Research in Gerontological Nursing

Instrument Development 

Development of a Visiting Nursing Practice Self-Evaluation Scale: Assessment of Skill for Caring for Individuals With Behavioral and Psychological Symptoms of Dementia

Takaomi Furuno, MD, RN; Narumi Fujino, PhD, RN; Yuji Fujimoto, MD, RN; Hiroko Shirai, MD, RN; Yuichi Iwamoto, MD, RN; Yuki Kamada, MD, RN; Fumi Yamaguchi, PhD, RN

Abstract

Behavioral and psychological symptoms of dementia (BPSD) continue to be a concern for our rapidly progressing aging society. Visiting nurses play an important role in community service for individuals with BPSD. The aim of the current study was to develop a visiting nursing practice self-evaluation scale for nurses who care for individuals with BPSD. The study was conducted in two phases. Semi-structured interviews were arranged to generate a draft scale that was further examined by an expert panel. A national survey was performed using the draft scale and two existing scales. Four factors and 22 items were obtained from exploratory factor analysis: (a) assessment and response factors related to BPSD, (b) interventions for reducing family care burdens, (c) nonpharmacological approaches, and (d) attitudes in trying to understand a patient's intentions. Reliability and validity were verified. The scale is useful for improving visiting nursing services for individuals with dementia. [Research in Gerontological Nursing, xx(x), xx–xx.]

Abstract

Behavioral and psychological symptoms of dementia (BPSD) continue to be a concern for our rapidly progressing aging society. Visiting nurses play an important role in community service for individuals with BPSD. The aim of the current study was to develop a visiting nursing practice self-evaluation scale for nurses who care for individuals with BPSD. The study was conducted in two phases. Semi-structured interviews were arranged to generate a draft scale that was further examined by an expert panel. A national survey was performed using the draft scale and two existing scales. Four factors and 22 items were obtained from exploratory factor analysis: (a) assessment and response factors related to BPSD, (b) interventions for reducing family care burdens, (c) nonpharmacological approaches, and (d) attitudes in trying to understand a patient's intentions. Reliability and validity were verified. The scale is useful for improving visiting nursing services for individuals with dementia. [Research in Gerontological Nursing, xx(x), xx–xx.]

The older adult population is rapidly increasing around the world, intensifying the issues surrounding dementia. Alzheimer's Disease International (2015) reported that the number of individuals with dementia is predicted to reach 74.7 million by 2030. The World Health Organization (2017) has listed dementia to be a high priority for public health institutions and has proposed the Global Action Plan on the Public Health Response to Dementia.

Dementia is characterized by progressive symptoms (Van Zadelhoff, Verbeed, Widdershoven, Van Rossum, & Abma, 2011), core symptoms (e.g., memory impairment, disorientation), and behavioral and psychological symptoms (BPSD), including hallucinations, delusions, excitement, aggressiveness, wandering, diminished motivation, and sleep disturbances. BPSD are problematic, causing difficulties in caring for community-dwelling individuals with dementia. Individuals experiencing excessive wandering and excitement are at a high risk for falls (Sato et al., 2018), and BPSD are associated with impairments in daily living activities (Hinton, Tomaszewski, & Wegelin, 2008). BPSD are also associated with an increase in health care expenditures (Herrmann et al., 2006). The increasing number of individuals with dementia highlights the need to address challenges in caring for those with BPSD.

Although community medicine is being promoted worldwide, BPSD are regarded as problems for individuals with dementia living in the community, and may indicate the need for long-term care placement (Cepoiu-Martin, Tam-Tham, Patten, Maxwell, & Hogan, 2016). Various measures have been taken for community-dwelling individuals with dementia. England is working on a national strategy for dementia, called Dementia Friendly Communities, which promotes social inclusion wherein participation is endorsed as policy (Buckner et al., 2019). Sweden is also working on a national strategy to secure improved quality of care and increased safety and security for people with dementia and their families (Government Offices of Sweden, 2018). In mental health services for dementia care, health care professionals, such as psychologists, nurses, pharmacists, case managers, psychiatrists, and general practitioners, play important roles and must collaborate when providing care (Fredheim, Danbolt, Haavet, Kjønsberg, & Lien, 2011).

Role of Visiting Nurses in Communities

According to Karam, Brault, Van Durme, and Macq (2018), nurses are in the best position to assume leadership roles because of their close interaction with patients. Therefore, visiting nurses play an important role in community health services for individuals with BPSD. In particular, visiting nurses tend to improve the functional ability of patients (Liebel, Powers, Friedman, & Watson, 2012). This service also enables continuance of home care for individuals with greater needs (Oyama et al., 2013). In addition, for individuals who receive visiting nursing care because they either live alone or with children who work, their acute hospital stays tend to be shorter than patients without such resources (Kitamura, Shiota, Jinkawa, Kitamura, & Hino, 2018). Thus, the benefit of visiting nursing care is well established.

Within the visiting nursing system in Japan, nursing staff provide services that allow individuals to stay at home as long as possible (Japan Visiting Nursing Foundation, 2013). In visiting nursing, caregiving services are also provided to various family types, including individuals who live alone. According to the Ministry of Health, Labour and Welfare's (2017) Comprehensive Survey of Living Conditions, the most common caregiver relationship in Japan is spouse (25.2%), followed by children (21.8%) and children's spouses (9.7%).

Due to medical insurance systems, duration and frequency of visiting nursing services are limited. Therefore, it is difficult to provide adequate and effective care for individuals with BPSD.

Aim and Significance of Research

To provide high-quality visiting nursing services to individuals with dementia who experience BPSD, evidence-based indicators and assessments for efficacious practice must be determined. Currently, there is no scale available for assessing visiting nursing practice components concerning individuals with BPSD. Such a scale would allow nurses to consider their own practice while highlighting areas of maintenance and improvement (Campbell & Mackay, 2001). Thus, the aim of the current study was to develop a visiting nursing practice self-evaluation scale for caring for individuals with BPSD and verify its validity and reliability through a national survey.

The scale's development should clarify the constructive concept of visiting nursing practice for individuals with BPSD, while helping improve the quality of nursing care in this area. Furthermore, such assessments could help contribute to improved quality of life among individuals with dementia and their families within a home care context.

Theoretical Framework

Nurse competency frameworks have been established in dementia care. Dementia UK (n.d.) proposed the Admiral Nurse Competency Framework. Admiral nurses are specialists caring for individuals with dementia and their caregivers in the community in the United Kingdom. The framework has six competencies: (a) person-centered care, (b) therapeutic skills, (c) triadic relationship, (d) sharing knowledge, (e) best practice, and (f) critical reflective practice. A literature review of 59 publications by Traynor, Inoue, and Crookes (2011) specified 10 nursing competencies in dementia care: (a) understanding dementia, (b) recognizing dementia, (c) effective communication, (d) assisting with daily living activities, (e) promoting a positive environment, (f) ethical and person-centered care, (g) therapeutic work (i.e., interventions), (h) responding to the needs of family caregivers, (i) preventive work and health promotion, and (j) special needs groups.

Visiting nursing is characterized by the visits themselves and the on-site judgments and practices required. Professional autonomy is one of the critical requirements in visiting nursing practice, which means having one's own practice, ability, independence, control, responsibility, accountability, and authority (Varjus, Leino-Kilpi, & Suominen, 2011).

Benner's (2001) From Novice to Expert theory conceptualizes that nurses develop skills and understanding of patients through practice from a robust educational background and personal experiences. Benner classified nursing practice into seven domains: (a) helping role, (b) teaching–coaching function, (c) diagnostic and patient-monitoring function, (d) effectively managing rapidly changing situations, (e) administering and monitoring therapeutic interventions and regimens, (f) monitoring and ensuring quality of health care practice, and (g) organizational role competencies. Benner (2001) also emphasized the importance of ethical reasoning and caring in nursing practice. Her theory supports the current authors' research interests in professional autonomy and learning from experiences in dementia care to improve nursing practice.

Method

The study had two phases: Phase 1 was development of a draft scale with qualitative interviews for visiting nurses and verification of face validity. Phase 2 was development of the scale with a quantitative survey for visiting nurses across Japan and verification of validity and reliability.

Phase 1: Draft Scale

Participants and Data Collection. Semi-structured interview surveys were conducted among 12 visiting nurses from three visiting nursing offices to extract scale items. Participants were recruited through the Administrator of Cooperation Office. All participants had experience with visiting nursing practices for patients with BPSD and gave written informed consent. The survey period was between March 2017 and May 2017.

Survey Content and Item Extraction Method. Visiting nurses were told to talk freely about their visiting nursing practice experience for patients with BPSD and their families. Nurses were asked to describe (a) the details of their visiting nursing practices, and (b) the things they have not done but consider important in practice. Interview data were audiotaped and collected verbatim, and descriptions about visiting nursing practice were extracted. Based on the extracted descriptions, visiting nursing practice for dementia was coded. In addition, descriptions of visiting nursing practice were also extracted from literature reviews. Based on the identified codes, survey items of visiting nursing practice were created. As a result, 147 items were pooled and presented to an expert panel, including nurses providing visiting nursing services to individuals with dementia and researchers of home nursing theory, geriatric nursing science, and psychiatric nursing science.

Development of the Draft Scale. Question items were extracted using the following criteria: (a) potential for making a statement based on recorded content deemed necessary by experts in the various domains, as well as the reasoning for the contents' inclusion; (b) correspondence with Benner's seven domains of nursing practice; and (c) practicality based on home visiting nursing practice characteristics, such as limits to time duration and number of times that direct visits can be made. Thirty-three items agreed on by all expert panel members were selected. In addition, in terms of home visit nursing characteristics, the visit duration and number of visits changed based on the conditions of older adults with dementia. Therefore, it was determined that asking about frequency of visits gave rise to bias in respondents' interpretations. To reduce bias in the answers and include items that could be evaluated objectively, each item was rated on a 5-point Likert scale, where 5 = strongly agree, 4 = agree a little, 3 = neither agree nor disagree, 2 = disagree a little, and 1 = strongly disagree.

Verification of Face Validity. After excluding visiting nurses who were interviewed during preparation of the draft scale, the questionnaire survey was administered to 23 nurses. Participants were asked whether item phrasing was hard to understand, and whether all visiting nursing practices were covered by the existing items. In another expert meeting, three items that were hard to understand were deleted and one missing item was added. For the new item, participant understanding was confirmed in the face validity assessment.

Phase 2: Development of the Scale and Verification of Validity and Reliability

Participants. The sample comprised 618 home visit nurses working at 144 visiting nursing offices. The facilities were located in 35 administrative divisions of 47 total administrative divisions of Japan: eight in the Tokyo metropolitan area, 127 in cities, and nine in towns.

Participant Selection. According to the National Association for Visiting Nurse Service in Japan (2018), in 2018, there were 10,418 visiting nursing offices in Japan, with 5,705 (approximately one half) registered with the association. The survey request document and study cooperation consent form were sent to 1,500 visiting nursing offices randomly selected from the 5,705 offices. These offices were asked to send completed consent forms only when visiting nursing services were provided to older adults with BPSD and from nurses who consented to participate in the survey.

Data Collection. Questionnaire packets were mailed to 618 participants via the 144 home visit nursing offices. The survey period was between July 2018 and November 2018.

Survey Contents. Participants reported their gender, age, years of nursing experience, and years of visiting nursing experience. In addition to the 31-item draft scale, the Scale for Professional Autonomy in Nursing (5-point Likert scale, 57 items; Kikuchi & Harada, 1997) and Self-Evaluation Scale on Home Health Nursing (5-point Likert scale, 30 items; Miura, Funashima, & Suzuki, 2005) were also administered. Both scales have verified validity and reliability.

Kikuchi and Harada (1997) developed the Scale for Professional Autonomy in Nursing, which aims at demonstrating nursing expertise through voluntary and proactive nursing judgments and practices. The scale is used for the comprehensive assessment of clinical nursing competence in all types of nursing staff and to evaluate cognitive ability, competence, ability for specific judgment, ability for abstract judgment, and ability for independent judgment. Higher scores indicate more autonomy as nursing professionals. The scale states that individuals engaged in nursing work need to be capable of autonomous decision making informed by professional knowledge and skill and should integrate correct nursing practices.

The Self-Evaluation Scale on Home Health Nursing is available for the self-assessment of home nursing practice by nursing professionals engaged in home health care, including visiting nurses and public health nurses. This scale is used to evaluate behaviors needed to: (a) maintain and develop a relationship with a client and the family, (b) provide knowledge and skills and solve and avoid problems in cooperation with other professionals, (c) maintain and enhance the relationship between family members, (d) protect the privacy of the client and his/her family and avoid intruding upon their privacy, and (e) clarify a problem and share it with the client and his/her family. Higher scores indicate that more nursing practice is implemented. This scale self-evaluates nursing practices pertaining to general home nursing but cannot evaluate nursing practices specific to patients with dementia. Therefore, this scale was used as an external standard for the current study.

Data Analysis

Selection of Valid Responses. Valid responses were defined as those without missing data across the 31 draft scale items. However, all survey items, wherein the Professional Autonomy in Nursing Scale and Self-Evaluation Scale on Home Health Nursing were included, were not treated as valid at the time of data input if ≥90% of answers were identical (e.g., all answers were rated 5).

Item Analysis. Exclusion criteria were defined as follows: an item in which a ceiling effect (mean + standard deviation [SD] > 5) or floor effect (mean − SD < 1) was present; an item where there was no difference between the highest and lowest quartiles for the total scale score in a Good-Poor analysis (G-P analysis) using the Mann-Whitney U test; and Spearman's rank correlation coefficient for the item-to-item and item-total correlation (I-T correlation) was <0.4.

Verification of Validity. To verify the validity of the developed scale, an exploratory factor analysis was conducted using the maximum likelihood method (promax rotation), and items with a factor loading <0.4 or a loading of at least 0.3 on more than one factor were excluded. The resulting factors were then named. The number of factors was determined based on the Kaiser-Guttman criterion, and the number of factors with eigenvalue ≥1 was treated as standard. For sampling adequacy, criteria were defined as a measure of sampling adequacy with a Kaiser-Meyer-Olkin (KMO) value ≥0.8. The model's fidelity was calculated via a confirmatory factor analysis using a covariance structure method. For the total scale and each factor scores, a Shapiro-Wilk test was used to perform tests of normality, with p ≥ 0.05 treated as a standard.

To verify criterion-related validity, correlations between the total scale score and total scores on the Scale for Professional Autonomy in Nursing and Self-Evaluation Scale on Home Health Nursing were calculated.

Reliability. To verify reliability, Cronbach's alpha coefficients for the total scale and each factor score were calculated to confirm internal consistency. All analyses were conducted in SPSS Statistics 24 and SPSS Amos 24. Statistical significance was set at p < 0.05.

Ethical Considerations

The current study was performed after approval from the ethical review board of the lead author's institution. The written study explanation included the study's purpose, methods, voluntary participation notification, ability for participants to withdraw from the study at any time with no consequences, assurance as to the protection of personal data, and consent to cooperate with the interview (which was obtained by collecting the consent form). In addition, verification of the face validity of the questionnaire and main survey was obtained by the answers.

Results

Response Rates

Of the 1,500 institutions, 144 visiting nursing offices (acceptance rate = 9.6%) consented to participate in the main survey. The questionnaire was distributed to 618 visiting nurses who indicated a willingness to participate. Of these, 427 visiting nurses (response rate = 69.1%) provided responses. Sixteen responses were excluded because nine questionnaires had identical answers on ≥90% of items and seven questionnaires were missing 31 items. A total of 411 valid responses were included in the analyses.

Participant Information

Of respondents, 396 (96.6%) were women, 14 (3.4%) were men, and one (0.2%) did not respond. The most common age group was 40 to 49 (n = 172, 41.8%). Mean nursing experience was 21.1 years (SD = 9.2 years), and mean visiting nurse experience was 7.3 years (SD = 6.3) (Table 1).

Demographics of the Sample (N = 411)

Table 1:

Demographics of the Sample (N = 411)

Item Analysis

No items had a ceiling or floor effect. As a result of the G-P analysis, there were significant differences across all items. Thus, no item responses were biased. Five items, whereby the item-to-item and item-total correlations were <0.4, were excluded from further analyses. Thus, a sample of 26 items was assessed for further analyses (Table 2).

Item Analysis for 31 Items Regarding Visiting Nursing Practice for Individuals With Behavioral and Psychological Symptoms of Dementia (BPSD) (N = 411)Item Analysis for 31 Items Regarding Visiting Nursing Practice for Individuals With Behavioral and Psychological Symptoms of Dementia (BPSD) (N = 411)

Table 2:

Item Analysis for 31 Items Regarding Visiting Nursing Practice for Individuals With Behavioral and Psychological Symptoms of Dementia (BPSD) (N = 411)

Verification of Reliability and Validity

Based on the Kaiser-Guttman criterion (eigenvalue >1), four factors were extracted. After items with factor loadings <0.4 (or at least 0.3 on more than one factor) were excluded, a second factor analysis was performed. Four more items were excluded, leaving 22 items across four factors. The KMO score was 0.919 (p < 0.05) (Table 3).

Exploratory Factor Analysis of Visiting Nursing Practice Self-Evaluation Scale for Older Adults With Behavioral and Psychological Symptoms of Dementia (BPSD) (N= 411)Exploratory Factor Analysis of Visiting Nursing Practice Self-Evaluation Scale for Older Adults With Behavioral and Psychological Symptoms of Dementia (BPSD) (N= 411)

Table 3:

Exploratory Factor Analysis of Visiting Nursing Practice Self-Evaluation Scale for Older Adults With Behavioral and Psychological Symptoms of Dementia (BPSD) (N= 411)

Factor 1 was referred to as Assessment and Response Factors Related to BPSD, because it included practice components for evaluating BPSD and the patient's condition (Steinberg et al., 2006). Factor 2 was Interventions to Reduce Family Care Burden, because it included reviewing services for reducing caregiver burden, adjusting the communication system during issues with BPSD, and arranging opportunities to express anxiety and concerns during caregiving. Factor 3 was named Nonpharmacological Approaches to reflect practice components for providing therapies such as relaxation, change of pace (i.e., during walking), and touching. Finally, Factor 4 was named Attitudes in Trying to Understand a Patient's Intentions to reflect the practice of spending time to ensure that nurses listen to the patient without overlooking non-verbal cues and being sensitive to the patient's complaints.

The confirmatory factor analysis, with a covariance structure method, indicated adequate model fidelity: goodness of fit index = 0.901, adjusted goodness of fit index = 0.877, comparative fit index = 0.913, and root-mean-square error of approximation = 0.059 (Figure 1). The mean total scale score was 84 (SD = 10), and factor scores ranged from 16.2 to 32.2 (SD = 2.0 to 3.9). For the revised full scale, the Shapiro-Wilk test indicated normality (p = 0.06) in the response distribution (Table 4).

Confirmatory factor analysis of the Visiting Nursing Practice Self-Evaluation Scale for Patients With Behavioral and Psychological Symptoms of Dementia. Goodness of fit index = 0.901, adjusted goodness of fit index = 0.877, comparative fit index = 0.913, and root-mean-square error of approximation = 0.059 (p < 0.01).

Figure 1.

Confirmatory factor analysis of the Visiting Nursing Practice Self-Evaluation Scale for Patients With Behavioral and Psychological Symptoms of Dementia. Goodness of fit index = 0.901, adjusted goodness of fit index = 0.877, comparative fit index = 0.913, and root-mean-square error of approximation = 0.059 (p < 0.01).

Mean (SD), Tests of Normality, and Criterion-Related Validity Results for the Entire Scale and Each Factor

Table 4:

Mean (SD), Tests of Normality, and Criterion-Related Validity Results for the Entire Scale and Each Factor

Criterion-related validity was also determined via Spearman's rank order correlations with the Scale for Professional Autonomy in Nursing and the Self-Evaluation Scale on Home Health Nursing (r = 0.356 to 0.634) (Table 4). The Cronbach's alpha coefficients for the whole scale and each factor ranged 0.729 to 0.904 (Table 3).

Discussion

Participant Characteristics and Data Adequacy

The current sample was adequately representative of all visiting nurses throughout Japan. According to a factual survey conducted on visiting nurses from the Japan Nursing Association (2014), the most common age range of visiting nurses was 40 to 49 years old (43.8%), with mean nursing experience of 22.3 years, and mean visiting nurse experience of 9.1 years. Similarly, the current results revealed a preponderance of respondents in the 40- to 49-year-old age range, mean nursing experience of 21.1 years, and mean visiting nurse experience of 7.3 years.

Validity and Reliability of the Developed Scale

Construct Validity. A four-factor solution was supported, providing evidence for acceptable construct validity. Based on results of the exploratory factor analysis, the sample size was deemed appropriate. Furthermore, the confirmatory factor analysis results indicated adequate model fidelity.

Criterion-Related Validity. The total scale and all sub-scale scores for the developed measure were significantly and positively correlated with the Scale for Professional Autonomy in Nursing and the Self-Evaluation Scale on Home Health Nursing, providing suitable evidence for criterion-related validity.

Reliability. The total scale score and all sub-scale scores for the developed measure exceeded acceptable Cronbach's alpha coefficients (alpha = 0.7) for determining appropriate internal consistency.

Taken together with the results from the validity checks, the developed scale for assessing visiting nursing practices for individuals with BPSD reflected high reliability and validity.

Concepts Constituting Visiting Nursing Practice for Patients With BPSD

Factor 1, Assessment and Response Factors Related to BPSD, comprised visiting nursing practices that focus on identifying aggravating aspects of BPSD, which require assessment or treatment of those physical symptoms. In particular, a recent survey performed among Japanese visiting nurses revealed that visiting nurses “identify characteristic symptoms of changes to the patient's condition with an ‘eagle eye’ through continuous involvement with the case” and “prevent and improve disease exacerbation by making sure to prepare an essential medical environment for older, single adults with dementia” (Matsushita, 2016, p. 37). These characteristics are assumed to help stabilize the physical and mental health symptoms of individuals with dementia (Matsushita, 2016). In addition, BPSD are associated with pain and discomfort (Husebo, Ballard, Sandvik, Nilsen, & Aarsland, 2011; Pelletier & Landreville, 2007; Steinberg et al., 2006).

Factor 2, Interventions for Reducing Family Care Burden, included visiting nursing practices that counsel family members on how to alleviate BPSD. Across several studies, the association between BPSD and family care burden has been established, and caregiver burden often leads to the discontinuation of informal care provided by family members (Chiao, Wu, & Hsiao, 2015; Hallikainen, Koivisto, & Välimäki, 2018). In addition, family members of individuals with dementia may engage in harmful behaviors (e.g., verbal abuse) toward the individual because of BPSD (Toda et al., 2018). Thus, intervening in family caregiving may help reduce this burden, delaying the need for institutionalization, and allowing the individual with dementia to continue living at home (Brodaty, Green, & Koschera, 2003). In addition, by introducing visiting nurses to individuals living alone, family caregivers achieve a sense of reassurance and experience a reduction in stress (Kitamura, Tanimoto, Oe, Kitamura, & Hino, 2019). Successful reduction of this care burden could help informal caregivers continue to provide adequate assistance to their loved ones with dementia.

A systematic review revealed the following treatments are effective in improving BPSD: aromatherapy; interventions focusing on sensory experiences, including music therapy; pain control; person-centered approaches; and patient–family education (Fung, Tsang, & Chung, 2012, Legere, McNeill, Schindel, Martin, Acorn, & An, 2018). The effectiveness of improving BPSD symptoms through nonpharmacological therapy has been confirmed across several studies. Relaxation via aromatherapy and hand massage, as well as walking initiatives, kinesitherapy, and hortitherapy were described as constructive. This finding suggests the possibility that visiting nurses might regard relaxation and enhancements to physical activities as useful nonpharmacological treatments for BPSD. Thus, Factor 3, Nonpharmacological Approaches, was a constructive concept identified by the current sample of visiting nurses. Overall, successful improvements in BPSD through nonpharmacological treatments could lead to improvements in stress reactions among patients, while also helping reduce caregiver burden and allowing patients to continue living at home.

Person-centered care focuses on respecting the patient's individuality and intentions for treatment (Brooker, 2003). However, given that individuals with dementia may focus mostly on core symptoms, such as cognitive impairment, difficulties expressing intentions could occur. In the Guidelines for Protecting the Dignity of Elderly People Receiving Medical Care and Nursing from the Japan Nursing Ethics Association (2015), medical professionals must judge the intentions and experiences of distress and discomfort among patients with dementia based on the following: facial expressions, body movements, and strain. Thus, Factor 4, Attitudes in Trying to Understand a Patient's Intentions, comprises content relevant to these guidelines. For example, visiting nurses reported that trivial changes in a patient's facial expression, speech, and behavior should not be overlooked. Even if speech patterns are inconsistent, nurses must listen patiently and respect the patient's intentions.

Overall, from the results of the four core factors identified in the developed scale, the constructs and concepts fit well with prior research on visiting nursing practice for patients with BPSD. Thus, the sub-scales identified provide evidence of adequate construct validity.

Significance and Use of the Scale

In nursing science, scale visualization contributes to clarifying factors related to a concept. For example, Burtson and Stichler (2010) clarified the relationship between nursing work environment and nurse caring. The current study contributes to improvement of nursing practice by clarifying related factors using the scale developed in this research.

Given the shift in older adult population dynamics in Japan, the quality of visiting nursing practice for patients with BPSD must be improved. The current authors' scale could allow nurses to assess their practice for patients with BPSD more objectively and clarify and identify issues necessary to improve their practice. The devised scale is not only intended for reflecting on one's own nursing practice, but for indicating where educational resources should be directed. Given that the constructive concepts identified in the current scale are supported by previous research, the measure can also be used as an indicator of evidence-based nursing practice.

Limitations and Future Directions

One limitation of the current study is whether the current scale can help prevent or improve BPSD or improve caregiver burden based on improvements to visiting nursing competence. However, there were no restrictions in regard to the following: home visit nursing participants, time since diagnosis of dementia, type of dementia, presence of comorbidities, whether the patient lived alone or with others, and the relationship between the patient and caregiver (e.g., spouse, child). Second, given that the scale was based on self-reported data from nurses, assessing higher-precision visiting nursing practice (through objective, third-party reports) may be necessary to better determine the applicability of the scale. In addition, a multidimensional approach, where another home visit nurse evaluates home visit nursing practices, would be effective.

Finally, the scale was developed with Japanese home visit nurses as participants. Therefore, verifications must be made with other home visit nurses from different cultures for its applicability outside of Japan. There is a need to expand the scale's applicability among countries with cultures and insurance systems similar to Japan.

Conclusion

The current scale may help improve the quality of visiting nursing services for individuals with BPSD, as well as potentially contribute to improved quality of life among patients with dementia wishing to maintain residence in the community. In addition, this scale can contribute to the development of a best practice model for visiting nurses working with individuals with dementia.

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Demographics of the Sample (N = 411)

DemographicValue
Sex (n, %)
  Female396 (96.6)
  Male14 (3.4)
  No response1 (0.2)
Age (years) (n, %)
  20 to 2917 (4.1)
  30 to 3978 (19)
  40 to 49172 (41.8)
  ≥50143 (34.8)
  No response1 (0.2)
Years of experience (mean, SD) (range)
  Nurse21.1 (9.2) (2 to 50)
  Visiting nurse7.3 (6.3) (1 to 30)

Item Analysis for 31 Items Regarding Visiting Nursing Practice for Individuals With Behavioral and Psychological Symptoms of Dementia (BPSD) (N = 411)

ItemMean (SD)Item-Total Correlation Coefficienta
1.I spend time to listen to the patient.3.9 (0.7)0.523*
2.I do not overlook trivial changes in facial expressions, speech, and behavior of the patient in order to detect their complaints and needs that they cannot express.4.1 (0.6)0.571*
3.I respect the patient's complaint, even if there is no consistency in their speech due to their delusions.4.2 (0.6)0.490*
4.When the patient is excited and confused, I intervene after he/she calms down.4.0 (0.7)0.484*
5.I actively talk to patients with dementia to bring them back to the real world, so that they are not fettered by symptoms, such as delusions.3.2 (0.9)0.423*
6.I spend time on patient's hobbies or walking with the patient to help him/her refresh.3.6 (1.0)0.533*
7.I propose daytime activities, including mild exercise, shopping, and hobbies to the patient to help him/her regulate his/her life.3.9 (0.8)0.616*
8.I actively touch the patient so that he/she feels relieved.3.9 (0.8)0.568*
9.I provide the patient relaxation techniques, including aromatherapy and hand massages.28 (1.1)0.474*
10I prepare an environment for the patient, using a poster or markings in the place where he/she lives, to prevent him/her from having difficulties.3.5 (1.0)0.519*
11.I try to show my appreciation to patients who engage in cooking, washing, and cleanup.4.2 (0.7)0.592*
12.I confirm whether there is any factor that reduces the patient's quality of sleep (e.g., irregular habits, afternoon naps).3.9 (0.7)0.579*
13.If the patient does not care about his/her appearance, or his/her room is messy, I consider these as symptoms related to dementia.3.6 (0.9)0.373*
14.When health care, such as eating habits or medication management, is insufficient, I watch until the condition is aggravated.3.4 (1.0)0.301*
15.When delusions are observed, I try to confirm them as a team (e.g., search for stolen things).3.5 (0.9)0.435*
16.When the patient complains of anxiety, I listen until he/she is relieved.3.8 (0.7)0.536*
17.I utilize objective information, such as vital signs, so as to not overlook the physical disorder.4.3 (0.6)0.569*
18.I cooperate with the physician to help reduce the patient's discomfort due to physical symptoms (e.g., pain from constipation).4.2 (0.6)0.551*
19.I look back on the situation and try to identify factors that worsen the patient's symptoms.3.9 (0.7)0.689*
20.Worsening BPSD can be noticed through changes in the patient's facial expressions, speech, and behavior.3.7 (0.7)0.569*
21.I try to think of the reasons why patients wander and refuse care, from the patient's point of view.3.9 (0.7)0.600*
22.I use nonpharmacological therapies, such as kinesitherapy and hortitherapy, which are effective in improving BPSD.2.9 (1.0)0.570*
23.I share information with other medical professionals so that patients and families are not confused about the directionality of care.4.1 (0.7)0.555*
24.When I am troubled while addressing BPSD, I hold a conference with other professionals to solve the problem.3.6 (0.8)0.518*
25.I arrange opportunities to allow family members to express their anxiety and distress due to caregiving.3.9 (0.7)0.571*
26.I prepare a communication system to help family members having difficulties with BPSD.3.5 (0.9)0.556*
27.I give advice to family members about addressing BPSD.3.6 (0.8)0.624*
28.I review necessary services to reduce family caregiving burden associated with BPSD.3.6 (0.8)0.583*
29.I encourage patients to participate in day service or local mutual self-help groups to help maintain connections with society.3.8 (0.8)0.577*
30.I propose patients and family members participate in local exchange meetings, such as dementia cafes.2.9 (1.0)0.463*
31.I collect information about character and lifestyle factors before dementia onset from the patient and family members.4.0 (0.8)0.627*

Exploratory Factor Analysis of Visiting Nursing Practice Self-Evaluation Scale for Older Adults With Behavioral and Psychological Symptoms of Dementia (BPSD) (N= 411)

Factor 1Factor 2Factor 3Factor 4Communality
Factor 1 Assessment and response factors related to BPSD (Cronbach's alpha = 0.860)
17. I utilize objective information, such as vital signs, so as to not overlook the physical disorder.0.800−0.034−0.0810.0070.443
19. I look back on the situation and try to identify factors that worsen the patient's symptoms..7570.0490.100−0.0710.484
18. I cooperate with the physician to help reduce the patient's discomfort due to physical symptoms (e.g., pain from constipation).0.7490.055−0.096−0.0500.346
20. Worsening BPSD can be noticed through changes in the patient's facial expressions, speech, and behavior.0.5860.081−0.0010.0220.402
23. I share information with other medical professionals so that patients and families are not confused about the directionality of care.0.5490.146−0.055−0.0030.449
12. I confirm whether there is any factor that reduces the patient's quality of sleep (e.g., irregular habits, afternoon naps).0.506−0.0920.1420.1360.392
11. I try to show my appreciation to patients who engage in cooking, washing, and cleanup.0.458−0.1160.2210.0810.351
21. I try to think of the reasons why patients wander and refuse care, from the patient's point of view.0.4150.080−0.0680.2910.435
Factor 2 Interventions to reduce family care burden (Cronbach's alpha = 0.820)
28. I review necessary services to reduce family caregiving burden associated with BPSD.−0.0290.813−0.043−0.0010.345
27. I give advice about addressing BPSD to family members.0.0050.7900.046−0.0130.402
26. I prepare a communication system to help family members having difficulties with BPSD.0.0060.6480.062−0.0490.555
25. I arrange opportunities to allow family members to express their anxiety and distress due to caregiving.0.0750.501−0.0460.1920.504
29. I encourage patients to participate in day service or local mutual self–help groups to help maintain connections with society.0.1690.4750.097−0.0710.636
Factor 3 Nonpharmacological approaches (Cronbach's alpha = 0.765)
9. I provide patients relaxation techniques, including aromatherapy and hand massages.−0.0550.0580.725−0.1520.432
22. I use nonpharmacological therapies, such as kinesitherapy and hortitherapy, which are effective in improving BPSD.0.093−0.0130.687−0.0630.448
6. I spend time with hobbies or walking with the patient to help him/her refresh.−0.114−0.0280.6440.1610.485
7. I propose daytime activities, including mild exercise, shopping, and hobbies, to patients to help them regulate their life.0.193−0.0010.4740.0470.393
8. I actively touch the patient so that he/she feels relieved.−0.0680.1180.4650.1560.428
Factor 4 Attitudes in trying to understand a patient's intentions (Cronbach's alpha = 0.729)
1. I spend time to listen to the patient.−0.150−0.0050.1430.6780.435
4. When the patient is excited and confused, I intervene after he/she calms down.0.0990.010−0.1090.6110.657
2. I do not overlook trivial changes in facial expressions, speech, and behavior of the patient to detect complaints and needs that he/she cannot express.0.1350.038−0.0380.5950.598
3. I respect patients' complaints, even if there is no consistency in their speech due to their delusions.0.072−0.0580.0170.5560.380
Cronbach's alpha for the entire scale0.904
Kaiser-Meyer-Olkin0.919
Correlation among factors
  Factor 10.6720.5080.684
  Factor 20.4830.504
  Factor 30.539

Mean (SD), Tests of Normality, and Criterion-Related Validity Results for the Entire Scale and Each Factor

Factor(N = 411)Criterion-Related Validitya
Mean (SD)Shapiro-Wilk Test (p Value)Scale for Professional Autonomy in Nursing (n = 399)Self-Evaluation Scale on Home Health Nursing (n = 405)
1 Assessment and response factors related to BPSD32.2 (3.9)<0.010.610*0.568*
2 Interventions to reduce family care burden18.6 (3.2)<0.010.539*0.537*
3 Nonpharmacological approaches17 (3.5)<0.010.383*0.356*
4 Attitudes in trying to understand a patient's intentions16.2 (2)<0.010.496*0.501*
Entire scale84 (10)0.060.634*0.610*
Authors

Dr. Furuno is Public Health Nurse and Assistant Professor, Dr. Fujino is Public Health Nurse and Professor, Dr. Fujimoto is Senior Lecturer, Department of Nursing, Faculty of Medicine, Saga University, Saga-city; Dr. Shirai is Associate Professor, Department of Nursing, Faculty of Nursing, Fukuoka Jo Gakuin Nursing University, Koga-city; Dr. Iwamoto is Public Health Nurse and Senior Lecturer, Department of Nursing, Faculty of Medicine, Oita University, Oita-city; Dr. Kamada is PhD Student, Saga University Graduate School of Medical Science, Saga-city; and Dr. Yamaguchi is Public Health Nurse and Professor, Department of Nursing, Faculty of Health Science, Hiroshima Cosmopolitan University, Hiroshima-city, Japan.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The current study was supported by the Yuumi Memorial Foundation for Home Health Care.

The authors acknowledge the visiting nursing managers and nurses who participated in this study.

Address correspondence to Takaomi Furuno, MD, RN, Public Health Nurse and Assistant Professor, Department of Nursing, Faculty of Medicine, Saga University, 5-1-1, Nabeshima, Saga-city, 849-8501, Japan; e-mail: tfuruno@cc.saga-u.ac.jp.

Received: April 05, 2019
Accepted: July 29, 2019
Posted Online: October 04, 2019

10.3928/19404921-20190930-01

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