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Aims: To identify key factors influencing institutional nurses' self-perceived competencies in spiritual care., Background: In the past decade, interest in spiritual care has been increasing; however, in long-term care facilities, limited knowledge is available about nurses' competencies in spiritual care., Methods: The cross-sectional study was conducted with 202 nurses in 11 long-term care facilities. Data were collected in a survey using the Spirituality and Spiritual Care Rating Scale, the Nurse Spiritual Care Therapeutics Scale, the Spiritual Care Competence Scale and demographic questions. Data were analysed using stepwise linear regression., Results: Study findings revealed that nurses' perceptions of spirituality and spiritual care, frequency of spiritual care provision and self-satisfaction with the spiritual care given all significantly predicted overall spiritual care competence, which together explain 58% of the total variance., Conclusions: Improving nurses' perceptions of spirituality and spiritual care and encouraging the performance of spiritual care may be an effective pathway to enhance the spiritual care competence of institutional nurses., Implications for Nursing Management: Additional continuing education on spiritual care topics and the establishment of clear guidance and support from institutional administrators are required to enable nurses to deal with spiritual issues as they arise and improve the quality of holistic care., (© 2020 John Wiley & Sons Ltd.)

Aims: The purpose of this study was to validate patient's primary caregiver and their nurse's perception of patient discharge readiness assessment and their association with postdischarge medical consumption., Design: The study employed a descriptive research, prospective longitudinal study design., Method: The study was performed in a ward of a medical centre in Taipei, Taiwan, from June 2017-May 2018. Obtained data were analysed using an independent t test, one-way ANOVA and logistic regression approach., Results/findings: The number of comorbidities and the number of days of hospital stay were positively associated with post discharge emergency room visits. Caregiver readiness for hospital discharge had significant negative correlation with patient's 30-day readmission. Both caregiver and nurse readiness for the hospital discharge scale score were not factors associated with the patients' 30-day emergency room visit., Conclusion: Based on the research findings, to assess the discharge readiness as perceived by caregivers at patients' discharge is recommended., Impact: Caregiver and nurse scores on readiness for hospital discharge showed a significant positive correlation. The higher the score of a caregiver's readiness for a patient's hospital discharge, the lower the 30-day readmission rate. Family-centred care enables patients to safely pass though the transition phase from hospital to community and reduces the postrelease consumption of medical resources. The discharge readiness perceived by caregivers should be included in any decision-making., (© 2020 John Wiley & Sons Ltd.)

Aim: To determine whether acupressure can prevent or relieve the adverse drug reactions (ADRs) of anti-tuberculosis drugs., Background: People receiving drug treatment for TB often experience ADRs that may cause them to stop taking their medication. Acupressure is a form of traditional Chinese medicine that can be applied to alleviate or prevent disease symptoms., Design: A double-blinded, repeated-measures clinical trial in hospitals in Taiwan was carried out from April 2015 - May 2017., Methods: Convenience sampling was used to select 32 people (15 for the experimental group and 17 for the control group) aged >20 years who were taking anti-tuberculosis drugs. The people were randomized to receive 4-week of true acupressure and 4-weeks of sham acupressure. Acupressure therapy was given by a researcher in all cases. Both groups received treatment once per day on weekdays, with 15 min for each acupressure session. Outcomes (gastrointestinal irritation and adverse skin reactions) were assessed according to the people feedback and the physicians' recordings during the treatment course, and during monthly follow-up visits for 6 months thereafter., Results: Both groups typically experienced gastrointestinal irritation and adverse skin reactions within 2 months of beginning anti-tuberculosis drug treatment. The 4-weeks intervention involving relevant acupressure points successfully relieved both types of side effects in both immediate and delayed manner., Conclusions: When correctly implemented, acupressure can prevent and relieve the ADRs of anti-tuberculosis drugs, and motivate people to complete their treatment course., (© 2018 John Wiley & Sons Ltd.)

Aims and Objectives: To investigate the effectiveness of spaced retrieval for improving hyperphagia in patients with dementia in residential care settings., Background: Although 10-30% of patients with dementia have hyperphagia, most studies have focused on eating difficulties. Only a few studies have focused on hyperphagia. Various memory problems cause hyperphagia in patients with dementia. Spaced retrieval, a cognitive technique for information learning, can be used as a training method to improve memory loss. Recent studies showed that patients who received the training successfully memorised information learned in the training and correctly applied it to their daily lives., Study Design: Single-blind experiments were performed., Methods: The 97 subjects with dementia were recruited from seven institutions. All research participants were stratified into three groups according to cognitive impairment severity and Hyperphagic Behavior Scale scores and then randomly assigned to the experimental and control groups. The experimental group received a six-week one-by-one spaced retrieval training for hyperphagia behaviour. The control group received routine care., Results: After the intervention, the frequency and severity of hyperphagia in the patients with dementia, and food intake were significantly lower in the experimental group than in the control group. However, body mass index did not significantly differ., Conclusion: Our results suggest that the spaced retrieval training could decrease the frequency and severity of hyperphagia in patients with dementia. The content of this training programme is consistent with the normal manner of eating in daily life and is easy for patients to understand and perform. Therefore, it can be applied in residents' daily lives., Relevance to Clinical Practice: This study confirms the efficacy of the spaced retrieval training protocol for hyperphagia in patients with dementia. In future studies, the follow-up duration can be increased to determine the long-term effectiveness of the intervention., (© 2016 John Wiley & Sons Ltd.)

Aims and Objectives: This study aimed to evaluate the level of care quality received by disabled older patients residing at home vs. those residing in institutions., Background: Taiwan has an aging society and faces issues of caring for disabled older patients, including increasing needs, insufficient resources and a higher economic burden of care., Design: Retrospective study extracting patient data from Taiwan's National Health Insurance database., Methods: We enrolled 76,672 disabled older patients aged 65 years and older who resided at home or institutions and had submitted claims for coverage of National Health Insurance for home care received for the first time between 2004-2006. Propensity score matching was applied to create a home-care group and an institutional-care group with 27,894 patients each. Indicators of care quality (emergency services use, hospitalisation, infection, pressure ulcers, death) within the first year were observed., Results: The home care group had significantly higher emergency services use, fewer hospital admissions and fewer infections, but had significantly higher occurrence of pressure ulcers. The institutional-care group had significantly lower time intervals between emergencies, fewer deaths, lower risk of emergencies and lower pressure ulcer risk. Males had significantly higher emergency services use than females, and higher risk of hospital admission and death., Conclusions: Care quality indicators for elder care are significantly different between home care and institutional care. The quality of home care is associated with higher emergency services use and pressure ulcer development, and institutional care is associated with number of infections and hospitalisations., Relevance to Clinical Practice: Care quality indicators were significantly different between home-care and institutional-care groups and were closely associated with the characteristics of individual patients' in the specific settings. Nursing capabilities must be directed towards reducing unnecessary care quality-related events among high-risk disabled older patients., (© 2015 John Wiley & Sons Ltd.)

Aims: To explore the long-term effects of standardized and individualized spaced retrieval combined with Montessori-based activities on the eating ability of residents with dementia., Background: Eating difficulty is common in residents with dementia, resulting in low food intake, followed by eating dependence, weight loss and malnutrition., Design: A single-blinded and quasi-experimental design with repeated measures., Methods: Ninety residents with dementia from four veterans' homes in Taiwan took part in this study. The intervention consisted of spaced retrieval combined with Montessori-based activities. Twenty-five participants in the standardized group received 24 intervention sessions over 8 weeks. Thirty-eight participants in the individualized group received tailored intervention sessions. The number of intervention sessions was adjusted according to the participant's recall responses in spaced retrieval. Twenty-seven participants in the control group received no treatment. The Chinese version of the Edinburgh Feeding Evaluation in Dementia was used, and eating amounts and body weight were measured pre-test, posttest and at 1-, 3- and 6-month follow-ups. Data were collected between July 2008-February 2010. Repeated measures of all dependent variables for the three groups were analysed by the linear mixed model., Results: The standardized and individualized interventions could significantly decrease the scores for the Chinese version of the Edinburgh Feeding Evaluation in Dementia and increase the eating amount and body weight over time., Conclusion: Trained nurses in institutions can schedule the standardized or individualized intervention in usual activity time to ameliorate eating difficulty and its sequels., (© 2014 John Wiley & Sons Ltd.)

Aim: To examine the long-term effects of fixed/individualized spaced retrieval combined with Montessori-based activities on nutritional status and body mass index and nutritional improvement's moderating effect on depressive symptoms for people with dementia during a specific follow-up period., Background: The decrease in food intake, often combined with poor nutrition, may induce depressive symptoms in people with dementia., Design: A single-blind, quasi-experimental study with repeated measures., Methods: Twenty-five fixed group participants received spaced retrieval combined with Montessori-based activities over 24 sessions. Thirty-eight individualized group participants received the same intervention with different sessions, which was adjusted according to each participant's learning response. Twenty-seven control group participants just received routine care. The Chinese version of the Mini-Nutritional Assessment and Cornell Scale for Depression in Dementia scores and body mass index were recorded at pre-test, posttest and 1-, 3- and 6-month follow-ups. Data were collected between July 2008-February 2010., Results: The Mini-Nutritional Assessment scores and body mass index of the fixed and individualized groups could be significantly increased over time. Additionally, the Cornell Scale for Depression in Dementia scores could be significantly reduced as a result of the improvement of the Mini-Nutritional Assessment scores arising from the individualized intervention., Conclusion: The depressive symptoms of residents with dementia could be moderated by the individualized intervention through nutritional improvement. Trained clinical nurse specialists can use this individualized intervention for residents with dementia who also have poor nutrition and depressive symptoms., (© 2013 Blackwell Publishing Ltd.)

Aims: To demonstrate the principles and application of Mokken scaling., Background: The history and development of Mokken scaling is described, some examples of applications are given, and some recent development of the method are summarised., Design: Secondary analysis of data obtained by cross-sectional survey methods, including self-report and observation., Methods: Data from the Edinburgh Feeding Evaluation in Dementia scale and the Townsend Functional Ability Scale were analysed using the Mokken scaling procedure within the 'R' statistical package. Specifically, invariant item ordering (the extent to which the order of the items in terms of difficulty was the same for all respondents whatever their total scale score) was studied., Results: The Edinburgh Feeding Evaluation in Dementia scale and the Townsend Functional Ability Scale showed no violations of invariant item ordering, although only the Townsend Functional Ability Scale showed a medium accuracy., Conclusion: Mokken scaling is an established method for item response theory analysis with wide application in the social sciences. It provides psychometricians with an additional tool in the development of questionnaires and in the study of individuals and their responses to latent traits. Specifically, with regard to the analyses conducted in this study, the Edinburgh Feeding Evaluation in Dementia scale requires further development and study across different levels of severity of dementia and feeding difficulty., Relevance to Clinical Practice: Good scales are required for assessment in clinical practice and the present paper shows how a relatively recently developed method for analysing Mokken scales can contribute to this. The two scales used as examples for analysis are highly clinically relevant., (© 2011 Blackwell Publishing Ltd.)

Aim: This paper is a report of an experimental study of the effects of relaxation-training programme on immediate and prolonged stress responses in women with preterm labour., Background: Hospitalized pregnant women with preterm labour experience developmental and situational stress. However, few studies have been performed on stress management in such women., Methods: An experimental pretest and repeated post-test design was used to compare the outcomes for two groups in northern Taiwan from December 2008, to May 2010. A total of 129 women were randomly assigned to an experimental (n = 68) or control (n = 61) group. The experimental group participants were instructed to listen daily to a 13-minute relaxation programme. Measurements involved the stress visual analogue scale, finger temperatures, State Trait Anxiety Inventory, Perceived Stress Scale and Pregnancy-related Anxiety. Two-way analysis of variance and hierarchical linear modelling were used to analyse the group differences., Results: Compared with those in the control group, participants in the experimental group showed immediate improvements in the stress visual analogue scale scores and finger temperatures. The State Trait Anxiety Inventory-State subscale score for the experimental group was significantly lower than that for the control group (P = 0·03). However, no statistically significant differences for the Perceived Stress Scale and Pregnancy-related Anxiety scores were found between the experimental group and the control group., Conclusions: The relaxation-training programme could improve the stress responses of women with preterm labour., (© 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.)

Aims: To investigate the efficacy of applying a Montessori intervention to improve the eating ability and nutritional status of residents with dementia in long-term care facilities., Background: An early intervention for eating difficulties in patients with dementia can give them a better chance of maintaining independence and reduce the risk of malnutrition., Methods: An experimental crossover design was employed. Twenty-nine residents were chosen from two dementia special care units in metropolitan Taipei. To avoid contamination between participants in units using both Montessori and control interventions, two dementia special care units were randomly assigned into Montessori intervention (I1) and routine activities (I2) sequence groups. A two-period crossover design was used, with 15 residents assigned to Montessori intervention sequence I (I1, I2) and 14 residents assigned to Montessori intervention sequence II (I2, I1). On each intervention day, residents were given their assigned intervention. Montessori intervention was provided in 30-min sessions once every day, three days per week, for eight weeks. There was a two-week washout period between each intervention., Results: There was a significant reduction in the Edinburgh Feeding Evaluation in Dementia score for the Montessori intervention period but not for the routine activities period, while the mean differences for the Eating Behavior Scale score, self-feeding frequency and self-feeding time were significantly higher than those of the routine activities period. Except for the Mini-Nutritional Assessment score post-test being significantly less than the pre-test for the routine activities period, no significant differences for any other variables were found for the routine activities period., Conclusion: This study confirms the efficacy of a Montessori intervention protocol on eating ability of residents with dementia. Adopting Montessori intervention protocols to maintain residents' self-feeding ability in clinical practice is recommended., Relevance to Clinical Practice: Montessori-based activities could provide caregivers with an evidence-based nursing strategy to deal with eating difficulties of people with dementia., (© 2011 Blackwell Publishing Ltd.)

Aim: The aim of this study was to investigate the association between care activities and pain and restraint and pain in residents with dementia., Background: If pain in people with dementia is not identified or alleviated in a timely manner, it could lead to an adverse effect on their physical, mental, social health and quality of life. Care activities and restraint might cause pain, but little is known as to whether they are true risk-factors of pain in people with dementia., Design: A cross-sectional research design was employed., Methods: One hundred and twelve people with dementia were chosen from two nursing homes located in northern Taiwan. The demographic and clinical data collected included diagnoses, analgesics, restraints, recent falls, etc. The severity of dementia was assessed using the Clinical Dementia Rating Scale. The researchers observed every participant immediately following instances of routine care and then recorded the level of pain using the Chinese version of the Pain Assessment in Advanced Dementia scale., Results: About 36·6% of the participants had a Chinese version of the Pain Assessment in Advanced Dementia scale score above two points and an overall mean score of 1·50 (SD 1·81) with a range from 0-8. Only one resident with dementia received regular analgesic. Pain level in residents with dementia that needed assisted care was higher than in residents who were able to move about freely. It showed a positive correlation between level of pain and the severity of dementia among residents. The major predictors for pain in residents with dementia included restraint, assisted bathing and assisted transfer., Conclusion: The findings confirm the association between care activities and pain and between restraint and pain in residents with dementia., Relevance to Clinical Practice: Formal caregivers need to minimise the triggering of pain when they assist residents' daily activities and avoid unnecessary restraints, while offering personalised, conventional nursing care to residents with late-stage dementia., (© 2011 Blackwell Publishing Ltd.)

Aims: To investigate why patients do not choose percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy as a route for long-term feeding., Background: Home enteral tube feeding is well recognised as a valuable therapeutic option for patients requiring nutritional support following discharge from hospital. The number of patients discharged from hospital and receiving home enteral tube feeding increases annually in Taiwan., Design: A cross-sectional study., Method: Participants (n = 607) were chosen from one free-standing home care agency and three hospital-based home care departments in Taipei. A review of the patients' records to gather demographic data, medical diagnosis, length of home care and length of intubation prior to the home visit was conducted. A face-to-face interview was conducted at the time of the home visit., Findings: The prevalence rate of home enteral tube feeding was 70.3% (n = 427). Of the 427 tube-fed subjects, 93.4% were fed with a nasogastric tube. The most common reasons for refusing to use percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy were 'too old to suffer from an operation', 'worried about wound infection or leakage after performing percutaneous endoscopic gastrostomy' and 'to keep subjects' body integrity'. Stroke, no dementia, poor activities of daily living and poor cognitive status were significant predictors of being tube-fed, while higher education and better cognitive status were significant predictors of percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy use., Conclusion: The reasons patients refused to use percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy reflect the influence of cultural values and the level of patients' education, which home health care nurses need to discuss with patients in detail., Relevance to Clinical Practice: Investigating patients' perspective on the meaning of 'body' in Taiwanese culture and the decision-making processes related to home enteral tube feeding is recommended for nurses to provide better care and support when home enteral tube feeding in an option., (© 2011 Blackwell Publishing Ltd.)

Aim: This paper is a report of the validity and reliability testing of the Chinese version of the Pain Assessment in Advanced Dementia Scale (PAINAD-C)., Background: Pain is under-reported and under-treated for people with dementia, largely due to impairment of communication. An adequate instrument for assessment of pain in this population is essential to improving their quality of life and decreasing disability and behavioural disturbances, but none were found that were appropriate for these purposes., Method: The PAINAD-C was developed in three phases in 2006. First, back-translation was used to create the Chinese version, where five medical and nursing experts assessed content validity. Inter-rater reliability, internal consistency reliability and test-retest reliability were then examined. Finally, principal component analysis and known-group comparisons were used to test construct validity. Participants with dementia were selected from five licensed long-term care facilities in Taiwan. Direct observation was used to collect data., Results: Inter-rater reliability showed an intra-class correlation coefficient of 0.80-0.86, and a test-retest reliability intra-class correlation coefficient of 0.71. The internal consistency reliability was 0.55-0.66. Factor analysis of the PAINAD-C showed two factors that explained 62.48% of variance. The PAINAD-C scores showed statistically significant differences between the non-dementia group and the advanced dementia group as well as significant differences between activities and rest groups., Conclusion: The PAINAD-C is useful in a clinical setting for people with advanced dementia for both research and practice. It is easy to use and is a comprehensive instrument., (© 2010 The Authors. Journal of Advanced Nursing © 2010 Blackwell Publishing Ltd.)

Aims: To study the effect of a music programme during lunchtime on problem behaviour among institutionalised older residents with dementia., Background: Symptoms of dementia among older people include depression, problems with memory, insomnia and problem behaviours. Problem behaviour has been identified by families and nurses as the greatest challenge that needs to be addressed. Several studies have found that music therapy can reduce problem behaviours among dementia sufferers and, based on this finding, music has been recommended for incorporation as part of dementia management., Design: This study used a quasi-experimental design with an eight-week time series follow-up. The intervention was background music when residents had their lunch meal., Methods: A purposive sampling technique was used. Forty-one participants were selected from an institution housing residents with dementia located in a city in Taiwan., Results: The mean age of participants was 81.68 (SD 6.39) years old. The mean score for Mini-Mental State Examination (MMSE) was 10.66 (SD 6.85). The mean of Barthel Activity of Daily Living score was 56.83 (SD 38.12). The results showed that the music programme reduced, significantly, physical and verbal aggressive behaviour among the older residents with dementia. The study identified that there was a one-week time lag between the implementation of the music programme and a significant effect on the residents., Conclusions: The results from this study suggested that music is able to reduce the degree of problem behaviours among the older residents with dementia and this helps to ease work-load of nurse aides and nurses during meal times., Relevance to Clinical Practice: The results may serve as a reference for the future treatment of problem behaviour among the older with dementia.

Aims and Objectives: To evaluate the usefulness of registered nurses' (RNs) and nursing assistants' (NAs) pain report among 304 institutional older people with dementia and elucidate the factors influencing the agreement of pain reports within dyadic assessors., Background: Using informant reports has been suggested as an effective strategy to solve the dilemma of pain assessment in people with dementia. However, the validity of pain information provided by institutional caregivers is still under-investigated., Design: A prospective study was undertaken in six dementia special care units in Northern Taiwan., Methods: Both the four-item pain inventory and Doloplus-2 scale were used to investigate different raters' pain reports., Results: Across pain variables, fair to moderate agreement was noted in RNs' assessment (Kappa = 0.29-0.42), but poor agreement in NAs assessment (Kappa = 0.11-0.24). Comparing mean scores on intensity, frequency of pain and Doloplus-2, statistically systematic bias existed in most pairs, but the greater bias occurred in NAs' assessment. In logistic regression analysis, when pain was assessed by the pain inventory, residents' cognitive impairment level and caregiver's age were associated with the agreement of pain presence perceived in either resident-nurse or resident-NA pairs. Nevertheless, when pain was rated by the Doloplus-2 scale, only residents' physical function influenced the agreement of pain report for both research assistants (RAs)-nurse and RAs-NA pairs., Conclusions: Nurses' pain report across pain variables may be more reliable than NAs. Furthermore, factors influencing the agreement of pain assessed by self-report measurement or behavioural observations may be different, needing further investigation., Relevance to Clinical Practice: Pain inquiry and behavioural observation should be performed routinely as the fifth vital sign for developing effective care plans. Institutional caregivers should be used as alternative or complementary informants for assessing pain in older people with dementia.

Aims: The aim of this study was to investigate the risk factors of institutionalised older people for developing low food intake., Background: Eating difficulties among patients with dementia have been identified in western society and typically progress as dementia advances. Findings from previous studies reflect that low food intake or weight loss might not be a consequence of people with dementia being unable or unwilling to eat independently., Design: The study consisted of observers' training and mealtime observations. Each data collector received two days of didactic and clinical training. Observation was done for two days during lunch and dinner., Methods: Four hundred seventy-seven participants were selected from residents with dementia at nine dementia special care units in licensed long-term care facilities in northern and central Taiwan. Data were collected using the Barthel index, Mini-Mental State Examination (MMSE), and the Edinburgh Feeding Evaluation in Dementia (EdFED) scale., Results: The prevalence of low food intake at meals in residents with dementia in LTCF's was 30.7%. Eating difficulty, no feeding assistance, moderate dependence, fewer family visits, being female and older, were six independent factors associated with low food intake after controlling for all other factors., Conclusion: Nursing staff need to assess residents' feeding ability to continue to self-feed. Also, to supervise the feeding of residents with moderate dependency and provide appropriate verbal or physical assistance at meal times is recommended., Relevance to Clinical Practice: Constructing strategies to encourage families to visit their older relatives in institutions is recommended.

Aims: The purpose of this study was to explore the characteristics of and the contexts related to sexual behaviours among institutionalised residents with dementia., Background: Institutionalised residents with dementia are frequently unable to manage their sexual needs properly resulting in caregivers having a more conservative and passive attitude toward residents with dementia than those with higher cognitive status., Design: A grounded theory study., Methods: The participants in this study were institutionalised older people with dementia and their formal caregivers. Data were collected using in-depth, face-to-face interviews of 12 formal caregivers and by observing 12 institutional older people with dementia for three days. All observations were recorded and interview data were tape recorded and transcribed verbatim., Results: The results indicated that the predisposing factors included having opportunity, presence of a cooperative target and personal space without privacy. The sexual expressions of institutionalised older people with dementia included: physically intimate touch, sexual expression without touching others and sexual talk. Responses by individuals to sexual behaviour from another resident included neutral response, negative response and positive response., Conclusion: To provide better care, it is recommended that an inventory regarding sexual expression for clinical and research usage be constructed from the research results., Relevance to Clinical Practice: The findings of this study can provide the basis to develop on-the-job training programmes for sexual education of residents with dementia in institutions. Regular seminars on sexual care for the residents with dementia might be beneficial for managing sexual issues among residents and to decrease caregivers' burden.

Aims: The aims of this study were to investigate whether the interaction effect between restraint and functional ability, and single ability during activities of daily living can predict agitation among residents with dementia., Background: Agitated behaviour is one of the most common symptoms of dementia and might endanger the patients themselves, caregivers and institutions. However, the prevalence of problem behaviours and its associated factors at long-term care facilities in Taiwan are less understood., Design: A direct observation was used to observe the agitated behaviours of residents with dementia in special care units., Methods: Residents of dementia special care units who were diagnosed with dementia in eight long-term care facilities were recruited. Measurements included: demographic data, the Barthel Index, the Mini-Mental State Examination and the Cohen-Mansfield Agitation Inventory., Results: The number of subjects who were identified with problem behaviours was 163 (43.5%). Significant differences in sex, being restrained, restrained time, age, family visits, functional status and mental status were found between the agitated and non-agitated groups. However, mental status, family visits, walking ability, being restrained and getting in and off toilet were five independent factors associated with agitated behaviours after controlling for all other factors., Conclusions: It is recommended that strategies be constructed to encourage the family to periodically visit older residents and to develop restraint-free environments in long-term care facilities., Relevance to Clinical Practice: Residents with dementia require significant daily living support and behaviour management as their illness progress.

Aim: This paper is a report of an assessment of the construct validity of the Chinese version of the Edinburgh Feeding Evaluation in Dementia scale., Background: The Edinburgh Feeding Evaluation in Dementia scale has previously been translated and back-translated and to determine the equality of the Chinese and English versions. However, the construct validity of the Chinese version has not been investigated., Methods: Participants (n = 477) were selected from residents with dementia in licensed long-term care facilities in Taiwan in 2006-2007. Data collectors received training before observing feeding for 2 days during lunch and dinner. Data were analysed using principal component analysis, Mokken scaling and correlation., Findings: A two-factor structure was demonstrated for the 11 items of the Chinese version of the scale and six items conformed to a Mokken scale. The Chinese version of the scale correlated with external constructs such as weight and body mass index, as predicted by the unmet needs model., Conclusion: A confirmatory factor analysis is needed to confirm that the Chinese version measures the same qualities, in the same proportions, and with the same factor structure as the original Edinburgh Feeding Evaluation in Dementia scale.

Aims: The aim of this study was to investigate the prevalence rate and influencing factors of pneumonia associated with long-term tube feeding in special care units for patients with persistent vegetative states (PVS) in Taiwan., Background: Pneumonia is a significant cause of morbidity, hospitalization and mortality in the nursing home population. Tube feeding has been found as a risk factor for the occurrence of pneumonia., Methods: Two hundred sixty subjects were chosen from three hospital-based special care units for patients with PVS and 10 nursing facilities for persons in PVS in Taiwan. All subjects, who were diagnosed with PVS, received either financial aid for institutional care or were means-tested from The Bureau of Social Welfare of cities and counties in Taiwan. Data were collected through chart review and observations., Results: The prevalence rate of pneumonia in nursing facilities for patients with PVS was 14.2%. The prevalence rate of tube-feeding in nursing facilities for PVS was 91.2%. The mean duration of tube-feeding was 73.21 SD 55.33 months. A total of 90.4% was fed with a nasogastric (NG) tube. Having a lower intake of food and fluids daily and having been institutionalized for a shorter period were three dominant factors associated with the occurrence of pneumonia., Conclusion: Research findings reveal that the incidence of pneumonia is higher in patients who do not receive adequate food and water. Continuing in-service training to improve caregivers' knowledge and skill in providing care to patients in PVS and monitoring their skills in feeding is needed to decrease the occurrence of pneumonia in this population., Relevance to Clinical Practice: Staff needs to be taught to monitor laboratory data and signs and symptoms of malnutrition and hydration deficit, and also be alert to early indicators of pneumonia in patients with PVS.

Aim: To explore the efficacy of hospitals using case management with Directly Observed Treatment - Short course (DOTS) to monitor the adherence of patients with pulmonary tuberculosis in Taiwan., Background: Non-adherence to anti-tuberculosis chemotherapy is the major problem in treating patients with tuberculosis. Community-based case management coupled with DOTS has been applied to patients with tuberculosis and has resulted in good results in some countries. Taiwan has a high incidence of tuberculosis, and although it has implemented DOTS, the expected increased efficacy has not yet been realized., Design and Methods: The study used a quasi-experimental design. Using age and gender as matching factors, 96 subjects were randomly assigned to one of three groups in 2002-2003. Experimental group I was to receive DOTS case management comprising in-hospital education, direct daily observation in the first two months and one home visit per week. Experimental group II received traditional case management comprising in-hospital education and one home visit per month. The control group did not receive any intervention., Results: The adherence, the rate of completion, the treatment success, sputum conversion and chest X-ray improvement of experimental group I were significantly improved compared with experimental group II and the control group. The completion rate in experimental group I was higher than the general rate for Taiwan during the past six years and the treatment success rate met the standards of the World Health Organization., Conclusion: Hospitals using case management with DOTS can improve the adherence of tuberculosis patients and the control of tuberculosis-epidemic situations. Relevance to clinical practice. In a rapidly changing healthcare environment, clinical nurses can make a significant contribution to healthcare delivery for tuberculosis patients. This study has provided further insight into the implementation of hospital-to-community level case management using DOTS by nurses.

Aims and Objectives: To explore the process of development of collaborative relationship between family caregivers of institutionalized elders with dementia and nursing home staff in Taiwan., Background: Evidence suggests that family members are continuously involved in the lives of loved ones and have not given up their roles as caregivers after the institutionalization of a family member. Little is known, however, about how family caregivers develop a collaborative relationship with nursing home staff, particularly in Asian countries., Design and Methods: Grounded theory methodology was used. Data were collected via interviews and observations from 11 family caregivers of patients who were suffering from dementia and living in an institution for persons with dementia in northern Taiwan. Data were analysed by constant comparative analysis., Results: Findings revealed that 'institutional social penetration' was the process most used by family caregivers to achieve an harmonious collaborative relationship with the nursing home staff. Institutional social penetration is a dynamic process, which includes three components: self-disclosure, evaluation of care and penetration strategies. Family caregivers, who had developed a 'socially penetrating' relationship with the nursing home staff, were more likely to disclose information in more breadth and depth, to receive positive care evaluations and to adopt multiple effective penetration strategies., Conclusions: Institutional social penetration between family caregivers and nursing home staff can sensitize healthcare providers to meet the family's needs during the placement of their loved one and provide a basis for developing intervention strategies., Relevance to Clinical Practice: Findings of this study may help healthcare providers to understand the ways in which collaborative relationships develop between the families of elders with dementia and nursing home staff. Interventions can be developed to facilitate self-disclosure of both the family members and nursing home staff through timely feedback and familiarising family caregivers with different penetration strategies.

Aim: This paper is a report of a study undertaken to translate the Cohen-Mansfield Agitation Inventory from the original English into a Chinese language version and to establish the content, semantic and technical equivalence of the Chinese version., Background: Ensuring the equivalence of a translated Chinese version of the Cohen-Mansfield Agitation Inventory for patients with dementia is an essential requirement for identifying culturally specific expressions of agitated behaviours., Methods: In Phase I, five experts scrutinized the Inventory items to determine whether the behaviour described was relevant to the agitated behaviours present in the Taiwanese culture. In Phase II, experts did the initial translation into Chinese and then back-translated it into English. Four bilingual observers rated 31 residents with dementia to determine semantic equivalence across versions. In Phase III, the agitated behaviours of 32 residents were assessed by four observers using staff ratings and direct observation to determine the technical equivalence of the Chinese version. The study was carried out in Taiwan from August 2004 to April 2005., Findings: In Phase I, the rating of behaviours described on the Cohen-Mansfield Agitation Inventory was relevant to the agitated behaviours based on Taiwanese culture with a content validity index (CVI) value of 0.993. In Phase II, intra-class coefficients for all items on the Chinese version and split-halves of Chinese and English versions ranged from 0.69 to 0.74. In Phase III, six possible results for estimation of reliability across methods and raters for the Chinese version ranged from 0.63 to 0.86., Conclusion: The Chinese Cohen-Mansfield Agitation Inventory had modest psychometric properties. Further studies are needed to assess criterion and conceptual equivalence.

Aims and Objectives: To investigate the efficacy of acupressure in decreasing agitated behaviours associated with dementia., Background: Agitated behaviour is found in nearly half of all patients who have dementia. The presence of these behaviours increases the likelihood of injury, weakness, dehydration and lack of sleep and contributes to caregiver frustration and fatigue., Design: This pilot study was designed with subjects receiving both acupressure and the control treatment. Each subject served as his or her own control. Subjects received four weeks of acupressure protocols; to avoid a carry-over effect there was a treatment-free period of one week. Subjects then were visited by one of the investigators for a six-week period., Methods: Participants were recruited from a nursing home caring specifically for patients with dementia. Twenty of the 31 subjects (64.5 %) completed the study, while 11 were discharged or hospitalized. All the subjects were assigned to an experimental protocol and had a six-week acupressure treatment program. Baseline data were collected in the first week. Individual treatment sessions began at the second week of the study and lasted 15 minutes, twice a day, five days a week for four weeks. After a treatment-free period of one week, all the subjects served as controls undergoing a four-week control protocol consisting of companionship and conversation., Results: Comparison between the control and experimental phases indicated significant differences between the two groups on all outcome measures (Cohen-Mansfield Agitation Inventory, daily agitation records about physical attack, verbal and non-verbal attack and non-physical attack) with better results found during the acupressure phase., Conclusions: Acupressure is recommended as an efficacious and non-intrusive method for decreasing the agitation behaviours in patients with dementia., Relevance to Clinical Practice: Conducting the acupressure treatment takes 15 minutes. It could provide caregivers with a viable alternative to deal with patients with dementia.

Aim: This paper reports an evaluation of a range-of-motion exercise programme aimed at improving joint flexibility, activity function, perception of pain, and depressive symptoms in a sample of stroke survivors in long-term care facilities., Background: The benefits of physical rehabilitation for stroke survivors have been well established. There is, however, little empirical data on the effects of a simple nurse-led range-of-motion exercise programme in improving function for these people., Method: A randomized controlled trial was conducted in 1999 with 59 bedridden older stroke survivors in residential care. Participants were randomly assigned to usual care or one of two intervention groups. The 4-week, twice-per-day, 6 days-per-week range-of-motion exercise protocols were similar in both intervention groups, and consisted of full range-of-motion exercises of the upper and lower extremities. To test the effect of different degrees of staff involvement, in intervention group I, a Registered Nurse was present to supervise participants performing the exercises, while intervention group II involved a Registered Nurse physically assisting participants to achieve maximum range-of-motion within or beyond their present abilities., Results: Both intervention groups had statistically significant improvement in joint angles, activity function, perception of pain and depressive symptoms compared with the usual care group (P < 0.05). Post hoc comparison revealed that the joint angles in intervention group II were statistically significantly wider than in both the other groups (P < 0.01)., Conclusions: A simple nurse-led range-of-motion exercise programme can generate positive effects in enhancing physical and psychological function of bedridden older people with stroke. Further studies are needed to investigate the long-term effects of the programme in maximizing function, reducing care utilization and enhancing quality of life for this population.

Aim: This paper reports an evaluation of the effect of symptom management programmed on drug adherence, CD4 count and virus load and the quality of life of patients with HIV/AIDS., Background: Patients with HIV/AIDS have to face the long-term side effects caused by highly active antiretroviral therapy regimens. There has been little research to evaluate the influence of drug intervention side effects on self-care., Methods: Sixty-seven patients with HIV/AIDS were randomly assigned to one-on-one teaching, group teaching, or control groups. All those in the one-on-one and group teaching groups attended a symptom management programme once a week, followed by 3 weeks of continuity and telephone counselling. Those in the control group were offered experimental intervention at the conclusion of data collection. The Customized Adherence Self-Report Questionnaire, CD4 count and virus load, and Quality of Life Index were used to evaluate the effectiveness of the symptom management programme before and at 3 months after the intervention., Results: Median differences on the Customized Adherence Self-Report Questionnaire, CD4 count and virus load, and quality of life in both experimental groups were statistically significantly better than in the control group., Conclusions: The symptom management programme can increase self-care ability in managing medication side effects in patients with HIV/AIDS.

Aims and Objectives: The purposes of this study were to develop a comprehensive feeding skills training programme for nursing assistants and to test the effects of this training programme on their knowledge, attitude and behaviour and the outcome of dementia patients including total eating time, food intake and feeding difficulty., Background: Dementia patients have a high probability of feeding problems that result in a substantial risk of malnutrition. Assisting residents with eating is a major task for nursing assistants and they require better training to provide adequate quality of nutritional care., Design Methods: A quasi-experimental study was conducted. Two convenience-chosen dementia-specialized long-term care facilities in North Taiwan were randomly assigned into either a control or a treatment group. Sixty-seven nursing assistants were enrolled (treatment: 31; control: 36). Twenty nursing assistants and the same number of dementia patients were observed during mealtime. The treatment group participated in a feeding skills training programme including three hours of in-service classes and one hour of hands-on training, whereas the control group did not receive any training., Results: The treatment group had significantly more knowledge (F = 47.7, P < 0.001), more positive attitude (F = 15.75, P = 0.001) and better behaviours (t = 6.0, P < 0.001) than the control group after the intervention. Dementia patients in the treatment group had significantly longer total eating time (t = 2.7, P < 0.05) and higher Edinburgh Feeding Evaluation in Dementia scores (more feeding difficulty) (t = 2.1, P < 0.05) than the control group. There was no significant difference on food intake between the two groups (t = 0.8, P = 0.49)., Conclusion: This feeding skills training programme has been found to change nursing assistants' knowledge, attitude, and behaviour as well as increasing the eating time for the dementia patients., Relevance to Clinical Practice: This study raises attention regarding on-the-job training for nursing assistants. Furthermore, the feeding problems among dementia patients should be further explored as well as the nutritional care.

Aim: This paper reports a study to investigate the prevalence of and risk factors for depressive symptoms in elders in long-term care facilities in Taiwan., Background: Depression has been identified as a major health concern and is very common among frail elders in Western nursing homes. It is under-diagnosed, and may be associated with eating difficulties and subsequent malnutrition, functional ability and sociodemographic factors. There have been no previous studies of these issues in Taiwan., Methods: Residents of 18 long-term care facilities were recruited. Those able to communicate in the Mandarin or Taiwanese dialect, resided in long-term care facilities including skilled nursing facilities and intermediate care facilities, and who scored three or above on the Short Portable Mental Status Questionnaire were selected. Data were collected using the Geriatric Depression Scale, Barthel Index and Masticatory Index, and age, duration of institutionalization, and level of impaired swallowing were also measured., Results: The number of participants identified as depressed was 267 (52.05%). There was no significant difference noted relating to age, gender, duration of institutionalization, type of institution, mental status and masticatory ability between the depressed and non-depressed groups, but significant differences of functional status and impaired swallowing between the two groups were found. However, functional status, impaired swallowing, and type of institution were three independent factors associated with depressive symptoms after controlling for all other factors., Conclusions: Future studies on the detection of symptoms of depression should use a validated observational measure to overcome under-reporting of symptoms by the frailest residents.

Background: Patients with chronic obstructive pulmonary disease (COPD) suffer from dyspnoea in their daily life and this may be increased by anxiety. Acupressure may promote relaxation and relieve dyspnoea. Thus, it is appropriate to explore the effectiveness of acupressure on dyspnoea in patients with COPD., Aims: To compare outcomes of acupressure using sham acupoints on different meridians and ganglionic sections with that using true acupoints, in patients with COPD who are living at home., Methods: Patients diagnosed with COPD were selected from a medical centre and three regional hospitals in Taipei. A randomized block experimental design was used. Using age, sex, pulmonary function, smoking, and steroid use as matching factors, 44 patients were randomly assigned either to a true acupoint acupressure or a sham group. The true acupoint acupressure group received a programme to decrease dyspnoea. Those in the sham group received acupressure using sham pressure points. Both acupressure programmes consisted of five sessions per week lasting 16 minutes per session, extending over 4 weeks for a total of 20 sessions. Before acupressure was initiated and at the conclusion of the 20th session, the Pulmonary Functional Status and Dyspnoea Questionnaire-modified scale and the Spielberger State Anxiety scale were administered, and a 6-minute walking distance test was performed. Physiological indicators of oxygen saturation and respiratory rate were measured before and after every session., Results: The results of this study showed that the pulmonary function and dyspnoea scores, 6-minute walking distance measurements, state anxiety scale scores, and physiological indicators of the true acupoint acupressure group improved significantly compared with those of the sham group., Conclusions: The findings suggest that acupressure can be used as a nursing intervention to improve dyspnoea in patients with COPD.

The purpose of this study was to evaluate the efficacy of a home-based nursing program in the diabetic control of elderly people with diabetes mellitus living alone. Patients meeting the sampling criteria were recruited from a medical center and 10 health centers in Taipei for this quasi-experimental study. By matching the effects of age, sex, education, and history of diabetes, subjects were assigned semirandomly to two groups based on the intensity of home-based nursing care visitations. Group I was defined as daily visits to supervise diet, exercise, medication, and self-monitoring blood sugar (n = 15) and Group II as weekly visits to supervise diet, exercise, medication education, and self-monitoring blood sugar (n = 15). Patients who agreed only to receive blood examination were assigned to the control group (n = 14). The results of the study showed that reductions in fasting blood sugar, postmeal blood sugar, and hemoglobin A1c (HbA1c) in Groups I and II were significantly greater than those in the control group. The reduction in the total cholesterol and low-density lipoprotein in Groups I and II was significantly greater than that in the control group. There were no significant differences among the three groups in the improvement of high-density lipoprotein (HDL) and triglycerides (TGs). Group I revealed a significantly greater weight reduction compared to Group II. There was no significant difference between Groups I and II in the improvements of diabetes knowledge, depression level, or quality of life. From the research findings, based on cost-effectiveness, it is recommend that Program II be implemented.

Background: The presence of dysphagia is associated with an increased risk of mortality, malnutrition, dehydration, compromised pulmonary function, and disability. Appropriate swallowing training can establish optimal nutritional status and eliminate or reduce the risk of developing medical complications associated with swallowing impairment., Aim(s) of the Study: The aim of this study was to examine the functional swallowing and nutritional outcomes of swallowing training in institutionalized stroke residents with dysphagia., Design and Methods: A quasi-experimental parallel cluster design was used. Seven institutions with similar bed sizes were selected. All subjects in the experimental group received a structured swallowing training programme. The subjects in the experimental group (n = 40) received 30 minutes of swallowing training each day for 6 days per week for 8 weeks. The control group (n = 21) did not receive any training., Results: After swallowing training, mean differences in volume per second, volume per swallow, mid-arm circumference and body weight between pre- and post-training of the experimental group were significantly higher than for the control group, while mean differences in neurological examination and choking frequency during meals for the experimental group were significantly lower than in the control group., Conclusion: This study used objective timed swallowing tests, a swallowing questionnaire, and a neurological examination to evaluate the effects of swallowing training. However, videofluroscopy is generally considered the best method for evaluating the pharyngeal and esophageal stages of swallowing, and introducing this technique is recommended for future studies. Furthermore, it is recommended that nursing professionals should conduct swallowing training protocols in stroke patients to help prevent aspiration from dysphagia.

Background: Post-operative nausea and vomiting is a common complication following general anaesthesia. Traditional Chinese medicine indicates that acupressure therapy may reduce nausea and vomiting in certain ailments., Aim(s) of the Study: The aim of this study was to examine the effect of stimulating two acupressure points on prevention of post-operative nausea and vomiting., Design and Methods: A randomized block experimental design was used. The Rhodes Index of Nausea, Vomiting and Retching (INVR) questionnaire was used as a tool to measure incidence. To control the motion sickness variable, the subjects who underwent functional endoscopic sinus surgery (FESS) under general anaesthesia were randomly assigned to a finger-pressing group, a wrist-band group, and a control group. There were 150 subjects in total with each group consisting of 50 subjects. The acupoints and treatment times were similar in the finger-pressing group and wrist-band pressing group, whereas only conversation was employed in the control group., Results: Significant differences in the incidence of the post-operative nausea and vomiting were found between the acupressure, wrist-band, and control groups, with a reduction in the incidence rate of nausea from 73.0% to 43.2% and vomiting incidence rate from 90.5% to 42.9% in the former. The amount of vomitus and the degree of discomfort were, respectively, less and lower in the former group., Conclusion: In view of the total absence of side-effects in acupressure, its application is worthy of use. This study confirmed the effectiveness of acupressure in preventing post-operative nausea and vomiting.