsuitable for Japanese children•I would love to utilize the guidebook if it were more acceptable forJapanese children.

1

4.5%

11

Partial utilization•I would like to utilize the guidebook, quoting it in part.

1

4.5%

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they would not utilize the youth guidebook very much provided valid data. The participant’ feedback was divided into
22 units of analysis and then grouped into 11 categories (Table 5).
Reasons participants would not utilize the guidebook
Three participants who answered that they would not utilize
the parent guidebook provided valid data, which were included in this analysis. Their feedback was divided into fiveunits of analysis and thereafter grouped into four categories:“Translation/explanation is difficult to understand” (two participants), “Small print,” “Long text,” and “Seems better utilized by other institutions” (i.e., “It would be appropriate toutilize at medical institutions”).
Five participants answered that they would not utilize theyouth guidebook. Only the valid data were included in thisanalysis, and their feedback was divided into seven units ofanalysis and then grouped into four categories: “No opportunities to utilize the guidebook” (two participants), “Necessary to consider children’s age and situation” (two participants), “Explanation is difficult to understand,” and “Unfamiliar illustrations for Japan.”

Discussion
As per our findings, it was determined that both guidebooks
were considered necessary and helpful for parents, children,and professionals; in fact, most participants would use themin their work (70%-95% of the participants), although it
should be noted that the participants had not used the guidebooks with their clients. These results are consistent with
Solantaus’s intention (Solantaus & Ueno, 2016a) for guidebooks to serve both families and professionals.
These two guidebooks were also reported to provide specific and helpful content for family members. They wereseen to provide emotional support for parents and children,to help them understand each other, and to help parents findways to deal with their children’s struggles. In line with
this, the guidebooks were assessed to have the potential toempower parents to overcome their helplessness when it
comes to parenting, which has been reported by Ueno andKamibeppu (2008).
As practically all participants perceived the guidebooks asboth helpful and necessary for families and professionals,
nearly half of them were hesitant to use them with their clients. This was deemed a very important and informative
finding.
Such hesitation to use these guidebooks with clients
seemed to come from little experience using them. Additionally, there were concerns regarding therapeutic relationship(Strand & Rudolfsson, 2018) and suitable clients. These arevalid concerns, as it reveals reveal that responsible professionals are not prepared to use tools they are not skilled
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https://doi.org/10.53044/jinr.2022-0017

with. Furthermore, discussing sensitive issues, such as parents’ mental illnesses, children and parenting (Solantaus,
Reupert, & Maybery, 2015), without a sense of mastery of
the method, can only do more harm than good, e.g., increased worries and anxieties in the client and the child andself-blame in the parent.
Biebel et al. (2015) have indicated that it is necessary for
professionals to understand families with parental mental illness to be able to work constructively with them. As per our
results, it demonstrates that guidebooks are likely to be
helpful learning resources for professionals to gain a deeper
sense and understanding of parents’ and children’s experiences and issues. Therefore, the respondents’ suggestions to
use these guidebooks as educational materials for professionals should be heeded. This was a novel type of use of
the guidebooks. To the best of our knowledge, guidebooks
have not previously been seen as educational materials for
professionals.
Following the participants’ suggestions, it is thus recommended that workshops, including lectures and groupwork
based on the guidebooks, be organized. In particular, roleplay may be effective in obtaining experiential understanding and practical knowledge and skills (van Ments, 1999).
Moreover, encouraging professionals to have discussions
with parents, children, and other professionals might help
them find their own ways of using the guidebooks based on
their clinical settings and clients’ features, including the clients’ needs and recovery stages. Such discussions could lead
to better and more effective practical approaches to support
both parents and children and provide valuable learning resources for professionals.
Limitations
As a first step, we have sought and analyzed professionals’
experiences as regards this topic. Then, we included those ofparents and children. We used a self-report questionnaire,
which might be limited in capturing the participants’ detailed thoughts. This was a selective sample, and the response rate was relatively low. However, we consider thefindings informative and useful in advancing ways to increase support for parents and children in families with parental mental illness.

Conclusions
Solantaus’s two guidebooks written for parents with mental
illness and for their children are found to be valuable andthus appreciated; in fact, their content is regarded as highly
beneficial for families and professionals. This study suggeststhat guidebooks are thus feasible resources in Japan forclinical practice and professional training, provided the clinicians receive training on how to use them. In this study, wewere able to capture real and significant issues one should

https://doi.org/10.53044/jinr.2022-0017

be aware of when supporting professionals and promoting
effective practices for parents and children. Thus, we recommend more systematic research on different support materials used in clinical work.
Author Contributions
R.U. obtained permission from Solantaus to translate thetwo guidebooks from English to Japanese, translated the two
guidebooks to Japanese, designed the study, collected andanalyzed the data, and drafted the manuscript. T.S. gave permission for R.U. to translate the two guidebooks from English to Japanese and contributed to the writing and revisions
for the intellectual context of the manuscript. H.O. madecomments on the translations of the two guidebooks, designed the study, provided data interpretation, edited themanuscript, and made intellectual contributions to the writing of the manuscript. All authors have read and approved
the final manuscript.
Declaration of Conflicting Interests
The authors declare no conflicts of interests.
Ethical Approval
This study was approved by the ethical committees of Tokyo
Medical University, Institutional Review Board for Nursing
Studies (approval number 6).
Funding
This work was supported by Grant-in-Aid for Young Scientists (B) (MEXT KAKENHI grant number JP 23792763).
Informed Consent
Informed consent was obtained from all participants by returning the completed questionnaire.
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Ueno, R., & Kamibeppu, K. (2012). Perspectives of Japanese motherswith severe mental illness regarding the disclosure of their mental
health status to their children. Archives of Psychiatric Nursing, 26(5), 392-403.
https://doi.org/10.1016/j.apnu.2012.01.002
Ueno, R., & Osada, H. (2018, July 27-28). Seishinshikkan wo yusuru
oya eno shien no jittai oyobi shiensha no niizu ni kansuru zenkokuchosa - Seishinkabyouin, hokenjo. Jidouosoudanjo ni okeru
hikakukentou [Healthcare professionals’ practices toward parents
with mental illness and their needs regarding to support the parents and their children: A nationwide survey of Japanese psychiatric hospitals, public health centers, and child guidance centers].
Dai. 49 kai Nihon Kango gakkai zaitaku Kango Gakujutsu Shuukai, Saga, Japan.
van Ments, M. (1999). The effective use of role play: Practical tech-

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niques for improving learning. (2nd ed., pp. 11-28). Kogan Page.
Wahl, P., Bruland, D., Bauer, U., Okan, O., & Lenz, A. (2017). What
are the family needs when a parent has mental health problems?

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https://doi.org/10.53044/jinr.2022-0017
Evidence from a systematic literature review. Journal of Childand Adolescent Psychiatric Nursing, 30(1), 54-66.
https://doi.org/10.1111/jcap.12171

https://doi.org/10.53044/jinr.2023-0011
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Education

Current status of the JINR: From the editor-in-chief
Naohiro Hohashi, PhD, RN, PHN, FAAN1, 2
Editor-in-Chief, Journal of International Nursing Research, and 2Graduate School of Health Sciences, Kobe University, Kobe, Japan
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JINR 2023, e2023-0011.
The Japan Society of Nursing Research (JSNR), whose forerunner was founded in 1970, is the oldest academic society in
the Japanese nursing community. To meet the demands of theera of globalization in nursing science, in February 2022 JSNR
launched the Journal of International Nursing Research(JINR) as its international English journal. In February 2023,
an online seminar being planned for JINR exceeded the limit of
500 registrations, indicating that JINR is attracting attention
among people in the nursing field. In light of this, we havedecided to include the essentials of the four speakers’ seminars
here. At first, the contents of my presentation are as follows.
Launched in February 2022, Volume 1, Number 1 of JINR
contained five papers. Its web version is publicly available on
J-STAGE. JINR is open to nursing researchers from all over theworld, and of course contributions by non-members of JSNR
are also welcome. JINR’s scope of research extends to a wide
range of areas related to nursing science.
For a newly launched publication JINR attracted considerably more submissions than anticipated. We began accepting
submissions on May 23, 2021, and as of February 9, 2023, wehave received a total of 77 submissions. Since many of thepapers have been published in advance publication on
J-STAGE, we decided to publish two issues per year (Februaryand August) to expedite the publication process. Volume 2,
Number 1 was published in February 2023, and the next issue,
Volume 2, Number 2, is scheduled to be published in August2023. A printed version of the issue is also available and has
been carried by the National Diet Library of Japan and otherinstitutions. The pdf file is available on the JINR website. The
printed version incorporates a table of contents, a list ofreviewers, the recipients of Outstanding Reviewer Awards andother information.
Currently, selection of reviewers has posed a challenge, due
in part to the Coronavirus pandemic, and this has resulted in
drawing out the time required for reviews. We would like torequest your cooperation in terms of both submissions and peer
reviews. Through various measures taken to address this problem, the period needed for reviews has been successively
reduced. One way we achieved this was by increasing the number of associate editors outside Japan, which has brought withit the benefit of expanding JINR’s international horizons. JINR
also established Outstanding Reviewer Awards, in which outstanding reviewers receive recognition. This hopefully will
also serve as an incentive for reviewers to undertake their tasks
with the aim of winning an award. We are, moreover, making
efforts to reduce the duration between acceptance of manuscripts and advance publication.
At present JINR does not pose a high threshold and is receptive to submissions, even from the uninitiated. We do hope you
will join with us in helping JINR to grow and thrive. In the very
near future, we aim to publish JINR in PMC and PubMed,
thereby attaining an impact factor (IF) among international
English journals. I am confident you will be seeing us develop
in the future.
Disclaimer
Naohiro Hohashi serves as Editor-in-Chief of Journal ofInternational Nursing Research as well as on the journal’s Editorial Committee. He was not involved in the process of editorial evaluation or the decision to accept this article forpublication.

Correspondence: N. Hohashi. Email: naohiro@hohashi.org
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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

Education

Boosting the chances of getting your paper accepted in the Journal of International Nursing Research: Understanding common reasons for paper
rejection in international nursing journals
Naoki Yoshinaga, PhD, RN1,2
Associate Editor, Journal of International Nursing Research, and 2School of Nursing, Faculty of Medicine, Universityof Miyazaki, Miyazaki, Japan
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JINR 2023, e2023-0014.
Nursing research is essential to expand the body of knowledge
needed to guide evidence-based nursing practice, education,and policy that modern healthcare requires. Publishingresearch papers is a responsibility of nursing researchers
because it promotes scholarship and the sharing of scientificknowledge, among other reasons. If you wish to publish
high-quality papers and/or have been discouraged by rejections
from international nursing journals, this article will help you
understand what factors could lead to rejections, thereby
enabling you to rectify deficiencies before submitting yourwork to the Journal of International Nursing Research (JINR).
Let us examine some of the common reasons for rejection proposed in an Editorial of the International Journal of Nursing
Studies (Griffiths & Norman, 2016).
“Failure to set the study clearly in the context of what isalready known”―Insufficient description of the novelty andsignificance of your work is one of the most common reasonsfor quick rejection. Authors must perform a comprehensive
search and review of existing literature in the early stages of
their research to explore what is known about a topic and what
the paper adds. It varies depending on the journal, but authors
are often required to address what the paper contributes to theadvancement of nursing knowledge and/or its clinical relevance. Some leading nursing journals request that the authors
include a clear statement on the novelty and clinical relevanceof the paper in the abstract or at the beginning of the paper.
“Out of scope” and “First study in Country X”―The International Journal of Nursing Studies and our journal (JINR) are
INTERNATIONAL journals, and a paper that does not matchthe aim and scope of the journal is likely to get rejected. The
aims and scope of JINR are reproduced here: “The purpose ofthis Journal is to publish advanced, evidence-based original
research findings and clinical information on clinical practice,nurse education, and management in the field of nursing tobroaden the knowledge of nursing professionals across theworld.” Moreover, Japanese authors sometimes emphasize theoriginality/novelty of their paper by saying something like“this is the first study in Japan”. The fact that a research topic

has not been studied in a particular country does not necessarily underscore its originality/novelty; this makes your paper
less interesting to readers in other countries. Certainly, journal
editors and reviewers recognize that some research focusing on
a particular location or group is valuable, but authors should
explain how, from a broader international perspective, theirresearch contributes to nursing knowledge/practice, and why it
is necessary to study the topic in terms of a novel location/group.
“Not (clearly) reporting essential details of the research”―
If your research is lacking in certain essential details, yourpaper is more likely to be rejected. JINR encourages authors tofollow the relevant reporting guidelines (https://www.equatornetwork.org/) when writing up research; this will help you provide essential details of your research and help reviewers andreaders understand what was done and what was found in astudy, so that they can judge whether such findings are likely tobe reliable. By following reporting guidelines, nursing
researchers will further ensure that their research papers arerobust, reliable, and usable, leading to advancement of knowledge in nursing science and better patient care.
Avoiding these common mistakes and addressing the reporting guidelines in your document will greatly boost the chancesof your research being accepted by the JINR.
Disclaimer
Naoki Yoshinaga is one of the Associate Editors of Journal ofInternational Nursing Research and on the journal’s Editorial
Committee. He was not involved in the editorial evaluation ordecision to accept this article for publication at all.
References

Griffiths, P., & Norman, I. (2016). Why was my paper rejected? Editors’reflections on common issues which influence decisions to reject
papers submitted for publication in academic nursing journals.
International Journal of Nursing Studies, 57, A1-A4.
https://doi.org/10.1016/j.ijnurstu.2016.03.017

Correspondence: N. Yoshinaga. Email: naoki-y@med.miyazaki-u.ac.jp
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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

Education

Tips for papers’ acceptance from a peer review perspective
Takiko Imai, PhD, RN, PHN
Japanese Red Cross Hiroshima College of Nursing, Hatsukaichi, JapanJINR 2023, e2023-0017.
To turn research into “shareable knowledge,” a paper must be
submitted to and accepted by a journal. The following prerequisites must be met for journal acceptance: submission rules,
manuscript-writing guidelines, ethical considerations, and correct referencing. Papers must pass muster with peer reviewers,
who judge whether a paper is worthy of being published.
Papers should be written in a reader-friendly manner. For
example, most readers read the title, abstract, results, and conclusion to gain an overview of the content to decide whether toread the whole paper. Papers should therefore describe thenecessary content through the following components: title,
introduction, purpose, methods, results, discussion, and conclusions. This type of logical sequence is called technical writing, which enhances the paper’s structure, consistency,
understandability, and completeness.
Peer reviewers partly base their decision on whether a submitted paper is suitable for publication based on this “logic.”
Reviewers also apply the following criteria during their adjudication: “legitimacy (appropriateness, reproducibility and reliability of research methods),” “ethics” (human rights),“originality and novelty,” and “importance of research” (theacademic value and usefulness of research). “Legitimacy” isthe lifeline of research, meaning that the paper’s hypotheses
are presented and argued with reliable data that are not fabricated. Authors should describe the “originality and novelty” oftheir study, including a logical presentation and discussion of
not only unpublished facts about the paper but also new findings and differences from previous research. This study
describes a research method that other researchers can emulate
to meet the aforementioned requirements.
Regarding the structure of the paper, the introduction is an
important part that conveys the “originality and novelty” of theresearch generated from the literature review, based on the
research question or problem. Research should be based on“problems to be solved,” related to the “importance of theresearch.” It is therefore essential to provide a description of
the research question or problem at the beginning of the introduction. The introduction must also include the research findings required to address the problem, which must be statedlogically by citing relevant literature. Authors must briefly
present the findings of previous, related research, and succinctly explain the difference between their papers and theresults of previous research. This is an important part of the“originality and novelty” of one’s research. The introduction
should also highlight the purpose of the research to acquaintthe reader with what can be expected in the rest of the paper.
A clearly stated purpose, supported by a sound research
design and the employment of appropriate research methods,
will enhance the quality of the paper and facilitate readers’
understanding and reproduction of the research. The results
should be presented graphically for ease of comprehension,
with text descriptions highlighting new and important findings.
The results should be germane to the research question/problem, and the discussion section should be used to interpret theresults, compare the findings with those of previous research,and logically convey the conclusions drawn from the results. It
is important to provide consistent and logical explanations
throughout the text.
The conclusion summarizes the results, interpretations, andconclusions. All studies have limitations. To avoid distorting
the interpretation of the research results, and as a point of caution when drawing conclusions from them, it is necessary todescribe the limitations of one’s study, and to state the scopefor future research.
Peer reviews serve to maintain high-quality papers. The
authors should understand that peer reviewers are collaboratorson an equal footing with the authors, working together toimprove the quality of the manuscript through scientificdiscussion.

Correspondence: T. Imai. Email: ti11191@jrchcn.ac.jp
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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

Education

Some tips for writing a paper in English
Kiyoko Fukai, PhD, RN, PHN
Editorial Advisor, Journal of International Nursing Research, and Honorary Professor of Okayama University,
Okayama, JapanJINR 2023, e2023-0016.
Welcome to the Japan Society of Nursing Research (JSNR) !
Fifty years have passed since the JSNR was founded. JSNR
was established as Japan’s first comprehensive academic organization for nursing science. I would like to describe some tips
for writing a paper in English to young nursing scientists.

The Mission of JSNR
Nursing research aims to find clues to solve the problems thatmaterial science has not been able to deal with, such as the pain
and conflicts of people in their daily lives. Nursing is a humanscience that is always close to people. Therefore, the mission of
JSNR is to bring out into the world meaningful studies that
contribute to nursing practice.

What Should be Learned from the Literature
Review?
It is a scientist’s duty to collect papers from around the worldin their specialized field. Get into the habit of regularly browsing literature in relevant areas to keep yourself up-to-date.
Researchers should know what has been clarified so far in a
related research field. Are you able to name excellent papers
and their authors in your field of research? It is preferable thatyour name is in it. If you find an excellent English paper (boththe content and English), read it carefully as an important reference. Besides, have another copy of it and use it as a language text (technical terms, grammar, English expressions
with markers, etc.).

A Message from the Seniors to the Young
Nursing Scientists

Why is it Necessary to Write Academic Papers
in English?

The ultimate goal of nursing science is human health andwell-being. Show respect for the truth and good scientificdecency. Please check the global standard reporting guidelines(i.e., ICMJE, equator network) frequently and follow themwhen writing a manuscript. The meaningful new knowledge
you discover will surely contribute to academics and society.

It is said that “scholars must write their papers in English”
because science is a culture that originated in the West andspread throughout the world. However, it is not easy for
non-native people.
Scientific papers are required to be described objectively
and concisely, and to develop a coherent argument. However,as scientific papers are not novels, easy and understandable
writing for readers (nursing scientists) is encouraged. To dothis, you need to use proper technical terms and use correct
English grammar (but at most high school English level).
I hope that young nursing researchers (scholars, teachers,
practitioners, and students) will engage in research with courage and hope. People all over the world look forward to theimportant results of your research.

Things to Keep in Mind When Starting Your
Research
The research method section is a description of how to convert
the nursing phenomena you want to know into data using justenough existing knowledge (90% of the mental work inresearch). Please brush up the research method through the
ethical review of the research protocol. If the research results
are meaningful new knowledge, the possibility of the paper
being accepted is very high.

Disclaimer
Kiyoko Fukai is an Editorial Advisor of Journal of International Nursing Research and on the journal’s Editorial Committee. She was not involved in the editorial evaluation ordecision to accept this article for publication.

Correspondence: K. Fukai. Email: scully@jikei.ac.jp, scully6313@gmail.com
Copyright Ⓒ 2023 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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