Volume 1│Number 1

February 2022

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

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

Associate Editors
Mikako Arakida, PhD, RN, PHN

Polly Siu Ling Chan, RN, BHSc, MPHC, DHSc

Justina Yat-Wa Liu, RN, PhD

Kawasaki City College of Nursing,Japan

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

School of Nursing, Hong Kong Polytechnic University

Yasuko Shimizu, PhD, RN, PHN

Mayuko Tsujimura, PhD, RN, PHN

Yoshie Yokoyama, PhD, RN, PHN

Graduate School of Medicine, Osaka
University, Japan

School of Nursing, Shiga University of
Medical Science, Japan

Graduate School of Nursing, Osaka City
University, Japan

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

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

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 © 2022 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 1

Number 1

February 2022

Volume 1 Number 1 February 2022

Contents
Editorial
Announcing the launch of Journal of International Nursing Research

e2021-1001

Naohiro Hohashi, PhD, RN, PHN, FAAN

Celebrating the launch of Journal of International Nursing Research

e2021-1002

Chia-Chin Lin, PhD, RN, FAAN

Preface to the rst issue of Journal of International Nursing Research

e2021-1003

Kiyoko Fukai, PhD, RN, PHN

Review Article
Nursing students’ understanding of children with disabilities in Japanese nursing education:
A literature review

e2021-0002

Akemi Nasu, RN, MW, M.A, and Yoshimi Tsunekuni, RN, MSN

Components of hospital-to-home care interventions for patients with heart failure in Japan:
An integrative review

e2021-0001

Mai Yoshimura, MS, RN, PHN, and Naomi Sumi, PhD, RN, PHN

Original Research
Development of family empowerment programs for caregivers of children with disabilities athome: Interim report up to “implementation of pretesting”

e2021-0004

Rie Wakimizu, PhD, Hiroshi Fujioka, PhD, Kaori Nishigaki, PhD, Iori Sato, PhD, Naoko Iwata, MSc,
and Akemi Matsuzawa, PhD

Dehydration of nurses working in the day shift and its factors:
A multicenter cross-sectional observational studye2021-0007

Ryutaro Kase, RN, MSN, Yuji L. Tanaka, RN, Ph.D, Ayumi Amemiya, RN, PHN, PhD,
Hisayoshi Sugawara, RN, Ph.D, Masayoshi Saito, RN, Akari Oouchi, RN, MSN,
Erina Matsushima, RN, MSN, Hiroko Yorozu, RN, MMA, and Masatoshi Komiyama, DVM, Ph.D

Technical Report
Effectiveness of using near-infrared vein visualizers by nurses in promoting successful
peripheral venous catheterization in patients receiving chemotherapy
Naoki Kuramoto, MSN, RN, and Yoriko Watanabe, PhD, RN

e2021-0014

https://doi.org/10.53044/jinr.2021-1001
https://www.jinr.jsnr.or.jp/

Editorial

Announcing the launch of Journal of International Nursing
Research
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
1

Those of us in the nursing professions are on the verge of a new beginning. In 2021, the Japan Society of Nursing Research(JSNR), a nursing study group with a long and distinguished history, will launch Journal of International Nursing Research(JINR) as an international English-language publication.
As the founding editor-in-chief of JINR, it is my great honor to be associated with this important undertaking. In connection
with the inaugural edition of JINR, I would like to express my thanks for the support of the directors and auditors of JSNR, as
well as to all of you who contributed your time. In particular, I am indebted to JSNR President Kiyoko Fukai for her understanding that brought about the creation of this journal. In addition, I greatly look forward to collaborating with the JINR Editorial
Committee and international reviewers.
Since 1978, JSNR has been publishing its Japanese-language periodical, the Journal of Japan Society of Nursing Research(JJSNR). The JJSNR can be considered representative of academic journals in Japan, with a long history and splendid traditions.
From 2014 to 2018, and from 2020 to the present, I served as an editor-in-chief. In the past JJSNR has published a number ofEnglish-language papers, and in 2015 was declared a multilingual publication in Japanese or English. From that point in time,
guidelines were put in motion for the future publication of an English-language journal. From past and present perspectives,
publication of academic papers on nursing in English has become the common practice, and this has also figured in our decision
to launch JINR. Concurrent to this, JJSNR will no longer be soliciting English-language papers for publication.
As an international English-language journal, JINR will function as an open-access journal, with the papers that have been
accepted promptly made public. Its scope will cover wide fields of nursing research, operating as a comprehensive journal not
limited to any particular fields of specialization. Some years in the future we are hoping to register with PMC (PubMed Central),with the content of our papers also appearing in PubMed.
JINR is open to submissions from around the world. It welcomes original contributions on nursing studies in a variety of formats such as Review Article, Original Research, Practice Guidelines, Technical Report and Brief Report. Instructions for contributors can be viewed on the JINR web site (https://www.jinr.jsnr.or.jp/).
JINR sees its role as contributing to development of nursing studies on a worldwide scale. In this regard, we are determinedthat our enthusiasm toward nursing studies will continue to burn brightly.
We extend the warmest of welcomes to aspiring contributors, as well as to our colleagues and associates around the world, andlook forward to hearing from you soon.
JINR 2022, 1 (1), e2021-1001

Correspondence: N. Hohashi. Email: naohiro@hohashi.org
Copyright Ⓒ 2022 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.2021-1002
https://www.jinr.jsnr.or.jp/

Editorial

Celebrating the launch of Journal of International Nursing
Research
Chia-Chin Lin, PhD, RN, FAAN1,2,3
Deputy Editor, Journal of International Nursing Research, 2Alice Ho Miu Ling Nethersole
Charity Foundation Professor in Nursing, and 3Head and Professor, School of Nursing, Li Ka
Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
1

It’s my honor to be invited by Professor Naohiro Hohashi to serve as the Deputy Editor for the Journal of International Nursing
Research (JINR). JINR is a brand new page transformed from the Journal of Japan Society of Nursing Research (JJSNR) which
has a long lasting history in publishing nursing journals in Japanese. It’s indeed my great honor to be a part of JINR, and have ashare of it at this historic moment.
Changes are never easy. Taking a lead to make a change is even harder. I appreciate the courage from the Japan Society of
Nursing Research to make a change, and am willing to witness such a change not just from an observer’s perspective, but froma participant’s point of view.
While such a change is just a beginning of the journey, I appeal to all you to join our journey, no matter which nursing specialty
you are in. Setting as a new platform to us, JINR welcomes a wide range of submissions, including original research, practiceguidelines, technical report, brief report or letter to the Editor.
With the concerted effort from the Editorial Committee, I hope together we could create a greater and higher impact in theregion and towards the globe.
JINR 2022, 1 (1), e2021-1002

Correspondence: CC. Lin. Email: chia.chin.lin@hku.hk
Copyright Ⓒ 2022 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.2021-1003
https://www.jinr.jsnr.or.jp/

Editorial

Preface to the first issue of Journal of International Nursing
Research
Kiyoko Fukai, PhD, RN, PHN1,2,3Editorial Advisor, Journal of International Nursing Research, 2President of Japan Society of
Nursing Research, and 3Graduate School of Nursing, The Jikei University, Tokyo, Japan
1

The Japan Society of Nursing Research (JSNR) was founded in 1970 with its predecessors, the Four National University
Research Councils. In 1981, the name was changed to its current academic society name (JSNR), and it was established as
Japan’s first comprehensive academic organization for nursing science. This society aims to organize people who are widely
involved in nursing science, to conduct nursing-related educational and research activities, to contribute to the progress anddevelopment of nursing science, and to contribute to the world. Our specialty, Research in Nursing, deals with various phenomena related to “human beings, health, environment, and nursing (care).” In particular, the purpose of Research in Nursing is to
explore and propose hints and clues (theories) for people to live healthier and more prosperous. In other words, nursing scienceis a human and practical science that is close to people, which cannot be achieved without actually living people.
The most important project of this society, “Journal of Japan Society of Nursing Research (JJSNR),” was first published in1978 as a journal written in Japanese centered on original papers, and a total of 44 volumes have already been published to date.
JJSNR has published many valuable academic papers and has made a great contribution to the development of nursing sciencein Japan. The only challenge was that the valuable evidence could only be read in Japanese.
Therefore, in May 2021, the international journal, which was longed for by not only members of our society but also nurse
scientists all over Japan, will finally be established. Nursing is a science that contributes to practice (applied science); therefore,
papers written in Japanese are useful for busy practitioners. However, if details of high-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. Thus, the Journal of International Nursing Research (JINR) is established as a new
step in the history of JSNR.
Lastly, we would like to express our deep gratitude to Dr. Naohiro Hohashi, Editor-in-Chief, for his great efforts in issuing
JINR. This journal would not have been possible without the efforts of Dr. Hohashi. We would also like to thank the staff ofKyorinsha for their devoted cooperation. We are looking forward to the first issue of JINR, which will be published in May 2021.
We do welcome postings from nurses (practitioners, educators, or researchers) not only in Japan but all from other countries
worldwide, as well as scientists engaged in nursing research. We hope that the papers published in JINR will be actively utilizedby many scientists and practitioners worldwide.
JINR 2022, 1 (1), e2021-1003

Correspondence: K. Fukai. Email: scully@jikei.ac.jp
Copyright Ⓒ 2022 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.2021-0002
https://www.jinr.jsnr.or.jp/

Review Article

Nursing students’ understanding of children with disabilities in Japanesenursing education: A literature review
Akemi Nasu, RN, MW, M.A1 , and Yoshimi Tsunekuni, RN, MSN2
1

Faculty of Nursing, Department of Nursing, Sanyo Gakuen University, Okayama, Japan, and 2Faculty of Healthand Welfare, Graduate School of Nursing, Department of Nursing, Kansai University of Social Welfare, Hyogo,
Japan

Abstract
In recent years, some Japanese nursing education facilities have started choosing facilities for children with disabilities as training sites. This provides students with a good opportunity to deepen their understanding of children
with disabilities. However, there are cases in which learning nursing care for children with disabilities is difficult. In
this study, we examined the literature on understanding children with disabilities in nursing education to practiceeffective practical training. We used CiNii, Google Scholar, PubMed, and Ichushi-Web (Ver. 5.0). For the analysis,
we chose those original primary documents that described the nursing students’ understanding of children withdisabilities. We classified and named the summaries based on similarity. Seventeen documents on nursing students’ understanding of children with disabilities were mostly analyzed through practical training in facilities forchildren with disabilities, and before the practical training, some students were anxious and confused. However,during the training, the students learned about the characteristics of the children’s disabilities, consideration for theenvironment where children with disabilities live, communication methods, and so much more. The students wereable to deepen their view of nursing through these experiences. It is important to reduce the anxiety of students
through prior learning; teach the nursing view, in which the children’s abilities are recognized and emotional interactions are valued; help students develop their independence and nursing view comfortably; show the importanceof proactive nursing; and help them link their experiences to learning.
Keywords
understanding, children with disabilities, nursing education, literature review
JINR 2022, 1(1), e2021-0002

Introduction
In recent years, due to a shortened hospital stay and low
number of pediatric wards caused by the declining birthrate, children are often admitted to general wards, making it
difficult for nursing students to learn the nursing process.
Consequently, some educational institutions started choosing
facilities for children with disabilities as a practice site forpediatric nursing practice (Miyatani et al., 2013). Nursing

care in facilities for children with severe motor and intellectual disabilities (SMID) requires qualities such as the ability
to identify problems through observation, the skill to provide safe and necessary care with minimal distress, the skill
to improve and enrich the quality of life, and a heart that is
attentive to the feelings of children with disabilities andtheir families. It can be said that these characteristics are thebasics of nursing (Manabe, 2011). Pediatric nursing practiceat facilities for children with disabilities is a good opportu-

Correspondence: A. Nasu. Email: akemi_nasu@sguc.ac.jp
Received: May 29, 2021, Accepted: August 24, 2021, Published: February 24, 2022
Copyright Ⓒ 2022 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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JINR 2022, 1(1), e2021-0002

nity for students to deepen their understanding of children
with disabilities and learn important lessons of the basics ofnursing. However, children grow and develop slowly, andthere are large individual differences in their growth. There
are many obstacles in pediatric nursing practice, such as difficulty in verbal communication, in understanding the childcompletely, and in understanding reactions due to disabilities
that vary from disease to disease (Manabe, 2011). In addition, due to the changes in social conditions, such as theshift to nuclear families, students who have no experience
with children with disabilities face difficulty in learning
nursing for children with disabilities. In the current situation, it is meaningful to clarify the challenges nursing students face in understanding children with disabilities andlearning to care for them and obtain suggestions for effective practical training. Therefore, this study aims to summarize the findings of domestic literature on nursing students’
understanding of children with disabilities in nursing education.
Definition of Terms
We have defined “understanding of children with disabilities” as perceiving without prejudice the whole aspect of thepersons under the age of 18 years who have considerable
and continuous restrictions on their everyday and social lives(Ministry of Health, Labour and Welfare, 2008) in terms of
their mind and bodily functions, body structure, activities,
participation, environmental factors, and individual factors(World Health Organization, 2013).

Methods
Selecting the Target Literature
We used CiNii, Google Scholar, PubMed, and the searchsystem “Ichushi-Web” (Ver.5.0) built by the Japan Medical
Abstract Society (JAMAS) and searched the words [Kangokyōiku (nursing education)/TH or Kango kyōiku (nursing
education)/AL], [Shōgai-ji (children with disabilities)/TH or
Shōgai-ji (children with disabilities)/AL], and [Rikai (understanding)/TH or Rikai (understanding)/AL] in “IchushiWeb.” In CiNii and PubMed, 642 searches for nursing education, children with disabilities, and understanding wereobtained, and in Google Scholar, “pediatric nursing practice”
was added. We limited our search to literature published in
the past 10 years to collect recent information. Of the 1,256
cases extracted, conference records and commentaries, special features, literature examinations, and literature that are
not in the nursing field were excluded. Finally, the title, abstract, and text from 17 literatures on the understanding ofchildren with disabilities by nursing students were analyzed.
We constructed a study selection flowchart adapted fromthe Preferred Reporting Items for Systematic Reviews andMeta-Analyses guidelines (Moher et al., 2009). The
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literature-selection process is shown in Figure 1. We carefully read each document using the review-matrix method of
Garrard (2011) (Abe, 2012). In the analysis, we summarized
the knowledge collected from each literature regarding how
nursing students’ understanding and guidance of children
with disabilities and occur in nursing education. In addition,
we focused on the changes that occurred before, during, andafter the training. We also analyzed the environment where
the children with disabilities reside to reveal where and how
nursing students develop their understanding of children
with disabilities. We analyzed and summarized the literatures using the content analysis technique of Krippendorff(1980) (Mikami et al., 2003). We classified and named thesummaries based on similarity. In the selection and categorization of the literatures, bias risks were discussed and decided by two researchers until a consensus was reached(Figure 1).
Ethical Considerations
To avoid copyright infringement, we have ensured that citations and references are specified.

Results
Figure 2 provides the published years of the 17 targeted literatures. The year 2011 has the most number of cases (n =4), whereas the remaining years vary, not showing any significant difference (Figure 2). Of our 17 targeted literatures,the research subjects comprised of 2 nurses and 15 nursing
students.
The literature analysis revealed that there was only one
study in which a parent of an individual with SMID provided lectures to the students. The others were all learningin practical training at facilities for children with disabilities
and clinical training.
We examined the students’ understanding of children withdisabilities, with a focus on the changes that occurred before, during, and after training. We classified and named thecontents summarizing the knowledge we collected from the
17 studies on the understanding of children with disabilities
by nursing students in the nursing education field. Subsequently, the following three categories were extracted: anxiety and confusion before training, learning about children
with disabilities at training, and what training leaders must
keep in mind. Table 1 lists the 17 literatures and the descriptions of the categories mentioned.
1. Anxiety and Confusion before Training
First, we analyzed the learning process of the practical pediatric nursing training of two students. One student showed aslightly negative reaction on hearing that he will be training
with children with motor and intellectual disabilities, although he had mentioned his affinity toward children andhttps://doi.org/10.53044/jinr.2021-0002

JINR 2022, 1(1), e2021-0002

Records identified through databasesearchIchushi-Web (n = 39)
Additional records identified

CiNii (n = 0)

through other sources

Google Scholar (n = 1,170)(n = 0)

PubMed (n = 47)

Records after duplicates were removed(n = 1,256)

Records excluded (n = 1,089)
Exclusion criteria
Records screened(n = 1,256)

࣭Literature outside the nursing field࣭Commentaries and meetings recording theliterature review

Titles, abstracts, and full-text articles
Titles, abstracts, andfull-text articles assessed for
eligibility (n = 167)

excluded due to the inclusion criteria (n =150)
Exclusion criteria
ʀLiterature other than the understanding ofchildren with disabilities by nursing students
in the Japanese nursing education fieldStudies assessed based on
quality (n = 18)

Records excluded (n = 1)

Studies included in the review(n = 17)

Figure 1. Study selection flowchart adapted from preferred reporting items for systematic reviews
and meta-analyses (prisma).

desire to become a nursery teacher beforehand. The student
was surprised, hesitant, and anxious when he met the children and noticed their deformities, knowing that they havecommunication difficulties and minimum facial expressions.
The other student who had previously interacted with individuals with motor and intellectual disabilities did not display any signs of anxiety or negative reactions when meet-ing the children; however, it was reported that this student
also faced difficulty in understanding the children (Harada& Tsuji, 2013). In the student questionnaire, “anxiety before
training” was significantly higher in the wards for children
with SMID, with an average of 4.5 ± 1.0, than in the general ward, with an average of 3.1 ± 1.1. However, the averages of “anxiety after the first day of training” were 2.9 ±3 of 7

JINR 2022, 1(1), e2021-0002

https://doi.org/10.53044/jinr.2021-0002

Number of papers
5(n = 17)

4
3
2
1
0

2011

2012

2013

2014

2015

2016

2017

2019

Figure 2. Publication years.

Ogata & Aihara, 2016; Sadakane & Haisa, 2011; Fujiwara
et al., 2015; Matsushita & Kinjo, 2014; Takahashi & Watanabe, 2011), the need for social support (Takahashi & Watanabe, 2011), and the importance of multidisciplinary cooperation (Nakata, 2019; Ogata & Aihara, 2016; Okada et al.,2014; Sugimoto et al., 2015; Hosoya & Nobusato, 2011).
They were also able to recognize the role of nurses (Shinozawa et al., 2015; Okada et al., 2014; Sugimoto et al., 2015;
Matsushita & Kinjo, 2014) and deepen their view of nursing(Sugimoto et al., 2015; Fujiwara et al., 2015; Wakase &Yamamoto, 2012; Hosoya & Nobusato, 2011; Sadakane &Haisa, 2011) while realizing their own challenges (Hara etal., 2012; Nagashima et al., 2010).
3. What Training Leaders Kept in Mind

1.1 and 2.8 ± 1.2, showing no significant difference (Shinozawa et al., 2015). There were also reports on students being confused when trying to picture children with SMID before practical training (Sugimoto et al., 2015), and it became
clear that the students felt anxious and confused before
practical training.
2. Learning about Children with Disabilities at Training
In the study in which a parent of an individual with SMID
provided lectures to students, a student said that he/she wastaught about the feelings of parents naturally present regardless of the child’s disabilities, making the student feel resentful toward the social environment and lack of public
support for people with disabilities. The student stated that,as an aspiring nurse, he/she want to do his/her best to become an understanding person (Sadakane & Haisa, 2011).
During the practical training at the facility for children
with disabilities, the students learned to understand the characteristics of children with disabilities (Nakata, 2019; Fujiwara et al., 2015; Matsushita & Kinjo, 2014; Okada et al.,2014; Hara et al., 2012; Nagashima et al., 2010; Sugimoto
et al., 2015; Nakata, 2019); the importance of providing asafe, secure, and comfortable living environment (Nakata,2019; Fujiwara et al., 2015; Hara et al., 2012; Hosoya &Nobusato, 2011; Shinozawa et al., 2015; Ogata & Aihara,
2016; Nagashima et al., 2010; Sugimoto et al., 2015); theimportance of trusting relationships (Matsushita & Kinjo,2014); how to interact with children with disabilities toovercome communication difficulties (Ogata & Aihara,
2016; Sugimoto et al., 2015; Hosoya & Nobusato, 2011);
and the necessary nursing assistance based on their growthand development (Nakata, 2019; Shinozawa et al., 2015; Fujiwara et al., 2015; Okada et al., 2014; Hara et al., 2012;
Hosoya & Nobusato, 2011; Nagashima et al., 2010), which
included playing (Matsushita & Kinjo, 2014) and learning in
training situations (Ogata & Aihara, 2016). The students
also learned about the importance of understanding and supporting families with children with SMID (Nakata, 2019;4 of 7

As noted by the practical training instructors, it was suggested that having students understand children with SMID
through enhanced prior learning and orientation using videos
before starting the practical training is necessary (Sugimoto
et al., 2015). In clinical practice, the supervising nurse
showed the best ways of interaction to help students understand the importance of being in their usual physical state,worked with them on interactions that would be difficult forthe students to do alone, and encouraged them to touch thechildren to help them approach without fear. The practicaltraining instructors also suggested that the nursing students
hug the child to bring them closer together mentally and encouraged the students to understand and relate to the background of the children with SMID (Todo, 2019). Furthermore, they conveyed the importance of accepting each childas they are (Nakata, 2019), the importance of seeing disabilities as the child’s individuality, and the nursing viewthat recognizes the child’s abilities while valuing any emotional interaction with the child (Wakase & Katada, 2017).
The instructors praised and developed the students’ positive
aspects, implemented teaching methods that enabled the students to express their thoughts (Wakase et al., 2014), accepted the students, and were conscious of creating a comfortable atmosphere (Wakase & Katada, 2017). Furthermore,
it was suggested that there is a need for educational involvement by teachers and instructors to aid students in adding
explanations to what they see and consciously consider andlearn from it (Fujiwara et al., 2015), as well as the need togive meaning to the importance of proactive nursing for preventing things getting worse (Todo, 2019).

Discussion
Children with disabilities are stigmatized by mainstream
health professionals (Pelleboer-Gunnink et al., 2017), andthe lack of nursing education has been pointed out in countries other than Japan (Lynn et al., 2018). Nursing education
is important for nursing students to understand children withhttps://doi.org/10.53044/jinr.2021-0002

disabilities to overcome stigma and provide high-quality
care for children with disabilities. In recent years, due to thestatus of pediatric nursing training, practical training in facilities for children with disabilities is becoming more common, and interest in the domestic literature on nursing students’ understanding of children with disabilities in nursing
education continues. To understand children with disabilities,
in nursing education, most of the learning was from practical training, except for one analysis of learning from a lecture by a parent of a child with SMID. This shows that mostof the facilities for children with disabilities are places forlearning and are the main focus of understanding for children with disabilities. We regarded and focused on thechanges that had occurred in the students’ understanding ofchildren with disabilities before, during, and after training.
Subsequently, it was observed that the nursing students wereunable to picture children with disabilities before the training and were anxious and confused.
Many universities are providing prepractice measures toincrease the effectiveness of practical training (Miyatani etal., 2013). To effectively derive learning effects from practical training at facilities for children with disabilities, whichis the core of nursing students’ understanding of children
with disabilities, aimed toward students who are greatly
nervous and anxious (Matsumoto & Tomioka, 2018), there
are also enhanced prestudy and orientation sessions that use
video to counter the negative images. We believe that this isalso an important preparation for understanding children
with disabilities. We analyzed what the nursing students
were learning during the training.
During their practical training at facilities for children
with SMID, the students learned about the characteristics ofthe children’s disabilities, consideration for the environment
in which they live, communication methods and how to interact with them, care based on growth and development,
family support, and a multidisciplinary approach. Nursing
care at facilities for children with SMID is a multifacetednursing practice, which can be considered the basics ofnursing (Manabe, 2011). Through a great deal of learning,they were able to recognize the role of nurses and deepen
their views on nursing. This indicates that practical training
in facilities for children with SMID is an important training
for nursing students, not only for understanding nursing carefor children with disabilities but also for developing nursing
views.
Clinical supervisors and teachers need to understand andaccept students’ feelings of nervousness, anxiety, and confusion and must try to interact with them in a way that will
help them learn effectively and deeply (Matsumoto &Tomioka, 2018). Emotional interaction, such as encouraging
the students to approach and touch and hold the child without fear, is also important (Todo, 2019) (Wakase & Katada,2017). It was important to convey a nursing perspective that

JINR 2022, 1(1), e2021-0002

recognizes the child’s abilities while valuing emotional interaction, allowing students to develop their independence andnursing perspective without anxiety, conveying the importance of proactive nursing, and connecting the experience tolearning.

Conclusions
The nursing students’ understanding of children with disabilities in nursing education has mostly been conducted
through practical training in facilities for children with disabilities, and there was some anxiety and confusion before
the training. However, the students learned about the characteristics of the children’s disabilities, consideration for theenvironment in which children with disabilities reside, communication methods and how to interact with them, carebased on growth and development, family support, and multidisciplinary approaches. They could recognize the role ofnurses and deepen their view of nursing through these experiences. Reducing students’ anxiety through prior learning,teaching the nursing view in which the child’s abilities arerecognized and where emotional interaction is valued, helping students develop their independence and nursing view
comfortably, showing the importance of proactive nursing,and helping students link their experiences to learning areimportant. To support nursing students’ understanding ofchildren with disabilities and improve the effectiveness ofpractical training in facilities for children with disabilities,
the continued evaluation of practical training instruction andexamination of results are essential.

Limits to the Research and Future Topics ofDiscussion
This study was a literature review of nursing students’ understanding of children with disabilities using a limited
number of keywords; therefore, it is undeniable that a bias
exists. Practical evaluation on training instruction to encourage nursing students’ understanding of children with disabilities and the construction of educational programs on
nursing for children with disabilities must be considered in
the future.
This report is a revised edition of a report that will bepresented at the 2021 24th East Asian Forum of Nursing
Scholars.
Author Contributions
AN performed the entire process of manuscript preparation.
YT provided advice and financial support for writing papers.
Both have reviewed and accepted the final manuscript.
Declaration of Conflicting Interests
The authors declare that there are no conflicts of interest.
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https://www.jinr.jsnr.or.jp/

Review Article

Components of hospital-to-home care interventions for patients with heart
failure in Japan: An integrative review
Mai Yoshimura, MS, RN, PHN1 , and Naomi Sumi, PhD, RN, PHN2
1

Graduate School of Health Sciences, Hokkaido University, Hokkaido, Japan, and 2Department of Fundamental
Nursing, Faculty of Health Sciences, Hokkaido University, Hokkaido, Japan

Abstract
Hospital-to-home care is important for improving the quality of life (QOL) of patients with heart failure (HF). However, there is little evidence of outcomes regarding hospital-to-home care interventions in Japan. Thus, this integrative review aimed to identify the components and outcomes of hospital-to-home care interventions for patientswith HF in Japan. Electronic databases, such as MEDLINE, CINAHL, and Ichushi-Web, were systematicallysearched, and all forms of hospital-to-home care interventions in Japan were examined. Studies regarding transitional care, discharge planning, home care, and disease management were included. The characteristics and results of the intervention studies were summarized. Furthermore, we analyzed the components of hospital-to-homecare interventions and considered the effective interventions for patients with HF, based on statistically significant
results. Ten articles including nine interventions were reviewed. The average age of intervention participants
ranged from 64 to 77.5 years old, and the sample sizes in the intervention groups ranged from 11 to 192 participants. The intervention components were categorized as follows: “hospital-based components,” “home- andoutpatient-based components,” and “both hospital- and home-based components.” The main intervention components comprised structured education, lifetime counseling, and follow-ups via telephone and video calls. The clinical outcomes included readmission, mortality, and QOL, measured up to 24 months after the interventions. There
was limited evidence of interventions being continued from the hospital to home, follow-up immediately after discharge, and nurse home visits in Japan. Further studies are necessary to evaluate the outcomes of patients’ experiences immediately after discharge and the quality of care transition.
Keywords
heart failure, patient discharge, quality of health care, transitional care
JINR 2022, 1(1), e2021-0001

Introduction
Heart failure (HF) is a life-threatening cardiac condition thatis becoming increasingly prevalent. It is caused by defects inthe cardiac structure, function, or both, which can ultimately
lead to impaired peripheral circulation and organ oxygenation (Rosa et al., 2019). The number of individuals with HF
in Japan is estimated to increase to 1.3 million by 2030

(Okura et al., 2008) and at least 26 million people worldwide (Savarese & Lund, 2017). The incidence of HF-related
hospitalization is the highest in the first 30 days after patients’ discharge, and the majority of HF-related rehospitalization cases in Japan occur within 90 days of discharge(Ishihara et al., 2020); the rate of readmission for HF is
40% within 1 year after discharge (Tsutsui et al., 2006). Rehospitalization burdens patients and affects their quality ofCorrespondence: N. Sumi. Email: nsumi@hs.hokudai.ac.jp
Received: May 27, 2021, Accepted: November 18, 2021, Published: February 24, 2022
Copyright Ⓒ 2022 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 12JINR 2022, 1(1), e2021-0001

life (QOL). Hence, proper care transitions for patients, who
are discharged from the hospital, are crucial to improve their
QOL and reduce preventable hospital readmissions.
Despite substantial advancements in treatments and multidisciplinary care, HF management remains a global healthchallenge for healthcare providers. In HF management,
hospital-to-home transitional care has become an importantintervention to improve the clinical outcomes of chronic
older patients as well as the rates of rehospitalization for HF(Murtaugh et al., 2017). Transitional care is defined as a setof actions designed to ensure the coordination and continuity of healthcare while patients are transferred between different locations or different levels of care within the same
location (Coleman & Boult, 2003). Older patients, who aredischarged to their homes, undergo a period of vulnerability
in which they must learn to adjust and adapt to their new
self-care regimen (Werner et al., 2019). In a study regarding
the discharge experiences of patients with HF, it was foundthat these patients were struggling with daily self-care,
symptom monitoring, severity judgment, medication management, inadequate discharge preparation, and poor carecoordination (Nordfonn et al., 2019). Therefore, hospital-tohome transitional care is vital to the improvement in QOLof patients with HF and to ensure a smooth transfer fromthe hospital to their homes.
There have been several systematic reviews on transitionalcare interventions for patients with HF (Feltner et al., 2014;
Fergenbaum et al., 2015; Mai Ba et al., 2020; Van Spall etal., 2017). However, none have included Japanese intervention studies. The Japanese healthcare system is extremely
different from those in the United States, the United Kingdom, Sweden, Germany, Australia, and China, where manytransitional care intervention studies have been conducted,
and it is likely that patients and their families face different
challenges. In Japan, older adults (primary insured adults
aged !
65 years and secondary insured persons aged 40-64
years) can use public long-term care insurance services,such as home-visit nursing. When the Japanese government
promotes home care for older adults, it differentiates hospital care and home care in the acute, convalescent, andchronic phases. Therefore, to enhance transitional care, discharge support departments have been established in acutecare hospitals. Nurses who specialize in discharge planningplay an important role in smooth and timely care transitions
for patients with high care needs (Tomura et al., 2011).
Moreover, ward nurses play a key role in coordinating multidisciplinary tasks in transitional care in Japan. In contrast,
transitional care in the United States and the United Kingdom is coordinated by transitional care nurses, who are
known as nurse practitioners and advanced practice nurses.
Transitional care nurses provide comprehensive dischargeplanning and home follow-ups through care transitions from
hospital to home. Therefore, it is necessary to identify the
2 of 12https://doi.org/10.53044/jinr.2021-0001

characteristics of the components of hospital-to-home careinterventions in Japan. Moreover, medical staff needs toidentify the outcomes of these transitions to determine
which clinical interventions can be implemented in practice(Son & You, 2015). Thus, this review aimed to analyze thecharacteristics of the components and outcomes of hospitalto-home care interventions for patients with HF in Japanand to consider recommended interventions in the Japanese
healthcare system through comparison to transitional care inother countries.

Methods
Study Design
An integrative review approach was adopted to capture theeffective components of hospital-to-home care interventions
for patients with HF in Japan. The methodology describedby Whittemore and Knafl (2005) was adopted, which involves identifying the problem, searching the literature,evaluating the data, and presenting the findings. Integrative
reviews summarize previous literature to provide a morecomprehensive understanding of a particular topic and allow
for the inclusion of the broadest type of research. Various
perspectives on components related to the effectiveness ofexisting transitional care interventions for patients with HF
in Japan were collected, and the resulting synthesized information provides insights for nursing practice.
Problem Identification
The three research questions that we aimed to answer in thisintegrative review were as follows: “What are the characteristics of the components of hospital-to-home care interventions for patients with HF in Japan?,” “What are the outcome measures and endpoints of hospital-to-home interventions for patients with HF in Japan?,” and “What are therecommended hospital-to-home interventions for patientswith HF in the Japanese healthcare system?” The evaluatedcharacteristics included the nature of the interventions, composition of the target population, and outcome measures andendpoints.
Literature Search
Relevant English and Japanese articles were searched fromthe electronic databases MEDLINE, CINAHL, and IchushiWeb. The following key words were used: “heart failure”
AND “(home care OR discharge planning OR transitionalcare OR disease management)” AND “Japan.” Articles published until June 2020 were searched. Studies regarding (1)transitional care and discharge planning interventions in hospitals and (2) home care and disease management for patients discharged from acute care hospitals were included.
Meanwhile, studies that involved no interventions, interventions that did not include hospital-to-home care, interven-Identification

https://doi.org/10.53044/jinr.2021-0001

JINR 2022, 1(1), e2021-0001

Records identified throughAdditional records identified

database searching

through other sources(n = 260)(n = 3)

MEDLINE = 130
CINHAL =7
Ichushi Web = 123

Screening

Records after duplicates removed(n = 257)
Records excluded(n = 242)
Records screened

Eligibility(n = 257)

Not intervention studies= 242

Full-text articles excluded,
Full-text articles assessedwith reasonsfor eligibility(n = 5)(n = 15)Intervention that is not
hospital-to-home care = 3

Included

Articles included in

Studies are protocol = 2

integrative review(n = 10)
English articles= 7
Japanese articles= 3

Figure 1. Flowchart of the study retrieval and selection process.

tions without nursing support, and study protocols were excluded. After duplicates were removed, 257 articles were initially identified in the three databases. A total of 242 articles were excluded because they were not intervention studies. The remaining 15 articles were retrieved mainly due totheir contents of the intervention and results. Five articles
were excluded because three articles did not include
hospital-to-home care interventions and nursing support, andtwo articles were study protocols. Finally, 10 papers, 7 inEnglish and 3 in Japanese, were reviewed. A flowchart of
the article selection process is shown in Figure 1. Two
authors independently screened and discussed the results of
the literature search.

Data Evaluation
All included studies were critically assessed according to theMixed Methods Appraisal Tool (MMAT, version 2018),
which was developed to critically appraise different study
designs (Hong et al., 2019). The MMAT allows for a criticalappraisal process in reviews of systematic mixed studies, byproviding methodological quality criteria for different study
designs, within a single tool. First, two optional screening
questions were evaluated. Secondly, the appropriate categories of study designs were applied to the five categories,
with different methodological quality criteria used dependingon the study design and methods: qualitative, quantitative
randomized controlled trials (RCTs), quantitative non3 of 12

JINR 2022, 1(1), e2021-0001

randomized, quantitative descriptive, and mixed methods(Hong et al., 2018). Excluding studies with low methodological quality is usually discouraged (Hong et al., 2018).
In our study, two screening questions obtained from the
MMAT manual were applied to all the 10 reviewed articles,i.e., “Are there clear research questions?” and “Do the collected data address the research questions?” All 10 studies
satisfied the two screening questions. The appropriate categories of studies to be appraised were then evaluated. The
MMAT scores are presented in Table 1. Of the six RCT
studies, two were unclear as to whether randomization wasappropriately performed, and three were unclear as towhether outcome assessors were blinded to the intervention
provided. Other quality appraisal criteria were satisfied in
RCT studies. One non-RCT study showed that potential
confounders could not be accounted for in the design andanalysis. All three quantitative descriptive studies satisfied
all quality appraisal criteria.
Data Analysis
The characteristics and results of the intervention studies are
summarized in Table 1. It summarizes the following: (a)study information (i.e., authors’ names, year of publication,
sample size, and average age of patients); (b) information
regarding hospital-to-home care interventions (i.e., intervention contents, intervention provider, and intervention duration); and (c) major findings regarding the outcomes. Theintervention components were analyzed according to thecategories included in the studies. These included predischarge and postdischarge interventions. The outcome measures/endpoints, evaluation times, and frequency of use aresummarized. Finally, the components of the recommended
practices were considered from interventions that were statistically effective.

Results
Characteristics of the Included Studies and Their ParticipantsThis review included 10 articles regarding 9 hospital-tohome care interventions for patients with HF. We have summarized all the studies in Table 1. In total, 3 of the 10 studies were conducted in Japanese (Ishibashi et al., 2018; Ito &Tanaka, 2018; Yamazaki et al., 2016). Regarding the research designs employed, there were six RCT studies (Katoet al., 2016; Kotooka et al., 2018; Mizukawa et al., 2019;
Otsu & Moriyama, 2011, 2012; Tsuchihashi-Makaya et al.,2013), three retrospective studies (Ito & Tanaka, 2018;
Kinugasa et al., 2014; Yamazaki et al., 2016), and one preand post-test study (Ishibashi et al., 2018). The participantsin these studies were patients with HF, not including theirfamilies. The sample sizes in the intervention groups ranged
from 11 to 192, and the age of the participants averaged be4 of 12

https://doi.org/10.53044/jinr.2021-0001

tween 64 and 77.5 years old. All RCT studies excluded patients with cognitive impairment, severe comorbidities, andend-of-life diseases. In seven of the nine interventions,nurses served as the primary providers. In four studies, multidisciplinary teams provided the interventions. Members ofmultidisciplinary teams consisted of nurses, cardiologists,
physiotherapists, pharmacists, dietitians, and social workers.
Interventions lasted from approximately 1 hour to 15
months. Four of the interventions took place at hospitals,
another four occurred at patients’ homes or as outpatients,and one transpired at both a hospital and the patient’s home.
Components of Hospital-to-home Care Interventions
We categorized nine components of hospital-to-home caretransitions for patients with HF, as shown in Table 2. These
were categorized into “hospital-based components,” “homeand outpatient-based components,” and “both hospital- andhome-based components,” respectively. Hospital-based components included discharge planning, including discharge
screening, discharge conferences, and care coordination.
Home- and outpatient-based components included lifetime
counseling by nurses, follow-up telephone and video calls,
self-monitoring support, telemonitoring, and nurse home visits. As for both hospital- and home-based components, theseincluded nurse-led education, disease management, and multidisciplinary care. The component with the highest frequency was nurse-led education. All education interventions
were predominantly delivered by nurses. Participants and intervention providers used printed materials, booklets, checklists, and calendars for lifestyle modification and selfmonitoring. Face-to-face individual structured programs
were delivered. There were no educational interventions forthe patient population. The second most frequent form of intervention was lifetime counseling by nurses, particularly regarding lifestyle, self-care, and problems. Counseling wasprovided via individual educational programs, phone calls,
home visits, and video calls.
Outcome Measures and Endpoints of Hospital-to-home Care
Interventions
We summarized the outcomes and endpoints of hospital-tohome care transitions for HF in Table 3. Outcomes included
all-cause death and rehospitalization due to worsening HF,
HF status, health-related QOL, HF-specific QOL, anxiety
and depression, self-care, self-efficacy, compliance, and HF
knowledge. The highest frequency of measured outcomes
was readmission or hospital admission, and all studies included readmission or hospital admission as outcomes. The
second highest frequency of outcomes was death, or mortality, which was noted in six studies. The highest frequency ofpatient-reported outcomes was QOL in five studies. Outcomes were assessed at 1-24 months after the intervention.

Educational self-management program androutine counseling

Discharge educationand home education,home-based disease
management program,home visits by nurse,
counseling, telephone
follow-ups, and symptom monitoring
Multidisciplinary
HF-management
program, cardiac rehabilitation, education,team conferences, anddischarge planning

HF self-care programand counseling

Telemonitoring andcontact by telephone
follow-ups whenmonitoring was
stratified and data
were exceededn = 47(63.8%)
74.6 years
NYHA II80.9%

n = 82(59.8%)
75.8 years
NYHA II
76.8%
LVEF(mean)
47.4%
n = 133(58.6%)
74 years
NYHA IIIand IV 9.0%
LVEF
(mean)
44.9%
n = 17 (59%)
65 years
NYHA II29%
n = 91(61.5%)
65.4 years
NYHA II
79.1% andIII 20.9%

n = 49 (63.3%)
71.6 years
NYHA II 79.6%

n = 79 (53.2%)
76.9 years
NYHA II 84.8%
LVEF (mean)
47.4%

n = 144 (60.4%)
75 years
NYHA III and IV
11.8%
LVEF (mean)
45.9%

n = 15 (80%)
64 years
NYHA II 27%

n = 90 (56.7%)
67.1 years
NYHA II 77.8% and
III 22.2%

RCT (Yes
3/5,
Cannottell 2/5)

Retrospective study,
intervention vs.
control(Yes 5/5)

RCT (Yes
4/5,
Cannottell 1/5)

RCT (Yes
4/5,
Cannottell 1/5)

Tsuchihashi-Makaya
et al. (2013)

Kinugasa et al.
(2014)

Kato et al. (2016)

Kotooka et al.
(2018)RCT (Yes
4/5, No
1/5)

Otsu and Moriyama(2011)
Otsu and Moriyama(2012)

Intervention group
Intervention

Author (year)

Participant and setting(number (male %), age, HF severity)
Control
group

Study
design(MMATscore)

Table 1. Summary table of included studies.

Home andmonitoring
centerHospital

Mainly nurses
Multidisciplinary team(dieticians andpharmacists)

Monitoring
nursesRuralhospital

Hospitaland home

Outpatient

Setting

Multidisciplinary team(cardiologists,
physiotherapists, nurses,
pharmacists,
dietitians, andsocial workers)

Mainly nurses
Multidisciplinary team(cardiologists,
dietitians, andpharmacists)

Researching
nurse

ProviderContents of intervention

All-cause death and
HF-cause rehospitalization (−)

Totaltime ofeducation
Mean =
68 minMean =
15
monthsSelf-care (+)

N/A

Depression andanxiety (+)

QOL (+++)
Compliance (+++)

BNP, systolic bloodpressure, weight,
and shortness ofbreath (+/++)Paroxysmal dyspnea, ankle edema,and coughing atnight (−)
Death and hospital
admission (not SA)

Depression (−)
Self-efficacy (−)
QOL (−)
HF-status (−)

HF-cause rehospitalization andcardiac death (+)
HF-knowledge (+)

N/APhysical health
QOL (−)
Mental health
QOL (+)
All-cause death (−)
HF-cause rehospitalization (+)

Secondaryoutcomes

Primary outcomes

All-cause mortality
and HF-cause
rehospitalization(++)

6 months

6 months

Duration

Outcomes (significance)

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JINR 2022, 1(1), e2021-0001

5 of 126 of 12n = 19(52.6%)
74.5 years
NYHA III or
IV 31.6%

Telemonitoring +self-managementgroup
70.5 years
n = 20 (50.0%)
NYHA III or IV
55%
Self-managementgroup
n = 18 (83.3%)
69.4 years
NYHA III or IV
38.9%

n = 192 (58.3%)
77.5 years
NYHA II 86.5%

n = 87 (67%)
72 years
BNP median523 pg/ml

n = 11 (63.6%)
72.7 years
NYHA III (36.4%)
BNP 75–1866 pg/ml

RCT (Yes
4/5,
Cannottell 1/5)

Retrospective study,
intervention vs.
control(Yes 5/5)

Retrospective study,
intervention vs.
control(Yes 5/5)

Prospective study
Pre vs.
post (Yes
5/5)

Mizukawa et al.
(2019)

Yamazaki et al.
(2016)
in Japanese

Ito and Tanaka(2018)
in Japanese

Ishibashi et al.
(2018)
in Japanese

NursesTelenursing intervention model, self-monitoring support, routine
video call follow-ups,
and counselingHome

Hospital

Hospital

Multidisciplinary team(doctors,
physicaltherapists, nurses, pharmacists,
dietitians, andsocial workers)

NursesHome

Setting

Mainly nurses
and physicians

Provider

Education andcounseling

Discharge planning

Self-monitoring,disease management
program, telemonitoring, education, andcounselingIntervention

Contents of intervention

12months

N/A

N/A

12
monthsDuration

N/A

N/A

QOL (−)
Hospital admission(not SA)
Blood pressure,weight, BNP, andsymptom of HF (not
SA)

N/A

Self-efficacy (−)
Self-care (−)
HF-cause rehospitalization (+)
All-cause mortality(−)

Secondaryoutcomes

All-cause death (+)
HF-cause rehospitalization (++)

Rehospitalization(++)

QOL (+/++)

Primary outcomes

Outcomes (significance)

Statistical significance; +: p < .05, ++: p < .01, +++: p < .001, −: p > .05. Not SA: not statistically analyzed. BNP: B-type natriuretic peptide. HF: heart failure. LVEF: left ventricle ejection fraction.
MMAT: mixed methods appraisal tool. NYHA: New York Heart Failure Association’s heart function level. RCT: randomized controlled trial. QOL: quality of life. N/A: not available.

N/A

n = 183(55%)
81 years
BNP median695 pg/ml

n = 194(63.9%)
75.6 years
NYHA II
85.6%

Controlgroup

Author (year)

Participant and setting(number (male %), age, HF severity)

Intervention group

Study
design(MMATscore)

Table 1. Continued.

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Table 2. Components of hospital-to-home care interventions.
Components

Contents

No. ofinterventions

Hospital-Based

Home- and Outpatient-Based

Discharge
planning

N/A•Screening of discharge planning, discharge support conferences, and carecoordination with multiple multidisciplinary care provided inside and outside the hospital

2

Lifetime counseling bynurses•Counseling support regarding lifestyle, self-care, and problems encounteredduring home visits, interviews during outpatient visits, telephone calls, andvideo calls

5

Follow-ups via telephone andvideo call by nurses•Two types of follow-ups: regular follow-ups and follow-ups only in theevent of an abnormality•Regular follow-up assessments and care regarding HF symptoms, general
health status, lifestyle, and self-care at home by nurses•When necessary, nurses consult a multidisciplinary team and coordinatesocial support and hospital visits.

3

Self-monitoring support•Self-monitoring support through face-to-face interventions at outpatient
visits•The implementation of self-monitoring regarding patients’ HF status andthe interpretation of measured values using video calls are supported.

2

Telemonitoring•Participants measure their body weight, blood pressure, pulse, and bodycomposition at home using a monitoring device.
•The nurses at the monitoring centers check the measured data every day.
•In case of abnormal data, the patient is called, and the causes of the abnormalities are assessed; then, either the patient is provided with advice, a visitby the physician is arranged, or home care is coordinated.
•Families can also access the remote monitoring system.

2

Nurse home visits•Home-visit nursing care once every 2 weeks until 2 months after discharge
for symptom monitoring, general health status assessments, education, andconsultations•First visit is conducted within 2 weeks after discharge.

1

Nurse-led education•Self-care and self-management education through a face-to-face individual
program•Structured educational program and discharge education based on models(e.g., behavior change model, cognitive behavior, and health belief model)•Educational program using tools such as booklets and checklists by nurses,
pharmacists, and nutritionists•The participants record information regarding their lifestyles, and the intervention nurses provide individual feedback.
•Advice and consultation support regarding self-management methods athome are provided.
•Long- and short-term goals with the participants are developed and evaluated.
•Education is provided regarding items that a target participant is interestedin.
•Educational contents include “heart failure,” “examination and treatment,”“self-monitoring,” “lifestyle,” and “symptoms and urgency when consultation is required,” as well as internal medication management, weight management, salt restriction, etc.

7

Disease management•Includes symptom monitoring, education, consultations, and the adjustmentof social support via home visits and telephone follow-ups by nurses in addition to follow-ups by cardiologists

2

Multidisciplinary care

•Patient education and conferences are conducted by a multidisciplinary
team.
•Cardiac rehabilitation•Progress sharing regarding the intervention with the team4

N/A

HF: heart failure. N/A: not available.
No. of interventions: Number of interventions in which the applicable component was performed out of all nine interventions.

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Table 3. Summary table of outcome measures/endpoints.
Outcome measures/Endpoints

Scale/Measure contents

Time of data collection(follow-up period)

No. ofinterventions

Rehospitalization

All-cause rehospitalization, rehospitalization due to worsening
HF, hospital admission (patients with a history of hospitalizations), number of readmissions, period until readmission after
discharge, and hospitalization period at the time of readmission

At 3, 6, 9, 12, and 24 months
after discharge (31 months)

9

Death

All-cause death, cardiac death, and period until deathAt 3, 6, 9, 12, and 24 months
after discharge (31 months)

6

QOL(HF-specific scales)
MacNew Heart Disease Health-Related Quality of Life
Questionnaire and Minnesota Living with Heart Failure Questionnaire(generic scales)
SF-8 Health Survey and the MOS 36-Item Short-Form Health
SurveyAt 3, 6, 9, 12, and 24 months
after discharge

5

Hospital Anxiety and Depression Scale,Patient Health Questionnaire-9

At 2, 6, and 12 months after
discharge

2

Self-care

European Heart Failure Self-Care Behaviour Scale

At 6, 12, 18, and 24 months
after discharge

2

HF status

BNP, NYHA, blood pressure, weight, and deterioration in thesymptoms related to HF

At 3, 6, 9, 12, and 24 months
after discharge

2

Self-efficacy

Chronic Disease Self-Efficacy Scale and General Self-Efficacy Scale

At 6, 12, 18, and 24 months
after discharge

2ComplianceFour-point scale: sodium-restricted diet, medicine administration, activities or exercise, smoking and drinking cessation,
self-monitoring of weight, and symptoms of HF

At 3, 6, 9, 12, and 24 months
after discharge

1

At 1 and 6 months after
discharge

1

Anxiety and depression

Knowledge about HF

15-item Japanese HF-knowledge scale

BNP: B-type natriuretic peptide. HF: heart failure. QOL: Quality of life. NYHA: New York Heart Association’s heart function level.
No. of interventions: Number of interventions that measured the applicable outcome/endpoints out of all nine interventions.

Effects of Hospital-to-home Care Interventions
The results of the outcome studies are shown in Table 1. Six
out of the nine interventions led to a statistically significant
reduction in the rate of readmission, compared to the control
groups (Ito & Tanaka, 2018; Kato et al., 2016; Kinugasa etal., 2014; Mizukawa et al., 2019; Tsuchihashi-Makaya et al.,2013; Yamazaki et al., 2016). The studies that showed statistically significant readmissions included components ofnurse-led education, lifetime counseling by nurses, regularfollow-ups via telephone, nurse home visits, self-monitoring
support, disease management, and multidisciplinary care.
Three out of the six interventions led to a statistically significant reduction in the rate of death (Ito & Tanaka, 2018;
Kato et al., 2016; Kinugasa et al., 2014). Of the five interventions (Ishibashi et al., 2018; Kotooka et al., 2018; Mizukawa et al., 2019; Otsu & Moriyama, 2011; TsuchihashiMakaya et al., 2013), three led to a significantly improved
QOL in the intervention group, compared to the control
group (Mizukawa et al., 2019; Otsu & Moriyama, 2011;
Tsuchihashi-Makaya et al., 2013). The studies that showed
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statistically significant improvement in QOL included thecomponents of education, counseling, follow-ups via telephone, nurse home visits, self-monitoring support, and disease management. One of two studies indicated a statistically significant improvement in anxiety and depression(Tsuchihashi-Makaya et al., 2013). Statistically, self-efficacy
did not improve significantly. Telemonitoring and the assessment of acquired data, such as weight and blood pressure,and follow-up only at the time of abnormality, did not significantly change the clinical outcomes (Kotooka et al.,2018).

Discussion
In this integrative review, we revealed the components andoutcomes of hospital-to-home care interventions for patientswith HF in Japan. We analyzed components that were categorized into “hospital-based components,” “home- andoutpatient-based components,” and “both hospital- andhome-based components.” We identified only one study inJapan that included both hospital- and home-based interven-https://doi.org/10.53044/jinr.2021-0001

tions (Tsuchihashi-Makaya et al., 2013), in contrast to thenumerous intervention studies overseas. In Japan, there is
still a lack of evidence regarding the effectiveness of intervention methods for the transitional care of patients with
HF; thus, further studies evaluating both pre- and postdischarge interventions are needed. The studies we investigatedshow that nurse-led patient education, counseling, and discharge planning are important components in interventions.
These findings are similar to those of previous studies(Bryant-Lukosius et al., 2015; Rice et al., 2018). Studies ontransitional care for patients with HF have been predominantly conducted in the United States, the United Kingdom,
Spain, Sweden, Canada, and Australia. Early follow-ups andcontact, such as medication and symptom management
within 3 days after discharge, were the main forms of intervention in transitional care for patients with HF (Coleman etal., 2006; Mai Ba et al., 2020). However, a few early postdischarge interventions in the investigated studies involved
home visits within 14 days after discharge and follow-up assessments 2 months after discharge (Tsuchihashi-Makaya etal., 2013). Therefore, early postdischarge interventions andmedication management at home may require further verification of their effectiveness. The evidence regarding homevisit nursing outcomes further promotes the need and effectiveness of home-visit nursing, immediately after discharge
in Japan.
The participants of all the investigated intervention studies
were patients, and the interventions did not involve thefamilies of the patients. Older patients with HF often requirelong-term care, livelihood support, and social support. The
transitional care model and the care transition interventions
lead to the establishment of a trustworthy relationship withfamily caregivers and consider family needs involved in patient care (Coleman et al., 2015; Naylor et al., 2018). A patient’s family also influences HF self-care and outcomes(Dunbar et al., 2008); hence, research on support and interventions that includes family members may be necessary,with investigation on caregiver education and engagement
needed.
We uncovered the outcome measures, endpoints, andmeasurement times involved in the interventions. The mostfrequent outcome was rehospitalization. The most common
patient-reported outcome was QOL, similar to that reported
in a previous study (Mai Ba et al., 2020). Both the HFspecific QOL scale and generic QOL scale were significantly improved (Mizukawa et al., 2019; Otsu & Moriyama,
2012; Tsuchihashi-Makaya et al., 2013), and the recommended HF-specific scale, namely, the Minnesota Livingwith Heart Failure Questionnaire, was used (Kelkar et al.,2016; Kotooka et al., 2018; Mizukawa et al., 2019). However, emergency department visits and costs were not measured in the Japanese intervention studies investigated. For
this reason, it can be said that there are few emergency vis-

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its in Japan due to outpatient visits being planned 2-4 weeks
after discharge as well as the difficulty in collecting cost
data. Little is known about the hospitalization costs associated with HF in Japan (Kanaoka et al., 2019; Kotooka et al.,2018). Cost evaluations may need to be assessed in the future to strengthen the evidence regarding the effectiveness of
hospital-to-home care in patients with HF. Canadian andChinese RCT studies on heart disease included patientreported outcomes and patient-experience measures of discharge preparedness and care transition quality measure(Cao et al., 2017; Van Spall et al., 2018; Van Spall et al.,2019). The patient and caregiver’s desired outcomes of caretransitions can be identified from participant experience(Mitchell et al., 2018). The use of patient-experience measures that capture the quality of care transitions or patientconcerns and anxiety should be implemented in Japan, andfor this purpose, the use of a validated quality of care transition scale, such as the Care Transitions Measure (Coleman
et al., 2005; Yoshimura et al., 2018), PREPARED (Graumlich et al., 2008), or the Readiness for Hospital Discharge
Scale (Weiss & Piacentine, 2006), should be adopted. It isnecessary to develop a validated tool for capturing patient
experiences, such as those related to their concerns, lifestyle,and self-care, when counseling and assessing outcomes.
Older patients immediately after discharge are also vulnerable to a higher risk of adverse health outcomes and experience feelings of uncertainty (Blakey et al., 2017; van Seben
et al., 2019). Although the measurement times for the interventions were between 1 and 24 months after discharge orintervention in this review, it may be necessary to evaluate
immediately after or 1 week after discharge.
Finally, recommended intervention components for patients with HF were considered, including regular and structured counseling and education, follow-ups via telephone bynurses, nurse home visits, multidisciplinary care, and disease
management. Studies that combine multiple intervention
components are shown to be effective. In previous metaanalyses on transitional care for patients with HF, nurse
home visits were the most recommended care practice thatcare providers can apply (Feltner et al., 2014; Van Spall etal., 2017). However, only one intervention included nurse
home visits in this review. In addition, most of the elderly
patients are registered for long-term care insurance, but onlya small proportion of these patients receive home-visit services in Japan (Takabayashi et al., 2016). Home-visit nursing
care should be actively provided as well as visits immediately after discharge for older patients with HF. Research on
the effectiveness of home-visit nursing for patients with HF
in Japan is urgently needed.
A limitation of our study is that we did not search allgray literature, such as dissertations and non-peer-reviewed
articles, and the limited number of intervention studies regarding HF in connection to hospital-to-home care transi9 of 12

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tions is also a limitation.

Conclusions
This integrative review uncovered the components of
hospital-to-home care interventions for patients with HF,
their related outcome measures, and their measurement
times. Hospital-to-home care interventions should include
both hospital- and home-based care and combine multiple
intervention components by nurses and multidisciplinary
teams. With respect to outcome evaluation, it is necessary toassess outcomes immediately after discharge, as well as thequality of care transitions. The findings from this literature
review highlight the need for further research on the effectiveness of nurse home visits and interventions that involvethe families of patients with HF.
Author Contributions
M. Y. and N. S. contributed to the conception and design ofthis study, carried out the analysis, drafted the manuscript,
and approved the final manuscript.
Declaration of Conflicting Interests
The authors declare no conflict of interests.
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Original Research

Development of family empowerment programs for caregivers of children
with disabilities at home: Interim report up to “implementation ofpretesting”
Rie Wakimizu, PhD1 , Hiroshi Fujioka, PhD2 , Kaori Nishigaki, PhD3 , Iori Sato, PhD4 ,Naoko Iwata, MSc5 , and Akemi Matsuzawa, PhD6
1

Department of Child Health Care Nursing, Division of Health Innovation and Nursing, Faculty of Medicine,
University of Tsukuba, Tsukuba, Japan, 2Department of Nursing, Faculty of Health Sciences, Ibaraki Prefectural
University of Health Sciences, Ami, Japan, 3Department of Child Health Nursing, Graduate School of Nursing
Sciences, St. Luke’s International University, Tokyo, Japan, 4Department of Family Nursing, School of Health
Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, 5Tsukuba University
Hospital, Medical Liaison and Patient Support Services Center, Tsukuba, Japan, and 6Department of Nursing,
School of Nursing, Ibaraki Christian University, Hitachi, Ibaraki, Japan

Abstract
Objective: For both children with disabilities and their families to continue living at home, families should achieve
and maintain healthy family functioning. This is achieved by enhancing family empowerment. This pilot study systemizes the program development process and identifies the problems and results to move to the program implementation. Methods: The program was developed through a step-by-step process emphasizing on the previous
research findings, theories, and collaboration with families. We identified the factors related to family empowerment
from an in-depth interview study of 34 families and the Delphi method questionnaire survey of 158 professionals.
Next, we identified a family empowerment model by a national survey of 1,659 families. We further reviewed literature on family intervention programs, set action goals based on the theoretical framework of program formulation,and finally developed a family empowerment program with the families. The problems and effectiveness of “implementation of pretesting” were qualitatively and quantitatively verified. Results: Through the program, the participants created eco-maps and life charts, dealt with issues in their daily lives, set goals for the life they wanted,
worked toward those goals, and took actions to make adjustments in their lives and use resources. Due to thesmall number of participants, the efficacy of the program was not significantly confirmed; however, no adverse
events were observed. Conclusions: We developed and pretested a participatory program to enhance family empowerment. As a pilot study, the results support the value of conducting the program on a larger scale. Further
verification of the effects of our program is required.
Keywords
family empowerment, children with disabilities, intervention program, pretesting
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Correspondence: R. Wakimizu. Email: riewaki@md.tsukuba.ac.jp
Received: June 23, 2021, Accepted: October 25, 2021, Published: February 24, 2022
Copyright Ⓒ 2022 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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Figure 1. Six steps for the development of this program.

Introduction
Families raising children with disabilities face much higher
risks to their own health and lives than families raising
healthy children. Families caring for children with disabilities at home often do not enjoy a break. As such, this situation has a significant impact on these caregivers’ mental
and physical health. The mother, who is usually the primary
caregiver, carries the burden of time and responsibility associated with providing the required care to the child and,thus, tends to have poor mental health (Raina et al., 2005).
Families become increasingly fatigued; it is common formembers to develop physical and mental disorders (Ozawa
et al., 2011). Their capacity to participate in social activities,
including their work, is constrained (Okumura et al., 2009).
In Japan, advances in pediatric medicine have led to a
rapid increase in the number of children with disabilities, especially those with more severe conditions (Maeda, 2015);
thus, direct support for families raising children with disabilities is an urgent need. However, most studies of families
raising children with disabilities are observational studies,and how interventions are more effective in improving thehealth and quality of life of these families has not been fully
tested.
There are intervention studies that are focused on the parent carer (Bradshaw et al., 2019; Edelstein et al., 2017).
Edelstein et al. (2017) reviewed that several interventions
tackled many types of stressors (i.e., emotional stress, social
isolation) and changes (i.e., well-being, satisfaction withcare). The most recent review by Bradshaw et al. (2019) addresses more interventional outcomes (i.e., family functioning) by including the parents of children with special healthcare needs as a scope. Families who care for disabled children at home should be cared for from several aspects (i.e.,
individual, family, social).
It is essential to enhance family empowerment, that is, theability to appropriately control their own lives while utiliz2 of 15

ing social resources and working together with family members and professionals (Koren et al., 1992). This will enable
the children and the family caring for children to continue
with their lives at home (Noguchi & Ohmachi, 2020). The
Family Empowerment Scale (FES) comprised three domains(i.e., family, social services, social-political) and total score.
By assessing the FES from these four aspects, it is possible
to examine measures to enhance family empowerment; however, no previous studies have directly considered these aspects (Bradshaw et al., 2019; Edelstein et al., 2017).
We are currently developing a program based on the intervention mapping (IM) approach model proposed by Bartholomew Eldredge et al. (2016; Figure 1). This program is
implemented in six steps: needs assessment, program objectives and indices for behavioral change, theoretical selectionof methods, design of program content, implementation ofpretesting, and program evaluation. We have now implemented Step 5: implementation of pretesting. This study is afeasibility or pilot study that systemizes the program development process up to this point and identifies the problems
and results to move to the next step, which is program implementation.

Materials and Methods
Program Creation (Step 1 to Step 4)
Based on the conceptual framework of family empowerment
in caring for children with disabilities by Koren et al.
(1992), we conducted a large survey of family caregivers
raising children with disabilities at home (Wakimizu et al.,2018). In this survey, we measured family empowerment ofchildren with disabilities and developed a Japanese family
empowerment model for families raising children with disabilities. The theoretical framework of the program is basedon this theory and model. This will be explained in moredetail in Step 1: needs assessment. To reduce the caregiverburden of these families and promote the utilization of so-https://doi.org/10.53044/jinr.2021-0004

cial resources, we developed a program to visualize the relationship between family, service, and community and lead tobehavioral change based on the intervention theory steps.
Program creation was implemented in the following order:needs assessment, program objectives and indices for behavioral change, theoretical selection of methods, and design ofprogram content. This order was based on the IM approachmodel proposed by Bartholomew Eldredge et al. (2016).
This theoretical framework has also been used in intervention programs based on groups of parents caring for children
with disabilities (Borek et al., 2018). The participants answered the questionnaire before and after the program implementation.
Step 1: Needs Assessment
We conducted various surveys on the empowerment of families with severely disabled children. We further conducted
in-depth interviews with 34 families with severely disabledchildren living at home (mothers, fathers, and siblings aged
12 years or older; Wakimizu et al., 2015). We then extracted
comprehensive information on each family member’s experience and recognition of their roles living with a severely
disabled child, expected roles of other family members, andsupport needs as a family. Along with mental support andnursing advice, support needs related to utilizing social resources were extracted from 56 people in families with severely disabled children living at home. These support needs
include the expansion of effective and easy-to-use services
and the provision of information and consultation to enable
the use of services. A total of 48 nurses and 149 administrative staff were surveyed using the Delphi method on thecontent of families’ support needs extracted from the said
survey. Data were used to ascertain the importance and practicality of support for empowering these families (Wakimizu
et al., 2016). The family support needs extracted from thesurvey results were as follows: “I would like to talk tosomeone when I do not know how to use the services,” “Iwould like mental support for my family, including my siblings,” and “I would like to be provided a place where I caninteract with other severely disabled children and similarly
situated families.” However, while nurses and administrative
staff are aware of support’s importance, putting it into practice is impossible. We gradually visualized the direction offamily support programs that we needed to work on fromthis point. The factors expected to define family empowerment were identified based on in-depth interviews withfamilies with severely disabled children living at home(Wakimizu et al., 2015). A provisional family empowerment
model was then formulated. A self-administered questionnaire based on this model was sent to 1,659 families nationwide with severely disabled children living at home. The
goodness of fit and validity of the family empowerment
model were verified using path analysis (Wakimizu et al.,2018). Consequently, family empowerment was mainly de-

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fined by the “utilization of social resources” and “long-termcare burden.” The model clarified the axis of content thatshould be included as an intervention to enhance family empowerment in the future. Studies on families with children
with developmental disabilities have also revealed that social
resources’ utilization is directly involved in family empowerment (Nachshen & Minnes, 2005).
Step 2: Program Objectives and Indices for Behavioral
ChangeWe reviewed the literature on the previously reported programs before considering the program methods and content.
First, we set the selection criteria for the literature as intervention studies on families living with severely disabledchildren to serve as a reference for the methods and content
of our program; case studies were excluded. Second, we selected literature on interventions for family members living
at home; studies dealing with support for transfer to home atdischarge from the neonatal intensive care unit (NICU) were
excluded. We also selected literature on interventions aimed
at parental or whole-family effects; however, literature addressing interventions affecting severely disabled children
living at home was excluded. The type of disability was not
specified.
First, we searched the literature on intervention studies forfamily members (main caregivers) of children with severe
mental and physical disabilities living at home from
“Ichushi” (https://www.jamas.or.jp/), a literature databaselisting many medical and nursing journals. We conducted asearch on August 23, 2018 and identified 68 search results.
After reading the titles and abstracts of all papers and selecting literature based on the criteria, one paper remained (themain literature excluded dealt with support for transfer tohome at discharge from the NICU and literature dealing
with the admission of mothers and children for education).
This paper addressed the facilitation of interactions amongfamilies of homebound persons in remote areas with severe
motor and intellectual disabilities by constructing an Internet
telephone environment (Hiramoto et al., 2017). We found noEnglish language literature published in Japan. Based onthese findings, we concluded that, in Japan, there were almost no intervention studies that quantitatively assessed theeffect on parents living in a family with severely disabledchildren.
Next, we searched Ovid Medline for literature on intervention studies on family members (main caregivers) ofchildren with severe mental and physical disabilities living
at home. We conducted the search on November 8, 2018
and found 30 search results. After reading the titles and abstracts of all papers and selecting literature based on the criteria, four papers remained (the main literature that was excluded dealt with ethical reviews, observational studies, andinterventions aimed at influencing severely disabled children
living at home; Kuo et al., 2013; Looman et al., 2015;
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Table 1. Various interventions for parents caring for their children with severe disability from our literature review.
First Author

Year

Country

Setting and Intervention

ProviderType of Children

Looman, W. S.

2018

USA

Telehealth care coordination andconsultation

Advanced practiceregistered nurse

CMC

Looman, W. S.
Toly, V. B.

2015
2014

USA

Improved Outcomes
Family impact
Family functioning
Healthcare satisfaction

USA

Resourcefulness training based on a
cognitive–behavioral
intervention
with four-week, face-to-face sessions

Pediatric nurses

TDC

Mothers’ mental health

Coordinate nurses

CMC

Parents’ QOL

Nurse practitioners
via online

CMC

Healthcare utilization
Parents’ QOL
Family-centered careKuo, D. Z.

2013

USA

Multidisciplinary and comprehensive
care oversight and tertiary care center-based care coordination, especially in usual care

Cohen, E.

2012

CanadaCommunity-based complex care clinics integrated with a tertiary carecenterNote. CMC, children with medical complexity; QOL, quality of life; TDC, technology-dependent children.

Looman et al., 2018; Toly et al., 2014). One additional paper was included after conducting a manual search (Arksey
et al., 2002). The five papers show that various parents’ andfamilies’ outcomes are improved (Table 1); however, almost
no intervention programs attempt to improve the family empowerment of families with severely disabled children living
at home. Moreover, it is possible to provide effective andcomprehensive interventions in line with the needs of families without limiting the type of disease or disability. Lastly,
many interventions reported to be effective are provided byor heavily involve nurses.
Based on the results of the aforementioned literature review and the needs identified in Step 1, we decided to develop a program to enhance family empowerment. The program enables families to “utilize social resources” and “reduce the long-term care burden” for families with severely
disabled children living at home. Family empowerment was
set as the main outcome. Further, improving social resource
utilization and reducing long-term care burden were set as
the first secondary outcomes (other secondary outcomes will
be added in the later steps).
Based on the concept of family empowerment, the family
itself can grow and self-actualize by focusing on its advantages, abilities, and strengths rather than simply receiving
assistance. Currently, interventions reducing caregiver stressin children with medical complexity (CMC) are categorized
into “care coordination,” “respite,” “telemedicine,” “peer andemotional support,” “insurance and employment support,”and “health support” (Arksey et al., 2002; Edelstein et al.,2017). The results of the literature review indicated that“care coordination” was the most common type of support(Cohen et al., 2012; Kuo et al., 2013; Looman et al., 2015;
Looman et al., 2018), followed by “peer and emotional support” (Toly et al., 2014; Hiramoto et al., 2017). Therefore,
we believe that “care coordination” and “peer and emotional
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support” are important elements in our program; however, in
our program, families with severely disabled children living
at home must develop a behavior that enables them to improve their own social resources and reduce the long-termcare burden. This should be done rather than directly tampering with the amount of care and family relationships.
Therefore, “enabling families with children with physicaland mental disabilities living at home and their children to
take the necessary action based on the gap between theircurrent situation and their desired life” was set as the program’s goal and the (target) behavioral change desired forthe families participating in the program.
Step 3: Theoretical Selection of Methods
The goal of Step 3 is to select a theoretical method and an
associated practical method to achieve the behavioral change
objective. This program equips families raising children withdisabilities, particularly the main caregiver, with the ability
to coordinate their family life in cooperation with otherfamilies, medical and welfare service providers, local people, and government officials. It ultimately achieves family
empowerment. We selected social cognitive theory (Bandura,
1986) for this program in anticipation of this behavioral
change. Social cognitive theory regards human behavior as
the interaction of behavioral, cognitive, and environmental
factors; moreover, it emphasizes the interaction between individuals and the environment. We identified knowledge,
skills, social support, and awareness as factors related to behavior modification in these families. These are the determinants of change, based on the main concepts of social cognitive theory. Self-compassion was also added to this list
based on a review of previous studies (Bohadana et al.,2019).
The taxonomy of behavior change techniques (BCTs;
Abraham & Michie, 2008) was used as a practical intervention method. This taxonomy, which involves 26 types ofhttps://doi.org/10.53044/jinr.2021-0004

BCTs, presents techniques to achieve behavioral change. Accordingly, techniques, such as encouraging clear goalsetting, self-monitoring, providing information, and identifying barriers for the benefits and risks of health and life,
were selected based on the characteristics of families raising
severely disabled children.
This program also confirmed that peer support’s effect between parents of children with disabilities has already beenverified in previous studies (Shilling et al., 2015; Bray et al.,2017); therefore, a group-based learning program emphasizing peer support is set. Based on the selected theoretical andpractical intervention methods, this group was set up for primary caregivers raising severely disabled children at different developmental stages, with intervention by peer facilitators. These strategies provide opportunities to observe amodel person performing the desired behavior (role model);thus, it facilitates modeling behavior.
When we developed this group session, we encouraged
the families to imagine their goals and attempt to undertake
their target actions on the basis of self-monitoring, which
recognizes the current situation of their families, including
their children and themselves. Subsequently, we decided thatthose experiences would be shared with the group; moreover, feedback and praise were provided when actual actions
were taken to reinforce the outcomes. We intended to use atextbook for the participants and a booklet on family empowerment as tools to put the series of group sessions into
practice.
Step 4: Program Design and Production
Adjustments were made in Step 4 to enable continuous implementation of the practical method in the program, basedon the theoretical method found in Step 3.
First, four hours of discussions were held with threecaregivers of children with disabilities (hereinafter referred
to as concerned family members) to inquire about theiropinions on the program structure’s validity and feasibility,
content, and management method. These caregivers support
activities, such as patient associations and parent associations. The program structure was set once a week (twohours per session), using a group work format that would becompleted in four sessions, based on the opinions expressedin the discussions. The concerned family members expressed
their desire for a program content that would provide participants with an opportunity to allow deep self-disclosure,fun, and friends. Based on these expectations, a management
method policy that focuses on activating the group work between concerned parties was adopted. This method is conducted by minimizing transmission from the program managers (comprising the research team) to inspire the participants themselves to realize child-rearing knowledge andskills and share local resource information, lifestyle benefits,
and barriers related to risk. A policy was also established toassign the concerned family members as “program peer sup-

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porters” who participated in the program as observers or advisors, separate from the program managers.
We also incorporated work to create life charts and ecomaps (Hartman, 1995; Ray & Street, 2005), based on the
BCTs, to allow the subjects to reflect on the lifestyle oftheir children and families. In the life chart, children andtheir family members were asked to describe their daily life
on weekdays, holidays, and other days, and in the ecomapping, the participants were asked to describe their family genogram, relationships among family members, and social relations outside the family, such as school and social
resources. This work uses eco-mapping to self-monitor andvisualize their ability to coordinate family life in cooperation
with other families, medical and welfare service providers,local people, and government officials. It also helps themvisualize family life and the collaboration and cooperation
between families within this framework. Furthermore, modeling opportunities were provided by sharing the visualized
work deliverables with other participants. This task allowed
the participants to become aware of their ability to adjust
family life and their situation of family empowerment,
which they had not been conscious of until now. This willlead them to generate change (Tsuda et al., 2007). Mechanisms were prepared to promote these changes by impartingknowledge and skills to family empowerment. The firstmechanism is a booklet on family empowerment created by
the representatives of our research group, based on the results of our research to date. Presenting the three aspects offamily empowerment clearly with illustrations will make itpossible to immediately acquire knowledge about empowerment through self-work; moreover, sharing this information
during group work also allows knowledge to be establishedby promoting discussion (Borek et al., 2018). The second
mechanism is eco-mapping. Eco-mapping the lifestyles of
their children and families enabled them to acquire natural
knowledge about social support. Such a concept is difficult
to understand with words alone. The third mechanism is the
textbook and facilitator book. The textbook contained thestructure of the program and the work to be done in eachsession of the program. The textbook systematically lists thework and clearly shows the goals to be achieved for eachtask. It is a tool for participants to look back on their work
outcomes when needed. It was decided that facilitators do
not need to have any specific qualifications to aim for use inpeer support in the future. Using the facilitator book, the facilitators answered questions and encouraged group dynamics so that the subject’s thinking could progress during thework. This program included parents of disabled children athome who responded to the call for participation in flyers
and who signed up to participate in the program.
The content of the program completed throughout thisprocess (Figure 2) is described below for each session every
week.
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Figure 2. Overview of each session in the program.

First session: The roles within the family, utilization
awareness and utilization of social resources, and relationships with professionals were discussed through the participants’ self-introduction and the creation of genograms/ecomapping. Figure 3 shows an example of a participant’swork. The participants were also given homework to record
a week in their lives and that of their families. They wereasked to summarize the information in a table. Figure 4
shows an example of a participant’s entries.
Second session: The content of the previous group workand homework (i.e., a record of a week in their lives) was
shared among the group. The participants thought about the
problems they faced and the kind of life they wanted. The
homework for this session was to set goals to achieve thelives that they wanted.
Third session: The lives that they wanted and their goals
were shared among the group. The participants were then
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asked to set more positive and concrete goals. The homework for this session was to evaluate their own practices toward reaching their goals.
Fourth session: The actions, lifestyle changes, and selfevaluation practiced for working toward their goals wereshared among the group. Then, the participants praised eachother’s efforts.
In the first session, the participants ascertained the current
situation of their own lives and promoted awareness of family empowerment’s current status. The second, third, andfourth sessions aimed at further promoting family empowerment awareness and enhancing self-compassion. Throughthese sessions, it was also hoped that the participants would
enhance their own changes and awareness throughout their
participation in the program.
The facilitator book was designed to present the facilitator
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Figure 3. Example of the created eco-map. The participants directly wrote in japanese onto the map in the workbook. In
the interest of sharing the contents, what they wrote is shown in english.

proceed with the work in the program, and what to say toparticipants) in detail in a form corresponding to the textbook to increase the program’s versatility. Ultimately, we
created a textbook and workbook as tools to enable the participants to conduct self-monitoring by visualizing their own
learning and work throughout the program. The concernedfamily members also confirmed the content’s validity andfeasibility.
The program improved awareness, self-monitoring, andself-compassion of children and their families. This wasachieved by combining group work with self-work at homeusing textbooks for participants and booklets on family empowerment. We also decided to set tasks in the latter half ofthe program to encourage participants to consider actions
from the perspective of family empowerment, help them
imagine the life they wanted for their family, and further
promote change.
Implementation of Pretesting (Step 5)
Design
We conducted a controlled pretest to identify the likely effects of our program.

Procedure
Information leaflets were placed at medical treatment andcare facilities near the program site to publicize the program
and recruit participants. We provided detailed information
about the date, time, venue, and who to contact for those
who wished to participate. The applicants were divided into
intervention and control groups. The program was implemented for the intervention group, whereas no particular intervention was used for the control group during that time,
and they were asked to wait. The intervention group participants were asked to complete the questionnaire just before(the first session) and after the program. The control group
participants were asked to complete the questionnaire at thesame time as the intervention group via email.
The program (four times in total) was conducted in aseminar room that could be used for public purposes where
privacy was assured. The group facilitator prepared snacks
and drinks so that people would feel relaxed. The participants and supporters sat around the desk. When the group
work was presented, the facilitator took a picture of the participants’ workbooks. The facilitator then projected them sothat the contents could be shared with the entire group.
The program was implemented from January to February
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Figure 4. Examples of life described. In actuality, the participants wrote directly in japanese onto the maps in the workbook. In
the interest of sharing the contents, what they wrote is shown in English.

2020.
Questionnaire
Because of research feasibility, we set all outcomes of thispretest as parent (themselves)-reported outcomes. The questionnaire asked about the basic attributes of the participants
and their families (including children with disabilities) andlife-related matters and included measures of selfcompassion (a secondary outcome defined at Step 3),
caregiver burden (one of the first secondary outcomes defined at Step 2, including daily sleep time and nocturnal
awakening), social resource utilization (one of the first secondary outcomes defined at Step 2), health-related quality oflife (new outcomes from our literature review (Table 1)),and family empowerment (main outcome). Furthermore, thequestionnaire was used after the program’s implementation
to seek the intervention group’s input regarding their satisfaction level while attending the program. It also looked into
their opinions on the number of sessions and program content.
The questionnaire included questions on the participant’sage, relationship with the child or children, educational
background, working status, the number of hours of sleep,
nocturnal awakening frequency, marital status, total numberof adults living in the same house, total number of children,
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total number of children with special needs, household income, child’s age, severity score, diagnosis name, and age at
diagnosis.
The short form of the Japanese version of the SelfCompassion Scale (SCS-J-SF) was used to measure selfcompassion (Arimitsu et al., 2016). The SCS-J-SF comprises
12 items that are rated on a five-point scale, with two items
each for the following six subscales: self-kindness, selfjudgment, common humanity, isolation, mindfulness, andoveridentification; the higher the total score, the more compassion one has for oneself.
The short version of the Japanese version of the Zarit
Caregiver Burden Interview (J-ZBI_8) was used to measure
the caregiver burden (Arai et al., 2003). The J-ZBI_8 iscomposed of eight items that are rated on a five-point scale.
The questions posed relate to the physical and mental burden and social restrictions associated with elderly care; thehigher the score, the greater the caregiver burden. This scaleis also used in the context of parents raising children withdisabilities (Toki et al., 2010).
The questions on social resource utilization were based on
the original items used in a previous study (Wakimizu et al.,2018). Specifically, using a four-point scale, questions on
the general awareness of social resource utilization werehttps://doi.org/10.53044/jinr.2021-0004

asked. More detailed questions on the service utilization
status, type of service used (e.g., medical, nursing care, daycare), and social resource utilization awareness (e.g., public
services, medical institutions, schools) were asked.
The SF-8 standard version was used to measure thehealth-related quality of life. It comprised eight items (Fukuhara & Suzukamo, 2005). A component summary score canbe calculated, based on the responses received, for each of
the two subscales: the physical component scale (PCS),
which assesses physical health, and the mental component
scale (MCS), which assesses mental health. Higher PCS andMCS scores indicate higher physical and mental healthrelated quality of life, respectively.
The Japanese version of the Family Empowerment Scale(J-FES) was used to measure family empowerment(Wakimizu et al., 2010). The J-FES assesses the ability tocoordinate the lives of oneself and one’s family; moreover, it
collaborates with service personnel and government officials
to raise children. It comprises 34 items rated on a five-point
scale; the higher the scale score, the higher the level of family empowerment.
Analysis
Descriptive statistics were calculated relating to the subject
attributes and each variable’s score based on the questionnaire response results. The scores for the SCS “selfcompassion” domain could not be calculated due to a printing error; therefore, these results were excluded from theanalysis. The changes before and after the intervention were
evaluated using the paired t-test for the intervention andcontrol groups. The number of changes in the scores before
and after the program was compared between the intervention and control groups. SPSS version 26 was used for statistical analysis. The significance level was set at 5%; moreover, the level of satisfaction, opinions, and free responses
related to the program was all listed.
Ethical Considerations
We promised each participant that we would comply withthe following to ensure that they participated in the program: participation was at the participant’s free will,whether or not they could participate would not affect children’s care and their families’ lives, they could withdraw
from participation in the middle of the program, and personal information collected for participation (completed
questionnaires and group work contents) would be strictly
managed so that no individual was identified when publishing the results. Written consent has been obtained from allparticipants to publish their information, including theircomments for the program. This study was conducted withprior approval from the ethics committee of the institution towhich the principal investigator belongs.

JINR 2022, 1(1), e2021-0004

Results
Participant Attributes
The responses were obtained from seven participants. Threeparticipants were from the intervention group and four fromthe control group. All subjects were mothers of children
with congenital disorders, such as cerebral palsy or chromosomal abnormality, aged 4-12 years. The children were 8.14
± 3.64 (mean ± standard deviation (SD)) years old. The participants (mothers) were in their 30s (n = 2), 40s (n = 4),
and 50s (n = 1). The choices for the highest level of education were high school (n = 2), junior college (n = 2), anduniversity (n = 3). The mothers’ employment statuses werepart-time employment (n = 5) and housewife (n = 2). There
was no significant difference between the intervention andcontrol groups, except for the highest level of education (Table 2).
Table 3 presents the scores for each variable before andafter the program for the intervention and control groups.
There was a significant improvement in total family empowerment scores in the intervention group.
There was no significant difference in any variable when
the change in scores before and after the intervention wascompared between the groups (Table 4).
Evaluation and Revision of the Program
The program was revised on the basis of the questionnaire
responses from the intervention group (n = 3) at the program’s completion, opinions provided during participation in
the program, and the subsequent social conditions, including
the COVID-19 pandemic. The comments and the program’s
revisions are listed in Table 5. The participants looked backon the course in general and commented, “I could tackle theproblem, thanks to the company of other participants,” “Igained confidence by performing plans toward the goal,” “I
got a positive feeling,” and “It was good that an experienced
mother led us to talk about our stories.”

Discussion
This family empowerment program was systematically developed in collaboration with the participants using an IM
approach model characterized by adapting theoretical interventions to each behavioral and environmental factor. The
program improves the empowerment of caregivers of children with disabilities.
Consequent to the pretest for this program, there were
only few participants in the intervention and control groups(n = 7). This resulted in insufficient statistical power, which
may have been the reason for not detecting any significant
difference between the two groups in the family empowerment score or any other variable. However, there was a significant improvement in the total family empowerment score
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Table 2. Attributes of both groups.
Intervention group (n = 3)
N/mean ± SDp

Relationship

Mother

3

4

Age

30s
40s
50s

1
2
0

1
2
1

Marital status

Married3

4

Living with partner

Living together
Husband living away for work

3
0

3
1

.35 a

Highest level of education

High school
Junior college
University

0
0
3

2
2
0

.03 a

Employment

Part time
Housewife

2
1

3
1

.81 a

Household income≥3 to <5 million yen≥5 to <7 million yen≥7 to <10 million yen
Not answered

1
0
2
0

2
1
0
1

.19 a

6.67 ± 3.51

9.25 ± 4.35

.44 b

Age of child with disabilityaControl group (n = 4)
N/mean ± SD

.65 a

Chi-squared test; b, t-test.

Table 3. Intragroup comparison before and after intervention.

Mean daily sleep time (hours)
Frequency of nocturnal awakening
1 = every night2 = several times a week
3 = several times a month
4 = only during attacks
Social resource utilization
1 = do not utilize at all
2 = do not utilize very often
3 = utilize a little
4 = utilize often
SCS-J-SF self-judgment
SCS-J-SF common humanity
SCS-J-SF isolation
SCS-J-SF mindfulness
SCS-J-SF overidentification
J-ZBI_8
SF-8 PCS
SF-8 MCSJ-FES family
J-FES service system
J-FES community/political
J-FES total

Intervention group (n = 3)
Pre
Post
Mean ± SDp

Control group (n = 4)Pre
Post
Mean ± SDp5.33 ± 0.58
2.67 ± 0.58

4.67 ± 1.15
2.67 ± 1.15

.18
1.00

4.75 ± 0.96
2.25 ± 1.50

4.63 ± 0.95
2.75 ± 1.26

.39
.39

2.67 ± 1.53

3.67 ± 0.58

.23

2.75 ± 1.26

2.25 ± 1.26

.18

5.00 ± 1.73
6.67 ± 2.52
6.33 ± 3.51
5.33 ± 1.15
4.00 ± 2.00
14.00 ± 9.54
46.00 ± 2.54
43.19 ± 7.39
41.67 ± 8.14
45.00 ± 9.54
28.33 ± 7.51
115.00 ± 25.16

5.33 ± 1.53
9.00 ± 1.73
7.00 ± 3.00
7.33 ± 2.52
5.33 ± 3.06
17.33 ± 9.71
49.62 ± 6.89
47.76 ± 7.35
46.67 ± 5.03
46.00 ± 8.72
34.67 ± 16.77
126.67 ± 26.27

.42
.07
.18
.18
.18
.15
.57
.54
.14
.42
.36
.01

7.25 ± 0.96
7.50 ± 1.00
6.75 ± 0.96
7.50 ± 0.58
6.75 ± 1.50
9.00 ± 6.24
41.74 ± 5.00
46.24 ± 8.23
38.00 ± 6.68
39.75 ± 7.68
25.75 ± 6.29
104.00 ± 18.02

6.25 ± 1.50
7.25 ± 0.96
7.25 ± 1.50
8.25 ± 0.96
5.50 ± 1.29
8.75 ± 5.12
49.28 ± 4.71
45.71 ± 7.95
39.25 ± 3.50
41.75 ± 6.34
29.50 ± 6.45
110.25 ± 13.05

.31
.79
.18
.22
.55
.42
.20
.74
.62
.12
.09
.19

Paired t-test.
Note. J-FES, Japanese version of the Family Empowerment Scale; J-ZBI_8, short version of the Japanese version of the Zarit Caregiver Burden Interview; MCS, mental component scale; PCS, physical component scale; SCS-J-SF, short form of the Japaneseversion of the Self-Compassion Scale; SF-8, scale measuring health-related quality of life and consisting eight items.

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Table 4. Intergroup comparison of the amount of change before and after the intervention(after intervention–before intervention).
Intervention group (n = 3)
Mean ± SD

Control group (n = 4)p

Mean daily sleep time (hours)
Frequency of nocturnal awakening
1 = every night2 = several times a week
3 = several times a month
4 = only during attacks−0.67 ± 0.58
0.00 ± 1.00

−0.13 ± 0.25
0.50 ± 1.00

.15
.54

Social resource utilization
1 = do not utilize at all
2 = do not utilize very often
3 = utilize a little
4 = utilize often
SCS-J-SF self-judgment
SCS-J-SF common humanity
SCS-J-SF isolation
SCS-J-SF mindfulness
SCS-J-SF overidentification
J-ZBI_8
SF-8 PCS
SF-8 MCSJ-FES family
J-FES service system
J-FES community/political
J-FES total

1.00 ± 1.00

−0.50 ± 0.58

.05

0.33 ± 0.58
2.33 ± 1.15
0.67 ± 0.58
2.00 ± 1.73
1.33 ± 1.15
3.33 ± 2.52
3.62 ± 9.42
4.57 ± 10.68
5.00 ± 3.61
1.00 ± 1.73
6.33 ± 9.29
11.67 ± 1.53

−1.00 ± 1.63
−0.25 ± 1.71
0.50 ± 0.58
0.75 ± 0.96
−0.75 ± 2.22
−1.00 ± 1.73
7.54 ± 9.31
−0.53 ± 2.88
1.25 ± 4.57
2.00 ± 1.83
3.75 ± 3.10
6.25 ± 7.41

.24
.08
.72
.27
.20
.07
.61
.39
.30
.50
.68
.28

t-test.
Note: J-FES, Japanese version of the Family Empowerment Scale; J-ZBI_8, short version of the Japanese version of the Zarit Caregiver Burden Interview; MCS, mental component scale; PCS, physicalcomponent scale; SCS-J-SF, short form of the Japanese version of the Self-Compassion Scale; SF-8,
scale measuring health-related quality of life and consisting eight items.

in the intervention group after participating in the program.
This result suggests that this program is effective for enhancing family empowerment.
The reason for the total family empowerment score’s improvement is the visualization effect using the tools, participants’ modeling, and the “program peer supporters.” First,
this program reflected on the children and family support
systems and current life situations using eco-maps and life
charts as part of group-based, participant-led work. This
process promotes the visualization of behavioral and environmental factors related to the outcome of empowerment.
Adams et al. (2017) qualitatively surveyed the experience of
creating care maps by the parents of children who require
medical care. They stated that creating care maps clarifies
the priorities and needs of these families. The experience ofobjectively visualizing how family members spend their timein their daily lives by creating life charts has led to an understanding of their family’s current situation within theirbusy lives.
The participants, who were mothers in similar situations,discussed specific behaviors to create the future of theirchildren, their families, and themselves based on the ecomaps and life charts; moreover, they set life goals to achievethat end. They said that they could tackle problems morepositively due to interactions with other participants. Thisfinding suggests that self-compassion, an element of the program, was enhanced through positive exchanges among theparticipants. Furthermore, it may have had a positive effecton the participants’ empowerment as well. In prior research,families caring for children with thalassemia, who have experienced family empowerment programs, reported thatsharing information and other families’ experiences and beliefs related to the care of their children improves their ability to make decisions about family problems and needs andmanage the care of their children and family relationships(Wacharasin et al., 2015). This suggests that it is appropriate
to set up group work with families of children with disabilities as a program format.
The participants’ caregiver burden was significantly
higher than the caregiver burden (8.9 ± 6.4; Matsuzawa et
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Table 5. Comments identified by the participants through “implementation of pretesting” and improvements made for the program implementation.
Comments from the participants

Improvements made for the program implementation(specific details of how the program content and management format were revised in response to each issue)

Program overall

All participants were generally positive. This content will be
kept as is.

The program gave me pleasure.
The program was so good that I could confidently recommend it to my friends.
It would be better for everyone to make the most out of theopportunities, such as medical checkups, so basically, everyone raising children with disabilities can participate inthis program.
Participating in the program was helpful. I felt positive. It
was good that the experienced mothers led the discussions.
The input from other participants was inspiring.
Face-to-face implementation is no longer possible due to the
COVID-19 pandemic.

Participants

Parents with children aged around 1 year should be able toparticipate in the program.

It would be better to participate in the program with myspouse.

Program sessions

Program content
structure

The number of program sessions is good as is.
It would be good if there were a number of different patterns for the days of the week when the program sessions
will be held.
The length of one program session is perfect.
The homework of setting goals for the future was a painfultask that made me sad and distressed because I could not see
any future or hope.

It may be easier to tackle the tasks by giving the participants
time to discuss their efforts toward the goals.

Communicating
program to otherfamily members

The language used in the program is difficult to comprehend, which makes it challenging to understand the purpose
and intent of the program.
I told my family a little about the content of the program
and what I had learned (n = 2) /I did not tell my family
about it at all (n = 1).

al., 2019) of Japanese parents raising children with severe
motor and intellectual disabilities in a previous study. The
reason for the higher caregiver burden score among the participants in this study may be because the children’s mean
age in the aforementioned study (Matsuzawa et al., 2019)was 12.0 ± 3.6 years, which was higher than that of thechildren in this study. Mothers tend to establish their own
child-rearing style, their own lifestyle, and their family’s
lifestyle while learning how to care for their child. This en12 of 15

The presence of other participants and supporters was favorable. There is no problem with proceeding with this format.
The program’s format has been changed from face-to-face toonline. Some of the textbooks and facilitator books will be
modified to deal with this situation.
This program was originally designed to include participants
with children of any age up to school age, so the content andstructure will remain unchanged. However, during the recruitment process, we will request the participation of parents with younger children.
Although the participation of spouses is expected to be effective, it is necessary to consider the consent and privacy ofthe other participants. This will be considered carefully inthe future.
The content will remain unchanged.
It was decided to set suitable times and days of the week forholding the program sessions based on the needs of the participants at the time the program is run.
The content will remain unchanged.
If the participants are distressed about setting future goals,
they are unable to receive follow-up from the other participants. Therefore, it was decided to invite these participants tojoin a group work to enable them to make presentations andhold discussions on the spot.
It was decided to color-code the goals set representing thethree levels of family empowerment so that the participants
can discuss the tasks they can do at each level.
It was decided to explain the purpose of empowerment andthe programs at the beginning of the program using a separate pamphlet.
The program includes a task where the participant is asked toshare his or her problems with their family. However, someparticipants reported that they did not tell their families
about it at all. Therefore, it was decided to use the individual
consultations after the program to try to understand the situation of individual participants during the program.

ables them to explore ways to incorporate rest and wellbeing into their lives; thus, it is assumed that the participantsin this study were still in the process of establishing theirchild-rearing styles. Furthermore, the participants wished toparticipate in the intervention program to enhance their empowerment. They had a desire to improve their child-rearing
styles and their own and their family’s lifestyles; therefore,
it can be assumed that the participants were mothers with ahigh caregiver burden.

https://doi.org/10.53044/jinr.2021-0004

A characteristic of this program was that it was developedin collaboration with the participants. Consequently, there
were no negative comments from the participants regarding
the way the program was run, including ones regarding thelength and number of sessions; moreover, no participants
dropped out midway through the program. Therefore, incorporating the participants’ viewpoints on the program’s aspects, such as the length and number of sessions, is considered effective, without overburdening the participants. Furthermore, no participants reported any negative impacts,
such as family discord and psychological instability, becauseof participating in the program. These findings suggest that
Step 6 (program evaluation) can be performed, based on the
program management and content in the pretest.
The program was conducted face-to-face; however, programs should be conducted online during the COVID-19
pandemic. The methods for advertising the program and facilitating group work should be adapted to support programs
remotely.
Limitations and Future Research
The effect of this program on enhancing family empowerment was clearly confirmed by the statistical results fromthe data gathered through the questionnaire and participants’verbal responses; however, it is impossible to generalize its
efficacy because there were only three participants in thegroup. Considering that this study is a pilot study, the results are promising; however, the efficacy of the program
should be further evaluated, applying some revisions to theprogram as suggested above.
Additionally, feelings of family empowerment before theprogram could be characterized as “sometimes” for two participants and “often” for one participant. Future programs
should be conducted and evaluated with participants who“seldom” or “never” have feelings of family empowerment.
The efficacy of the program can then be verified on a larger
scale.
Conclusions
We developed and implemented a participatory program toenhance family empowerment. The results indicate that the
program was effective in enabling participants to take actions regarding adjustments to their lives and use social resources; therefore, their sense of family empowerment had
increased. As a pilot study, the results support the value of
conducting the program on a larger scale; however, further
verification of the program’s efficacy is needed in future research.
Author Contributions
All authors had full access to all data in the study and takeresponsibility for the integrity of the data and the accuracyof the data analysis.

JINR 2022, 1(1), e2021-0004- Conceived or designed the study: RW, HF, KN, IS, NI,
and AM- Performed research: RW, HF, KN, IS, NI, and AM- Analyzed data: RW, HF, KN, IS, NI, and AM- Wrote the paper: RW, HF, KN, IS, NI, and AM
Declaration of Conflicting Interests
We received no financial support or relationships that may
pose a conflict of interest in connection with this manuscript.
Ethical Approval
This study was conducted with prior approval from the ethics committee of the University of Tsukuba (No. 1420).
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Toki, M., Washio, M., Furukawa, A., Narita, H., Yokogushi, K., &Ishiai, S. (2010). Shougaiji wo sewa-suru hogosha no futankan-nihongoban Zarit kaigo futan shakudo wo mochiita kentou- [Investigating parental caregiver burden for children with disabilities
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3.11.003
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kenkou ni kansuru kenkyuu [The relation between lifestyle andpsychosomatic health in handicapped school children]. The Journal of Child Health, 66(6), 773-778.
Wacharasin, C., Phaktoop, M., & Sananreangsak, S. (2015). Examining the usefulness of a Family Empowerment Program guided by
the Illness Beliefs Model for families caring for a child with thalassemia. Journal of Family Nursing, 21(2), 295-321. https://doi.org/10.1177/1074840715585000
Wakimizu, R., Fujioka, H., Furuya, K., Iejima, A., & Yoneyama, A.
(2010). Shougaiji wo youiku-suru kazoku no empowermenthttps://doi.org/10.53044/jinr.2021-0004
sokutei shakudo Family Empowerment Scale nihon-go-ban no
kaihatsu [Development of the Japanese version of the Family Empowerment Scale (J-FES)]. Journal of Health and Welfare Statistics, 57, 33-41.
Wakimizu, R., Fujioka, H., Nishigaki, K., Matsuzawa, A., Iwata, N.,
Kishino, M., Yamaguchi, K., & Sasaki, M. (2018). Zaitaku
juushou-shinshin-shougaiji no kazoku empowerment ni kansuru
jisshouteki model no kouchiku [Construction of empirical model
focused on the family empowerment nurturing the child with severe motor and intellectual disabilities at home in Japan]. The
Journal of Child Health, 77(5), 423-432. https://www.jschild.medall.net/Contents/private/cx3child/2018/007705/005/0423-0432.pdf
Wakimizu, R., Fujioka, H., Numaguchi, C., Nishigaki, K., Sato, N., &Yamaguchi, K. (2015). Juushou-shinshin-shougaiji to seikatsu wotomoni-suru hahaoya, chichioya, kyoudai no ninshiki-suru jik-

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oyakuwari, hoka no kazokuin heno yakuwari kitai, Kazoku toshiteno support needs [Role recognitions of their own, role expectations for other family members, and support needs for the family empowerment of the family members living with the childwith severe motor and intellectual disabilities]. International
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Original Research

Dehydration of nurses working in the day shift and its factors:
A multicenter cross-sectional observational study
Ryutaro Kase, RN, MSN1 , Yuji L. Tanaka, RN, Ph.D1 , Ayumi Amemiya, RN, PHN, PhD1 ,Hisayoshi Sugawara, RN, Ph.D2 , Masayoshi Saito, RN3 , Akari Oouchi, RN, MSN3 ,Erina Matsushima, RN, MSN4 , Hiroko Yorozu, RN, MMA5 , and Masatoshi Komiyama, DVM, Ph.D1
1

Department of Health Promotion in Nursing and Midwifery, Graduate School of Nursing, Chiba University, Chiba,
Japan, 2Department of Foundational Nursing, Graduate School of Nursing, Chiba University, Chiba, Japan,
3
Department of Nursing, Center Hospital of the National Center for Global Health and Medicine, National
Research and Development Agency, Tokyo, Japan, 4Department of Nursing, Tokatsu Tsujinaka Hospital, Kashiwa,
Japan, and 5Department of Nursing, National Center for Child Health and Development, Tokyo, Japan

Abstract
Objective: Dehydration has a risk of reducing cognitive function, which can lead to misjudgment by nurses.
Nurses are required to be in optimal physical and mental conditions since their misjudgments affect the lives ofpatients. Therefore, it is desirable to prevent dehydration in nurses; however, the prevalence and factors of dehydration in nurses have not been clarified. This study aimed to clarify dehydration prevalence in nurses and examine dehydration factors before and after their shift. Methods: Data were collected during the day shift of 115 registered nurses in 19 wards of 2 hospitals in Japan. Urine specific gravity (USG) and body weight were measured
before and after the shift to determine dehydration. Questionnaires, including demographic characteristics and fluid
intake, were recorded before and after their shift. Multivariate analysis was performed based on the fluid intake,number of steps, and years of experience as dehydration factors. Results: Overall, 59 (51.3%) and 82 (71.3%)
nurses were dehydrated before and after their shift, respectively. USG before the shift (odds ratio [OR]: 2.328, 95%
confidence interval [CI]: 1.424-3.807) and years of experience (OR: 0.946, 95% CI: 0.899-0.996) were factors related to dehydration at the end of the shift. USG before the shift (OR: 2.573, 95% CI: 1.347-4.914) was also a factor related to dehydration factors after the shift for beginner nurses. Conclusions: Over 70% of nurses were dehydrated after their shift. USG before the shift and years of experience were related to dehydration after the shift. To
prevent dehydration, it is desirable for managers to encourage beginner nurses to drink water.
Keywords
dehydration, fluid intake, nurse, shift work schedule, urine specific gravity
JINR 2022, 1(1), e2021-0007

Introduction
Dehydration has various physical and mental effects, regardless of the process (Sawka & Coyle, 1999). Mild dehydration of 1%-2% of the total body weight results in a delayed

working memory response, decreased cognitive and psychomotor functions, such as attention, concentration, and mood,and an increased error and difficulty in work (Armstrong etal., 2012; Ganio et al., 2011; Grandjean & Grandjean, 2007;
Shirreffs et al., 2004).

Correspondence: R. Kase. Email: rkase@chiba-u.jp
Received: July 8, 2021, Accepted: November 27, 2021, Published: February 24, 2022
Copyright Ⓒ 2022 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

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Hydration in the workplace is a specific concern since dehydration can affect productivity, safety, and morale (Kenefick & Sawka, 2007). Most previous studies investigating
the workers’ hydration status in the workplace have focusedon those performing physical activities in hot and humid environments (Butler-Dawson et al., 2019; Cvirn et al., 2019;
Polkinghorne et al., 2013; Wagoner et al., 2020); however,
only a few studies have investigated the hydration state ofhealth care professionals (HCPs) working in several indoor
workplaces where the temperature and humidity are controlled (Alomar et al., 2013; El-Sharkawy et al., 2016).
HCPs should be in optimal physical and mental conditions since their misjudgments affect the lives of patients.
Previous studies investigating the dehydration of doctors andnurses (HCPs) in a hospital have shown that approximately
half of them developed dehydration at the end of a shift(Alomar et al., 2013; El-Sharkawy et al., 2016). HCPs had
an impaired cognitive function by measuring cognitive tests
using a Personal Computer (El-Sharkawy et al., 2016). Another study reported that gender, age, and lack of fluid intake were related to the dehydration of HCPs in a hospital(Alomar et al., 2013). However, the tasks of nurses and doctors at work are different. Half of the nurses’ tasks demand
mild and moderate physical activities (Chen et al., 2011;
Reed et al., 2018); therefore, we hypothesized that theprevalence and factors of dehydration in nurses differ fromthose found in previous studies when investigating only
nurses.
If hospital nurses were dehydrated before or after a shift,
impaired cognitive function and increased difficulty in work
might result in an increased occurrence of mistakes and accidents. Such a situation is undesirable for the hospital aswell as for the patients and should be prevented. This study
aimed to clarify the prevalence of dehydration in nurses
working in hospitals and examine factors related to the dehydration of nurses before and after a shift.

Materials and Methods
This multicenter cross-sectional observational study was
conducted in Japan. Data were collected from July to November 2018. This study was conducted according to the
Declaration of Helsinki and Strengthening the Reporting ofObservational studies in Epidemiology (STROBE) checklist(von Elm et al., 2007). The protocol was approved by the
Ethical Committee of the Graduate School of Nursing,
Chiba University (No. 29-120) and the Ethical Committee of
the Center Hospital of the National Center for Global Healthand Medicine (NCGM-G-002513-00). Written informed consent was obtained from each participant before enrollment.
Recruitment was performed in all wards in two hospitals.
All nurses working in the wards of the two hospitals were
eligible for inclusion. Exclusion criteria were pregnant or
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menstrual women, those with existing renal disease, or thoseon diuretics or antihypertensive medication (El-Sharkawy etal., 2016). The criteria for discontinuing data collection
were: (1) if no urination was observed on the day of datacollection and it was difficult to measure the urine specificgravity (USG), (2) physical upsets during data collection(headache, nausea, malaise, and extreme thirst), (3) it wasdifficult to cooperate in research due to work conditions,and (4) it was not possible to meet the measurement time
due to absenteeism or late arrival on the day of data collection. The sample size was 115 when calculated, assumingthat the α value was .05 on both sides, β value was .2,
prevalence of dehydration was 36%, and missing data were20% (El-Sharkawy et al., 2016). Additionally, participants
whose research cooperation was discontinued were not recruited again.
After waking up on the day of data collection, participants urinated to discard the urine accumulated in the bladder at night, which might affect the USG before their shift(Armstrong, 2007). Participants submitted urine samples before starting their shifts, and researchers or participantsmeasured USG using a pocket refractometer (PAL-09S;
ATAGO, Japan). Within an hour of collection, urine samples
were tested only for specific gravity and immediately discarded. Considering the effect on USG, participants refrained from drinking water 5 min before the USG measurement (Kovacs, et al., 1999; Popowski et al., 2001). Body
weight was measured using scales that can measure at 50-gintervals (HJ325; OMRON, Japan). Participants weighed
only their bodies and clothes with their pockets empty. Afterthe weight measurement, a pedometer was attached aroundthe participant’s waist to measure the number of steps as
physical activity (Copeland & Chambers, 2017; Croteau,
2017; Irimagawa & Imamiya, 1993). Participants completed
a questionnaire before and after their shifts. They were thenasked to complete their shift as usual. After the shift, USG
and body weight were measured again, as mentioned above.
In this study, dehydration was defined as having a USG
of !
1.020. Although USG >1.030 evaluates severe dehydration (Armstrong et al., 2010; Epstein & Armstrong, 2000), a
USG cutoff of 1.020 results in a sensitivity of 96% and a
specificity of 96% (Bartok et al., 2004). USG !
1.020 hasfrequently been used as a criterion for dehydration (Armstrong et al., 1994; Bartok et al., 2004; Popowski et al.,
2001; Polkinghorne et al., 2013) and has an impaired cognitive function (Piil et al., 2018). Participants were divided
into the dehydrated group (DG) and the euhydrated group(EG) according to their USG values before and after theirshift; moreover, the weight change rate was calculated using
the following formula (Cheuvront et al., 2004):%ΔBody Mass: %BM = [post-shift weight (BM post) −pre-shift weight (BM pre)] / pre-shift weight (BM pre) ×100.

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Table 1. Participant characteristics grouped according to the hydration states at theend of their shift.

USG after shift
Age (years)
Sex
FemaleMale
BMI
Years of experience%ΔBM (%)
No. of steps

Dehydrated (n = 82)

Euhydrated (n = 33)

p-Value1.0294 (1.0228, 1.0294)
25 (24, 31)

1.0164 (1.0101, 1.0182)
27 (25, 38)<.001*.037*

70 (85.4)
12 (14.6)
20.9 (19.6, 22.9)
2 (0, 5)−0.41 (−0.89, −0.08)
7,471 (6,352, 9,293)

29 (87.9)
4 (12.1)
21.1 (19.0, 22.6)
4 (1.25, 16.5)−0.51 (−1.03, 0.20)
6,982 (5,882, 8,112)

.725
.740
.028*
.643
.217

Median (first quartile, third quartile). n (%). *p < .05. USG: urine specific gravity. BMI:
body mass index. %ΔBM: %ΔBody Mass.

%BM was used to determine mild dehydration of 1%-2%of the total body weight at risk of cognitive decline (Armstrong et al., 2012; Ganio et al., 2011; Grandjean & Grandjean, 2007; Shirreffs et al., 2004).
Questionnaires, including demographic characteristics andfluid intake, were recorded at the beginning and at the endof the shift. In the questionnaire, participants answered before and after their shift on a 10-cm visual analog scale(VAS): thirst, hunger, tiredness, and concentration (ElSharkawy et al., 2016; Millard-Stafford et al., 2012). These
were used to assess the effect of hydration on subjective
sensations. In the case of thirsty, 0 shows not thirsty at all,and 10 shows very thirsty. Conversely, in concentration, 0
shows high concentration, and 10 shows no concentration atall.
Statistical analyses were performed using IBM SPSS Statistics ver. 23.0 (IBM, Chicago, IL, USA). Descriptive data
were expressed as median (first quartile, third quartile) for
continuous variables and n (%) for categorical variables. In
this study, a two-tailed p-value (p = .05) was considered statistically significant. Kolmogorov-Smirnov test was conducted before data analysis. Each variable in the two groups
was compared using the Mann-Whitney U test, χ2 test, andFisher’s exact test. A logistic regression analysis was performed to search for the factors related to dehydration at theend of the shift. Variables with a p-value of <.05 were selected for the forced entry method in the analysis. For variables with a correlation coefficient of >.6, a variable was selected to exclude multicollinearity. If there was multicollinearity between age and years of experience, years of experience was selected as a variable. In the end, logistic regression analysis with the forced entry method was performed on the finally determined variables. At that time, age
was used as an adjustment variable. When before-shift USG
was used as an independent variable in the logistic regression analysis examining the factors of dehydration after theshift, it was adjusted to 0.01 as a unit.

Second, a subgroup analysis was performed between DG
and EG before their shift. It was also performed between
nurses experienced for 5 years or less (beginner group: BG)
and nurses experienced for 6 years or more (expert group:
ExG) since health and work environments are important for
nurses with 5 years or less (Watanabe, 2011). After confirming dehydration at the end of the shift between the twogroups, each variable was compared. Finally, a logistic regression analysis was performed to examine the factors ofdehydration at the end of the shift due to the differences inyears of experience.

Results
Data were collected in 19 wards from 2 hospitals, and 115
nurses participated in each shift. Participant characteristics
are shown in Table 1. None of the participants dropped out
or stopped from collecting the data. All nurses worked in
the day shift and took a 60 min break (45, 60) during theirshift and worked 585 min (525, 653). The median years ofexperience were 2 years (1, 10). Participants comprised of
86 (74.8%) direct care staff and 29 (25.2%) others, including managers. Twenty-seven (23.5%) participants consumed
alcohol on the day before their shift. Thirty-five (30.4%)
participants skipped breakfast. The nurses walked 7,288(6,013, 9,172) steps during their shift.
The median USG at the start and at the end of the shift
was 1.0204 (1.0117, 1.0251) and 1.0234 (1.0196, 1.0281),
respectively. Of the 115 participants, 59 (51.3%) and 82
nurses (71.3%) were dehydrated before and after their shift,respectively (Figure 1). Of the 59 nurses dehydrated before
their shift, 47 (40.9%) were still dehydrated after their shift;
however, 12 (10.4%) nurses became euhydrated. Of theother euhydrated nurses (56 nurses, 48.7%) before theirshift, 35 (30.4%) became dehydrated after their shift; however, 21 (18.3%) nurses were euhydrated. No significant difference was observed in the proportion of dehydrated par3 of 9

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ticipants before and after their shift between the two hospitals (p = .577, p = .680).
%ΔBM of participants determined to be dehydrated at theend of their shift was −0.41% (−0.89, −0.08) (Table 1), andno significant difference was noted between the two hospitals (p = .646). Of the dehydrated participants after theirshift, 19 (23.2%) had a %ΔBM of 1% or more.
Each outcome was compared between DG and EG after
their shift to examine the factors related to dehydration at
the end of their shift (Tables 1, 2). DG was significantly
younger and had significantly shorter years of experience

than EG (p = .037, p = .028). Furthermore, DG had a significantly higher USG at the start of their shift than EG (p <.001). DG had a significantly lower frequency of urination
than EG (p = .031). Nurses had a feeling of thirst after theirshift, and no significant difference was observed between
DG and EG. Lack of breakfast was 〜30% in both groups,
and no significant difference was noted between the twogroups. Additionally, no significant differences were observed in gender, body mass index (BMI), break time, shifttime, fluid intake before shift, fluid intake during the shift,number of steps, %ΔBM, or VAS (Table 1, Appendix 1).
The logistic regression analysis was performed using thetwo variables, years of experience and before-shift USG (Table 3). USG at the start of the shift (odds ratio [OR]: 2.328,
95% confidence interval [CI]: 1.424-3.807) and years of experience (OR: 0.946, 95% CI: 0.899-0.996) were factors associated with dehydration at the end of the shift.
Each outcome was compared between DG and EG at thestart of their shift; however, no significant difference wasobserved in age, gender, BMI, alcohol intake last night, lackof breakfast, fluid intake before the shift, and subjective
symptoms (Appendix 2).
Grouping was performed according to the number ofyears of experience, and subgroup analysis was performed
Table 3. Predictors of dehydration at the end of the shift.

Figure 1. Hydration status of nurses before and after their shift.
n (%), ■ Dehydrated: urine specific gravity ≥1.020, □ Euhydrated< 1.020.

Variables

Adjusted odds ratio (95% CI)

p-Value

USG before shift
Years of experience

2.328 (1.424–3.807)
0.946 (0.899–0.996)

.001*
.034*

*p < .05. Age is controlled as a factor. 95% CI: 95% confidence interval. USG: urine specific gravity.

Table 2. Hydration states, fluid intake, urination, and subjective feelings at the endof the shift.

USG before shift
Urination (times)
Fluid intake (mL)
Before shift
During shift
Before shiftThirstHungerTiredness
Concentration
After shiftThirstHungerTiredness
Concentration

Dehydrated (n = 82)

Euhydrated (n = 33)

p-Value1.0294 (1.0228, 1.0294)
1.0 (0, 1)

1.0164 (1.0101, 1.0182)
2.0 (1, 3)<.001*.031*

200 (100, 300)350 (250, 500)

200 (100, 225)
300 (300, 500)

.398
.957

3.8 (1.8, 5.6)
1.6 (0.3, 3.3)
3.7 (2.4, 5.3)
2.7 (1.3, 4.9)

4.5 (1.9, 6.5)
1.8 (1.0, 6.0)
5.0 (1.9, 6.2)
2.8 (1.7, 5.2)

.597
.098
.483
.355

8.9 (7.3, 9.6)
7.3 (5.1, 9.0)
8.0 (6.5, 9.3)
7.0 (4.9, 8.3)

8.0 (4.9, 9.3)
7.2 (5.0, 9.2)
8.1 (6.0, 9.2)
7.3 (5.1, 8.8)

.067
.845
.901
.275

Median (first quartile, third quartile). n (%). *p < .05. USG: urine specific gravity.

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Table 4. Participant characteristics in the subgroup analysis.

Age (years)
Sex
FemaleMale
BMI%ΔBM (%)
No. of steps
USG before shift
Hydration after shift
Dehydrated
Euhydrated
Urination (times)
Fluid intake (mL)
Before shift
During shift
Before shiftThirstHungerTiredness
Concentration
After shiftThirstHungerTiredness
Concentration

Beginner group (n = 77)

Expert group (n = 38)

p-Value

24 (23, 25)

37 (32.3, 43.8).001*

65 (84.4)
12 (15.6)
20.8 (19.5, 22.8)−0.55 (−1.04, −0.09)
7,594 (6,800, 9,839)
1.0238 (1.0210, 1.0288)

34 (89.5)
4 (10.5)
21.1 (18.9, 22.5)−0.19 (−0.72, 0.18)
6,272 (5,396, 7,521)
1.0224 (1.0168, 1.0266).574

60 (77.9)
17 (22.1)
1.0 (1, 2)

22 (57.9)
16 (42.1)
2.0 (1, 3).030*

200 (100, 300)300 (250, 500)

250 (150, 400)300 (300, 500)

.006*
.313

3.6 (1.8, 5.7)
1.6 (0.7, 3.6)
4.0 (2.5, 5.8)
3.2 (1.7, 5.1)

4.8 (2.0, 6.5)
1.7 (0.2, 3.6)
3.6 (1.7, 5.8)
2.4 (1.2, 5.1)

.439
.846
.475
.282

8.6 (7.2, 9.6)
7.4 (5.0, 9.2)
8.1 (6.8, 9.3)
7.5 (5.3, 8.8)

8.1 (5.8, 9.6)
6.9 (5.1, 8.6)
7.6 (5.9, 8.7)
6.2 (4.5, 7.4)

.282
.534
.104
.012*

.041*
.076
<.001*.022*<.001*Median (first quartile, third quartile). n (%). *p < .05. USG: urine specific gravity.
BMI: body mass index. %ΔBM: %ΔBody Mass.
Table 5. Predictors of dehydration at the end of the shift inthe subgroup analysis.
Variable

Adjusted odds ratio (95% CI)

p-Value

USG before shift

2.573 (1.347–4.914).004**p < .05. Age is controlled as a factor. 95% CI: 95% confidence
interval. USG: urine specific gravity.

since it became clear that the number of years of experience
was related to dehydration at the end of the shift. BG had asignificantly lower BMI than ExG (p = .041) (Table 4). Furthermore, BG had a significantly lower fluid intake before
their shift than ExG (p = .006). Additionally, BG had significantly more number of steps than ExG (p < .001). BG
had a significantly worse concentration after their shift than
ExG (p = .012). BG worked significantly more as the directcare staff than the manager in their shift (p < .001). BG had
a lack of breakfast at 35.5% and ExG at 21.6%, and no significant difference was observed between the two groups(Appendix 3). Concerning other variables, no significant difference was noted between the two groups.
Logistic regression analysis was performed to examine thedehydration factors at the end of the shift in BG (Table 5).
Consequently, USG before the shift (OR: 2.573, 95% CI:
1.347-4.914) was related to dehydration at the end of theshift in BG.

Discussion
This is the first study to examine the prevalence of dehydration in nurses and its factors before and after a shift. Of the
115 participants, 59 (51.3%) and 82 (71.3%) nurses were
dehydrated at the start and at the end of their shift, respectively. It was also found that 25% of the dehydrated nurses
at the end of their shift lost more than 1% of their weightafter their shift, which is associated with a declined cognitive function (Ganio et al., 2011; Shirreffs et al., 2004). Additionally, it was clarified that USG before the shift andyears of experience was related to dehydration after the shift
in nurses. In nurses experienced for 5 years or less, USG
before their shift was associated with dehydration at the endof their shift.
Regarding our hypothesis, the prevalence of dehydrationin HCPs could be different. The prevalence of dehydrationin nurses revealed in this study was higher than that of the
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HCPs in a previous study (El-Sharkawy et al., 2016). In theprevious study, 〜1 l of water was drunk during the shift(El-Sharkawy et al., 2016), whereas in this study, only 〜
350 ml of water was drunk. It is possible that the absoluteamount of water consumed during the shift made a difference in the prevalence of dehydration between the previous
study and this study. In this study, of 82 nurses who were
dehydrated after their shift, 19 (23.2%) had a %ΔBM of 1%
or more. Several previous studies have reported that dehydration with %ΔBM of 1% or more has a risk of cognitive
decline (Armstrong et al., 2012; Ganio et al., 2011; Grandjean & Grandjean, 2007; Shirreffs et al., 2004); therefore,
nurses should be aware of dehydration.
It was clear that USG at the start of the shift was associated with hydration status at the end of the shift. Based on
this result, if nurses start a shift with dehydration, there is apossibility that the dehydration cannot be hydrated during
their shift. It is possible that the nurse would end their shift
with insufficient drinking water since the nurse could only
drink 300 ml of water during their shift. In this study, there
was no significant difference in fluid intake at the start ofthe shift between EG and DG. This result showed that fluid
intake before the shift was unrelated to the dehydration ofnurses at the end of their shift. If people drink water in a
dehydrated state, the ingested water is excreted as urine
without being absorbed by the body (Kovacs et al., 1999;
Popowski et al., 2001). It is probable that those who were
dehydrated at the start of their shift had an inappropriate
fluid intake before their shift. Each outcome was compared
between DG and EG at the start of their shift since the USG
before the shift was related to dehydration after the shift.
However, there was no significant difference in any outcome. Future research should further investigate the factorsof dehydration before the shift for the development of interventions to prevent dehydration.
In this study, there was no significant difference between
DG and EG; however, fluid intake during a shift is a factor
related to dehydration after a shift (Alomar et al., 2013; ElSharkawy et al., 2016). It is likely that DG drank water only
during their break time since the number of urination times
during a shift was significantly lower in DG. A previous
study also reported that participants with oliguria had lower
fluid intake and micturition than those without oliguria (ElSharkawy et al., 2016). Therefore, it is desirable to drink
water frequently rather than drinking a large amount ofwater at once during the shift (Kenefick & Sawka, 2007;
American College of Sports Medicine et al., 2007).
The results of this study showed that beginner nurses(younger people) were more likely to become dehydrated.
Older people were more likely to become dehydrated (Bossingham et al., 2005). From a physiological perspective, it isexpected that younger people are less likely to become dehydrated in the case of nurses. The results of this study, in
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which young nurses are more likely to become dehydrated,
may have been influenced by work content and performanceabilities that are not physical factors. Additionally, beginner
nurses are supposed to have a tendency to have some troubles in health and work environments compared with experienced nurses because these factors are more important for
nurses with 5 years or less than experienced nurses to continue the work (Watanabe, 2011). Therefore, it is necessary
to pay attention to the hydration status of the beginner
nurse.
Because of the subgroup analysis between BG and ExG,
the USG before the shift was related to the dehydration innurses experienced for 5 years or less at the end of theirshift. BG had a significantly lower amount of water consumed before their shift than ExG. This is because beginner
nurses often start working before their shift and cannot afford to drink water until the shift ends. BG worked significantly more in direct patient care than the manager’s role intheir shift. Expert nurses have more management opportunities, such as adjusting patient numbers and staff workload,other than direct patient care; therefore, BG had a significantly higher number of steps than ExG. Physical activity isa factor in dehydration (Benelam & Wyness, 2010; American College of Sports Medicine et al., 2007). The high number of steps in BG means that there are several opportunities
to provide direct care for patients, and it is possible thatthey are performing a moderate-intensity physical activity,
such as patient transfer. Additionally, it is assumed thatyoung nurses have not been accustomed to working andtend to make several unnecessary movements. Comparedwith ExG, BG had a significantly decreased concentration at
the end of their shift. Nurses with less years of experience
probably need more concentration since they have not beenaccustomed to working.
Two significant considerations exist for nurses to prevent
dehydration. First, nurses should understand the prevalenceof dehydration before and after a shift. Comparing EG and
DG, there was no significant difference in thirst before andafter their shift, as reported in a previous study (ElSharkawy et al., 2016). Despite feeling thirsty, nurses areunaware of their own hydration status. Some nurses started
work dehydrated and needed adequate hydration before theirshift. Education on drinking water is significant in maintaining water balance for shift workers (Kenefick & Sawka,2007). Regardless of being thirsty or not, managers should
encourage nurses to drink water since it is expected of themto drink water.
Second, it is necessary for nurses to be conscious ofdrinking water outside of breaks. A short break of <5 minenables behavioral activities, such as eating and drinking,which can ameliorate executive function deterioration(Stachenfeld et al., 2018), improve attention, and reduce
mistakes (Kopardekar & Mital, 1994; Tucker, 2003). There-https://doi.org/10.53044/jinr.2021-0007

fore, fluid intake at any time during a shift, other thanbreaks, prevents dehydration and maintains executive function, which can help promote a better quality of nursing.
Regarding the prevention of dehydration in organizations, it
is desirable for managers to coordinate the workload of beginner nurses and encourage them to drink water.
This study had some limitations. First, it is possible thatthe prevalence of dehydration can include false positives
since the USG reflects the previous hydration status bymeasuring the urine collected in the bladder generated after
the last urination. In this study, USG was used since it iseasy to measure in the clinical setting and can reflect thehydration status during a shift. Second, lunch was not investigated. A previous study has reported that diet affects the
body’s water balance (Shirreffs et al., 1996). It was not possible to investigate the diet because the number of participants could decrease if the dietary items were added to themeasurement and became complicated. However, even if thenurse was rehydrated during the break, the problem is serious because the nurse was dehydrated after the shift. Third,
it is unclear as to what type of work affects dehydration at
the end of a shift since physical activity was estimated onlyby the number of steps. For example, moving a patient frombed to wheelchair is a physical activity that is not measured
as a step. There is a possibility that moving a patient induces dehydration due to sweating; therefore, it is necessary
to investigate various physical activities during nursing carethat affect dehydration. Fourth, there are restrictions on generalization since data were collected during the day shift.
Additionally, it is possible that the difference in wards is related to the prevalence of dehydration. In the future, it will
be necessary to research nurses working the night shift andto compare nurses among different wards.
In conclusion, this is the first study to examine the prevalence of dehydration in nurses and its factors related to dehydration before and after a shift. It was revealed that
51.3% and 71.3% of nurses were dehydrated at the start andat the end of their shift, respectively. USG before the shift
and years of experience was related to dehydration at theend of the shift as predictors. It is desirable for nurses toprevent dehydration after their shift by preventing dehydration before their shift and managers to coordinate the workload of beginner nurses and encourage them to drink water.
Acknowledgments
We would like to express our sincere gratitude to the directors of the nursing departments of the surveyed hospitals
and the nurses who cooperated with this survey.
Author Contributions
Substantial contributions to the conception or design of thework: R.K., Y.L.T., A.A., H.S., E.M., H.Y., and M.K.,
Acquisition, analysis, or interpretation of data for the

JINR 2022, 1(1), e2021-0007

work: R.K., Y.L.T., A.A., H.S., E.M., M.S., A.O., and M.K.,
Drafting the work or revising it critically for important intellectual content: R.K., Y.L.T., A.A., H.S., E.M., M.S.,
A.O., H.Y., and M.K.,
Final approval of the version to be published: R.K.,
Y.L.T., A.A., H.S., E.M., M.S., A.O., H.Y., and M.K.,
Declaration of Conflicting Interests
The authors report no relevant conflict of interests.
Ethical Approval
The protocol was approved by the Ethical Committee of the
Graduate School of Nursing, Chiba University (No. 29-120)
and the Ethical Committee of the Center Hospital of the National Center for Global Health and Medicine (NCGM-G002513-00).
Funding
This study was funded by the Initiative for Realizing Diversity in the Research Environment at Chiba University.
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https://www.jinr.jsnr.or.jp/

Technical Report

Effectiveness of using near-infrared vein visualizers by nurses inpromoting successful peripheral venous catheterization in patients
receiving chemotherapy
Naoki Kuramoto, MSN, RN , and Yoriko Watanabe, PhD, RN
School of Nursing, University of Shizuoka, Shizuoka, Japan

Abstract
Objective: Visibility and palpability of peripheral veins may affect peripheral intravenous catheterization (PIVC)
failure and complications. A near-infrared (NIR) vein visualizer is recommended to select peripheral veins with low
visibility. Chemotherapy reduces the number of peripheral veins suitable for PIVC; however, no study has shownthat NIR vein visualizers can prevent PIVC failures during chemotherapy. We investigated the effectiveness of using an NIR vein visualizer by nurses for PIVC during chemotherapy. Technical Report: We investigated the veincharacteristics (i.e., visibility, palpability), PIVC difficulty before puncture, and success or failure. The study field
was a chemotherapy room at the General Hospital (Shizuoka, Japan). The study participants were nurses who
performed PIVC in patients receiving chemotherapy. Six nurses were enrolled, and eighty-four PIVC cases wereobtained (with duplicate patients). There were 34 cases in the NIR vein visualizer group and 50 in the standard insertion group; the NIR vein visualizer group had a significantly higher number of difficult PIVC cases (p < .01). Peripheral veins with successful PIVC in the NIR vein visualizer group had significantly higher visibility and palpability than those with PIVC failure (p < .05). Conclusions: During chemotherapy, nurses used an NIR vein visualizer
for the peripheral veins deemed difficult to catheterize; PIVC was successfully performed in the peripheral veinswith high palpability. The results showed that an NIR vein visualizer facilitates successful PIVC during chemotherapy.
Keywords
peripheral intravenous catheterization, vein visualizer, chemotherapy, infusion therapy, near-infrared
JINR 2022, 1(1), e2021-0014

Introduction
To safely perform peripheral intravenous catheterization(PIVC), determining the appropriate site, thickness, andlength of the peripheral vein by visually examining the contours of the peripheral vein and palpating it with the fingertips is necessary (Gorski et al., 2021). However, puncture
failure or complications occur in 20%-70% of PIVC cases(Jacobson & Winslow, 2005; Murayama et al., 2017; Wallis
et al., 2014). Visibility and palpability of peripheral veins

may affect PIVC failure and complications (Jacobson &Winslow, 2005; Piredda et al., 2017). The visibility of peripheral veins decreases with the distance from the skin surface, starting at a distance of 3 mm (Kimori et al., 2011).
Palpability decreases with the distance from the surface ofthe skin and a smaller cross-sectional area (Ichimura et al.,2015). Additionally, the contact of the PIVC needle with thevein’s inner wall may cause edema in the peripheral veins(Murayama et al., 2015; Takahashi et al., 2017), resulting in
the extravasation of the chemotherapy medications. Deter-

Correspondence: N. Kuramoto. Email: naoki-k@u-shizuoka-ken.ac.jp
Received: August 3, 2021, Accepted: October 19, 2021, Published: February 24, 2022
Copyright Ⓒ 2022 The Japan Society of Nursing ResearchThis work is licensed under the Creative Commons Attribution International License (CC BY-NC-SA).

1 of 5JINR 2022, 1(1), e2021-0014

mining visible and palpable peripheral veins may lead tosafer and successful PIVC.
A vein visualizer is recommended to select peripheral
veins with low visibility (Gorski et al., 2021). Near-infrared(NIR) vein visualizers are based on the absorption of NIR
light by hemoglobin in the peripheral veins. AccuVeinⓇ, an
NIR vein visualizer, can visualize superficial peripheral
veins by projecting lasers of two different wavelengths, visible and infrared, onto the skin to depict peripheral veins asblack lines on the skin. However, no previous study has
shown that NIR vein visualizers can prevent PIVC failures.
In a study of pediatric to elderly patients with hemophilia
requiring multiple PIVC, there was no association found between PIVC success and failure with the use of an NIR vein
visualizer (Guillon et al., 2015). A similar previous study,
wherein a randomized controlled trial of patients in their50’s-60’s was conducted in the emergency room also foundno association between success and failure of PIVC with theuse of an NIR vein visualizer (Aulagnier et al., 2014). Because the NIR vein visualizer assists with peripheral vein
visibility, it may not be effective for highly visible peripheral veins. Since the visibility and palpability of peripheral
veins and the difficulty of PIVC in patients were not uniform in previous studies, it is necessary to limit the study toperipheral veins with a high difficulty of PIVC.
Chemotherapy reduces the number of peripheral veins
suitable for PIVC due to multiple PIVC within the treatment
period. Regardless of chemotherapy, patients undergoing
PIVC complain of pain, anxiety, despair, and fear of repeated punctures, making failed punctures unbearable (Plohal, 2021). Furthermore, anticancer drugs can cause ulceration and necrosis if even a small amount leaks outside thevessel; therefore, a peripheral vein must be carefully selected, which makes PIVC more difficult for nurses. No report has investigated the efficacy of NIR vein visualizers for
PIVC in patients receiving chemotherapy. We used NIR vein
visualizers because PIVC for chemotherapy is difficult due
to low visibility and palpability. Visibility assisted by an
NIR vein visualizer may promote the success of PIVC. We
investigated whether NIR vein visualizers promote the success of PIVC in patients receiving chemotherapy.

Technical Report
Objective
We investigated whether the use of an NIR vein visualizer
by nurses promotes successful PIVC in patients receiving
chemotherapy.
Methods
Study Design
This study used a quantitative, descriptive research design.
The study field was a chemotherapy room in a general hos2 of 5

https://doi.org/10.53044/jinr.2021-0014

pital in Japan. The study period was from December 2019
to March 2020. The participants were nurses who had performed PIVC in patients receiving chemotherapy. The nurses
used an NIR vein visualizer for PIVC during their routine
work. A questionnaire was created by the researchers, andthe nurses were asked to complete the questionnaire.
Study Participants
Nurses were not restricted by their years of experience. The
patients were adults, and there were no restrictions on age,sex, or disease.
Recruitment of Research Participants
The researchers made a documented and oral research request to the head nurse of a general hospital in Japan andobtained her consent. The researchers explained the research
to the nurses in writing and orally and obtained their consent. For the patients, the researchers provided the nurses
with oral and written explanations and obtained the patients’consent.
Data Collection
Survey Questionnaire
The nurses’ data regarding gender, years of experience, final
education course, and frequency of PIVC were collected.
The nurses filled out questionnaires for difficult-to-perform
PIVC cases. The items on the questionnaire were the patient’s gender, age, body size, peripheral vein characteristics(i.e., thickness, elasticity, tortuous veins, rolling veins, visibility, and palpability), PIVC difficulty before puncture, andsuccess or failure. Peripheral vein characteristics and PIVC
difficulty were rated using a 10-point scale, ranging from 1
to 10, to define peripheral vein catheterizations that ranged
from easy to difficult, respectively.
Investigational Devices
The NIR vein visualizer AccuVeinⓇ AV400 was used in thisstudy and purchased from a Grant-in-Aid for Scientific Research (Grant-in-Aid for Early-Career Scientists B: 17K
17409).
Statistical Analysis
A database was created based on a survey questionnaire.
Based on the database, the cases were divided into twogroups as follows: a standard insertion group without an
NIR vein visualizer and an NIR vein visualizer group using
the AccuVeinⓇ AV400. Furthermore, the PIVC was divided
into success and failure groups. The difference between thegroups in the contingency table was determined using thechi-squared test, and the 10-point scale was determined using the Mann-Whitney U test. Multiple logistic regression
analysis was used for the ordinal scale to explore the association between each of the success of PIVC and vein characteristics. Data were analyzed using the IBM SPSS Statistics version 27 (IBM Corp., Armonk, NY, USA).
Ethical Considerations
This study was conducted after obtaining approval from the
University of Shizuoka Research Ethics Review Committee

https://doi.org/10.53044/jinr.2021-0014

JINR 2022, 1(1), e2021-0014

Table 1. Description of PIVC.
NIR vein visualizer groupn = 34
Success n (%)
20 (58.8%)

Failure n (%)
14 (41.2%)

Table 2. Comparison of the PIVC difficulty.
Standard insertion groupn = 50
Success n (%)
38 (76.0%)

Failure n (%)
12 (24.4%)

Note. p = .095 (chi-squared test).
Abbreviations: NIR, near-infrared; PIVC, peripheral intravenous catheterization.

(Approval No. 30-37). The researchers explained to thenurses that they could freely decide not to participate in the
study, to withdraw their consent at any time, the invasiveness of the measurements and how to handle them, the protection of personal information, and the publication of thestudy results. For patients, the nurses explained the researchand obtained their consent.
Results
Demographics of the Nurses
The study participants were six nurses, with an average of
28.3 ± 7.1 years of nursing experience, four in the 3-year final education program and two in the certified nursing program. All nurses performed at least one PIVC per day.
Description of the PIVC
In total, 84 PIVC cases (duplicate patients) were included.
The gender was male in 40 cases (47.6%) and female in 44
cases (52.4%). The mean age was 67.1 ± 10.2 years, with aminimum of 42 years and a maximum of 87 years. The
body types were thin, 14 (16.7%); normal, 55 (65.5%); andobese, 15 (17.9%). The NIR vein visualizer group included
34 cases, of which 20 (58.8%) were successful and 14(41.2%) failed. The standard insertion group included 50
cases, of which 38 (76.0%) were successful and 12 (24.4%)
failed. There was no significant difference in the success andfailure of PIVC between the NIR vein visualizer and thestandard insertion groups (p = .095, Table 1).
Comparison of the PIVC DifficultyWith respect to PIVC difficulty, the NIR vein visualizer
group had a significantly higher number of difficult PIVC
cases than the standard insertion group (p < .05, Table 2).
Relationship between PIVC Success and Vein Characteristics
Peripheral veins with successful PIVC in the NIR vein visualizer group had significantly higher visibility and palpability than those with PIVC failure (p < .05, Table 3). We performed a logistic regression analysis in the NIR vein visualizer group using peripheral vein visibility and palpability as
independent variables and PIVC success as the dependent
variable. The results showed a significant association between palpability and PIVC success (p = .04), with an odds
ratio of 1.67 (95% IC 1.03-2.69). In the standard insertion
group, no significant association was observed between pe-

Difficulties
with PIVCNIR vein visualizergroup
n = 34Standard insertiongroupn = 50Mean

SD

MedianMean

SDMedian

9.06

1.63

10.00

7.06

2.58

8.00

p value<.01**
Note. Results tested by Mann-Whitney U test.
**p < .01; a score of 10 is more difficult than a score of 1.
Abbreviations: PIVC, peripheral intravenous catheterization; SD, standard deviation.

Table 3. Vein characteristics in the NIR vein visualizer group.
NIR vein visualizer groupVeincharacteristic

Success (n = 20)

Failure (n = 14)

p valueMean

SD Median

Mean

SD Median

Thickness
Elasticity
Tortuous veins
Rolling veins

7.65
7.45
8.05
7.35

3.15
2.56
2.26
2.64

9.00
8.00
9.00
8.00

9.43
9.07
9.21
8.29

1.02
1.21
1.31
2.05

10.00
10.00
10.00
8.50

.05
.06
.07
.30

Visibility

7.45

3.02

9.00

9.14

1.99

10.00

.02

Palpability

6.95

3.07

7.00

9.21

1.31

10.00

.01

*
*
Note. Results showed by Mann-Whitney U tests.
*p < .05; a score of 10 is more difficult than a score of 1.
Abbreviations: NIR, near-infrared; SD, standard deviation.

Table 4. Vein characteristics in the standard insertion group.
Standard insertion groupVeincharacteristic

Success (n = 38)

Failure (n = 12)

Mean

SD Median

Mean

SD Median

5.58
6.11
6.21
7.11
5.63
4.84

2.89
2.63
3.01
2.49
3.31
3.12

6.58
5.75
6.50
5.08
5.08
5.00

2.71
3.02
2.61
3.65
3.23
3.13

Thickness
Elasticity
Tortuous veins
Rolling veins
Visibility
Palpable vein

5.00
5.00
7.00
7.50
5.00
4.50

6.50
5.00
6.00
5.00
3.00
3.00

p value

.26
.65
.77
.09
.58
.95

Note. Results showed by Mann–Whitney U tests. A score of 10 was
more difficult than a score of 1.

ripheral vein characteristics and PIVC success or failure (Table 4).

Discussion
This study investigated if the use of an NIR vein visualizer
by nurses can promote successful PIVC in patients receiving
3 of 5JINR 2022, 1(1), e2021-0014

chemotherapy. We compared the outcome of using an NIR
vein visualizer with that of using standard insertion. The results showed that nurses used NIR vein visualizer on peripheral veins with high PIVC difficulty; hence, PIVC was successful in peripheral veins with high palpability.
This study examined patients receiving chemotherapy, assuming a high degree of difficulty in PIVC; however, similar to previous studies (Aulagnier et al., 2014; Guillon et al.,2015), the NIR vein visualizer was not associated with
PIVC success or failure (Table 1). We speculated that since
the NIR vein visualizer group had a higher PIVC difficultythan the standard insertion group (Table 2), there was nodifference between PIVC success and failure. There was no
significant difference in the characteristics of the peripheral
veins between PIVC success and failure cases in the standard insertion group; however, peripheral vein visibility andpalpability in the NIR vein visualizer group significantly differed between the PIVC success and failure cases (Table 3,4). Furthermore, in the logistic regression analysis, palpability was associated with PIVC success. The results showedthat PIVC was successful in peripheral veins with high palpability when the NIR vein visualizer was employed. Using
NIR vein visualizers in patients with difficult PIVC facilitated the identification of peripheral veins. Peripheral vein
palpability was associated with PIVC success. Therefore,
PIVC success can be enhanced if nurses select a palpable
peripheral vein using the NIR vein visualizer. The NIR vein
visualizer can assist in detecting peripheral veins (Guillon etal., 2015); however, it cannot assess their depth (Kaddoum
et al., 2012) and thickness. The depth and thickness of theperipheral veins can be assessed via palpation. Since theseparameters are important for PIVC, previous studies have investigated the promotion of peripheral vein size (Ichimura etal., 2015; Yamagami et al., 2017). Therefore, although it isdifficult to visualize the veins, the success rate of PIVC canbe increased if nurses promote peripheral vein size and select palpable peripheral veins using an NIR vein visualizer.
In chemotherapy, if the palpability of peripheral veins canbe assessed using an NIR vein visualizer, PIVC may be successful.
This study showed that the palpability of peripheral veins
is important. The palpation technique used to determine suitable peripheral veins for PIVC is challenging to explain;
however, no standardized method for teaching palpation
techniques has yet been established. In the future, investigating the palpation technique will be required for peripheral
veins that skilled nurses cannot visualize. Our study showedthat using an NIR vein visualizer in chemotherapy patients
increased the ability of nurses to select more palpable peripheral veins, which promoted the success of PIVC. Specifically, in the NIR vein visualizer group, the success rateof PIVC was higher when the peripheral veins were more
palpable. The use of vein visualizer devices is recommended
4 of 5https://doi.org/10.53044/jinr.2021-0014

for difficult PIVC; therefore, this study provides a new indication of the extent to which the NIR vein visualizers canbe effectively operated. This result is clinically significant
because it can impact the success rate of PIVC.
Conclusion
During chemotherapy, nurses used an NIR vein visualizer
for peripheral veins evaluated as difficult to catheterize, andPIVC was successfully performed in peripheral veins withhigh palpability. The results showed that the use of an NIR
vein visualizer by nurses facilitates successful PIVC in patients receiving chemotherapy.
Limitations
The nurses subjectively surveyed the depth and thickness ofthe peripheral veins; therefore, objective measurements areneeded. Furthermore, for a successful PIVC, the applicationof NIR vein visualizers and properties of peripheral veinsneed to be investigated.
Acknowledgments
We are grateful to the nurses who assisted with this study.
We wish to thank Sachiko Nagaya and Sadanori Higashino
for their helpful discussions.
Author Contributions
NK designed the study, coordinated the research sites, collected the data, and analyzed and interpreted the data. YWsupervised the study design and data analysis and was a major contributor in writing the manuscript.
Conceptualization: NK; methodology: NK, YW; formal
analysis and investigation: NK, YW; writing-original draft
preparation: NK; writing-review and editing: NK; funding
acquisition: NK; resources: NK; supervision: NK, YW. All
authors read and approved the final manuscript.
Declaration of Conflicting Interests
There are no conflicts of interest to declare.
Ethical Approval
This study was conducted after obtaining approval from the
University of Shizuoka Research Ethics Review Committee(Approval No. 30-37).
Funding
This study was supported by the JSPS Grant-in-Aid for
Early-Career Scientists B JP17K17409.
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5 of 5

List of Reviewers
The Editorial Committee members express their gratitude to the following individuals, who served as reviewers of manuscripts
for the Journal of International Nursing Research between April 2021 and March 2022.

Khatijah Abdullah

Junko Okada

Rie Chiba

Reiko Okamoto

Noriyo Colley

Mayumi Okuwa

Yuka Dai

Mayumi Okuyama

Hiroki Fukahori

Erika Ota

Sanae Fukuda

Toshiko Otsuka

Nadya Golfenshtein

Yuka Saeki

Setsuko Hanzawa

Aya Sato

Yuka Hayama

Taiga Shibayama

Taeko Hori

Yasuko Shimizu

Mari Ikeda

Karri Silventoinen

Sumie Ikezaki

Dragana Simin

Steve Iliffe

Yuri Takahashi

Miyuki Ishibashi

Naruse Takashi

Sarah Kagan

Hiroki Tamura

Takahiro Kakeda

Yuji Tanaka

Ayano Kit

Maki Taniyama

Rie Konno

Melynda Thelen

Shiho Kosaka

Masae Tsutsumi

Ziqiang Li

Angel O Rojas Vistorte

Hitomi Maeda

Victoria Willard

Yuko Matsuda

Sosei Yamaguchi

Inmaculada Méndez

Miyae Yamakawa

Chris Morris

Fumiko Yasukata

Keisuke Nakanshi

Naoki Yoshinaga

Taiki Ogata