When do Physicians and Nurses Start Communication about Advance Care Planning? A Qualitative Study at an Acute Care Hospital in Japan.

Although advance care planning (ACP) can lead to more patient-centered care, the communication around it can be challenging in acute care hospitals, where saving a life or shortening hospitalization is important priorities. Our qualitative study in an acute care hospital in Japan revealed when specifically physicians and nurses start communication to facilitate ACP. Seven physicians and 19 nurses responded to an interview request, explaining when ACP communication was initiated with 32 patients aged 65 or older. Our qualitative approach employed descriptive analysis to identify major themes, which included "initiation by patients" and "initiation by healthcare professionals." In the latter case, seven specific triggers were identified: (1) when the patients' medical condition changed in terms of symptom relief, (2) when the patients' medical condition changed in terms of prognostic prediction, (3) when serious events occurred, (4) when a choice of treatment was presented, (5) when the location for end-of-life care was chosen, (6) when the patients' cognitive function deteriorated, and (7) when serious events settled down. Within this group of healthcare professionals, physicians were more focused on changes in their patients' medical condition, whereas nurses focused more on their patients' desire for a long-term perspective. Nurses encouraged patients to consider ACP themselves, which developed into an approach to respect patients' autonomy. In acute care hospitals, it appeared to be desirable to have an early discussion where patients could understand the significance ACP, which would matter even after their discharge from the hospital.

Barriers to Promoting Advance Care Planning for Residents Living in a Sanatorium for Hansen's Disease: A Qualitative Study of Residents and Staff in Japan.

In Japan, most residents with Hansen's disease (leprosy) live in dedicated sanatoria because of an established quarantine policy, even after being cured of the primary disease. They suffer from secondary diseases and are advancing in age, and advance care planning (ACP) is increasingly crucial for them to live their lives with dignity in a sanatorium. In this study, we have three aims: (1) to understand how to promote communication about their wishes for medical treatment, care, and recuperation; (2) to identify required assistance; and (3) to explore how to promote ACP in a sanatorium. This study is a qualitative research conducted through semi-structured interviews. The study included 57 ex-Hansen's disease patients and 66 staff (10 doctors, 27 nurses, 23 care workers, and 6 social workers) from 10 facilities. Ex-Hansen's disease patients were expected to consider ACP, but this was in the context of uncertainty about whether a sanatorium would close and whether there would be doctors to manage their needs. They reported being confused when staff rushed to confirm their advance directives, feeling that they were not provided with enough information before being approached. Barriers to promoting ACP were found to be insufficient of team-based care and information sharing, ex-Hansen's disease patients' weak interest in their end of life, and their conservative thoughts. We believe that ACP can be achieved by listening to the wishes of recovered patients through regular home care visits by nurses and everyday support by care workers. Furthermore, multidisciplinary coordination is urgently needed for promoting ACP.

Narrative writing as a strategy for nursing ethics education in Japan.

OBJECTIVES: The purpose of this study was to explore the effectiveness of learning ethics of nursing practice using narrative writing. METHODS: Study design was qualitative descriptive research. The participants were 90 graduate students who took nursing ethics classes, of whom 86 graduate students (4 males and 82 females) agreed to this study. The data gathered for analysis were their narratives described as feeling uncomfortable in clinical settings and their comment sheets after narrative group work in nursing ethics classes. We used qualitative content analysis to identify graduate students' awareness gained through narrative writing and narrative group work. RESULTS: As a feature of the scenes described by graduate students, there were often conflicts that patients' autonomy were not respected, or that they were not able to engage in sincere engagement. The narrative writing was effective to make graduate students aware of the following two aspects: 1) habits and trends in one's own thoughts and 2) organizational and administrative issues related to ethical issues. CONCLUSIONS: Learning ethics of nursing practice using narrative writing that focused on nurses' sentiments helped reveal nurses' thoughts as well as their attitudes and approaches to patients. These findings suggest that narrative writing in nursing ethics education could lead to ethical practice. Additionally, our results indicate that narrative writing in research may be helpful as a strategy to clarify ethical issues and the awareness of nurses in clinical settings.

Consulted ethical problems of clinical nursing practice: perspective of faculty members in Japan.

BACKGROUND: There are several studies that have targeted student nurses, but few have clarified the details pertaining to the specific ethical problems in clinical practice with the viewpoint of the nursing faculty. This study was to investigate the ethical problems in clinical practice reported by student nurses to Japanese nursing faculty members for the purpose of improving ethics education in clinical practice. METHOD: The subjects comprised 705 nursing faculty members (we sent three questionnaires to one university) who managed clinical practice education at 235 Japanese nursing universities. We performed a simple tabulation of the four items shown in the study design. 1) the details of student nurse consultations regarding ethics in clinical practice (involving the students themselves, nurses, care workers, clinical instructors, and nursing faculty members); 2) the methods of ethics education in clinical practice; 3) the difficulties experienced by the nursing faculty members who received the consultations; and 4) the relationship between clinical practice and lectures on ethics. Furthermore, the analysis was based on the idea of ethical principles, respect for persons, beneficence, and justice. RESULTS: The response rate was 28% (198 questionnaires). The nursing faculty members were consulted for various problems by student nurses. The details of these consultations were characterized by the principles of respect for patient by nurses, the principles of benevolence by faculty and clinical instructors, and the principle of justice pertaining to evaluations. The results indicate that there is an awareness among the nursing faculty regarding the necessity of some sort of ethics education at clinical settings. Moreover, based on the nature of the contents of the consultations regarding the hospital and staff, it was evident that the nursing faculty struggled in providing responses. More than half of subjects exhibited an awareness of the relationship between the classroom lectures on ethics and clinical practice. CONCLUSION: The results suggest the need for analyzing the ethical viewpoints of student nurses, prior learning, and collaboration with related courses as part of ethics education in clinical practice.

[Communication with important others regarding their preferences for end-of-life care].

AIM: Our aim in this study was to explore individual factors that make it likely for Japanese older adults to engage in communication with important other persons regarding their preferences for end-of-life care. METHODS: We conducted a questionnaire survey of outpatients at Tokyo Metropolitan Geriatric Hospital in the last six days of March 2012. Nine-hundred and sixty-eight outpatients consented in writing to participate in this survey. Two items on the questionnaire concerned the participants' attempts to communicate their preferences regarding end-of-life care; that is, whether they had discussed this issue with their significant others and whether they had written notes indicating how they want to be cared for in the final days of their lives. RESULTS: The participants who had designated a surrogate decision-maker were more likely to report answers of both than only discussion (OR=2.52) and less likely to reports answers of no communication than only discussion (OR=0.37). In addition, (a) those who did not wish to rely on artificial nutrition or hydration (OR=0.68) and (b) those who often thought about their death were more likely to be in the only discussion group than in the no communication group, although these factors were not significantly associated with whether the participants were likely to be in the both or only discussion groups. CONCLUSIONS: Our findings indicate that individuals often attempt to clarify their preferences in order to make it easier for their significant others to make end-of-life care decision on their behalf, so that they may receive their desired care.