Understanding and measuring nurses' professionalism: Development and validation of the Nurses' Professionalism Inventory.

AIMS: To develop a self-report assessment inventory to evaluate nurses' professionalism and test its validity and reliability. BACKGROUND: Professionalism is essential for nurses' development. To promote professionalism, evaluation indices must be developed. METHODS: The Nurses' Professionalism Inventory (NPI) was constructed through a literature review and interviews with expert nurses and other medical personnel. An anonymized cross-sectional survey that included this inventory was administered to 5,739 nurses in hospitals throughout Japan. RESULTS: A total of 4,183 (72.8%) questionnaires were returned, of which 3,655 (63.7%) with valid responses were used for further analyses. The Nurses' Professionalism Inventory consists of five subscales containing 28 items: (a) accountability, (b) self-improvement, (c) professional attitude, (d) advancement of the nursing profession and (e) professional membership. The internal consistency reliability (Cronbach's alpha) ranged from 0.84 to 0.90. Confirmatory factor analysis revealed that this five-factor structure had good fit. The test-retest intraclass correlations were consistently greater than 0.6. CONCLUSIONS: The Nurses' Professionalism Inventory is valid and reliable. IMPLICATIONS FOR NURSING MANAGEMENT: The Nurses' Professionalism Inventory could be used to evaluate changes in nurses' professionalism and programmes designed to promote nurses' professionalism.

Clinical practice and work-related burden among second career nurses: A cross-sectional survey.

AIMS AND OBJECTIVES: To explore the differences in clinical practice activities and work-related burden between nurses with past work experience other than nursing (second career nurses: SCNs) and nurses without any past work experience (nonsecond career nurses: NSCNs). BACKGROUND: The number of SCNs is increasing. Some studies note that SCNs must perform additional clinical practice activities and experience more work-related burden than NSCNs. However, there are no quantitative studies exploring SCNs' clinical practice and work-related burden. DESIGN: A cross-sectional survey. METHODS: Research was conducted according to the STROBE statement. Participants were 2,013 nurses working at 56 hospitals in Japan. A 30-item questionnaire was developed to capture clinical practice activities using clinical ladders, asking about the types of clinical practice activities participants had practiced. Every practiced activity received a score of 1. The total count of each clinical practice activity was then summed. The quantitative workload (QW) scale score was used to investigate levels of QW. Higher QW scores indicated higher levels of work-related burden. These variables were then compared between SCNs and NSCNs, and the factors that were associated with high QW among SCNs were examined. RESULTS: Altogether, 961 participants (328 SCNs and 633 NSCNs) were included in the analyses. No significant differences were shown in clinical practice activities between the groups; however, SCNs' QW was significantly higher than was NSCNs' after controlling for demographic variables. SCNs' high QW was associated with the following variables: unmarried marital status, not having role model nurses and previous employment as a care worker. CONCLUSIONS: Quantitative workload was significantly higher among SCNs than among NSCNs. Tailored support for SCNs' high QW based on their specific needs should be considered. RELEVANCE TO CLINICAL PRACTICE: These results can help nurse managers reduce SCNs' work-related burden and illustrate future research directions for this minority group.

Nurses' and Care Workers' Perception of Care Quality in Japanese Long-Term Care Wards: A Qualitative Descriptive Study.

Despite the growing importance of long-term care for older adults, there has been limited attention to its quality assurance issues in Japan. To start planning the initiation of continuous quality improvement in long-term care hospitals, we explored how nurses and care workers themselves perceived current approaches to quality assurance and improvement on their ward. We interviewed 16 licensed nurses and nine care workers, transcribed and analyzed data using qualitative content analysis techniques, and derived six categories: keeping clients alive is barely possible, the absence of a long-term care practice model, the lack of quality indicators, long-term care hospitals as places for castaways, client quality of life as a source of satisfaction, and conflict between staff and client well-being. To develop continuous quality improvement in Japanese long-term care hospitals, it may be first necessary to introduce a practice model of long-term care and mechanisms to evaluate quality.

A Cyclic Model Describing the Process of Sustaining Meaningfulness in Practice: How Nurses Continue Working at One Home Care Agency.

This study aimed to elucidate the experiences of home care nurses who had continued working a single agency, to gain insight into the prevention of premature turnover. We adopted a grounded theory approach to qualitative exploration of the experiences of 26 Japanese nurses working in a home care agency, using semistructured interviews and participant observation. Nurses' experience progressed through three phases: "encountering difficulty," "enjoying the fruitfulness," and "becoming dissatisfied." Nurses' cognitive rounding involving these phases was conceptualized as "cycle of sustaining meaningfulness." To move from encountering difficulty to enjoying the fruitfulness, nurses needed to discover the meaningfulness of practice, and to move from becoming dissatisfied to encountering difficulty, they needed to requestion their practice. During their time at the agency, nurses progressed through the phases of the cycle of sustaining meaningfulness repeatedly. Knowing the point at which nurses are in the cycle and assisting their further progress could aid in their retention.

Work values and their association with burnout/work engagement among nurses in long-term care hospitals.

AIMS: To examine burnout and work engagement among nurses in Japanese long-term care hospitals and their relation to nurses' and organisational work values, and nurse-organisation congruence of such values. BACKGROUND: Nursing managers must help improve nurses' well-being; however, no research has considered strategies to improve staff outcomes in long-term care hospitals. We propose that individual nurse's work values and the congruence of these values with those of their organisations may influence burnout and work engagement. METHODS: We conducted a cross-sectional survey of nurses in long-term care hospitals. Multiple regression analyses were conducted to examine the effects of nurses' work values and nurse-organisation congruence in these values on burnout and work engagement. RESULTS: Higher individual intrinsic and altruistic work values were associated with improvements in nurses' burnout and work engagement. Nurse-organisation non-congruence in altruistic values was associated with lower work engagement, whereas that of intrinsic work values was not associated with either outcome variable. CONCLUSION: Promoting intrinsic and altruistic work values among nurses could be effective for improving both burnout and work engagement. IMPLICATIONS FOR NURSING MANAGEMENT: Opportunities such as case conferences could foster intrinsic and altruistic work values through the review of good care practices and communication between managers/colleagues about feelings and thoughts.

The Experience of Persons With Hematological Malignancy When Communicating With Health Care Professionals.

This study aimed to elucidate the experiences of Japanese persons with hematological malignancy (PHMs) in communicating with health care professionals (HCPs), from diagnosis to the end of life, as recalled by their families. We interviewed 14 bereaved families and analyzed the data using the basic techniques of grounded theory. We found that PHMs lived to the fullest possible when they experienced ownership of their illness process despite their disease. The ownership was made possible by active communication from HCPs: first, acknowledging the PHM's way of life, including reaching out from the HCPs and appreciating sincerely PHMs' hopes and will; and second, paving the way ahead, including giving prospects and offering choices. The study underlines that rather than just providing information about the disease, HCPs need to actively ask about and show respect for the PHM's way of life. Only after achieving this can HCPs communicate possible future pathways with PHMs.

The Process of Motivating Oneself to Resist Being Controlled by Chronic Pain: A Qualitative Study of Japanese Older People Living in the Community.

Perceptions and experiences of chronic pain in older adults have not been fully explored. This study aimed to explore experiences and perceptions of life with chronic pain among older Japanese adults in the community. The grounded theory approach was used to identify a process model of older people's perceptions and experiences of living with chronic pain. Twenty-four people were recruited via snowball sampling. Ten participants had suffered from pain for 30 years or more. Data were collected through semistructured, individual interviews. Responses were transcribed verbatim, coded, and clustered. Categories were integrated using the constant comparison method. A core category-motivating oneself to resist being controlled by chronic pain-emerged from the analysis of experiences among participants with chronic pain. Participants alternated between two phases: losing the self in pain (phase 1) and regaining the self in pain (phase 2). Flare-up pain was commonly experienced, and immobility and suffering led older adults to adopt several strategies to live with their pain. In phase 2, older participants adopted several strategies, such as "letting sleeping dogs lie" and "cutting corners." Their perceptions of and behaviors toward pain were often influenced by perceptions of their aging bodies. Nurses need to be aware of these conditions among older people with chronic pain and adjust their activities individually according to patient perceptions of their physical conditions.

Developing an instrument to self-evaluate the Discharge Planning of Ward Nurses.

AIMS: To develop the Discharge Planning of Ward Nurses (DPWN), a Japanese self-evaluation instrument for ward nurses' discharge planning practices. DESIGN: Cross-sectional survey. METHODS: Participants were 624 ward nurses from six hospitals in Japan with a discharge planning department. Items about discharge planning practices were collected from literature and interviews with nurses and researchers. Construct validity, concurrent validity, internal consistency and test-retest reliability were tested. RESULTS: Initially, 55 items were collected. Examination of the floor effect, item-total, good-poor analyses and exploratory factor analysis yielded a four-factor model with 24 items ('teaching home-care skills with community/hospital professionals,' 'identifying clients' potential needs early in the discharge process,' 'introducing social resources' and 'identifying client/family wishes and building consensus for discharge'). The four-factor structure was supported by confirmatory factor analysis. The DPWN correlated with scales ascertaining similar concepts, supporting concurrent validity. Internal consistency and test-retest reliability were generally satisfactory.

Workplace bullying among nurses and their related factors in Japan: a cross-sectional survey.

AIMS AND OBJECTIVES: To explore the association between workplace bullying and workplace environment factors among nurses in Japan. BACKGROUND: Workplace bullying among nurses is increasing globally and occurs more frequently than among other professions. However, there is little information on the impact of workplace environment factors on nurse bullying in Japan. DESIGN: A cross-sectional survey using a self-administered questionnaire. METHODS: Participants were 1152 nurses recruited at seminars or training courses outside of their workplaces in Tokyo. Workplace bullying was measured using the Negative Acts Questionnaire-Revised. Participants were considered to have been 'bullied' if they reported experiencing at least one negative act on a daily or weekly basis. Workplace environment factors were measured using the Practice Environment Scale of the Nursing Work Index, which comprises five domains: nurse participation in hospital affairs; nursing foundations for quality of care; nurse manager ability, leadership and support of nurses; staffing and resource adequacy; and collegial nurse-physician relationships. RESULTS: A total of 898 (78·0%) questionnaires were returned, of which 825 (71·6%) were analysed. Altogether, 153 (18·5%) nurses were considered 'bullied.' The three most frequent negative acts reported as occurring on a weekly or daily basis were 'someone withholding information which affects your performance' (6·7%), 'being exposed to an unmanageable workload' (4·4%) and 'being shouted at or being the target of spontaneous anger (or rage)' (3·6%). Logistic regression analysis indicated that 'bullied' were associated with low scores on two work environment domains: nurse manager ability, leadership and support of nurses and staffing and resource adequacy. CONCLUSIONS: Effective nurse manager leadership and support as well as appropriate staffing management may positively influence workplace bullying among nurses in Japan. Authentic leadership styles and allowing nurses to easily request days off might also be important. RELEVANCE TO CLINICAL PRACTICE: Nurse managers' leadership may influence nurses' workplace bullying.

How does collegial support increase retention of registered nurses in homecare nursing agencies? a qualitative study.

BACKGROUND: Collegial workplace support has been linked to higher registered nurse (RN) retention in various clinical settings. In Japan, homecare agencies experience high RN turnover. The purpose of this study was to develop a conceptual framework to describe how perceived support from colleagues affects RNs' decision to remain in an agency. METHODS: A qualitative research method based on grounded theory was used. Participants were RNs with at least 4 years of experience at the same homecare agency. Participants were theoretically sampled via managers of 12 homecare nursing agencies. Semi-structured interviews and supplementary participant observations were conducted. Data were analyzed using a constant comparative technique, and the process of how workplace support affected participants' decision to remain at their agency was clarified. RESULTS: In total, 26 RNs were interviewed, 23 of whom were observed in their practice setting. Participants' perception of support from colleagues was framed as being "encouraged to grow in one's own way", which comprised practicing with protected autonomy in an insight-producing environment. Participants reported that they were able to practice with protected autonomy, receiving 1) mindful monitoring, 2) semi-independent responsibility, 3) help as needed, and 4) collegial empathy and validation. RNs also felt supported in an insight-producing environment by 1) enlightening dialogue, 2) being set for one's next challenges, and 3) being able to grow at one's own pace. Reportedly, these were defining characteristics in their decision to continue working in their agencies. CONCLUSIONS: For RNs to willingly stay at a homecare nursing agency, it is essential that they are able to practice with protected autonomy in an insight-producing environment that encourages them to grow in their own way. Further research is needed to explore ways to create and enhance such environments to lower RN turnover.

Literature review of pain management for people with chronic pain.

AIM: Multimodal approaches toward relieving pain, patients' participation, and improving self-efficacy are important for chronic pain management. The aims of this review were to identify possible options of nursing strategies for pain management in individuals with chronic pain and to determine the effectiveness of these strategies for pain relief/pain-related problems; therefore, nurses and researchers could consider and/or adopt multimodal chronic pain management strategies. METHODS: A Systematic Integrated Literature Review was conducted. Published work related to pain management in individuals with chronic pain was identified by searching databases and reviewed. RESULTS: Among the studies reviewed, we identified 35 studies that focused on pain management strategies. In 10 studies, interventions such as integrated and multidisciplinary pain management programs were associated with significant decreases in pain intensity. However, they reported that the long-term effectiveness of pain relief was not satisfactory. Individuals with chronic pain reported that strategies including pharmacotherapy, physical activity, social support from friends and family, acupuncture, heating, rest, diets, or life-style changes helped them to effectively manage their pain. CONCLUSION: We identified possible options of pain management strategies and explored effectiveness of chronic pain interventions. The long-term effects of pain relief interventions and social support for individuals with chronic pain require further investigation.

Differences between nurses' and care workers' estimations of pain prevalence among older residents.

A high prevalence of pain and difficulties with pain assessment has been widely reported among residents of long-term-care facilities. We explored nurses' and care workers' estimations of residents' pain (both general and chronic) and the number of residents with unknown pain status. We also examined the relationship between the prevalence of pain and assessment strategies undertaken by nurses and care workers. A cross-sectional design was used. Nurses and care workers across 750 long-term care facilities in four Japanese prefectures were asked to participate. Questionnaires were administered to one nurse and care worker at each facility. The questionnaires assessed the estimated numbers of residents who had pain in general, chronic pain, or unknown pain status on the day of data collection, and pain assessment strategies use by the health care professionals. In all, 263 (17.5%) questionnaires were returned from 147 nurses (55.9%) and 116 care workers (44.1%). The nurses' and care workers' median estimations of pain and chronic pain prevalence among residents were 11.6 and 9.4 and 29.4 and 15.5, respectively (p < .001). Estimations of pain prevalence were significantly higher among nurses who had observed signs of pain among residents in the previous month (p = .04) and who applied a multidisciplinary approach to pain assessment and management (p = .007) than among nurses who did not do either. Nurses and care workers had relatively low estimations of the prevalence of pain among their residents. Staff should undertake appropriate and sufficient pain assessments in order to improve their understanding of residents' pain.

Feasibility and clinical utility of the Japanese version of the Abbey pain scale in Japanese aged care.

Active usage of observational pain scales in Japanese aged-care facilities has not been previously described. Therefore, to examine the feasibility and clinical utility of the Abbey Pain Scale-Japanese version (APS-J), this study examined the interrater reliability of the APS-J among a researcher, nurses, and care workers in aged-care facilities in Japan. This study also aimed to obtain nurses' and care workers' opinions on use of the scale. The following data were collected from 88 residents of two aged-care facilities: demographics, Barthel Index, Folstein Mini-Mental Examination (MMSE), 15-item Geriatric Depression Scale (GDS-15), and APS-J for pain. The researchers, nurses, and care workers independently assessed the residents' pain by using the APS-J, and intraclass correlation coefficients (ICC) for interrater reliability and Cronbach alpha for internal consistency were examined. The ICC between researchers and nurses, researchers and care workers, and nurses and care workers were 0.68, 0.74, and 0.76, respectively. Nurses and care workers were invited for focus group interviews to obtain their opinions regarding APS-J use. During these interviews, nurses and care workers stated that the observational points of APS-J subscales were the criteria they normally used to evaluate residents' pain. Several nurses and care workers reported a gap between the estimated pain intensity and APS-J score. Unclear APS-J criteria, difficulties in observing residents, and insufficient practice guidelines were also reported. Our findings indicate that the APS-J has moderate reliability and clinically utility. To facilitate APS-J usage, education and clinical guidelines for pain management may be required for nurses and care workers.

Differences in pain measures by mini-mental state examination scores of residents in aged care facilities: examining the usability of the Abbey pain scale-Japanese version.

The validity and reliability of the Abbey Pain Scale-Japanese version (APS-J) have been examined. However, the range of cognitive levels for which the APS-J can be accurately used in older adults has not been investigated. This study aimed to examine the differences between total/item scores of the APS-J and Mini-Mental State Examination (MMSE) scores of residents in aged care facilities who self-reported the presence or absence of pain. This descriptive study included 252 residents in aged care facilities. Self-reported pain, MMSE scores, and item/total APS-J scores for pain intensity were collected. The MMSE scores were used to create four groups on the basis of the cognitive impairment level. Self-reports of pain and the APS-J scores were compared with different MMSE score groups. The total APS-J score for pain intensity as well as scores for individual items such as "vocalization" and "facial expression" were significantly higher in those who reported pain than in those reporting no pain across all MMSE groups. The total APS-J score and item scores for "vocalization," "change in body language," and "behavioral changes" showed significant differences in the four MMSE groups. Pain intensity tended to be overestimated by the APS-J, especially among those with low MMSE scores. The APS-J can be used to assess pain intensity in residents despite their cognitive levels. However, caution is required when using it to compare scores among older adults with different cognitive capacity because of the possibility of overestimation of pain among residents with low cognitive capacity.

Nursing ward managers' perceptions of pain prevalence at the aged-care facilities in Japan: a nationwide survey.

This study aimed to examine nursing ward managers' perceptions of pain prevalence among older residents and the strategies of pain management at the Health Service Facilities for the Elderly Requiring Care (HSFERC) in Japan and to investigate the factors related to the prevalence. Nursing ward managers in 3,644 HSFERC were asked to participate in this study. Questionnaires were sent to them regarding pain prevalence among the older residents in their wards, their provisions for pain care, and other pain management strategies. The perceived pain prevalence factors were examined statistically. The final sample comprised 439 participants (12.0%). A total of 5,219 residents (22.3%) were recognized as suffering from pain on the investigation day. Only 8 wards (1.8%) used pain management guidelines or care manuals, and 14 (3.2%) used a standardized pain scale. The ward managers' age (p = .008) and nursing experience (p = .006) showed a significant negative association with pain prevalence estimation. Moreover, there was a significant association between the groups' pain prevalence estimation and the nursing managers' beliefs that older adults were less sensitive to pain (p = .01), that pain was common among older people (p = .007), and that the time to treat residents' pain was insufficient (p = .001). The ward managers' perceptions regarding pain prevalence varied; the perceived pain rates were possibly lower than the actual percentages. Insufficient pain management strategies at the HSFERC were also suggested. An appropriate pain management strategy for Japanese aged care and its dissemination are urgently required.

Developing and validating a Japanese version of the Assessment of Pain in Elderly People with Communication Impairment.

This study aimed to develop a Japanese version of the Assessment of Pain in Elderly People with Communication Impairment (PACSLAC-J) and evaluate the validity and reliability of the scale for use in older patients with dementia in Japan. All patients from 2 dementia wards at a geriatric hospital and 2 aged care facilities were asked to participate. Demographic data, medical prescriptions, Behavior Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) score, and PACSLAC-J score were obtained from the patients or their medical charts. Researchers used the PACSLAC-J to assess pain behaviors while the patients walked or were transferred between a bed and a wheelchair. Intra-class correlation coefficients (ICC) for inter-rater and test-retest reliability, Cronbach's alpha, and correlations between PACSLAC-J score and other variables were examined. A total of 117 older patients participated. Dementia, including Alzheimer's disease (n=54) and/or vascular dementia (n=35), had been diagnosed in almost all of them. The ICC for inter-rater and test-retest reliability were 0.917 and 0.600, respectively. Internal consistency of the entire sample was 0.782. Patients who stated they were experienced pain during movement had higher scores than did patients who stated they had no pain during movement. PACSLAC-J total score was not associated with BEHAVE-AD score. Multiple regression analysis showed that total dependence on assistance during transfer (ß=0.32, p=0.001), and psychiatric medication prescription (ß=0.26, p=0.003) were independently associated with PACSLAC-J score. We found sufficient evidence of the validity and reliability of the PACSLAC-J.

Prevalence of pain among residents in Japanese nursing homes: a descriptive study.

It is often observed that pain causes substantial problems for nursing home residents. However, there has been little research about the prevalence of pain for nursing home residents in Japan. This study aimed to examine the prevalence of pain in older adults living in nursing homes in Japan by using self-reporting and the Abbey Pain Scale-Japanese version (APS-J) and to explore factors related to pain. This is a descriptive study. Residents in two Special Nursing Homes for the Elderly in Tokyo, Japan, were asked to participate in this study, with the exclusion of short-term temporary residents. Data collected from participating residents included their demographics and the results from the Barthel Index, the Folstein Mini-Mental State Examination, the APS-J, and the Verbal Descriptor Scale for pain. The residents were divided into two groups: residents able to report their pain (self-report group) and residents not able to report their pain. The second group was assessed by using the APS-J (APS-J group). The Mann-Whitney U test, the χ2 test, and logistic analyses were performed to derive factors related to pain prevalence. Data were obtained from 171 residents. The prevalence of pain in the self-report group (n = 96) was 41.7%. For the 75 residents unable to report their pain, 52.0% were assessed by the APS-J to have pain. The overall pain prevalence of all residents was 46.2%. Age, Barthel Index score, and length of time of institutionalization were significantly associated with residents' pain in the APS-J group. Logistic regression analysis showed that contracture (odds ratio 3.8) and previous injury (odds ratio 3.4) were associated with residents' pain in the self-report group, whereas only the length of nursing home stay (odds ratio 1.03) was a predictor for pain in the APS-J group. Nearly one-half of residents had pain when they moved or were moved. Pain assessment and management is needed for residents.

Family caregiver strategies to encourage older relatives with dementia to use social services.

AIM: To elicit the strategies used by Japanese family caregivers in the community to encourage older relatives with dementia to use adult daycare and respite stays. BACKGROUND: Older adults with dementia often require adult daycare and respite stays for their family caregivers to gain respite from care-giving. However, persons with dementia often face difficulty in new environments and timely access to sufficient services may be difficult to achieve. Few studies have examined how family caregivers encourage their service use. DESIGN: A qualitative method. METHODS: Semi-structured interviews were conducted with 16 family caregivers who were caring for relatives with dementia at home between 2005-2007. Data were analysed qualitatively. RESULTS: Family caregivers used various strategies to encourage older relatives to use services, allowing the older adult to decide whether to use the service, yearning and searching for the least harmful service, tailoring the service to the older adult, persuading the older adult to use the service, conforming the older adult to the service and coercing the older adult to use the service. Different strategies were used depending on factors such as desperation in needing respite, willingness to do what is best for the older adult, confidence in taking care of the older adult and the anticipated response of the older adult to services. CONCLUSION: Nurses should carefully assess caregivers' strategies in their attempts to encourage service use and should provide adequate assistance in accordance with those strategies.

Prevalence and incidence of pressure ulcers in Japanese long-term-care hospitals.

In Japan, long-term-care hospitals and facilities face the problem of quality of care, and providing adequate pressure ulcer care is one of the most urgent quality issues. Purpose of the present study was to explore the prevalence and incidence of pressure ulcers in long-term-care hospitals in Japan, and to identify factors associated with them. An anonymous questionnaire was sent to 720 randomly sampled, long-term-care hospitals all over Japan. The prevalence and incidence of pressure ulcers and their factors, including organizational strategies for pressure ulcer prevention and management, were examined. The mean prevalence and incidence of pressure ulcers was 9.6 and 1.9% per month, respectively. Almost all hospitals had established an interdisciplinary team for pressure ulcer prevention, developed a clinical protocol for pressure ulcers, and implemented education for staff. However, 35% of the interdisciplinary teams were not useful, more than half of the clinical protocols were not used frequently, and about half of the wards did not have sufficient pressure-relieving mattresses. In multiple regression analyses, a low prevalence of pressure ulcers was associated with a lower ratio of clients with a high medical severity level (p=0.034), the use of a clinical protocol including the management of preventive devices (p=0.023), the standardized pressure ulcer assessment tool (DESIGN-R; p=0.017), and staff education (p=0.003). This study demonstrated a higher prevalence and incidence of pressure ulcers in long-term-care hospitals in Japan as compared to regular acute-care hospitals, as well as poor organizational strategies for managing pressure ulcers.

The Gap Between Flare-Up Recognition and Judgment of Need for Physician Visit in Patients With Ulcerative Colitis.

Background: Although patients with ulcerative colitis (UC) recognize that their conditions are worsening, they do not always visit a doctor immediately. Our aim was to investigate how patients recognize a flare-up of UC and how significant a gap there is between symptoms recognized as a flare-up and symptoms judged to require physician visit. Methods: Questionnaires were distributed to 1,641 Crohn's and Colitis Foundation of Japan members and returned by 426, with 260 UC patients subsequently analyzable (Crohn's disease patients were excluded). Symptoms recognized as a flare-up of UC and symptoms judged to require physician visit were collected as free descriptions. A gap was determined if descriptions of symptoms judged to require physician visit contained expressions of prolonged symptoms, aggravation of symptoms, or critical symptoms. Furthermore, obvious delay was also determined if described symptoms contained critical symptoms. Results: Blood in stool was the most significant flare-up symptom recognized in patients with UC. A gap was observed in 134 cases (56.8%) and obvious delay was present in 70 cases (29.7%). Moreover, 52% of subjects debated whether to consult with a doctor when their conditions became subtly worse. Conversely, approximately 50% subjects also reported "If my condition subtly worsens, I want to visit a doctor immediately". Conclusions: Although patients with UC recognized flare-ups accurately, a gap was observed in half of our subjects. Our data are important evidence that health professionals must educate patients effectively to improve patient outcomes.