The Development of the Japanese Psychiatric Nursing Assessment Classification System (PsyNACS © )

The purpose of this study was to develop the Japanese Psychiatric Nursing Assessment Classification System (PsyNACS) © . This study used the on-line survey method from February to April 2015. There were 644 respondents comprised of professional nurses with minimum qualification of 3 years’ experience being in a psychiatric unit of a stand-alone 200-bed or health assessment, (PAD6) Self-care, (PAD7) Social support, (PAD8) Activity, sleeping and mobility capability, and (PAD9) Sexual function and sexual behavior. The PsyNACS © is a classification of items assessing health care needs within the Japanese psychiatric nursing care environment, and also can be used in various psychiatric patient care situations in all psychiatric units.


Introduction
In 2011, the Japanese Government unveiled its health care policy focusing on five major diseases: malignant neoplasms, cerebral stroke, acute cardiac infarction, diabetes mellitus, and psychiatric diseases. The Japanese Government considers psychiatric diseases a major disease [1]. The psychiatric healthcare in-patient environment shows that the average hospital stay is longer compared to other countries [2]. Psychiatric disease does not only exhibit subjective symptomatology, but also includes functional disturbances, disability and social disadvantage [3]- [5]. Characteristics of psychiatric diseases are that the progression and remission repeatedly occur and the disease becomes chronic [6] forcing psychiatric patients to continually stay in hospitals rather than live in their communities [7] [8].
Furthermore, Japan is facing a super-aging society where the elderly population, older than 65 years old, accounts for more than 25% of the total population. This percentage is expected to increase to 40 percent by 2055 [9]. More than 50 percent of total in-patients at psychiatric hospitals are the elderly [10]. In addition, as they age, psychiatric patients, having physical complications associated with malignant neoplasms, after-effects of cerebral stroke and pneumonia, require increased nursing care practices for their physical care needs [11].
Generally, psychiatric hospitals in Japan, systematically collect patient information following methods set forth by the North American Nursing Diagnosis Association (NANDA) [12] [13] and the framework of nursing care needs from Henderson [14]. At psychiatric hospitals in Japan, the Orem's self-care theory of Nursing [15], focusing on supporting and meeting self-care needs of patients [16] [17], and the 14 basic needs according to Henderson, focusing on patients' needs, can be readily observed. However, there is no reference to a Japanese psychiatric nursing-care assessment data system reflecting the human health and nursing needs of Japanese psychiatric patients.
Patients' assessment data generated in general hospitals because aimed for somatic disorders, are not comprehensive enough or do not work well enough for psychiatric patients. Because of these inadequacies, some hospitals have added information to meet their assessment needs. To be cognizant of these diseases and cover all information necessary to respond to the demands of nursing care of psychiatric patients, it is important that a culturally-based psychiatric patients' assessment data system is designed and implemented.
Hospitals that introduce electronic health records can build a unique database of information for the assessment of patients cooperatively developed by engineers and other health care personnel of the hospital's medical information department [18]. With an electronic health record system, it is possible not only to use the database for the systematic processing of nursing-care activities, but also to comprehensively use the information which may be of relevance for other health care occupations for the purpose of assuring human health care [19]. However, in 2005, the introduction rate of electronic health records by psychiatric hospitals was under the 10 percent mark [20]. This shows that many hospitals have difficulty collecting the required information for adequately assessing patients, and developing and implementing nursing-care plans.
Therefore, in order to respond to the needs of Japanese psychiatric patients based on cultural-social backgrounds, medical treatments, nursing care, and post-discharge rehabilitation, a thorough assessment should be effortlessly and comprehensively conducted. Effective nursing-care can be provided through a method of holistic assessments of patients by clarifying their symptomatology characteristics of being a patient with psychiatric nursing care problems requiring nursing interventions.
The purpose of the study was to design and develop the Japanese Psychiatric Nursing Assessment Classifica-tion System (PsyNACS) © .

Description of PsyNACS ©
A descriptive correlational survey method was used to determine the clusters of assessment items that comprise the Cluster Assessment Data (CAD) and the Patient Assessment Data (PAD) of the PsyNACS © . The PsyNACS © is composed of three levels or sections: The general data set is composed of 9 PADs, with each PAD having 2 to 5 CADs. There are 31 CADs derived from selected evaluation items. In order to investigate the items necessary for a psychiatric nursing-care assessment data, 211 assessment items were derived from specific assessment items based on selected theoretical models or frameworks of self-care theory by Orem-Underwood [17], the 14 basic needs by Henderson [14], Gordon's 11 functional health patterns [21] and items from the stress adaptation model by Stuart [22]. The level of importance of each indicator was evaluated as 1) Unnecessary, 2) Not very important, 3) Important and 4) Very important.

Data Analysis
Data analysis used descriptive and multivariate statistics to determine the distribution of items within the Psy-NACS © . Factor analysis (principal factor analysis, varimax rotation) was used in order to determine CAD together with the Kaiser-Meyer-Olkin (KMO) and the Bartlett's test of Sphericity to assess the adaptive validity of the factor analysis. Factor loadings were set at 0.4 or more for the configuration of items. Factor loadings of less than 0.4 were omitted because of its low-level importance.
Internal consistency and reliability of the assessment data scores was done using Cronbach's alpha coefficient. Mean factor points were calculated, including the standard deviation, range, and confidence interval (CI) at 95%. Statistical significance was set at 0.05 level. All statistical analyses were performed using the SPSS for Windows software (version 20.0; SPSS Inc., Chicago, IL).

Selection of Nurse-Practice Setting and Data Collection
The subjects of the survey were 644 professional nurses practicing at 116 psychiatric hospitals in Japan. These hospitals were stand-alone or single service hospitals with 200 beds or more. In addition, subjects had to work in psychiatric units for at least three years and the clinical experience of more than 5 years of nursing (excluding licensed practical nurse). Since the desire was to extract the specific features of psychiatric nursing in Japan, psychiatric units in general hospitals were excluded.
Initial contact with the managers of the psychiatric hospitals was done to enhance cooperation to participate with the survey. Once commitment was obtained from the managers, the password for the PsyNACS © on-line internet-based survey questionnaire was provided to them. The on-line questionnaire package contained the following items: The PsyNACS © Questionnaire, and the Demographic Data Sheet. The Demographic Data sheet required respondents to provide their personal data, e.g. age, gender, place of work, years of experience as a nurse in general and years of experience in Psychiatric Units, etc.
The time frame was from February 2015 to April 2015. Follow-up telephone calls to the managers were made to ensure timely access and completion of the questionnaire and to enhance the return rate. The survey was conducted by SurveyMonkey © .

Ethical Considerations
The University of Tokushima Hospital Clinical Study Ethical Review Board approved this study. No harm to the subjects could be identified. Return of the survey implied that the subjects gave consent. The subjects were notified that privacy would be protected; only aggregate data would be used in reporting the findings.

Characteristics of Respondents
Of the selected hospitals with 200 or more beds, 116 nursing hospital directors were invited to approve this survey and distribute to their staff. As a result, the questionnaire was accessed by 644 Japanese psychiatric nurses, of which 435 (67.5%) were received with valid answers. The respondents' ages, clinical experiences as a nurse, experience in psychiatric nursing, type of ward functions, and hospital bed size are shown in Table 1.

Factor Analysis and the Excluded Items of Each CAD
As a result of the factor analysis, 31 factors (that is CADs) were extracted to comprise nine PADs. Their alpha factors were in the range of 0.858 to 0.979. This showed that the over-all data obtained high internal consistency for each factor. The KMO sample adequacy was in the range of 0.86 -0.96 and the Bartlett's test of sphericity was p < 0.001; therefore, this instrument was reliable.
Following the factor analysis the following items were excluded: (PAD1) seven items of Incoherence, Circumstantiality of thinking, Perseveration, Trance, Allotriophagy, Factors relating to stress becoming stronger, and Conscious level; (PAD2) Two items of Family history, and Infectious disease; (PAD3) Two items of Thought toward excretion, and Amount of perspiration; (PAD4) Three items of Religious faith, Characteristic, and Kinds of plays and recreations, (PAD5) Two items of Painkiller, and Daily health management; (PAD6) Two items of Degree of satisfaction for clothes, and Feeling of cleanliness; (PAD7) Two items of Address, and Social resources; (PAD8) Four items of Tension of muscles, Muscle strength, Amount of exercise, and Way to spend a day. However, in the (PAD9) assessment item was not excluded ( Table 2).

Evaluation Results of Important Level of Each CAD
Considering the factor loading score criteria, the factors with average scores evaluated as "3 or more than 3 points-importance" were identified. However, other CADs were evaluated as "not very important" ( Table 3).

Discussion
This study reflected the responses of professional and experienced nurses who are skilled in psychiatric nursing care in Japan. This raised the level of accuracy of the results of the research. Sampling was considered appropriate, and the number of responses were critical statistically satisfactory. This raised the level of accuracy of the results of the research.
The results of the study demonstrated the degree of importance that the assessment data items of the Psy-NACS © serve to distinguish the needs of patients in psychiatric care. These levels provided ways to categorize the Patient Assessment Data (PAD), and the Cluster Assessment Data (CAD). Factor loadings of "4 or more" signifying importance of the items facilitated the development of the PsyNACS © .
Thirty one CADs were extracted in this research. However, twenty seven items were excluded based on results of factor analysis. For example, allotriophagy of psychological symptoms was one of the assessment data items excluded because this was a problem with autism and/or intellectual disability [23]. Furthermore, other items which are included in the rehabilitation care situations provided by occupational therapists were also excluded. Family support evaluation item is a psychiatric item in which social workers can often intervene. These items were also excluded because these are functions which are performed by other health care professionals. Items related to religion were considered cultural characteristics of Japanese people who are unlikely to have strong religious affiliations and were also excluded.
In PAD1, all of the factors were rated as "important". Mood disorders and dementia are increasing in Japan. The evidence is supported by increased patient admissions in psychiatric hospitals [24]. The numbers of patients admitted to the psychiatric hospitals are about 29 million patients, most often due to schizophrenia [25]. In particular, facilitation of adaptive coping with serious mental illnesses is an important part of psychiatric-mental health nursing care [26].
In PAD2, regarding Information about treatments, Information of adherence, and Information about psychiatric rehabilitation were all rated as "important". According to Bowers [27], the roles of the nurse is to provide safety for patient and others, collect valuable information about patients, monitor treatment efficacies, manage disturbed behavior, provide personal care, and manage a comfortable environment for patients. Therefore, it is considered important to patient care success that nurses acquire crucial information concerning the patient's ability to understand, the developmental stage, and treatments performed. This is particularly critical to psychiatric patients who may have relapsing condition of the psychiatric disease.
Nourishment management, and blood tests were assessment data which were evaluated as "not very important". However, blood test is included because of the average value which was in the range of 2.93 -3.02 95% CI. These assessment data are physiological information that may have value that is vital to the patient's health condition.    In PAD3, Function of eating, Excretion situations, and Balance of water were rated as "important". Excretion situation included the items concerning the symptom and personal situations at the time of excretion. This was considered to be an observation item necessary for the assessment of physical symptoms. Disturbance in the balance of fluid intake including water is considered to cause physiological problems that can directly and indirectly influence the whole-body management, and the consequent pharmacological effects of psychoactive drugs for long term effects. Balance of water was rated "important" by respondents. However, in Japan, in-patients with schizophrenia accounts for about 60%, while the number of patients with eating disorders are few. This may explain why "Eating cognition" was evaluated as "not very important." In PAD4, all factors influencing human life were considered valuable, including Intention/point of view, and thoughts of the patient. These were evaluated as important. In a study by Kataoka et al. [28], Japanese nurses' involvement in patient situations included four factors based on the assessment which focused on social resources; holistic assessment, person's way of living, and the strengths of individuals with mental disability. It is considered that, in order to understand patients [29] responses to care involving appreciation of human wholeness occur in a momentary resolution often from their viewpoints on nursing care, and thoughts of the patient as an "important" factor.
In PAD5, assessing Vital signs and General health condition, respondents evaluated these items as 'important'. However, items such as Sensory organ, Respiratory and chest symptom, and Seeing and hearing were evaluated as "not very important". While these are items related to the five senses, visual acuity and sense of hearing, was evaluated as "not very important" as well. This was also observed in the case of Respiratory and chest symptoms, as these were treated efficiently by moving the patient to a ward or hospital which has a physician.
In PAD6, in the area of Self-care, Egestion and cleanliness was evaluated as "very important". ADL and Appearance however, were evaluated as "not very important". The ADL was also evaluated by the capability to be mobile in PAD8. In some cases, a patient with schizophrenia may lose all interest in his or her personal grooming because negative symptoms of schizophrenia, which involve a loss of function, may include lack of motivation, social avoidance, and lack of emotional response [30]. Support for a person's Appearance may be important for social activities. However, for long term hospitalization, this might not be important by the nurses.
In PAD7, Situations of the family and social life, Disease and family, Relationship to the health care provider and Relationship with others were found to be "important". A study by Sawada et al. [31] reported that the roles of psychiatric nursing care as "basic activities of daily living, psychological support/interpersonal skills, medical support, monitoring, family support and miscellaneous" may be required interventions for patients in acute psychiatric hospitals in Japan.
In PAD8, Activity and sleeping and Mobility capability, includes items concerning "Risk of falls and tumble". The risks of tumbling down and falling are not caused by purely psychiatric symptoms. The research by Sano et al. [32] indicated that every antipsychotic pill drug increases the risk of tumbling and falling at the rate of 2.63 times as the result of side effects of internally administered medicines. Stenhagen M. et al. [33] explained that the lowering of Cognition function; and the condition of Instrumental Activities of Daily Living caused by aging are related to the risks of tumbling and falling. In the research by Soderqvist A. et al. [34], assessments of "Cognition function" by nurses were lower than in actual conditions. Psychiatric hospitals in Japan are considered to put emphasis on the risk assessments for tumbling and falling particularly for the advancing population of the aged.
In PAD9, Interest toward sexuality and Sexual function were evaluated as "not very important". Antipsychotic polypharmacy was associated with increased side effect burden, increasing rates of Parkinsonian side effects, anticholinergic symptoms, hyperprolactinemia, sexual dysfunction, hypersalivation, sedation/somnolence, cognitive impairment, and diabetes [35]. Although the events concerning sexuality tends to be considered less serious in the hospital than in the community society, "Interest toward sexuality" was regarded as "important" not only for the young, but also by the elderly; therefore, it is necessary to include "Sexual behavior problems" as a very important assessment data as this condition sometimes occur because of inappropriate judgments owing to the psychiatric symptom in psychiatric wards. According to the research by Steven et al. [36], many of the patients with chronic psychiatric disease were sexually active. Therefore, it is appropriate that PsyNACS © include sexual behavior of patients as critical assessment data, recognizing the importance of sexuality human living without ignoring their desire [37].

Limitations
The researcher used theoretically-based assessment data from selected theoretical sources such as textbooks on nursing theory and models. Furthermore, the survey items had included symptoms and names of diseases in part, and some synonyms. In the PAD9 of Sexual function and sexual behavior, the most asked commonly questions were concerning female sexual behavior and those concerning male sexual activities were few.

Conclusion
Assessment items of the PsyNACS © were evaluated "important" by professional nurses who practiced in psychiatric hospitals in Japan. Through the dissemination of the PsyNACS with publications in a clinical nursing journal and distribution to staff in psychiatric hospitals, patient care will be improved. The PsyNACS © will provide an excellent assessment data classification system specific to Japanese psychiatric health care environment. It can be used for psychiatric nursing care practice, from acute to chronic care; also it can facilitate the implementation of an efficient and practical psychiatric patient care plan.