Abstract

Nursing

SCHEDULE
Session 1 : 11 : 00 ~ 11 : 40
Session chair: Prof. Yuko Ikematu
1.Alternatives to the family in nursing care: A study of tensions faced by nurses dealing
with possibilities and impossibilities
Yoko Kageyama
2.Hypoglycemia simulation performance evaluation for nursing students
using the Lasater Clinical Judgment Rubric tools
Jung Ji Soo
3.The relationship between professional autonomy, self-esteem and moral sensitivity ofCertified Nurse Specialists in cancer nursing
Kaori Asaba

Session 2 : 13 : 30 ~14：30
Session chair: Prof. Yun Hee Shin
4.Affecting factors on maternal role competence of mothers of premature infants: A
literature review
Jung Hee Song5.Establishment of new lymphatic routes from edematous limb after lymphadenectomy
in rats
Yukari Takeno
6.Relations health literacy to knowledge and selfcare behaviors in patients receiving
hemodialysis
Dong Eun Shin
7.Life activities improve heart rate variability in patients with hypertension and/orheart failure
Natsuki Nakayama- 15 minutes rest –Session 3 : 14 : 45 ~15：45
Session chair: Prof. Katsumasa Ota
8.Post-trauma stress and anxiety among ICU nurses : A preliminary study
Guen Sook Lee
9.Factors related to musculoskeletal symptoms among female family caregivers
Kishiko Suzuki
10.The role of nurses in trauma teams
Suk Chan Kim
11.Association between work environment and resignation intention of visiting nurses
Konami Mori

ALTERNATIVES TO THE FAMILY IN NURSING CARE: A STUDY OF TENSIONSFACED BY NURSES DEALING WITH POSSIBILITIES AND IMPOSSIBILITIESY. Kageyama1)
1) Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan

Introduction
The re-conceptualization of the family is currently being
actively debated in fields such as sociology, politics andfeminist research, with a focus on care, which is an importantfunction of the family. Focusing on this function of thefamily in care, this study is an attempt to examine the clinicalpractice of nurses providing care to patients instead of theirfamilies, identifying areas in which nurses can serve as analternative for families, and areas in which nurses are notable to serve as an alternative for families. This research is
expected to clarify issues around how nurses define family
and how they explain family, and re-conceptualize the family
ex-post facto. Through this re-conceptualization, the paper
contributes to thinking about relationships between people
and about concepts of family not constrained to existing
notions of blood relations, official family registers,
cohabitation and sexual love.
Aim
To identify the ways in which nurses perceive families,
with a focus on tensions described by nurses in thepossibilities and impossibilities of serving as an alternative.
Methods
Participants, data collection and analysis: Ten nurses
employed in the neurological center of a regional medicalcare support hospital were interviewed individually in detailregarding clinical family nursing practice on two occasions,each lasting approximately one hour. Interviews wererecorded using an IC recorder, and verbatim transcripts werecreated after the interviews finished. Based on the transcripts,
the ways nurses explained families in the practice of nursing
care were recorded.
Data collection period: July 2011 – January 2012
Ethical considerations: The study was conducted after
obtaining approval from the University of Shizuoka Research
Ethics Committee. Nurses’ participation in the study wascompletely voluntary, with participants recruited through arequest posted in wards. Each research participant wasprovided with both oral and written explanations of the study
protocol and gave consent before participating in the study.
Results
Elements of support for daily life for which the nurses
could serve as alternatives were related to physical andpractical matters. It was possible for nurses to serve as analternative in some emotional and psychological matters, butthey recounted that this was not possible in many aspects.
However, there was no clear distinction between the two, andthe issue of which elements it is possible to serve as analternative and which elements it is not possible was a matterof “patients deciding” and “nurses finding areas in therelationship with patients and their families”, that is, the careof patients was implemented in a mutually complementary
way by families and nurses. When nurses talked about
possibility/impossibility of serving as an alternative, they

conceived “family” as a continuous relationship and place to be
and as the sharing of time from past to present to future, where
the patient could have the security to be a patient. They
explained that, if these conditions were satisfied, unmarried
partners, friends and acquaintances could be “family”,
regardless of blood relations, cohabitation or official family
register.
Examples nurses gave of being unable to serve as
alternatives, which applied not only to nurses but to all parties
outside the family, were economic matters and proxy decision
making when patients were no longer capable of making
decisions themselves (particularly decisions regarding life, forexample, prolongation of life and gastrostomy, decisions aboutplace of treatment after hospital discharge, signing of consent
forms for surgery and tests etc.). When talking about theimpossibility of serving as alternatives, nurses explained bloodand legal ties as “family”. Nurses had to be involved withfamilies in regard to economic matters and proxy decision
making, and experienced this as a source of tension in cases
where patients had been estranged from their family for a longtime, or where families did not get along well even if they lived
together, or where families were not really interested in thepatient.
Discussion
Through everyday nursing practice, nurses develop anawareness of the kind and extent of care that will be required
from other people after patients are discharged from hospital, inorder for them to live in society. This may account for why
nurses explain “family” as “people who provide support to live”,
as they express concern for patients embarking on daily life
with disabilities or illnesses. However, in terms of economic
matters or cases where proxy decision making concerning life
has to be undertaken, blood and legal ties become “family”. In
everyday nursing practice, nurses do not perceive family merelyin legal or economic terms. Nonetheless, it is a fact that in Japan,
intimacy has been reduced to the family to an excessive degree
because of the legal and economic protection of the familysystem, leading to a situation whereby the burden of care very
often ends up being placed on the “family” of blood and legal
ties (Saito & Takemura, 2001). Nurses’ mode of practice inconceiving “family” as “people who provide support to live”,
beyond the legal and economic framework of the family, may
provide a hint to consider new “relationships between people”
that place the patient at the center. If the family is perceived inthis way, it may be possible to lighten the burden on careproviders, who have often been alone and most often been
women in the traditional unit of the family as a couple ofopposite sexes. Moreover, the practice of nurses creating“connections” between patients and people who provide support
to live leads to a situation in which patients and families are notlocked into a “family”, but always have someone else torespond.
The participants in this study were nurses working at theneurological center, dealing with patients who needed care invarious aspects of daily life due to disorders and disabilities,many of whom had difficulty in independent decision
making. Consequently, the tensions experienced by thesenurses may be specific to neurological centers. However, it isconsidered that these nurses’ tensions could have important
implications for various problems involving families incontemporary society in Japan, such as abuse of children andelderly people, and solitary death.
Acknowledgements
I would like to extend my gratitude to the nurses who
participated in interviews for this study, and to the project
members of the study, Mutsumi Ogura, R.N., P.H.N. andProfessor Kyota Inuzuka (Faculty of International Relations,
University of Shizuoka).
References[1] Fineman AM. The neutered mother, the sexual family andother twentieth century tragedies. NY, London: Routledge;
1995. (Japanese translation available)[2] Kittay FE. Lover’s labor: Essays on women, equality, anddependency. NY, London: Routledge; 1999. (Japanesetranslation available)[3] Saito J, Takemura K. “Between” the intimate sphere andthe public sphere: Concerning solitude and justice[Conversation]. Thought. 2001;925:7-26. (in Japanese)*This report presents part of the results of a research project
funded by the Toyota Foundation Research Grant Programfor Fiscal 2010.
*An earlier version of this paper, which has since beenrevised and expanded, was presented at the 19th Annual
Conference of the Japanese Association for Research in
Family Nursing.
Author address
E-mail: kageyama.yoko@h.mbox.nagoya-u.ac.jp

Hypoglycemia simulation performance evaluation for nursing students
using the Lasater Clinical Judgment Rubric tools
Hur, Hea Kung1), Shin, Yun Hee1), Choi, Hyang Ok1), Jung, Ji Soo2)
1)
2)

Professor, Yonsei University Wonju College of Medicine, Department of nursing

MSN student, Yonsei University Wonju College of Medicine, Department of nursing
Gangwon-do, Republic of Korea

Introduction
Hypoglycemia is known as one of the mostcommon complications in patients with diabetes. In the caseof acute hypoglycemia, lack of emergency managing canlead to death, bodily dysfunction and psychosocial disorders[1]. For managing those emergency clinical situations, nurses
need to learn how to manage or provide nursing intervention
to the patients through clinical judgment [2]. However, theopportunity to learn how to manage hypoglycemia
emergencies is limited in clinical practicum as a nursing
student.
A simulation-based education will helps to improvenursing students’ skills for managing the patients withhypoglycemia by indirect experiences in the simulation
situation. Therefore, researchers provided a simulation-based
practice with a hypoglycemia emergencies patient scenario
and assessed their simulation performance by Lasater
Clinical Judgment Rubric (LCJR) [3].
The results of this study provide the basic
information about nursing students’ clinical judgment ability
which is the indicators for the effectiveness of the
Simulation-based education. The objectives of this study are
as follows; (1) Evaluating the validity of LCJR. (2)Determining the reliability of the LCJR. (3) Assessing theclinical judgment ability for nursing students in
hypoglycemia emergency simulations.
Materials and Methods
This study used one group posttest-only
experimental designed to assess the clinical judgment abilityof nursing students who received simulation-based education
by clinical judgment tools with LCJR. Validity and reliabilityof the LCJR were tested prior to use by evaluating of item
content validity index (I-CVI: 1 = very inappropriate, 4 =very appropriate) [4, 5, 6] and inter-observer reliability byexperts. Experts were consisted with 8 nursing professors
experienced in simulation-based training whom ensured
content validity. Sixty of senior nursing students in Y
University were participated to the simulation-based
education and evaluated their clinical judgment ability by
LCJR. In addition, Clark’s instrument which evaluates thesimulation performance was used for concurrent validity [7].
The video tape which was recorded during the
hypoglycemia emergency simulation practicum was used toanalyze students’ clinical judgment ability from 2 to 4 of July
2012. All the procedures were ethically considered.
Lasater Clinical Judgment Rubric (LCJR) was
consisted with 11 questions (1 = beginning, 4 = exemplary).
It was composed with four sub-categories, 3 noticing
questions (N1, N2, and N3), 2 interpreting questions (I1, andI2), 4 responding questions (R1, R2, R3, and R4), and 2
reflecting questions(Re1, and Re2), according to Benner’s 4
levels of nursing grading scale (rubric) [3].

To improve the consistency between two research
assistants who acted as the analysts, they were trained with 5
movie clips until they reached consistency value up to .80. Afterthe training, they reviewed 55 videos to analyze means,standard deviation (SD), inter-observer reliability coefficient(Kappa) and correlation coefficient using PASW.
Results

The mean age of the participants was 22.13 years.
Forty eighty (87.3%) were female and seven (12.7%) were male.
1) For validity, the value of I-CVI of the LCJR by experts was'reasonable'. The value was more than 3.0 for all items. And thevalue of concurrent validity with Clark's instrument was'reasonable'. The correlation coefficient between LCJR and
Clark’s was .899.
2) For reliability, the value of inter-observer consistency
were .577 < k < .836 and .767 < r < .914. The results show as'reliable'
3) The mean (SD) of the student nurses' clinical judgment was
2.04 (.50). The details are shown in Table 1.
Table1.
Evaluation of Hypoglycemia simulation performance by
LCJR(N=55)
Item

Mean (SD)

Range

Total

2.04 (.50)

(1~3)

N1

2.16 (.74)

(1~3)

N2

2.07 (.72)

(1~3)

N3

2.00 (.77)

(1~3)

I1

1.96 (.61)

(1~3)

I2

2.02 (.56)

(1~3)

R1

2.22 (.71)

(1~4)

R2

2.20 (.78)

(1~3)

R3

1.98 (.76)

(1~4)

R4

1.96 (.51)

(1~3)

Re1

1.82 (.51)(1~3)

Mean (SD)for each sub-category

2.08 (.63)

1.99 (.53)
2.09 (.54)

1.82 (.51)

notes. N1, N2, N3: Noticing; I1, I2: Interpreting; R1, R2, R3, R4: Responding;Re1: Reflecting

Conclusions
Based on the results of this study, Lasater's clinicaljudgment rubric tool can be used for assessing the simulation
performance evaluation for improving nursing competency of
nursing students. This result provides the basic information todevelop a simulation-based education program and evaluate theclinical judgment of nursing student.

References[1]Anthony SF, Eugene B, Dennis LK, Stephen LH, Dan LL,Jameson JL, Joseph L. Herrison’s principles of internal
medicine 17thedition. The McGraw-Hill companies. 2008.
[2]Kathie L. High-Fidelity simulation and the developmentof clinical judgment: Student’s Experiences. Journal of
Nursing education. 2007;46(6):269-276.
[3]Kathie L. Clinical judgment: The last frontier forevaluation. Nurse Education in Practice. 2011;11:86-92.
[4]Joan SG, Linda LD. Selection and use of content experts
for instrument development. Research in Nursing &Health. 1997;20:269-274.
[5]Denise FP, Cheryl TB, Steven VO. Is the CVI an
acceptable indicator of content validity? Appraisal andrecommendations. Research in Nursing & Health.
2007;30:459-467.
[6]Denise FP, Cheryl TB. The content validity index: Are
you sure you know what’s being reported? Critique andrecommendations. Research in Nursing & Health.
2006;29:489-497.
[7]Laura TG. Using the Clark simulation evaluation rubric
with associate degree and baccalaureate nursing students.
Nursing Education Perpectives. 2010;31(2):101-105.

Author address

E-Mail: papaya1978@hanmail.net

THE RELATIONSHIP BETWEEN PROFESSIONAL AUTONOMY,SELF-ESTEEM AND MORAL SENSITIVITYOF CERTIFIED NURSE SPECIALISTS IN CANCER NURSING
K. Asaba, RN, MSN student1), A. Okawa, RN PhD1)
1)

Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya, Japan

Introduction
According to the medical advancement and the increase incancer patients, specialized competencies in cancer nursing
are called for. In response to these social changes, master’s
prepared Certified Nurse Specialist has been introduced. Inorder to accomplish their role as specialists, they need tofunction autonomously.
It was thought that seniority and current position wererelated to professional autonomy. However, it has become
clear that what and how they learn from experience are more
important for professional autonomy. Personal self-esteem andmoral sensitivity may play an important role in the way oflearning. Therefore, the purpose of this study is to clarify
relationship between professional autonomy, self-esteem andmoral sensitivity.
Materials and Methods
Subjects: We surveyed all 327 Certified Nurse Specialists inCancer (OCNSs) (as of April, 2012) in Japan.
Requirements of OCNS certification are five or more yearsof clinical experience including three or more years of cancer
nursing, master's degree in oncology nursing, and success inan examination conducted by Japanese Nursing Association.
A survey consisted of 75 items including 9 items for
demographic characteristics, 47 items for professional
autonomy, 10 items for self-esteem, and 9 items for moralsensitivity.
Scales:Demographic characteristics included age, sex,
educational background, years of clinical experience, years ofexperience as OCNS, sub-speciality, an affiliation, position
and rank, and activity time . These items were derived fromliterature.
Professional Autonomy Scale was developed by Kikuchi tomeasure the level of autonomy of nurses in general. It is a 5
point Lykert scale consisting of 47 items of five subscales,"cognition", "performance", "concrete judgment", "abstract
judgment", and "independent judgment". Total possible scores
range from 47 to 235; the higher the score, the higher the levelof professionl autonomy.
Self-Esteem Scale (RSES-J) is a Japanese version of
Rosenberg Self-Esteem Scale developed by Mimura. It
measures the level of self-esteem. It has been developed basedon the assumption that one with high self-esteem canunderstand others well, can sympathize well, and respect
other's feeling and intention. Total possible scores of this 4point Likert scale range from 10 to 40; the higher the score,
the higher the level of self-esteem.
Moral-Sensitivity Scale (J-MSQ) is a Japanese version of
Lutzen's rMSQ developed by Maeda. It is a 6 point Likert
scale consisting of 9 items of 3 subscales, "moral
strength","sense of moral burden",and "moral responsibility".
Total possible scores range from 9 to 54; the higher the score,
the higher the level of moral sensitivity.

We distributed and collected this questionaire via mail. All
participants provided weitten informed consent.
This study was approved by Nagoya University Medical
Department Bioethics Screening Committee (approval number
11-164).
Operational definitions ;Professional autonomy: To recognize oneself as a profession,
make a selection and/or decision based on one's own values andjudgment, and act with responsibility, while understanding therelationship with others.
Self-esteem: A feeling connoting self-respect and selfacceptance which articulates the perception of oneself regarding
one’s own value and ability (or talent, competence, potential).
Moral sensitivity: A consideration to moral values andawareness of one's own role and responsibility in the situationof value conflict. Ethical sensitivity.
Data analysis: Peason’s product moment correlation
coefficient was used to determine relationship among variables.
Significance was set at P<0.05.
Results
1) 118 OCNSs responded (response rate 39%) and all of themwere valid for analyses. The average age of the respondents was
40.9 years old (SD=5.82). An average of clincal experience
was 206.67 months (SD=66.461), 80% of the respondents werewith less than 5 years of the OCNS experience. Most prevalent
position was management (48.3%), and 27% of the respondents
worked solely as Cerftified Nurse Specialist. Majority of therepondents (66.9%) belong to Local Cancer Hub Hospital.
About half of the respondents were assigned to wards oroutpatient departments, and the rest belonged to nursing
administration departments or the palliative care teams. Even if
they worked as general nurses as well, 22% of the respondents
functioned as OCNSs in their given circumstances.
2) The average scores of the professional autonomy, the selfesteem and the moral sensitivity were 4.1429 (± .42316), 2.7102(± .45412) , and 4.5278 (± .45704), respectively.
3) The correlation coefficient between professional autonomy
and self-esteem was r = 0.319. The correlation coefficient
between professional autonomy and overall moral sensitivity
was r = 0.556, and the "moral strength" subscale of moral
sensitivity showed r= 0.690.

Table 1 Respondent's characteristics
Item

Average value±SD or the number (%)
40.85 ±

Age (range)

5.867

Sex

male/female
0/117 ( 0/99.2)
no answer1( 0.8)The last school education
Graduate school (a master/doctor)
115/3 (97.5/ 2.5)
Years of experience (month) 206.67 ±66.461
OCNS experience
five or less years
98 (83.1)
more than 5 year
17 (14.4)
10 years or more
3 ( 2.5)
no answer
2 ( 1.7)
Position and rank
OCNS only
27 (22.9)(those with amanagement
57 (48.3)
multiple answer)
staff position and rank
32 (27.1)
in addition to this7 ( 5.9)(teaching profession and team devotion)

Affiliation
Speciality

cancer specialty hospital
14 (11.9)
local cancer hub hospital
79 (66.9)
general hospital
18 (15.3)
others5 ( 4.2)( clinic, home nursing care, andeducational facilities)
OCNS only
27 (22.9)
inpatient ward
34 (28.8)
outpatientdepartment
27 (22.9)
others24 (12.4)

Activity style(consultation support section,
nursing department, educational facilities,
relief team, and medical-examination section)

Activity time reservation scheduled by myself
there is an activity day / time.
(except OCNS only
generaten = 91 )during daily work
carry out by overtime
no answer

20 (22.0)
23 (25.2)
22 (24.1)
4 (4.4)21 (1.9)

Table 2
Descriptive statistics of professional autonomy , selfesteem and moral sensitivity
average value ± SD
N
professionals

autonomy (PA)116

4.1429±.42316: cognition (c)117

4.1966±.44527: performance (p)118

4.0436±.47683: concrete judgment (cj)118

4.2397±.50770: abstract judgment (aj)117

3.9805±.51265:independent

118

4.3763±.44389

self-esteem (SE)moral sensitivity (MS)118

2.7102±.45412

116

4.5278±.45704: moral strength (ms)117

4.4872±.81006: sence of moral burden (smb)117

4.3483±.52106: moral responsibility (mr)118

4.9449±.59479

judgmen (ij)Tabel 3
Correlation of a professional autonomy, self-esteem
and amoral sensitivity
PA

c
.274

p

.566**.536**.518**.478**.497**.378**

ms.690**.661**.635**.598**.579**.462**

smb

.146

.153

.136

.123

.157

.027

mr
.291** .235* .253** .202*
correlation of Pearson*p≺ .05 **p≺ .01.249**.315**

**

.346

ij

MS

**

.346

aj

.319

**

.250

cj

SE

**

**

.101

Discussion1) Increased number of nurses who work as OCNS’s role
only and significant proportion of affiliation to hospitals
specilized in cancer treatment indicate improvement of theirworking environment where OCNSs are able to demonstrate
their specialized competences.
Moreover, even if they are employed as general nurses they
act as OCNSs during they are performing their duty on theirown.
2) All scores of total professional autonomy and its sub
scales showed consistent high scores.Total score of aprofessional autonomy was higher than those of senior
generalist nurses studied previously. It may be cocluded that
OCNSs possess high level of autonomy regardness of theirworking situations.
Moral sensitivity was also higher than those of previously
studied senior generalist nurses. It is noteworthy that the
average score of an item "feels very difficult to control myemotion while the patient is in pain" among the subscale"moral strength" was lower than those of previous study. This
item was considered negative trait for moral sensitivity in thisscale. However, the low score may indicate that OCNSs areknowldgeable enough to understand the patient and his/her
circumstances and are capable in providing appropriate care to
the patient without being over-involved.
3) Professional autonomy and moral-sensitivity aremoderaltely positively correlated. A nurse with highprofessional autonomy is also highly moral sensitive. In
particluar, a subscale "moral strength" showed the highest
correlation with professional autonomy. It may imply that
OCNSs are able to analyze the patient's situation
comprehensively and are courageous enough to advocate theirpatients and families.
Conclusions
1) OCNSs have been extended their activity in theorganization without limiting to an assigned work places.
Moreover, they have acquired positions which they candemonstrate their specialized competencies.
2) Positive weak correlation between professional autonomy
and self-esteem, and positive correlation between professional
autonomy and moral sensitivity were demonstrated.
3) The moral strength which is necessary to advocate apatient was related to the professional autonomy of OCNSs.
References[1] Kikuchi A, Tadashi H. Research on measurement of thespecial autonomy of nursing The Shizuoka University
department-of-education report of research (humanities social science editing). 1997;47: 241-254.
[2] Mimura C, Griffiths P. A Japanese version of the
Rosenberg Self-Esteem Scale : Translation and equivalence
assessment. Journal of Psychosomatic Researrch. 2007;62,:589-594[3] Meda J, Konishi E. Deveropment and validation of aJapanese version of the revised Moral Sensitivity
Questionnaire: a preliminary study. Journal of JapaneseNursing Ethics. 2012; 1(4): 32-37.
Author address
E-Mail: asaba.kaori@b.mbox.nagoya-u.ac.jp

Affecting factors on maternal role competence of mothers of premature infants: A literature review
Jung Hee Song, MSN student
Yonsei University Wonju College of Medicine, Department of Nursing, Gangwon-do, Republic of Korea
Introduction
The birth rate in South Korea is 1.17, the lowest
in the world; however, due to development of technologies
such as external fertilization and in-vitro fertilization, birthrates of low-weight infants and premature infants showed asteady increase by 4 to 10 percent from 1995 to 2005 [1].
Despite these increasing trends, as a result of developmentof domestic medical technology and the reality ofshortening the funding period due to introduction andenforcement of the comprehensive medical fee system(DRG), mothers of premature infants are charged with theduty of caring for their premature infants without adequate
psychological preparation [2].
In particular, regarding the maternal role,competence for mother-infant interaction is commonly
considered the most important factor in growth anddevelopment of premature infants [3]. However, the birthof a premature infant and hospitalization in the NICU
disrupts the expected development of interactive skills forboth the parent and the infant [4]. Lack of this motherinfant interaction leads to adversities of maternal role
adaptation. Therefore, in order to increase motherpremature infant interaction, the importance of nursing
intervention for improvement of maternal role competence
should be emphasized [5].
A sense of self-efficacy is defined as therecognition of self-ability as a parent, being able to parent
children and to cope with the problems associated withparenting children [6]. In addition, it is also defined as the
expectation of how much a parent can have an effect on thedevelopmental results of children [7]. In order to determine
a sense of self-efficacy of mothers of premature infants, it
is important to evaluate the factors affecting a sense of selfefficacy. However, most previous studies focused on therelationship between mothers of mature infants or thegeneral characteristics of the mothers in relation toparenting of children; few studies have focused on analysis
of factors affecting a sense of self-efficacy of mothers ofpremature infants.
Thus, this study was conducted in order toprovide verification of the factors affecting a sense of selfefficacy of mothers through consideration of previous
studies as to a sense of self-efficacy of the mothers. In
addition, the factors affecting a sense of self-efficacy of
mothers of premature infants as reflecting thecharacteristics of premature infants are discussed. This
study may be leveraged as an important source of basic
information for use in development of nursing intervention
for the sake of improving a sense of self-efficacy in thecase of development of a discharge education program formothers of premature infants from NICU.
Materials and Methods
Subjects: The database PubMed (provided by
the US National Library of Medicine) and RISS (provided

by the Korea Education and Research Information Service)
were used in the search for the following terms: maternalrole competence, infant, prematurity, and premature infant
in abstracts published from 1999 to the present date.
Data analysis: Among the 12 searched papers, a
total of six research papers (five research papers from
PubMed, one research paper from RISS) that matched the
purpose of this study, to verify the affecting factors ofmaternal role competence, were studied.
Results

According to the study reported by Chien-Chi
Liu et al., which analyzed factors affecting maternal rolecompetence for mothers of normal mature infants,
maternal confidence, infant temperament, number ofmaternal parity, maternal health status, and infant healthstatus were confirmed as the significant affecting factors ofmaternal role competence [8].
In the study reported by Fry and Joan,
emotional support, physical comfort, status of self-care,burden of infant care, information, advocacy, referral,
support for infant care, support for sibling care, andhousehold organization were the affecting factors [9].
In the study reported by Chae, breast feeding,infant temperament, and infant health status wereconfirmed as the affecting factors of maternal rolecompetence [10].
In the study reported by Tarkka, targeting firsttime mothers, emotion, demandingness of mother, copingwith child by the mother, mother's feeling of isolation,
whether the mother receives aid from a network,
attachment to the child, and acceptability of mother wereconfirmed as the affecting factors of maternal rolecompetence [11].
In the study reported by Holditch-Davis et al.,targeting mothers of medically fragile infants, maternal
identity and vulnerability of the infant were confirmed as
the affecting factors [12].
Finally, in the study reported by Zahr and Cole,which verified maternal role competence and sensitivity of
mothers of premature infants, mother's affective behaviors
and mother's caretaking skills were confirmed as thesignificant affecting factors [13].
Discussion
According to the literature review of the six
studies, it is possible to classify the affecting factors ofmaternal role competence into the factors of mother side,
factors of infant side, and environmental factors.
First, regarding factors of mother side, maternal
confidence, emotional status, maternal identity, number ofmaternal parity, health status, physical comfort, status ofself-care, demandingness, acceptability, attachment to thechild, and caretaking skills were the affecting factors.

Second, regarding factors of infant side, resultsof our analysis indicated that infant health status,
vulnerability of infant, infant temperament, and breastfeeding were the affecting factors.
Finally, regarding environmental factors,
information, emotional support, support for infant andsibling care, household organization, whether the motherreceived aid from a network, and referral system wereconfirmed as the affecting factors.
Interaction between premature infants andmothers is important as a way of promoting growth anddevelopment of premature infants; thereby, absolutely
requiring promotion of maternal role competence. Thus,
based on basic information regarding the affecting factorsof mother side, infant side, and environmental side ofmaternal role competence, which was verified in this study,
for the sake of ensuring the health of premature infants, it
is believed that development of a nursing intervention
program to enable mothers to achieve efficient nursing ofpremature infants is necessary. This may be leveraged asimportant information for use in development of an
educational program for mothers of premature infants in
the NICU.
Conclusion
This study was conducted for evaluation andanalysis of six research studies, which were searched using
the following key words: maternal role competence, infant,prematurity, and premature infant, in order to verify thefactors affecting maternal role competency of prematureinfants. The affecting factors of maternal role competence
were confirmed as being classified into the factors ofmother side, infant side, and environmental side. The
affecting factors confirmed in the results provide important
information for promotion of maternal role competence ofmothers of premature infants.
References[1] Park YK. Perceived Training Needs of Mothers ofPremature Infants hospital discharge education.
Unpublished Master’s Dissertation. Dong-A University.
Korea. 2011 .
[2] Lee YJ. Self Confidence and Educational Needs ofNewborn Care in Normal and High-Risk Newborn Mothers.
Department of Nursing science. Unpublished Master’s
Dissertation. KonYang University. Korea. 2006.
[3] Kärtner J, Keller H, Yovsi RD. Mother-infantinteraction during the first 3 months: the emergence of
culture-specific contingency patterns. Child Development.
2010;81:540-554.
[4] Talmi A, Harmon RJ. Relationships between preterm
infants and their parents: disruption and development. Zeroto Three. 2003;24(2):13-20.
[5] Lawhon G. Facilitation of parenting the prematureinfant within the newborn intensive care unit. Journal of
Perinatal and Neonatal Nursing. 2002;16(1):71-82.
[6] Johnston. & Mash, E. J. A measure of parenting
satisfaction and efficacy. Journal of Clinical Child
Psychology. 1989;18, 175-197.
[7] Luster,T & Kain, E. L. The relationship between family
context and perception of parental efficacy. Early child
Development and care. 1987;29, 301-311.
[8] Chien-Chi Liu, Yueh-Chih Chen, Yen-Po Yeh & YeuSheng Hsieh. Effects of maternal confidence andcompetence on maternal parenting stress in newborn care.

Journal of Advanced Nursing. 2011;18(6): 908-918[9] Judith Fry McComish and Joan M. Visger Domains ofPostpartum Doula Care and Maternal Responsiveness andCompetence. The Association of Women’s Health,
Obstetric and Neonatal Nurses. 2009; 2 (1):148-156[10] Chae MY. A Study on the Effects of Home Care
Nursing based Maternal Role Strengthening Programs hason the maternal identity and maternal role confidence offirst-time mothers. Unpublished Master’s Dissertation. Sun
Kwan University. Korea. 2009.
[11] Tarkka MT. Predictors of maternal competence by
first-time mothers when the child is 8 months old. Journalof Advanced Nursing. 2002 ; 21(10):233-240.
[12] Holditch-Davis DD, Miles MS, Burchinal MR,
Goldman BD. Maternal Role Attainment With Medically
Fragile Infants: Part 2. Relationship to the Quality of
Parenting . Research in Nursing & Health. 2011; 34, 35-48.
[13] Zahr L, Cole J. Assessing maternal competence andsensitivity to premature infant's cues. Issues inComprehensive Pediatric Nursing. 1991; 14: 231-240.
Author address : leesong713@naver.com

ESTABLISHMENT OF NEW LYMPHATIC ROUTES FROM EDEMATOUS LIMB
AFTER LYMPHADENECTOMY IN RATS
Y. Takeno1), E. Fujimoto1)
1) Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya Japan

Introduction
Secondary lymphedema is most often caused by mechanicalinsufficiency of the lymphatic drainage system. It leads toswelling of the extremity on the surgical side, which occurs as aresult of the accumulation of interstitial fluid. Combined
decongestive therapy (CDT) has been applied to mild or moderatecases in general [1]. However, the mechanism of lymphedema
formation and the therapeutic mechanism of CDT and its efficacy
are still unclear [2]. The purpose of the present study is toinvestigate lymphedema formation and progression, and to search
for an escape route for excess interstitial fluid, from the aspect of
fluid movement.
Materials and methods
Materials
Twelve male Wistar rats (age range, 10-14 weeks) were used.
All in vivo experiment protocols were reviewed and approved by
the Animal Experiment Committee of Nagoya University.
Procedures
During surgery, rats were anesthetized with isoflurane
inhalation, and 0.2 ml of a 1 mg/ml solution of ICG was injectedsubcutaneously into the dorsum of the right paw and both themedial and lateral ankle to detect lymph nodes in the groin andlymph vessels in the femoral area. After normal lymph flow wasconfirmed by the photodynamic eye system (PDE: Hamamatsu
Photonics K.K. Hamamatsu, Japan). A circumferential incisionfrom a surface of skin to subcutaneous tissue was made at the rightgroin. Lymph nodes in the right groin and the ipsilateral popliteal
fossa were completely excised. Lymph vessels were carefully
ligated under optical imaging. The skin edges were then sutured
end to end by 4-0 nylon.
Evaluation of limb edema
The treated hind limb was evaluated by ICG lymphography andcircumferential measurement. Both evaluations were performed at
specific periods of time from the Day 3 post-surgery and ten
weeks thereafter. Limb circumferences of the surgical site and thecontralateral site were measured at the inguinal regions. Lengths
are presented as medians and ranges. The significance ofdifferences was assessed with the non-parametric Wilcoxon single
rank test with Bonferroni correction.
Results
Preoperative image
All rats showed the same fluorescent image before surgery. On
the right foot pad including the injection sites, intense
fluorescence of ICG was observed by PDE. From the right ankle,
two linear fluorescent signals immediately appeared after the
injection and then reached to the right popliteal fossa and theinguinal region, respectively. No fluorescent signal was observedon the proximal area of the inguinal region, nor on the other partsof the body except for the right hind limb.
Circumferential lengths of the right hind limbs were almost
same as the left in all the rats.
Abnormal images limited in the limb
The fluorescent signal did not show a linear pattern in any partsof the treated hind limb, but was distributed diffusely and/or madespotted fluorescent signals in all the cases. Such abnormal images
were limited to the treated hind limb.
Circumferential lengths of the treated hind limbs increased soonafter surgery and achieved peak lengths as follows: the period of
the maximum difference between the lengths of treated anduntreated hind limbs was on day 3 for three rats, week 1 for fiverats and week 2 for two rats.
Appearance of new flow patterns
As new flow patterns, network-like and linear fluorescentsignals appeared in all the rats. Such patters appeared at week 1 in
two of twelve rats, week 2 in five rats, and week 3 in five rats after
surgery, respectively.
A network-like pattern of the fluorescent signal was dense
around the surgical site from the anterior thigh to the lower
abdomen. In addition, the fine and small network–like signal wascollected at one or several points of the lower abdomen andbecame a linear pattern. All lines led to and reached the ipsilateralaxillary fossa and accompanied superficial epigastric andthoracoepigastric veins. With moving pictures by PDE, thefluorescent flow which moved from the lower abdomen toward theaxillary fossa was identified. In nine of twelve rats, thenetwork-like pattern of fluorescent signals was also observed topass transversely on the suprapubic region and then reached to thecontralateral inguinal fossa. A linear pattern was not seen in thispart. The diffuse and spotted fluorescent signals remained in theanterior thigh even though the network-like and linear flow
patterns appeared. In the gluteal area and the dorsal region of thetrunk, the network-like fluorescent signal was barely or neverseen.
Regarding circumferential length, there was a considerable
variation among the rats.
Stability of flow pattern
All the rats showed a new route to the ipsilateral axillary fossa
beyond the incision line. When the new flow patterns began toappear, three rats had a single route to the ipsilateral axillary fossa,
and in addition, the remaining rats had another route to thecontralateral inguinal fossa. However, the route to the contralateral
inguinal fossa disappeared in three rats during observation. The
disappearing time of the route to the contralateral fossa in each rat
was at week 2, week 5, and week 8 after surgery, respectively. As aresult of adding three rats which had only a single route to theipsilateral axillary fossa from the beginning, at least a total six rats
had a single route to the axillary fossa at the end of the observation.
Regarding the network-like pattern and the route to the ipsilateralaxillary fossa, there were a few variations among the rats, but each
rat maintained one’s specific flow patterns at least until the end of
the observation. Diffuse and spotted signals decreased with thepassage of time, since the flow patterns were stabilized andcompletely disappeared at around eight weeks after surgery in all
the rats. The network-like pattern at the lower abdomen and thelinear pattern to the axillary fossa had been seen continuously, atleast until the end of observation. Less fluorescent signals still
remained in the gluteal and dorsal regions of the trunk, comparedto the anterior thigh and the abdomen.
In the circumferential lengths of the treated hind limbs, a mild
reduction continued to be close to those of the untreated hind limb.
Statistical analysis
The median difference of the circumferential lengths was 0 cm
(from -0.1 to 0.2) on the preoperative period. Then it became
longer as 0.75 cm (from -0.2 to 1.9) on the day 3, 0.9 cm (from-0.2 to 2.6) on the week1 respectively. Shortly after that, it
dropped to 0.55 cm (from -0.1 to 1.8) on the week 2. After the
week 3 to the week 10, the median difference decreased from 0.4
cm (from -0.4 to 1.2) to 0.1cm (from -0.2 to 0.6).
As results of Wilcoxon test with Bonferroni correction, there
was significant differences between the pre-operative length andthe day 3, and between the pre-operative length and the week 1(p<0.005). After the week 3, there were no significances.
3
2.5
2

*
*

1.5
1
0.5
0

lymphatic circulation from a lower extremity. In particular, thepathway to the ipsilateral axillary lymph nodes may have a large
potential allowing lymph fluids to drain into the deep lymphatic
system, because lymph flow movement toward the ipsilateralaxillary lymph nodes was continuously observed in spite of thedisappearance of the suprapubic pathway. This was first confirmed
as real time lymph movement using the PDE video system. Lymphlabeled by ICG was observed by vide-recording to vigorously
move from the paw, beyond the incision and to the ipsilateralaxilla. Considering our findings using PDP video, it is possiblethat the collateral pathway to the ipsilateral axillary lymph node
may be activated in patients suffering from lower extremity
lymphedema.
Superficial cutaneous lymph capillaries seen as network-likepatterns were observed from the thigh to the lower abdomen
beyond the incision. Therefore, it is supposed that they also play agreater role in connecting the treated hind limb and the collateralpathway. In the present study, a spread of the superficial lymph
network crossing the incision line was observed. We emphasizethat lymph capillaries regenerate and/or connect to each other, andspread to beyond the affected region where the lymphtransportation system is damaged. The capillaries might reachadjacent normal lymph collectors and then drain into normal
lymph nodes.
The present study employed circumferential measurements inparallel with ICG lymphography. The statistical analysis showsthat there are significant differences in the median differences of
the circumferential lengths between the preoperative period andthe day 3, and between the preoperative period and the week 1.
This may coincide with the stage that abnormal images limited in
the treated limb. The decline from the week 2 could overlap thestage of the appearance of new flow patterns. Although apparent
swelling of the treated hind limbs was not identified until two
weeks after surgery, ICG lymphography could detect significant
changes in lymph flow during this period. Therefore, for the early
detection of lymphedema, it is important to not depend exclusively
on visible swelling. Indocyanine green lymphography may
improve clinical practice greatly.

pre 3d 1w 2w 3w 4w 5w 6w 7w 8w 9w 10w

Acknowledgements
This study was supported by Grant-in-Aid for Scientific
Research (B) from The Ministry of Education, Culture, Sports
Science and Technology, Japan to E.F. (No.22390408)

Fig.1 The vertical axis is for the median difference of
circumferential lengths between the treated and theuntreated hind limbs. The horizontal axis is for time.
There are significant differences between the pre andthe day 3, and between the pre and the week 1(*p<0.05)

References[1] Cormier, JN, Rouke, L, Crosby, M, et al.: The surgicaltreatment of lymphedema: A systematic review of thecontemporary literature (2004-2010). Ann Surg Oncol. 2012; 19:642-651.
[2] Norman, SA, Localio, AR, Kallan, MJ, et al.: Risk factors for
lymphedema after breast cancer treatment. Cancer Epidemiology,
Biomarkers & Prevention. 2010; 19 (1): 2743-2746.

-0.5
-1
(cm)

Discussion
In the present study using the PDE system, it appears thatlymph node excision and vessel ligation at the inguinal site leads
to the development of collateral pathways to the ipsilateral axillary
and contralateral inguinal lymph nodes. Dermal backflow signs
considered as lymphedema appeared in the treated hind limbs andthen gradually disappeared after the collateral pathways were
established. Therefore, collateral pathways are presumed to have a
crucial role in improving lymphedema and for compensating forRelations health literacy to knowledge and selfcare behaviors
in patients receiving hemodialysis
Dong Eun Shin, RN, MSN Student
Yonsei University Wonju College of Medicine, Department of Nursing, Gangwon-do, Republic of Korea
BackgroundThe development of medical technology has
increased the average life expectancy, but 50 % of people
older than 40 years show signs of chronic disease. The
number of patients receiving hemodialysis with diabetes
mellitus, hypertension and nephritis was 117,000 in 2010,
which was 36 % higher than the number in 2005 reported[1]. Health care providers should help to prevent aworsening of symptoms and complications through selfcare
at home. These efforts will help to enhance the quality oflife of patients with chronic disease.
Health literacy means the ability to obtain basic
information and services, processes and understanding [2].
Health literacy is an important predictor of selfcare
behaviors for patients with chronic disease [3]. In previous
studies, patients with low level of health literacy have ahigher frequency of complications than those with highlevel of health literacy within similar demographics [4].
According Korean Educational Development
Institute (KEDI) [5] report, low level of health literacy of
Koreans was 38 %, which was the lowest among OECD
countries. Therefore, it needs that analyzing the previous
study to identify the affecting factors on health literacy
among patient receiving hemodialysis.
PurposeThe aim of this study was to identify of healthliteracy, knowledge on disease, and compliance of selfcare
through the literature review in patients receiving
hemodialysis. The results may support to plan and provide
an education program.
The specific objectives as follows:(1)
identifying the study design; (2) identifying thecharacteristics of the study participants; (3) identifying themeasurements to evaluate the health literacy; and (4)analyzing the relating factors on health literacy.
MethodDesignThe database PubMed (provided by the US
National Library of Medicine), RISS (provided by the
Korea Education and Research Information Service) and
NDSL (National Discovery for Science) were used in the
search for the following terms: hemodialysis, healthliteracy, knowledge and adherence to self-care.
Among the 10 searched papers, three research
papers (from RISS and NDSL) and seven research papers(from PubMed) that matched the purpose of this study, toidentify the relating factors on health literacy.
Result1. Design

The studies included one literature review study[18] and nine descriptive studies [9-12, 14-17, 19] to
identify the relationships between demographic
characteristics and health literacy.

2. Study participants
Four studies for the patient receiving
hemodialysis, one for hypertensive patient, two for elderly
patient, one for outpatient, and one for inpatient were
examined.
3. Measurement
Three studies used a rapid estimate of adultliteracy in medicine (REALM) [6] and one study used theTest of Functional Health Literacy in Adults (TOFHLA)[7]. In addition, two studies used a developed instrument
by researchers.
In Korean studies, one study used the Newest
Vital Sign [8], one study used the REALM, and one study
used a developed instrument by researchers.
4. The relationship between health literacy andvariables
4-1 Researches in Korea
1) A study for the Korean elderly, 45.4% wasfound to have low level of health literacy [9]. This
proportion was higher than 38% which is the proportion of
low level of health literacy in Korean population [5].
2) A study for outpatients revealed 18.3% tohave low level of health literacy and 24.5% with apossibility of having low level of health literacy [10].
3) A study for inpatients located rural area
revealed 30.6% to be unable to interpret the Korean
language [11].
4-2 Researches in other countries
1) Two studies that analyzed the characteristicsof hemodialysis patients, 34% had low level of healthliteracy.[12,13] Moreover, African Americans, Hispanics,
males, low education level, and those with a lower income
had low level of health literacy [12-16].
2) The mortality of hemodialysis patients withlow level of health literacy was 1.5 times higher thanpatients with adequate health literacy [13].
3) In elderly patients, 28.7% had low healthliteracy, 18.9% had a possibility of having low level ofhealth literacy. The reason of the high proportion for
elderly patients was self-care behavior such as medication,
exercise, and regular check-up [17].
4) One of the reasons of noncompliance taking
medication for hemodialysis patients was low level ofhealth literacy. The present result shows that the patientswere not able to take right dose of medicines cause by thepatients were difficult to understand of their prescriptionsor the size of letters of the prescriptions was too small toread. [18] This result showed in the study for hypertensive
patients. There was a significant positive correlation
between the level of knowledge and the level of healthliteracy [19].

Conclusion
Low level of health literacy was found to berelated to a higher mortality rate of hemodialysis patientsand negatively effect to patient outcomes cause by poor
understanding on their disease. In addition, low healthliteracy effect to patients by a poor understanding of
unfamiliar medical terms or a poor practical medical
application. Therefore, the incidence rate of complication,
readmission, hospital days, and mortality will increase.
Before developing health education programs, it
is important to identify the patients’ health literacy andrelating factors. It will help to develop the suitableeducation program to consider their health literacy level.
Implication & Suggestion
1) These results highlight the need to evaluate
the health literacy of hemodialysis patients in Korea
considering age, education level, etc.
2) All Korean studies used different
measurements to exam health literacy. It suggest to
develop standardized measurements for Korean.
3) The current status of health literacy ofhemodialysis patients should be examined, and after
considering the variables in previous studies, the influential
factors for self-care compliance should be investigated.
Reference[1]Korean Statistical Information System: prevalence of
CKD. http://kosis.kr/wnsearch/totalSearch.(2010) assessed
October 3. 2011.
[2]Institute of Medicine. Health literacy: A prescription to
end confusion. The National Academic Press. 2004.
Washington D.C.
[3]Lee JE. Relationship between functional health literacy
and compliance for treatment in patients with diabetes
mellitus. Master thesis, A-jou University, Soo-Won, Korea,
2011[4]Park JS, Lee HS, Lee SY, Im HB & Oh HS.
Relationship between knowledge and adherence to selfmanagement guideline, and influencing factors ofadherence for hemodialysis patients. Korea J of rehab nur,
2011;14(1): 39-46.
[5]Korean Educational Development Institute. The OECD
international comparative research of Korea Adult literacy
status, 2001.Seoul.
[6]Davis TC, Long SW, Jackson RH, Mayeaux EJ, George
RB, Murphy PW, Crouch MA. Rapid estimate of adultliteracy in medicine: A shortened screening instrument.
Jour of family med, 1993; 25(6):391-395.
[7]Parker RM, Baker DW, Williams MV & Nurss JR. The
test of functional health literacy in adults:A new instrument
for measuring patient’s literacy skills. Jour of generalinternal medicine, 1995;10(10):537-541.
[8]Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA,
Pignone MP, et al. Quick assessment of literacy in primarycare:The newest Vital sign. Annals of family medicine,
2005;3(6):514-522.
[9]Lee TW & Gang SJ. Prevalence and influencing factorof elderly persons in Korea. Jour of the Korean
gerontological society, 2008; 28(4), 847-863.
[10]Kim JE. Measuring the level of health literacy andinfluence factors:Targeting the visitors of a university
hospital's outpatient clinic. Jour of Korean clin nursing
research, 2011;17(1):27-34.

[11]Hong IH. A study on health literacy of hospitalized
patients. Master thesis, Gyeong-Sang National University,
Jin-Ju, Korea, 2011.
[12]Kerri LC, Rebecca LW, Raymond MH, Svetlana E,
Ayumi S, Kenneth AW, et al. Low health literacy associateswith increased mortality in ESRD. Jour of the Amer societyof nephr, 2010;21:1979-1985.
[13]Kerri C, Rebecca LW, Raymond MH, Tom AE, Alp IT.
Patient dialysis knowledge is associated with permanentarteriovenous access use in chronic hemodialysis. Jour ofAmer society of nephr, 2009; doi:10.2215/CJN.04580908.
[14] Jamie AG, Maria KM, Anne MS, Mary AS, Paul MP,
Michael JF, et al. Prevalence and demographic and clinicalassociations of health literacy in patients on maintenancehemodialysis. Jour of Amer society of nephr, 2011;6:13541360.
[15]Yoshio N, Andy IC, Glenn MC & Andrew BB. Chronic
kidney disease in the urban poor. Jour of the Amer societyof nephr, 2010;doi:10.2215/CJN.09011209.
[16]Christian VW, Katherine K, Andrew S, & Jane W.
Functional health literacy and health promoting behavior ina national sample of british adults. Jour of Epid commhealth, 2007;61:1086-1090.
[17]David WB, Michael SW, Joseph F, Jason AT, Julie AG& Jenny H. Health literacy and mortality among elderly
persons. Arch inter med, 2007;167(14):1503-1509.
[18]Teri B. & Joseph RM. Barrier to adult hemodialysis
patients' self management of oral medications. Amer Jourof kidney disease, 2010;56(3):547-557.
[19]Shibuya A, Inoue R, Ohkubo T, Takeda Y, Teshima T,
Imai Y, et al. The relation between health literacy,
hypertension knowledge, and blood pressure among
middle-aged Japanese adults. Blood pressure monitoring,
2011;16(5):224-230.
Author address

E-Mail: adel0408@hanmail.net

LIFE ACTIVITIES IMPROVE HEART RATE VARIABILITY IN PATIENTS WITH
HYPERTENSION AND/OR HEART FAILURE
N. Nakayama, M. Hirai
Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Introduction
Recently we found the potential importance of life
activities in patients with mild hypertension and/or initialstage of heart failure1).
We will present some data
concerning these findings for possible usefulness in nursing.
Heart failure is a common, disabling syndrome, and is the
final common pathway for a number of cardiac conditions,but it is most commonly related to hypertension or
atherosclerotic disease. In the 2001 version of the ACC/AHA
guidelines, heart failure was classified on the basis of a newconcept of disease progression in heart failure. The
importance of the stage classification has been emphasized ineach subsequent revision of the guidelines. Furthermore,
appropriate treatment, early diagnosis, and early intervention
have been reported to be extremely important. In other words,
it has been emphasized that prevention is an important
treatment. The continuation of physical activity has been
demonstrated to be indispensable for prevention even with orwithout medication.
A common finding in patients with chronic heart failure
is exercise intolerance, which causes progressive functional
deterioration. There are multiple mechanisms that arepotentially responsible for the impairment of physicalcapacity. There are two important issues involved, namely
the maintenance of heart function and physical capacity.
Several prior studies have demonstrated the ability of
exercise training to improve functional capacity in patientswith heart failure2). Laterza et al. reported that exercise
training significantly reduced blood pressure in hypertensive
patients3). Most of these previous studies showed thatexercise training had positive effects on physical capacity,
health related quality of life (HRQOL), and biomarkers, andobserved relatively few complications during training. A
number of investigators have reported that comprehensive
cardiac rehabilitation has beneficial effects on mortality andphysical capacity4).
The purpose of the present study was to determine theeffects on heart rate variability (HRV) of home-based daily
activity in patients with mild hypertension and/or the stableangina pectoris and to clarify the relationship between daily
activity and sympathovagal balance.
Materials and Methods
This study was conducted from 2010 to 2011 as anonrandomized 6-month prospective longitudinal study
involving patients with mild hypertension and/or stableangina pectoris in ACC/AHA stage A, who were being
treated in primary care clinics in two different areas. Sixty
patients participated in the present study. Daily activity andHRV were measured at the start of the study (BASE) and 6
months after the start of the study (6MoA). Daily activity
was calculated according to the calorie consumption for an
active mass meter. A total of 19 participants were unable tocomplete the study protocol. Implementation of the Holter
24-hour ambulatory electrocardiograms and/or measurementof daily activities were difficult for the patients. Forty-one
patients were investigated for the final analyses.
Subjects: This study consisted of 41 patients (59 to 83 years
old; 25 men). The inclusion criteria were: (1) clinically stablestatus with mild hypertension and/or stable angina pectoris in
ACC/AHA stage A; (2) in sinus rhythm; and (3) receiving
standard medical therapy without change during the study.
Exclusion criteria included the inability to measure daily
activity, and the presence of a pacemaker, atrial fibrillation, ordementia. BASE characteristics of the study population are
given in Table 1. All patients provided written informed consent
to participate in this study. This study was approved by the
Scientific and Ethical Committee of our university..
Data analysis: Data were expressed as median and range
unless otherwise indicated. All statistical analyses were
performed using a commercial software package. For statisticalevaluation, nonparametric tests (Mann-Whitney U test,
Wilcoxon signed-rank test) were used to avoid potential errors
from non-normally distributed data. A value of p < 0.05 wasconsidered statistically significant.
Results
The daily activity increased in 23 patients (the increase(IC) group) 6MoA, while it decreased in the remaining 18
patients (the decrease (DC) group). Most of the patients in bothgroups were men (13 in the IC group, 12 in the DC group; p =0.540). Twelve patients in the IC group suffered from only
hypertension without stable angina pectoris, while 8 patients
suffered from only hypertension without stable angina pectoris
in the DC group (p = 0.756). There were 8 patients with mild
hypertension and stable angina pectoris in the IC group, and 7
patients with mild hypertension and stable angina pectoris in the
DC group. The patients in the present study were taking somemedication, but their medication did not change during thestudy period. There were no significant differences in coronary
heart disease risk factors and use of concomitant medications
between the IC and DC groups (Table 1).

Table 1. Baseline characteristics.
Increase group Decrease group(n = 23)(n = 18)

Ｐ

Age, median (interquartile range), y
70 (59-83)
72 (61-83)
0.854
Men sex, n (%)
13 (56.5)
12 (66.6)
0.540
BMI, median (interquartile range)
23(19-37)
23(18-31)
0.803
HT without AP, n
12
8
0.756
AP without HT, n
3
3
1.000
AP and HT, n
8
7
1.000
Medications, n (%)
Angiotensin Ⅱ
15 (65.2)
9 (50.0)
0.358
receptor antagonist
Calcium antagonist
13 (56.5)
12 (66.6)
0.540
Coronary vasodilator
5 (21.7)
2 (11.1)
0.438
Diuretics
2 （8.6）
3 (16.6)
0.638
β -blocker
4 (17.3)
7 (38.8)
0.164
Smoking history
4 (17.3)
1 (5.5)0.363
Abbreviations: BMI, Body Mass Index; AP, Angina Pectoris; HT, Hypertension.

There were no significant differences in HF, sleep HF,
LF/HF, and sleep LF/HF in the DC group between the BASE
and 6MoA. There were significant increases in HF in the ICgroup from BASE to 6MoA (p = 0.048). There weresignificant decreases in sleep LF/HF in the IC group fromBASE to 6MoA (p = 0.038) (Table 2).

Table 2. Autonomous nervous system indices in patients at baseline and after 6 months.
Increase group (n = 23)

Decrease group (n = 18)

Characteristics
Baseline After 6 months P
Baseline After 6 months P(ms 2 )
HF
144 (18-401) 151 (48-440) 0.048
107 (22-279) 135 (33-327) 0.151
Sleep HF
182 (51-579) 184 (71-783) 0.162
142 (24-395) 194 (18-437) 0.098
LF/HF
1.9 (0.4-4.6) 1.5 (0.7-4.8) 0.090
2.2 (0.8-6.2) 2.2 (0.7-7.2) 0.305
Sleep LF/HF
1.5 (0.4-4.3) 1.4 (0.5-3.8) 0.038
1.6 (0.5-5.2) 1.8 (0.6-5.9) 0.102
Abbreviations: HF, High Frequency at the average for 24 hours; Sleep HF, High Frequency during hours of sleep;
LF, Low Frequency; LF/HF, LF to HF ratio at the average for 24 hours; Sleep LF/HF, LF to HF ratio during
hours of sleep.
Date are presented as the median (minimum-maximun).
Discussion
This study demonstrated that home-based daily activity
had positive effects on improving the autonomous nervous
system in outpatients with mild hypertension and/or stableangina pectoris in ACC/AHA stage A. The present study also
showed that an increase in active mass was able to improve
HRV outcomes such as increased HF and decreased LF/HF
during sleep, whereas there was no statistical change with adecrease in active mass. Pagani et al. showed that in
hypertensive patients who feature clear signs of elevatedsympathetic activity, moderate exercise training decreased
the LF component of HRV while simultaneously increasing
the HF component5). The participants in the present study
were older compared to participants in previous studies, anddid not undergo exercise training. Nevertheless an increase in
home-based daily active mass was able to improve HRV.
Our results partly accord with findings that cardiac
rehabilitation was effective in patients with a mean age of 78
with coronary artery disease6). Hammill et al. demonstrated
that a significant dose-response relationship existed between
the number of cardiac rehabilitation sessions attended andlong-term outcomes among elderly patients. The average ageof the participants in the present study was 717). As shown inprevious studies, it is not clear whether participants were able
to further increase physical capacity in the present study.
However, the increase in active mass may have contributed
to the improvement in HRV.
The patients in the present study did not participate inrehabilitation in a hospital. The cost of inpatient
rehabilitative care was significantly higher than that of
outpatient care8). If the benefits obtained from outpatient
services are not significantly inferior to those of longer
inpatient rehabilitation, such outpatient approaches could
result in substantial cost reductions. Previous studies havenot indicated that hospital-based rehabilitative care hadlasting benefits9). In addition, Taylor et al. reported that
home- and center-based cardiac rehabilitation appeared to beequally effective in improving clinical and HRQOL
outcomes. This suggests that daily low intensity exercise canbe effective. Hwang et al. sought to examine theeffectiveness of home-based exercise on physical capacity inpatients with heart failure compared with conventional
medical care10). O’Connor et al. demonstrated that home-

based exercise training had a statistically significant effect on
the primary end point of all-cause mortality or all-cause
hospitalization and for the secondary end point ofcardiovascular mortality or heart failure hospitalization11).
Gando et al. reported that, with low intensity physical activity,
attenuation of arterial stiffening was greater with a high quantityof activity than with a low quantity of activity, especially in
unfit elderly people12). These results suggest that incorporating
the rehabilitation of patients in everyday life may be important.
People accumulate low intensity movement in addition towalking in everyday life. Future studies should focus on homebased low intensity exercise programs in order to further
evaluate their subtle positive effects.
Conclusions
In patients with mild hypertension and/or stable angina
pectoris in ACC/AHA stage A, an increase in active mass
improved HRV in daily life outcomes, with increased HF, anddecreased LF/HF during sleep.
References[1]Nakayama N, Negi K, Watanabe K, Hirai M. Life activities
improve heart rate variability in patients with mild
hypertension and/or the initial stage of heart failure. J Clin
Nurs, In press.
[2]Belardinelli R, Georgiou D, Cianci G, et al. Randomized
controlled trial of long-term moderate exercise training inchronic heart failure: effects on functional capacity, quality oflife, and clinical outcome. Circulation. 1999;99:1173-1182.
[3]Mateus C. L, Luciana D.N.J. de Matos, Ivani C, et al.
Exercise training restores baroreflex sensitivity in nevertreated hypertensive patients. Hypertension. 2007;1298-1306.
[4]Flynn KE, Pina IL, Whellan DJ, et al. Effects of exercise
training on health status in patients with chronic heart failure:
HF-ACTION
randomized
controlled
trial.
JAMA.
2009;301:1451-1459.
[5]Pagani M, Somers V, Furlan R et al. Changes in autonomic
regulation induced by physical training in mild hypertension.
Hypertension, 1988;12: 600 -610.
[6]Lavie CJ, Milani RV. Disparate effects of improving aerobic
exercise capacity and quality of life after cardiac
rehabilitation in young and elderly coronary patients. J
Cardiopulmonary Rehabilitation. 2000;20:235-240.
[7]Hammill BG, Curtis LH, Schulman KA, et al. Relationshipbetween cardiac rehabilitation and long-term risks of deathand myocardial infarction among elderly Medicare
beneficiaries. Circulation. 2010;121:63-67.
[8]Ottenbacher KJ, Jannell S. The results of clinical trials instroke rehabilitation research. Arch Neurol. 1993;50:37-44.
[9]Chien CL, Lee CM, Wu YW, et al. Home-based exercise
increases exercise capacity but not quality of life in people
with chronic heart failure: a systematic review. Aust J
Physiother. 2008;54:87-93.
[10]Hwang R, Marwick T. Efficacy of home-based exercise
programmes for people with chronic heart failure: a metaanalysis. Eur J Cardiovasc Prev Rehabil. 2009;16:527-535.
[11]O’conner CM, Whellan DJ, Lee KL, et al. Efficacy andsafety of exercise training in patients with chronic heart
failure: HF-ACTION randomized controlled trial. JAMA.
2009;301:1439-1450.
[12] Gando Y, Yamamoto K, Murakami H, et al. Longer timespent in light physical activity is associated with reduced
arterial stiffness in older adults. Hypertension. 2010; 56: 540546
Author address

E-Mail: nakayamanatsuki@g.mbox.nagoya-u.ac.jp

Post-trauma stress and anxiety among ICU nurses : A preliminary study
Guen Sook Lee, MSN student
Yonsei University Wonju College of Medicine, Department of Nursing, Gangwon-do, Republic of Korea

Introduction
The intensive care unit (ICU) is a stressful environment
due to high patient mortality, daily confrontations withethical dilemmas, and a tension-charged atmosphere [1]. ICU
nurses work in a demanding environment where they are
repetitively exposed to traumatic situations and stressful
events. Repetitive exposure to extreme stressors and theinability to adjust to this environment may result in thedevelopment of significant psychological problems, such as
anxiety or depression in some critical care nurses[2]. There islittle research on the psychological effects on nurses as aresult of working in the ICU[3]. The purpose of this study,
hence, was to explore the post-trauma stress and anxiety
among ICU nurses.
Materials and Methods
Descriptive research design was conducted. Using
convenient sampling, twenty-two nurses working at theintensive care unit in a general hospital participated. The
instruments were Korean version of Impact of Event Scale –Revised (K-IES-R) and Korean version of Beck Anxiety
Inventory (K-BAI). K-IES-R consists of 22 items with 5
Likert type scale ranging from 0(not at all) to 4 (often). KIES-R includes 4 subscales, which are hyperarousal,
avoidance, intrusions, and sleep & numbness[4]. K-BAI
consists of 21 items with 4 Likert type scale ranging from 0(not at all) to 3(severely)[5]. For data analysis, descriptive
statistics and correlational analysis were done.
Results
General characteristics of ICU nurses are shown in table 1.
In this preliminary study, the common traumatic experiences
encountered for one year period were stress related to not
being able to save a specific patient (n = 20, 91%), seeing
patients die (n = 19, 86%), verbal abuse from family
caregivers (n = 17, 77%), and verbal abuse from physicians
and nurses (n = 17, 77%). Seventeen of the 22 (77%) nurses
have been having traumatic experiences more than and equal
to 3 episodes during one year. For the severity of
posttraumatic stress reaction, the average IES-R score in thissample was 1.0. Among 4 subscales, the mean score of
intrusion subscale was 1.2, which was the highest. In the
intrusion subscale, mean of ‘any reminder brought backfeelings about it’ item was 1.9, the highest score. For anxiety,the mean score of ‘nervous’ item was 1.0, which was thehighest among 21 items. No significant relationships were
found between demographic factors and traumatic
experiences, suggesting that everyone would have an equalchance of being affected by traumatic events in the ICU.
There was a statistically significant correlation between
posttraumatic stress reaction and anxiety (r = .425, p < .05),
indicating that the more post-traumatic stress, the higher
anxiety occurs.

Table 1. General characteristics of participants
Variable
GenderMale
FemaleAge(years)
21-30
≥ 31
Marital status
MarriedSingleReligion
Yes
No
Education in nursing
Diploma
BSN
Clinical experience(years)
≤1
1-5
6-10
> 10
ICU experience(years)
≤1
1-5
6-10
> 10

n (%)

(N = 22)

Mean ± SD

4 (18.2)
18 (81.8)
14 (63.6)
8 (36.4)

30.0 ± 5.32

8 (36.4)
14 (63.6)
16 (72.7)
6 (27.3)
6 (27.3)
16 (72.7)
4 (18.2)
7(31.8)4 (18.2)
7 (31.8)

6.6 ± 5.77

7 (31.8)
7 (31.8)
6 (27.3)
2 ( 9.1)

3.6 ± 3.42

Conclusions
In recent, the traumatic events are more prevalent in ICU
nurses. In this study, ICU nurses who had more post-traumaticstress experienced high anxiety. These findings may haveimportant implications regarding methods that could reduce
psychological problems (i.e., anxiety, depression) and could
enhance job satisfaction for ICU nurses. Further studies that
determine the specific characteristics that predispose individuals
to the development of psychological problems and identify
specific interventions for these individuals are warranted.
References[1]Moola S, Ehlers VJ, Haltingh SP. Critical care nurses`
perceptions of stress and stress related situation in theworkplace. Curations. 2008;31(2):77-86.
[2]Mealer ML, Shelton A, Berg B, Rothbaum B, Moss M,
Increased prevalence of post-traumatic stressdisordersymptoms in critical care nurses. American Journal of
Respiratory and Critical care medicine. 2007;175:693-697.
[3]Kerasiotis B, Motta RW. Assessment of PTSD symptom inemergency room, intensive care unit, and general floor nurses.
International Journal of Emergency Mental Health.
2004;6(3):121-133.

[4] Eun HJ, Kwon TW, Lee SM, Kim TH, Chio MR, Cho SJ.

A study on reliability and validity of the Korean version of
impact of event scale revised. J Korean Neuropsychiatr
Assoc.2004;44(3):303-310.
[5]Yook SP, Kim ZS. A clinical study on the Korean versionof Beck anxiety inventory : comparative study of patientand non-patient. Korean Journal of Clinical Psychology.
1997;16(1):185-197.
Author address

E-Mail:eormsdl00@naver.com

FACTORS RELATED TO MUSCULOSKELETAL SYMPTOMS AMONG FEMALE
FAMILY CAREGIVERS
K. Suzuki, K. Tamakoshi
Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
Introduction
Japanese society is aging rapidly. Long-Term Care
Insurance Act was enforced in 2000 to resolve the problemof an aging society by the socialization of caregiving. After
that, the caregivers have used various services, while they arehaving various mental and physical symptoms. The
musculoskeletal symptoms such as stiffness in the shoulder
and lumbago are major ones among the family caregivers.
However, the association between caregiving andmusculoskeletal symptoms remains unclear because those
symptoms are popular even among elderly noncaregivers. In
addition, the lifestyle factors related to musculoskeletal
symptoms among elderly females also remain to be discussed.
The purpose of this study is to clarify the lifestyle factors
associated with musculoskeletal symptoms and to elucidate
the contribution of caregiving to the onset of musculoskeletal
symptoms among elderly females.
Methods
Study population: Study subjects consisted of 160
female in-home primary caregivers for persons requiring care
at level 3 or suffering from dementia (caregiver group) and
160 noncaregiver females matched 1:1 in the same decade oflife (noncaregiver group). Average age was 62.8 ± 11.9 years
in the caregiver group and 63.0 ± 12.2 years in the
noncaregiver group. They were asked to fill out a selfadministered questionnaire about lifestyle and health status,
including musculoskeletal symptoms.
Study variables: Participants were asked, “Do you have
stiffness in the neck, shoulder, or back?”, “Do you have painor stiffness of muscle and joint?”, and “Do you havelumbago?” about musculoskeletal symptoms. Our
questionnaire also included several other items covering
demographics such as: age, body weight and height,
menopausal status, current employment (Yes/No), perceived
stress (Yes/No), sleep disturbance (Yes/No), hypertension(Yes/No), regular exercise (Yes/No), smoking status(Current/Former or Never), and alcohol consumption(Current/Former or Never).
Statistical methods: To elucidate the differences in study
variables between caregiver and noncaregiver groups, we
calculated proportions, means, and standard deviations. Chisquared test or Student’s t-test was performed to explore thepotential association of caregiving with study variables. Next,
320 study subjects were divided into two groups by thepresence or absence of the musculoskeletal symptoms which
present the significant differences between caregiver andnoncaregiver groups. We aimed to elucidate the factors
related to musculoskeletal symptoms. So we computed theodds ratios (ORs) and 95% confidence interval (CI) of
musculoskeletal symptom for each study variable using
logistic regression analysis. Furthermore, multiple logistic
regression analysis was performed to identify variables
independently associated with musculoskeletal symptoms.
The multiple logistic regression model included the variables
whose crude ORs were significant.
All analyses were performed using the SPSS 17.0
statistical package. P<0.05 was considered statisticallysignificant.

Results
Table 1 shows comparisons of characteristics between
female caregivers and noncaregivers. As for musculoskeletal
symptoms, the proportions of subjects with stiffness in the neck,shoulder, or back and those with lumbago in the caregivers(60.6% and 55.0%, respectively) were significantly higher thanin the noncaregivers (46.9% and 33.8%, respectively). The
proportions of subjects who felt stress and who had sleep
disturbance in the caregivers were significantly higher than in
the noncaregivers. More subjects in the caregivers had
hypertension. The proportions of subjects who were employed
and who exercised regularly were significantly lower in the
caregivers.
Comparisons of characteristics between persons with andwithout stiffness in the neck, shoulder, or back and ORs (95%
CI) for stiffness in the neck, shoulder, or back are presented inTable 2. Caregiving, perceived stress, and sleep disturbancewere significantly and positively associated with stiffness in theneck, shoulder, or back. Additionally, age, BMI, menopause,and regular exercise were significantly and negatively
associated with it. After multivariate-adjustment, perceived
stress [OR (95% CI) =1.85 (1.06-3.21)], sleep disturbance [OR(95% CI) =2.23 (1.30-3.83)], and regular exercise [OR (95%
CI) =0.52 (0.31-0.85)] were still significantly associated withstiffness in the neck, shoulder, or back. The association ofcaregiving with stiffness in the neck, shoulder, or back wasattenuated.
Table 3 shows comparisons of characteristics between
persons with and without lumbago and ORs (95% CI) for
lumbago. Caregiving and perceived stress were alsosignificantly and positively associated with lumbago and regularexercise was also significantly and negatively associated withlumbago. After multivariate-adjustment, caregiving [OR (95%
CI) =1.94 (1.19-3.14)] and perceived stress [OR (95% CI)=1.73 (1.01-2.94)] were mutually and independently associatedwith lumbago.
Discussion
In our study, we found that family female caregivers felt
more stress, had more sleep disturbance, and exercised lessregularly than female noncaregivers. It was also found thatfemale caregivers had higher proportion of stiffness in the neck,shoulder, or back and lumbago than female noncaregivers.
Furthermore, we elucidated some factors related to
musculoskeletal symptoms among elderly females. Perceived
stress, sleep disturbance, and regular exercise were significantly
associated with stiffness in the neck, shoulder, or back.
Perceived stress was significantly associated with lumbago
independent of caregiving. These findings suggest that morestress, more sleep disturbance, less regular exercise in female
caregivers may lead to their musculoskeletal symptoms. It is
well known that the causes of stress, sleep disturbance, and lackof exercise in caregivers are different from those innoncaergivers. Therefore, information and support for eachfemale caregiver should be proposed in consideration of her
situation and according to her needs
Another important finding in our study was that caregiving
was independently associated with lumbago. Lumbago may be
associated with factors specific to the caregiving situation otherthan lifestyle. It is necessary to conduct further studies on theassociation between musculoskeletal symptoms and the
caregiving situation among caregiver group.
Conclusion
More female in-home primary caregivers felt stiffness inthe neck, shoulder, or back and lumbago than noncaregiver
females. The stiffness of the neck, shoulder, or back wassuggested to be due to stress, sleep disturbance, and lack of
exercise in female caregivers, while lumbago may be
associated with factors specific to the caregiving situation
other than lifestyle besides stress.
Acknowledgment
We are deeply grateful to Prof. Y. Hori, Prof. H.
Sakakibara, and Prof. K. Ota for their supports.
References[1] Ministry of Health, Labour and Welfare. Comprehensive
Survey of Living Conditions of the People on Health andWelfare：2010.
http://www.mhlw.go.jp/english/database/db-hss/cslc.html
Author address
E-Mail: suzuki.kishiko@j.mbox.nagoya-u.ac.jp

Table1 Comparisons of characteristics between female caregivers and noncaregivers.

Demographics
Age
Height (cm）Weight （kg）

Family caregiver（n ＝160）
Mean ± SD
number（%）

Noncaregiver（n ＝160）
Mean ± SD
number（%）

p value

62.8 ± 11.9
152.8 ± 5.6
52.3 ± 7.9
22.4 ± 3.1
136 (85.0%)
37 (23.1%)

63.0 ± 12.2
151.5 ± 6.4
52.2 ± 7.5
22.8 ± 3.3
131 (81.9%)55 (34.4%)

ns
*
ns
ns
ns
*

75 (46.9%)*

53 (33.1%)
54 (33.8%)
88 (55.0%)
56 (35.0%)
37 (23.1%)

ns
**
**
*
*

BMI (kg/m2）
Menopause (Yes)
Current employment (Yes)
Health status
Stiffness in the neck, shoulder, or back (Yes)
97 (60.6%)
Pain or stiffness of muscle and joint (Yes)
69 (43.1%)
88 (55.0%)
Lumbago (Yes)
135 (84.4%)
Perceived stress (Yes)
74 (46.2%)
Hypertension (Yes)
61 (38.1%)
Sleep disturbance (Yes)
Lifestyle53 (33.1%)
Regular exercise (Yes)
37 (23.1%)
Alcohol consumption (Current)
8 (5.0%)
Smoking status (Current)

92 (57.5%)
46 (28.8%)
6 (3.8%)**ns
ns
P values were calculated using chi-square test for categorical data and t-test for quantitativedata.
*: p<0.05 **: p<0.01; ns: not significant

Table 2 Comparisons of characteristics between persons with and without stiffness in the neck, shoulder, or back and odds ratios (95% confidence
interval) for stiffness in the neck, shoulder, or back.
With stiffness in the neck,
Without stiffness in the neck,P
Crude OR (95% Multivariate ORshoulder, or back （ n ＝172）
shoulder, or back （ n ＝148）
value
Mean ± SD
Mean ± SD
CI)(95%CI)
number（ % ）number（ %）Demographics
60.6±12.565.5±11.0
Age** 0.96 （ 0.94-0.99） ＊ 0.97 （0.95-1.00）
222.2±2.923.1±3.5* 0.93 （ 0.86-1.00） ＊ 0.94 （0.87-1.02）
BMI (kg/m ）*136 (79.1%)
131 (88.5%)
Menopause (Yes)*
0.95 (0.38-2.38)
0.49 （ 0.26-0.92）
50 (29.1%)
42 (28.4%)
Current employment (Yes)ns1.03 (0.64-1.68)
97 (56.4%)
63 (42.6%)
Caregiving (Yes)*1.75 (1.12-2.72)＊ 1.12 （0.67-1.87）
Health status
136 (79.1%)
87 (58.8%)
Perceived stress (Yes)** 2.65 (1.62-4.33)* 1.85 （ 1.06-3.21） ＊69 (40.1%)
61 (41.2%)
Hypertension (Yes)ns0.96 (0.61-1.49)*
63 (36.6%)35 (23.6%)
Sleep disturbance (Yes)*
1.87 (1.14-3.05) 2.23（ 1.30-3.83）＊
Lifestyle62 (36.0%)
83 (56.1%)
Regular exercise (Yes)** 0.44 (0.28-0.69)* 0.52 （ 0.31-0.85) *49(28.5%)
34(23.0%)
Alcohol consumption (Current)ns
1.34 (0.81-2.22)
Smoking status (Current)
9 (5.2%)5 (3.4%)ns
1.58 (0.52-4.82)
P values were calculated using chi-square test for categorical data and t-test for quantitative data.
Dependent variable: stiffness in the neck, shoulder, or back (0: no; 1: yes)
Explanatory variable: age (continuous), BMI (continuous), menopause (0: no; 1: yes), current employment (0: no; 1: yes), caregiving (0: no; 1: yes),perceived stress (0: no; 1: yes), hypertension (0: no; 1: yes), sleep disturbance (0: no; 1: yes), regular exercise (0: no; 1: yes), alcohol consumption (0:former/never; 1: Current), and smoking status (0: former/never; 1: Current).
*: p<0.05 **: p<0.01; ns: not significant
Table 3 Comparisons of characteristics between persons with and without lumbago and odds ratios (95% confidence interval) for lumbago.

Demographics
Age2

BMI (kg/m ）Menopause (Yes)
Current employment (Yes)
Caregiving (Yes)
Health status
Perceived stress (Yes)Hypertension (Yes)
Sleep disturbance (Yes)
Lifestyle
Regular exercise (Yes)
Alcohol consumption (Current)
Smoking status (Current)With lumbago（ n ＝142）

Without lumbago（ n ＝178）

Mean ± SD
number（ %）Mean ± SD
number（ %）63.1±11.6
22.7±3.3
119 (83.8%)
34 (23.9%)
88 (62.0%)

P
Crude OR (95%
value
CI)

Multivariate OR(95%CI)62.7±12.4
22.5±3.1
148 (83.1%)
58 (32.6%)
72 (40.4%)

ns
ns
ns
ns
**

2.40 (1.53-3.77)

1.94 （ 1.19-3.14） ＊112 (78.9%)
58 (40.8%)
48 (33.8%)

111 (62.4%)
72 (40.4%)
50 (28.1%)

*
ns
ns

*
2.25 (1.36-3.73) 1.73 （ 1.01-2.94） ＊1.02 (0.65-1.59)
1.31 (0.81-2.11)

54 (38.0%)
35 (24.6%)9 (6.3%)91 (51.1%)
48 (27.0%)
5 (2.8%)*ns
ns

0.59 (0.38-0.92)
0.89 (0.54-1.47)
2.34 (0.77-7.15)

1.00 (0.98-1.02)
1.02 (0.95-1.09)
1.05 (0.58-1.90)
0.65 (0.40-1.07)**

0.74（ 0.46-1.18）

The role of nurses in trauma teams
Suk Chan Kim, MSN student
Yonsei University Wonju College of Medicine, Department of Nursing, Gangwon-do, Republic of Korea

Introduction
Since prompt treatment of trauma after various accidents
is critical in preventing further injuries and reducing deathrate, it is required to establish emergency medical system andraise trauma treatment levels of emergency medical
professionals[1].
Establishing a trauma center is the heart of creating
trauma treatment system. Well-established trauma treatment
system is still developing by continuous improvement, which
is a result of ceaseless effort as well as designating severe
trauma centers[2].
Medical professions working in trauma teams can bevarious in its propotion depending on the scale of trauma
center, but some specialists are necessary at least as below.
Any professions in the team treats trauma in association withother professions[3].
a. Trauma physician
b. Emergency medical physician
c. Anesthesiologist
d. Neuro-surgery, Orthopedic surgery specialiste. ICU Specialistf. Radiology specialist
g. Residents for each speciality above
h. Emergency RN
i. Medical record officer
j. Medical Laboratory Technologistk. Radiographerl. ICU RN
m. OR RN
n. Administration, Social worker and Security
Yonsei University Wonju Christian Hospital runs a
trauma team to meet the demand of a growing number oftrauma patients and tries to be designated as a regional
trauma center. When a trauma patient arrives at ER,
messages are sent to GS, CS, NS, OS, PS, Anesthesiologist
and chief residents through OCS(order communication
system) in the present system[3]. But there is no policy or
written forms to define criteria of role or duty of RN in
trauma team.
The purpose of this study was to review the role of thenurses in trauma teams in domestic and compare it withoversea cases.
Materials and Methods
Subjects: The database PubMed (provided by US
National Library of Medicine), RISS (provided by Korea
Education and Research Information Servise) and KISS
(Koreanstudies Information Servise System) were used tosearch for the terms trauma team, trauma center and role of
RN in abstracts published from 2001 up to present date.
Data analysis: Five studies were found to be eligible
showing the status of current trauma team and 2 of 5 studies
were reviewed to compare the roles of RN in the trauma teamin domestic and abroad.

Results
When a trauma patient arrives at ER, it’s often difficult totreat multiple or severe trauma systematically and promptly
because little experienced physicians are often responsible forprimary treatment with the current medical system. In 1999, theresult of the survey for trauma patient death status revealed thePDR (preventable death rate) reached 40.5% in domestic cases[4].
About the roles and duties of trauma team members, Lee has
explained some profession’s (as listed left) roles and duties indetail in his research related to establishing severe trauma center.
But he didn’t mention about the specific roles of RN who takes
care of the trauma patient at hand in the team except RNs in
ICU and ER[5].
On the contrary, in the guideline for trauma team of the
University of Florida, it explained its roles, report system andresponsibility of RN with 22 other professions in trauma teamvery specifically, classifying RN into chief nurse, bed side nurse
and scribe nurse[6].
Conclusions
As two different literature above has showen, the awarenessof the significance of RN's role in trauma team is absent indomestic research, while not in another oversea guidline.
Considering the domestic circumstance that the concept of
trauma team is still premature and the role of RN in the team is
uncertain, there is a strong need of detailed complement andprospective further studies as Lee[7] has suggested in his
research to define te roles of RN in trauma teams so that
advance RN’s speciality in Korean trauma treatment system.
References[1]The Korean Society of Traumatology. Traumatology 2nd ed.
2005. Seoul : Gunja Publish.
[2]Acosta JA, Yang JC, Winchell RJ, Simons RK, Fortlage DA,
Hollingsworth-Fridlund P, Hoyt DB. Lethal injuries and time
to death in a level I trauma center. Journal of the American
College of Surgeons. 1998; 186(5) : 528-533.
[3]Lee DK, Lee KH, Cha KC, Park KH, Choi HJ, Kim H,
Hwang SO. Effectiveness of simple trauma team activation
criteria on prognosis of severe trauma patients. Journal of
the Korean Association of Traumatology. 2009; 22(1), 71-76[4]Jung GY, Kim JS, Kim Y. Problems in trauma care andpreventable deaths. Journal of the Korean Association ofTraumatology. 2001;12(1):45-56.
[5]Lee KJ, Kim JY, Lee, Suh GJ, Youn YK. Review article :general scheme for the level I trauma center in south korea.
Journal of the Korean Association of Traumatology.
2005;18(1): 1-16.
[6]Delineation of Roles for Trauma Team Members, University
of Florida, 2005.
[7]Lee SH, Cho SJ, Yeom SR, Ryu JH, Jung JW, Han SK, Kim
YI, Park MR, Kim YD. Effect of the emergency trauma
team`s management on the treatment of patients withmultiple severe trauma. Journal of the Korean Association ofTraumatology. 2009;22(2):172-178.
Author address: E-Mail: sokchan@hanmail.net

Memo

ASSOCIATION BETWEEN WORK ENVIRONMENT AND
RESIGNATION INTENTION OF VISITING NURSES
K. Mori1), H.Sakakibara1)
1) Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya, Japan
Introduction
In Japan, home-visit nursing station is responsible for its
central role in the transition to home medical care. Homevisit nursing makes it possible to lead a life with home care.
It brings various benefits, since it brings comfort andimproves the QOL and reduces the burden of caring byfamily. On the other hand, the high rates of turnover ofhome-visiting nurses have become clear, so it is necessary to
backup and devise for securing a stable human resources.1,2
In general, the work environment and the resignation
intention have an influence each other. In this study, we
focused on work environment which includes thesegmentalized work characteristics. We referred tocomponents of job satisfaction and situation of home-visiting
nurses, relevant factors have been confirmed by early studies.
We aimed to clarify the factors that for work environmentand resignation intention of home-visiting nurses.

Relevant factors of resignation intention: (Table 1)
1) Demographic characteristics: educational backgrounds(p=0.005), years of experience as a nurse (p=0.033),
Health conditions (p=0.018), number of visiting cases in aweek (p=0.015).
2) Nakano’s Job Satisfaction Scale: job satisfaction in total(p=<0.001), Factor 1: Specialties (p=0.007), Factor 2:
Management (p=0.001), Factor 3: Human relations(p=0.007), and Factor 4: Intentionality (p=0.001).
Table 1 Relevant 18 items of resignation intention
among 28 items of Nakano’s Job Satisfaction Scale (n=284)

Results
The number of cooperated stations was 62. We sent 471
questionnaires, and obtained 306 responses (response rate:65 %). After editing, the number of valid questionnaires was
284. Cronbach's coefficient alpha of Nakano’s Job
Satisfaction Scale were 0.87 in total, 0.88 for factor1, 0.87
for factor 2, 0.81 for factor 3, and 0.88 for factor 4. With
those high rates, internal consistency of the scale wasconfirmed. Number of nurses who had current resignation
intention was 73 (25.7%), while that of those who did not
was 211(74.3%).

95%CI
Min
Max

0.514

0.285

0.926

0.027

0.373

0.173

0.805

0.012

0.426

0.232

0.781

0.006

0.498

0.281

0.885

0.017

0.443

0.214

0.915

0.028

0.426

0.238

0.764

0.004

0.359

0.201

0.642

0.001

Factor1: Specialties
D3
D4

Methods
Primary research: We called approximately 100
administrators of home-visit nursing stations, requested forcooperation to this investigation and obtained the number of
employees as home-visiting nurses in the station.
Secondary research:We conducted a self-administeredanonymous questionary investigation to the home-visiting
nurse by mail or bringing the document to 62 stations where
research cooperation agreement had been obtained byprimary research. Questionnaire items consisted ofdemographic characteristics, Nakano’s Job Satisfaction
Scale3 (4 factors, 28 items), job satisfaction (scale D 8 items)
that was uniquely-designed, segmentalized burdens (scale E
26 items) of home-visiting nursing which were also
uniquely-designed, the intention of resignation for the past
six months, current resignation intention, and feeling ofsatisfaction as a home-visiting nurse.
Analysis: The resignation intention was coded as [Yes] or[No] according to the current intention. Nakano’s Job
Satisfaction Scale score was categorized into [High degree ofsatisfaction] or [Low degree of satisfaction]. Job satisfaction
scale (D:8items) score was also categorized into [Highdegree of satisfaction] and [Low degree of satisfaction].
Score of segmentalized burdens (E: 26 items) of home-visit
nursing were categorized into [High burden] or [Low burden].
We mainly used Chi-square test, Mann-Whitney test, andmultiple logistic regression analysis.

OR

D6
D7
D9
D10
D12

「Exact assessment」「Explanation for exact selfdecision」「Professional knowledge andtechnical skill」「Specific assessment of
nursing」「Self-care coaching」「Effort to positively affectthe workplace」「Self-active effort to career」

0.007

Factor2: Management
D14
D15
D16
D17
D19
D20

「Effort to improve thequality of care in the station.」「Fully deliver the concept
and policy in the station」「Support for career in thestation」「Listen to opinion of juniorstaff in the station」「Appropriate advice byadministrator」「Trust relationship between
administrator and staff」

0.001
0.189

0.097

0.371

<0.001

0.291

0.158

0.535

<0.001

0.396

0.214

0.733

0.003

0.477

0.256

0.889

0.020

0.328

0.165

0.656

0.002

0.366

0.193

0.695

0.002

Factor3: Human relations
D23
D24「Burden of contact with thefamily of the user」「Dilemma between the
doctor and user」

0.007
0.447

0.254

0.787

0.005

0.562

0.321

0.982

0.043

Factor4: Intentionality
D26
D27
D28

「Like work in home-visit
nursing」「Be suited for home-visit
nursing」「Rewarding to home-visit
nursing」

pvalue

0.001
0.145

0.052

0.406

<0.001

0.117

0.057

0.242

<0.001

0.176

0.072

0.430

<0.001(By multiple logistic regression analysis, adjusting for age,educational backgrounds and years of experience as a nurse.)

3)
4)
5)
6)

Job satisfaction D of 8 items:7 out of 8.
Segmentalized burdens E of 26 items of home-visiting
nursing: 12 out of 26.
Resignation intention for the past six months (p<0.001).
Feeling of satisfaction as a home-visiting nurse (p<0.001).

Discussion
As shown in Table 1, Nakano’s Job Satisfaction Scale had
a close association with resignation intention. All four factors
were significantly related with the intention. Among them,
particularly Factor 2: Management and Factor 4:
Intentionality showed a strong relation with resignation
intention. Hence, we can infer that home-visiting nurses
would make much account of management and intentionality
in the job for the consideration of resignation.
Among uniquely-designed job satisfaction scale (D of 8
items) and segmentalized burdens scale (E of 26 items) of
home-visiting nursing, 19 items were significantly associatedwith resignation intention. We divided these 19 items into 5
categories, i.e. 1: education, 2: characteristic of the station, 3:
human relations, 4: conditions of employment, and 5:
characteristic of the home-visit nursing (Table 2).
As regarding education, inadequate or poor education
system in the home-visiting nursing business field might bemore likely to lead to resignation. Strong needs of education
were shown for improving specialties and their career of thehome-visit nurse. Nurses would want to improve their own
ability of nursing care at user’s house. It is, hence,necessary to create various educational occasions includingcase conference, in order to appropriately cope with eachcase by themselves , particularly acute deterioration of thecase.
As regarding characteristics of home-visit nursing stations,improvements in management solution and understanding of
the operation concept of the station would be important for
reducing the resignation of nurses. Nurses may want to havemore worthwhile possibility of home-visit nursing work withsupports from the station they work. Furthermore, concretely
speaking, it would be necessary to expand necessary
equipments (such as visiting car, PC and others) in the station
environment, and to have nurses less feel anxiety about the
management and situation of station revenue.
As to human relations, nurses tended to feel more burdensof having contact with the user’s family. We found that theposition and role of the family is large in home-visit nursing
care. Hence, the communication skills to the user and familyneed to be improved. In addition, improvement of skills forcollaboration with colleagues and other professions are also
required.
Among conditions of employment, proper working
conditions and assuring holidays will be necessary. As
regarding specific characteristics of home-visit nursing,particularly a wide range of determination that the user andfamily have was shown as nurses’ burdens. Short visitingtime and user’s home conditions such as materials andsanitation and drugs at user’s home need to be also
considered.
Each factor relevant to resignation intention revealed by
the present survey is considered to have influence on eachother comprehensively. It will be further necessary tomeasure the overall relationship. But the present findings
would be helpful for better operation of home-visit nursing
station to reduce the resignation of home-visiting nurses.
Conclusions
Job satisfaction had strong influence on nurses’ resigning
will in all four factors, especially in Factor 2: Management
and Factor 4: Intentionality. Among uniquely-designed,
segmentalized burdens of home-visiting nursing, we foundsignificant associations in 19 items, that were classified into
five categories: 1: education, 2: characteristics of the station,
3: human relations, 4: conditions of employment, and 5:
specific characteristics of the home-visit nursing. These

factors could be helpful for improving the management andenhancement of human resources in the home-visit nursing
business.
Table 2 Factors relevant to resignation intention
in original 5 categories (n=284)
OR

95%CI
Min
Max

pvalue

0.316

0.152

0.657

0.002

1.816

1.025

3.216

0.041

1.991

1.111

3.571

0.021

4.076

2.269

7.324

<0.001

2.956

1.584

5.518

0.001

0.548

0.313

0.959

0.035

0.327

0.178

0.599

<0.001

3.066

1.687

5.569

<0.001

2.101

1.196

3.688

0.010

0.500

0.276

0.906

0.022

0.345

0.170

0.701

0.003

2.639

1.493

4.664

<0.001

0.556

0.313

0.987

0.045

0.474

0.268

0.836

0.010

2.819

1.508

5.268

<0.001

2.583

1.432

4.659

0.002

1.821

1.035

3.202

0.037

1.860

1.032

3.353

0.039

1.856

1.023

3.369

0.042

1:Education
D35
E2
E6
E18
E26

「Occasion for case study」「Burden of home-visit anddecision by itself」「Burden of patient’s wide
variety diseases」「Burden of inadequate
educational system」「Burden of expedient treatment
and coping 」

2: Characteristic of the station
D33
D34
E16
E17

「Participate in policies andprograms of the station」「Possibilities of the station」「Burden of Handling of
personal information at
inside and outside the station 」「Burden of inadequate station
environment」

3: Human relations
D30
D36
E15

「Relationship with the doctor」「Human relations in thestation」「Burden of make a trust
relationship with otherprofessions」

4: Conditions of employment
D29「Feel about salary」「Satisfaction with conditions
D32
of employment」「Burden of difficult to take a
E10vacation」
5: Characteristic of the home-visit
nursing「Burden of user and family
E7
have wide range ofdetermination」「Burden of short time to homeE12
visit」「Burden of inadequate medical
E13
equipment, medicine andhygiene product」「Burden of maintaining
E25
sanitary conditions by itself」(By multiple logistic regression analysis, adjusting for age,educational backgrounds and years of experience as a nurse.)

References[1] The National Association for Home-visit Nursing care.
Research Project Survey and strengthen the foundations of
nursing office visit, national survey on the status of plant
management activities of visiting nursing. 2010.
[2] Sato M. Transition of home-visit nursing , Home-visit
Nursing White Book. 2002:11-18[3] Nakano Y. The relation between retention and job
satisfaction of visiting nurse. University Of Hyogo,College Of
Nursing Art And Science&Research Institute Of Nursing CareFor People And Community Bulletin. 2008:15. 43-59
Author address
yoshida.konami@e.mbox.nagoya-u.ac.jp