Background: Alzheimer's disease patients face higher risks of caregiver abuse and caregiver burden than healthy older adults,. However, the association between abuse tendency by AD caregivers and their burden remains understudied. This study aimed to investigate the association between caregivers' abusive tendencies and burden levels in Alzheimer's disease through latent class analysis. Methods: A total of 541 Alzheimer's disease caregivers from long-term care facilities in Zhejiang Province, China, were included in this cross-sectional study. Demographic characteristics、abusive tendencies and caregiver burden were assessed using scale. Heterogeneous subtypes of abusive tendencies were identified through latent class analysis, and their associations with caregiver burden were examined using multivariate regression models. Rseults: The prevalence of caregiver abuse tendency toward Alzheimer's patients in Zhejiang long-term care facilities was 39.4%, categorized into three latent classes: Class 1 ("high abuse tendency-low coping deficiency"), Class 2 ("overall low abuse tendency"), Class 3 ("high coping deficiency-low abuse tendency"). Significant differences (P<0.05) emerged among classes in marital status, chronic conditions, daily care duration, caregiving training, and patient neuropsychiatric symptoms. Compared with Class 2, caregivers in Class 1 had significantly higher odds of providing more than 12 hours of daily care (OR=0.252, P<0.001), whereas those in Class 3 had lower odds of having received Alzheimer's caregiving training (OR=0.435, P=0.002). Caregiver burden scores also differed significantly across classes (F=12.086, P<0.001). Conclusions: Caregivers for Alzheimer's patients exhibit distinct abuse tendency categories with caregiving burdens. Healthcare providers should implement targeted training programs to alleviate these burdens, reduce the incidence of abuse tendency.

Integrated Care for Older People (ICOPE), developed by the World Health Organization (WHO) with a global perspective, faces varying degrees of barriers to implementation, particularly in middle-and low-income countries. Therefore, as with other new public service interventions, we draw on established integrated care interventions to design a Theory of Change (ToC) model for ICOPE, and to propose methods and pathways for adapting community-based integrated care models for older people (OP) to specific contexts, thereby updating and enhancing the implementation of ICOPE. An initial ToC for the ICOPE was drafted based on the WHO guidelines and published literature, and synthesizing the results of semi-structured interviews, group discussions. A total of 36 healthcare stakeholder experts in geriatric nursing, geriatric care and chronic disease management, rehabilitation and quality of life, and psychiatric-mental health were recruited to participate in a 5-stage ToC group workshop conducted consecutively. Each workshop has 2–3 facilitators, and lasts from 60 to 120 min. In multiple workshops, the experts discussed the causal pathway, the interventions needed to activate it, the underlying principles and assumptions, evaluated and refined them, and finally reached consensus. The ToC design has improved the ICOPE program, identifying the resources, long-term outcomes, and impacts required for the implementation of ICOPE in a specific setting, and clarifying the specific components of the integrated care interventions, such as materials, procedures, and intervention providers. The localized, OP-centred model of integrated home care developed in our study may contribute to healthy ageing through four potential long-term outcomes: (1) reduction of unnecessary hospitalizations and increased utilization of referral services, (2) enhancement of self-care capacity to prevent, reverse, or delay the decline of intrinsic capacity in OP, (3) improvement of the quality of life of OP living at home, and (4) reduction of caregiving burdens and improvement in the level of caregiving. The ToC is effective in identifying key characteristics of resources, interventions, impact, and outcomes of integrated care for OP. Our ICOPE program has been strengthened by ToC, which forms an integrated care model for assessment, planning, implementation, and evaluation, adapted to a specific setting, and provides guidance for other areas in similar settings.

Background: Advanced breast cancer patients often require palliative care (PC) to manage significant symptoms, relying heavily on nurses’ competence. Objective: Evaluate whether a structured PC training program can enhance nurses’ competence in breast cancer care. Methods: After an online announcement at Zhejiang Hospital, nurses enrolled in the PC training program. Due to the imbalance in trained and untrained nurses post-training, stratified randomization was applied, forming untrained (n = 34) and trained (n = 24) groups. The primary outcome, nursing competence, was assessed using Competency Inventory for Nursing Students at baseline and three months post-training. Subsequently, patients were recruited and assigned to different study groups based on the nurses providing their care. The untrained group (n = 167) and trained group (n = 106) received three months of inpatient PC care. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 and Family Caregiver Satisfaction Scale-2, as secondary outcomes, were assessed at baseline and three months post-care to evaluate the training’s impact on care quality. Results: At baseline, there were no significant differences in nursing competence or patient quality of life between the trained and untrained groups. Trained nurses showed significant improvements in general clinical skills, critical thinking, and ethics compared to untrained nurses. Patients cared for by trained nurses also demonstrated improved quality of life and higher family caregiver satisfaction. Conclusion: Structured training improves nursing competence, patient quality of life, and family caregiver satisfaction.

Objective:The institutionalization of care for patients with dementia is becoming a trend. Understanding the burden on employed caregivers and exploring associated factors are of great importance in practice. Therefore, this study aimed to examine the relationship between basic attributes, caring ability, and caregiver burden in employed caregivers practicing in nursing homes. Methods:This cross-sectional study included 541 employed caregivers in 11 four-star nursing homes in Zhejiang Province from April to December 2022. Caregiver burden was assessed using the Zarit Burden Interview (ZBI). Demographic characteristics of participants, characteristics of the older patients with dementia, caring characteristics, training in dementia care, and caring abilities were collected for analysis of influencing factors. A hierarchical multiple regression analysis was conducted to explore the factors influencing the burden on employed caregivers in nursing homes. Results:The ZBI score of employed caregivers in nursing homes was 40.42 ± 10.18, representing a moderate caregiver burden. Factors such as age (U = 27.82, P < 0.001), residence (U = 7.89, P < 0.001), educational level (H = 55.81, P < 0.001), self-care of older patients with dementia (H = 85.21, P < 0.001), daily care hours (H = 73.25, P < 0.001), number of older people with dementia cared for (H = 14.56, P = 0.012) and training in dementia care (U = -9.43, P < 0.001) were significantly associated with caregiver burden.Caring ability was negatively associated with caregiver burden (r = -0.22, P < 0.01). Furthermore, after controlling for demographic characteristics, the characteristics of older people with dementia, caring characteristics, training in dementia care, and caring ability explained 8.5%, 5.8%, and 4.8% of the caregiver burden, respectively. Conclusion:The burden of employed caregivers on patients with dementia in nursing homes can be attributed to various factors. We recommend tailored interventions, such as dementia care training and reviewing the number and duration of hours worked to reduce the burden experienced by caregivers.

Background Caring for people with dementia is perceived as one of the most stressful and difficult forms of caring. Family caregivers always experience high levels of psychological burden and physical strain, so effective and practical support is essential. Internet-based supportive interventions can provide convenient and efficient support and education to potentially reduce the physical and psychological burden associated with providing care. Objective This review aimed to (1) assess the efficacy of internet-based supportive interventions in ameliorating health outcomes for family caregivers of people with dementia, and (2) evaluate the potential effects of internet-based supportive intervention access by caregivers on their care recipients. Methods An electronic literature search of the PubMed, EMBASE, Web of Science, CINAHL, Cochrane Library, and PsycINFO databases was conducted up to January 2020. Two reviewers (ML and YZ) worked independently to identify randomized controlled trials (RCTs) that met the inclusion criteria and independently extracted data. The quality of the included RCTs was evaluated using the approach recommended by the Cochrane Handbook for Systematic Reviews of Interventions. Standardized mean differences (SMDs) with 95% CIs were applied to calculate the pooled effect sizes. Results In total, 17 RCTs met the eligibility criteria and were included in this systematic review. The meta-analysis showed that internet-based supportive interventions significantly ameliorated depressive symptoms (SMD=-0.21; 95% CI -0.31 to -0.10; P<.001), perceived stress (SMD=-0.40; 95% CI -0.55 to -0.24; P<.001), anxiety (SMD=-0.33; 95% CI -0.51 to -0.16; P<.001), and self-efficacy (SMD=0.19; 95% CI 0.05-0.33; P=.007) in dementia caregivers. No significant improvements were found in caregiver burden, coping competence, caregiver reactions to behavioral symptoms, or quality of life. Six studies assessed the unintended effects of internet-based supportive intervention access by caregivers on their care recipients. The results showed that internet-based supportive interventions had potential benefits on the quality of life and neuropsychiatric symptoms in care recipients. Conclusions Internet-based supportive interventions are generally effective at ameliorating depressive symptoms, perceived stress, anxiety, and self-efficacy in dementia caregivers and have potential benefits on care recipients. Future studies are encouraged to adopt personalized internet-based supportive interventions to improve the health of family caregivers and their care recipients.

Background In the context of global population aging and the rapid development of information technology, the demand for Internet Plus Home Care Nursing (Internet+ HCN) services have been on the rise, especially in China. Internet+ HCN services have the potential to maximize existing human resources to counter the shortage of medical healthcare services. However, at present, Internet+ HCN services are difficult to scale due to the lack of standardized service quality governance. Quality indicators for service evaluation of Internet+ HCN services are under-defined. Objective To develop a quality indicator system for evaluating Internet+ HCN services, and to shed theoretical light on assessing mHealth service quality from a user experience perspective. Methods An initial quality indicator system was established based on scenarios related to Internet+ HCN services. The Delphi Method was applied to modify the indicators according to experts’ opinions, and the analytic hierarchy process (AHP) was applied to calculate the indicator weight. Finally, a quality indicator system for evaluating Internet+ HCN services was developed based on the SERVQUAL model. Results Altogether, 17 experts from relevant fields such as nursing education, clinical nursing, health management, and health informatics were consulted through email surveys. The response rates in both rounds of Delphi and the AHP were 100%. The average expert authority coefficients were 0.912 and 0.925 respectively in the two rounds of Delphi. Kendall’s W, indicating variation coefficients, ranged from 0.262 to 0.265. Finally, a quality indicator system for evaluating Internet+ HCN services, comprising five primary indicators and 15 secondary indicators, was developed. Primary indicators and their AHP generated the following weights: assurance (0.245), reliability (0.240), tangibles (0.192), responsiveness (0.190), and empathy (0.132). Conclusions By measuring the services quality gap between user expectations and perceptions, the proposed SERVQUAL model-based quality indicator system shows potential in improving the quality of Internet+ HCN services through the perspective of user experiences.

Objective:To integrate the best evidence of non-drug intervention of urinary incontinence in elderly women and to formulate practical recommendations.Methods:In this systematic review study, using “elderly woman”,“urinary incontinence”,“bladder training”,“pelvic floor muscle training”,“enuresis”,“leakage of urine” as the key words, the 6S evidence resource pyramid model was used to search in British Medical Journal best practice, Uptodate, World Health Organization, Guidelines International Network, National Institute for Health and Care Excellence, Chinese Medical Association, Scottish Intercollegiate Guideline Network, Registered Nurses Association of Ontario, Cochrane Library, The Joanna Briggs Institute (JBI), New Zealand Guidelines Group, Polish Society of Gynecologists and Obstetricians, PubMed, Embase, Medline, Web of Science, SinoMed, China National Knowledge Infrastructure, WanFang Data, etc. The evidence retrieved included evidence-based knowledge base resources, clinical practice guidelines, expert consensus, systematic review, etc. Data were retrieved from January 1, 2017 to May 1, 2022, and collated from May 2, 2022 to May 25, 2022. Two researchers independently evaluated the quality of literature and extracted data using the AGREE Ⅱ and JBI evidence-based health care center assessment tools. The JBI evidence-based health care center′s evidence pre-rating system and evidence recommendation rating system were applied to rank the evidence; and under the guidance of the evidence structure of JBI, the strength of evidence recommendation was determined and the best evidence was extracted and summarized in combination with the study group discussion and expert opinion.Results:A total of 9 articles were retrieved, including 7 guidelines and 2 systematic reviews; and 6 guidelines were classified as Grade A and 1 as grade B; both 2 systematic reviews were rated as Grade A; 84% (27/32) of the items were evaluated as “Yes”. Evidence were summarized as 34 pieces of best evidence from 6 dimensions, including “overall recommendation, evaluation of type and degree of urinary incontinence, lifestyle change, behavioral therapy, prevention of precipitating factors, intervention in special population”; the flow chart of screening, evaluation, special symptoms, life style and behavior therapy was combed, and the practical suggestions were formed.Conclusions:The overall quality of the literature on non-drug intervention of urinary incontinence in elderly women is high, and the level of evidence is high. Early identification of urinary incontinence types and assessment of disease severity, lifestyle changes, avoidance of predisposing factors and behavioral therapy are the key to non-drug treatment of urinary incontinence in those patients.

Objective:To focus on the physical activity strategy to maintain the activity ability of the elderly in the community, comprehensively retrieve and integrate the best evidence, form practical suggestions with the goal of the transformation and practice of evidence, so as to provide scientific, reliable and up-to-date basis for the implementation of relevant evidence.Methods:According to the 6S pyramid model, the British Medical Journal (BMJ) Best Practice, UpToDate, DynaMed, World Health Organization, Chinese Medical Association, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, New Zealand Guidelines Group, PubMed, SinoMed and other databases were retrieved layer by layer from top to bottom. This study obtained all articles of evidence-based knowledge base resources, clinical practice guidelines, expert consensus, systematic review and other types related to physical activity strategies to maintain the activity ability of the elderly in the community from January 1, 2017 to March 1, 2022. According to the inclusion and exclusion criteria of the article, 2 to 4 researchers conducted independent methodological quality evaluation on different types of article according to the tool requirements, extracted and summarized the best evidence, and formed practical suggestions.Results:A total of 14 articles were included, including 2 evidence-based decision-making, 6 guidelines, 1 expert consensus, 3 systematic reviews, and 2 overviews of systematic review. Seven dimensions such as "overall advice, health benefits, diversified sports training, aerobic training, balance training, muscle strengthening/resistance training, flexibility training" and 22 best pieces of evidence were extracted and summarized, and practical suggestions were formed.Conclusions:Medical and nursing staff should adopt evidence-based methodological practical suggestions to provide management guidance and consultation for the maintenance of physical activity ability of the elderly in the community, so as to help the elderly to maintain physical activity ability and gain health benefits.

目的 编制护理人员对间歇经口管饲的知信行问卷,并检验其信效度.方法 基于知信行理论,在文献分析、小组讨论的基础上,通过德尔菲专家函询和预调查形成问卷.2022 年 10 月至 11 月,选取浙江省 6 个市 10 家三级甲等医院的 328 名护理人员进行调查,测定问卷的信效度.结果 形成的问卷包括知识、态度、行为 3 个维度,共计 33 个条目.探索性因子分析共提取 3 个公因子,累计方差贡献率为 77.316%,问卷平均内容效度指数为 0.970.总问卷的Cronbach's α系数为 0.969,折半信度为 0.755,重测信度为 0.936.结论 编制的护理人员对间歇经口管饲的知信行问卷信度和效度良好,可用于护理人员对间歇经口管饲相关知识、态度和行为现况的调查.

BACKGROUND:Parkinson's disease (PD) is the second prevalent neurological diseases with a significant growth rate in incidence. Convolutional neural networks using structural magnetic resonance images (sMRI) are widely used for PD classification. However, the areas of change in the patient's MRI images are small and unfixed. Thus, capturing the features of the areas accurately where the lesions changed became a problem.METHOD:We propose a deep learning framework that combines multi-scale attention guidance and multi-branch feature processing modules to diagnose PD by learning sMRI T2 slice features. In this scheme, firstly, to achieve effective feature transfer and gradient descent, a deep convolutional neural network framework based on dense block is designed. Next, an Adaptive Weighted Attention algorithm is proposed, whose pursers is to extract multi branch and even diverse features. Finally, Dropout layer and SoftMax layer are added to the network structure to obtain good classification results and rich and diverse feature information. The Dropout layer is used to reduce the number of intermediate features to increase the orthogonality between features of each layer. The activation function SoftMax increases the flexibility of the neural network by increasing the degree of fitting to the training set and converting linear to nonlinear.RESULTS:The best performance of the proposed method an accuracy of 92%, a sensitivity of 94%, specificity of 90% and a F1 score of 95% respectively for identifying PD and HC.CONCLUSION:Experiments show that the proposed method can successfully distinguish PD and NC. Good classification results were obtained in PD diagnosis classification task and compared with advanced research methods.

Objective:To construct a scoring system for assessing intrinsic capacity in older adults, thus to provide scientific guidance on defining the intrinsic capacity among older adults.Methods:Adopting the theoretical concepts from previous research on healthy aging, the primary set of indexes is constructed through literature analysis. And the content of intrinsic capacity evaluation index system for older adults is determined through Delphi experts consultation. The weighted values of the evaluation indexes are established by the analytic hierarchy process.Results:Eighteen experts were selected and invited for correspondence consultation. The effective recovery rates of the questionnaires were 88.89% and 93.75%, the expert authority coefficients were 0.882 and 0.900, and the Kendall harmony coefficients were 0.225 and 0.227. After a two-rounded Delphi experts consultation involving 18 experts, an intrinsic capacity evaluation index system for older adults was established, including five first level indexes and 14 secondary indexes. The weights of primary indicators were as follows: cognitive function (0.310), mobility (0.184), vision and hearing (0.183), psycho-social (0.172), and vitality (0.151). The corresponding secondary indicators of cognitive function were time and spatial orientation (0.116), memory (0.072), language ability (0.064), calculate ability (0.058). The corresponding secondary indicators of vision and hearing were visual impairment (0.091), hearing impairment (0.091).The weights of the secondary indicators corresponding to mobility were movement restriction (0.107) and fall risk (0.076). The corresponding secondary index weights of psycho-social were subjective perceived social isolation (0.067), loss of interest (0.056), and depressed (0.050). The corresponding secondary indicators of vitality were malnutrition (0.062), oral frailty (0.050), loss of appetite (0.040).Conclusion:A comprehensive evaluation index for the intrinsic capacity of the older adults was established, which provides the scheme for comprehensive evaluation of the intrinsic capacity of the older adults, and provides possibility for early intervention based on comprehensive evaluation in the older adults.

对Vivifrail多组分运动的概念、作用机制、实施要素以及在老年人中的应用效果进行综述,为国内老年人开展Vivifrail多组分运动相关研究提供参考.

目的 对国内老年人虐待研究现状进行文献计量学分析,以期为今后深入研究提供参考与建议.方法 检索中国知网、万方数据知识服务平台、维普资讯中文期刊服务平台和中国生物医学文献数据库建库至2021年12月31日收录的老年人虐待相关文献进行分析.结果 共纳入237篇文献,发文量整体呈上升趋势;载文量前9位的期刊以医学类期刊为主;文献合作度2.35,合著率45.15％;研究类型以综述及经验总结类和调查性研究为主;研究热点主要集中于照顾者、影响因素和痴呆患者.结论 国内老年人虐待研究仍处于起步阶段,尚存在研究类型单一、缺乏干预性研究等问题,今后应加强多学科、多机构间的合作,进一步延展老年人虐待研究的深度和广度.

Objective:To construct a scientific and practical group activity program for senile dementia.Methods:A systematic search was conducted to identify the literature on group activities of senile dementia in the Registered Nurses Association of Ontario, guidelines from National Institute for Health and Care Excellence, JBI EBP database, Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, WanFang Data until January 1, 2022. Two researchers independently evaluated the methodological quality of the included literature. According to the retrieved literature, the first draft of group activity program was made. Two rounds of Delphi expert correspondence were conducted with experts from medical, nursing, rehabilitation and community care fields, and evaluated by expert authority coefficient and coordination coefficient, finally, the content index system of group activity program for senile dementia was established.Results:The recovery rates of the two rounds of expert consultation questionnaires were 94.44% and 94.74%, the degree of authority were 0.79 and 0.82, the coordination coefficients of importance were 0.149 and 0.184, and the coordination coefficients of feasibility were 0.130 and 0.366, all P < 0.01. Finally, the group activities program for senile dementia consists of 4 first-class indicators, 15 second-class indicators and 38 third-class indicators.Conclusion:The group activity program for senile dementia is scientific and feasible, and can be promoted and implemented within institutions with qualification and professional capabilitie at different levels.

Background Patients may be endangered if new graduate nurses cannot recognize and manage anaphylactic shock. Consequently, enhancing the new graduate nurses’ understanding of their roles and responsibilities during the rescue of a patient with anaphylactic shock is important. However, due to its inherent limitations, traditional classroom-based teaching makes it difficult to explore the potential of the students. Although popular simulation teaching has several notable advantages, it has not been proven to be effective in training inexperienced nurses on anaphylactic shock. We investigated the effect of a standardized patient-based simulation on the behaviors of new graduate nurses’ during anaphylactic shock rescue to identify an effective and safe method for contemporary nursing education. Methods Except for the ill or pregnant, all the new graduate nurses were included in the study as students to undergo a standardized patient-based simulation conducted in the clinical skills center of a general hospital. The simulation training was designed to teach students to recognize the signs and symptoms of anaphylactic shock, place the patient in the correct position, stop the ongoing intravenous infusion of the antibiotic which triggers the anaphylactic shock, restart an intravenous infusion on a new infusion apparatus, give 100% oxygen via a nasal cannula or mask, preserve airway patency, call the rapid response team, and correctly administer the medications prescribed by the clinicians. Before and after the training, the instructors evaluated each student’s skills and behaviors using a clinical competency evaluation list. After the training, all students completed the Chinese version of the Simulation Design Scale (SDS) to demonstrate their satisfaction with the program and then participated in semi-structured interviews with their instructors. Results All 104 graduate nurses had a significant improvement on the 6 competencies of the clinical competency evaluation list after the simulation training ( P < 0.001). The SDS scores revealed that the students were highly satisfied with all the aspects of the simulation training (the 20 satisfaction rates were all above 90.00%). During the semi-structured interviews, most of the new graduate nurses reported that simulation training in the management of anaphylactic shock was critical and would guide them in clinical practice. Conclusion Simulation training in anaphylactic shock is a potentially viable and effective method for teaching new graduate nurses to manage clinical incidents.

目的 观察以患者和家庭为中心的信息化探视在IC U的应用效果.方法 将246例患者和对应的246名家属根据院区分为对照组(122例患者和122名家属)及观察组(124例患者和124名家属).对照组实行远程电话探视,观察组实行以患者和家庭为中心的信息化探视.比较两组患者的谵妄发生率,评估两组患者家属的焦虑及抑郁程度、满意度.结果 观察组患者的谵妄发生率为8.9％,低于对照组的16.4％,差异无统计学意义(P>0.05);观察组患者家属的焦虑自评量表评分为(49.19±6.68)分、抑郁自评量表评分为(52.08±6.54)分,均低于对照组的(53.99±7.45)分、(55.77±7.58)分,P均<0.05;观察组患者家属的重危患者家属满意度量表评分为(112.23±11.10)分,高于对照组的(106.00±14.10)分,P<0.05.结论 以患者和家庭为中心的信息化探视可缓解IC U患者家属的焦虑、抑郁情绪并提高其满意度.

目的 探讨学员参与全民生命末期品质照护培训课程实践的体验,为进一步完善安宁疗护培训提供参考依据.方法 采用目的 抽样法选取浙江省某三级甲等医院参加过该课程的医护人员及志愿者7人,采用描述性质性研究方法 ,对受访者进行面对面半结构式访谈,运用传统内容分析法分析资料.结果 分析得出全民生命末期品质照护培训课程实践体验的三个主题:参与课程的原因、学习课程后的收获、课程学习实践中的困惑.结论 全民生命末期品质照护培训课程可以加强学员的理论及实践能力,但课程中的理论及实践的权重应根据学员的基础、学习动机来进行调整,满足个体化的需求.此外,情绪的调节能力亦是培训的重点,在课程中增设赋能环节帮助学员宣泄情绪,减少耗竭亦能增加学员的工作热情.

Nursing OpenVolume 9, Issue 4 p. 1926-1929 EDITORIALOpen Access Allowing family visits during COVID-19 pandemic: A family-centred moderate restrictive visitation programme in an intensive care unit Shulan Yang, Shulan Yang orcid.org/0000-0002-8214-0909 Nursing Department, Zhejiang Hospital, Hangzhou, ChinaSearch for more papers by this authorHuijuan Zhang, Corresponding Author Huijuan Zhang zjyyzhj@126.com Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China Correspondence Huijuan Zhang, Department of Critical Care Medicine, Zhejiang Hospital, 1229 Gudun Road, Hangzhou 310030, China. Email: zjyyzhj@126.comSearch for more papers by this authorFang Chen, Fang Chen Nursing Department, Zhejiang Hospital, Hangzhou, ChinaSearch for more papers by this authorCaixia Liu, Caixia Liu Nursing Department, Zhejiang Hospital, Hangzhou, ChinaSearch for more papers by this author Shulan Yang, Shulan Yang orcid.org/0000-0002-8214-0909 Nursing Department, Zhejiang Hospital, Hangzhou, ChinaSearch for more papers by this authorHuijuan Zhang, Corresponding Author Huijuan Zhang zjyyzhj@126.com Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China Correspondence Huijuan Zhang, Department of Critical Care Medicine, Zhejiang Hospital, 1229 Gudun Road, Hangzhou 310030, China. Email: zjyyzhj@126.comSearch for more papers by this authorFang Chen, Fang Chen Nursing Department, Zhejiang Hospital, Hangzhou, ChinaSearch for more papers by this authorCaixia Liu, Caixia Liu Nursing Department, Zhejiang Hospital, Hangzhou, ChinaSearch for more papers by this author First published: 23 May 2022 https://doi.org/10.1002/nop2.1254AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat 1 BACKGROUND The pandemic of COVID-19 has caused much concern and changes in intensive care unit (ICU), including the sudden interruption of “opening” ICU (Mistraletti et al., 2021). During the pandemic, family members are prohibited from visitation based on the physical isolation policy. The impossibility of routine family visits poses a challenge for healthcare professionals, especially those in ICU. In China, many ICUs have adopted WeChat to facilitate remote virtual family visits by means of instant text messaging and video calling. Worldwide, phone and video callings are widely used in communicating with families in the context of physical isolation (Mistraletti et al., 2020). The advantage of remote virtual visitation is preventing people from entering the patient unit, which lowers the risk of patients' exposure to COVID-19. But it is difficult for the family to fully communicate with the care team via video calls or messages when it comes to important medical decisions. Actually, family-clinician shared decision-making significantly improved families' satisfaction and depression, shortened patients' duration of ICU stay, and enhanced ICU clinicians' collaboration (Liu et al., 2021). Family plays an essential role in decision-making in ICU. Family support in times of the COVID-19 crisis is important, as the family–patient communication is restricted and the family has a strong need for information and support (Klop et al., 2021). Different from above, we constructed a family-centred moderate restrictive visitation programme, which might be a good choice applied during the pandemic of droplet transmitted infection disease such as COVID-19. For critically ill patients, virtual visitation can hardly meet the care and emotional needs of their families. Therefore, when constructing the family-centred moderate restrictive visitation programme, visitors are stopped from accessing the ward, but allowed to enter the hospital in-person, in collaboration with the updated hospital visitation policies. The in-person visitation is limited to the greatest extent possible considering the risk of COVID-19 transmission. 2 COVID-19 TRANSMISSION PREVENTION MEASURES In the proposed family-centred moderate restrictive visitation programme, face-to-face communication with the ICU team is supported. Physical environmental protections are strengthened as we set up a separate communication room outside ICU. In the meanwhile, COVID-19 transmission prevention measures are implemented prior to the visits, especially screening for epidemic exposure. In China, a colour-based “health code” system has been widely adopted to detect the possible exposures to Covid-19 since the crisis, relying on mobile technology and big data facilitated contact tracing.In the “health code” system, colours of the QR codes indicate people’s risk of Covid-19 exposures. People with green, amber or red coloured code indicate low, moderate or high risk of epidemic exposure to Covid-19 respectively. Nowadays in China, the “health code” system is widely applied in the health systems. The green coloured health code is considered as a necessary condition of accessing the routine health services, in case of lowering the risk of Covid-19 transmissions. Patients with amber codes or red codes are placed in separated areas different from the low-risk patient, such as fever clinic or Isolation ward. No access to visitors without green codes. Please refer to the figure of a diagram of the Family-centred Moderate Restrictive Visitation Program in the separate file, in which the demo of the “health code” system is presented by illustration. All visitors are screened for symptoms, temperatures and green codes. Any individuals with symptoms or suspicious exposures are stopped from entering the routine outpatient or inpatient service and are appointed to a certain area, such as fever clinics. All individuals in the inpatient area are tested for SARS-CoV-2 and are negative. Based on the above, we required all family visitors of ICU to provide their own negative SARS-CoV-2 report, to apply for a local authorized green-coloured health code, and to receive screening for symptoms, temperatures when entering the hospital and before entering the communication room. Only individuals who are negative for SARS-CoV-2 have green codes, and are free of symptoms are allowed to access the communication room. Generally, the health code system is a simple digitalized method to detect epidemic exposure. Using the health code system combined with SARS-CoV-2 test and symptom status can efficiently prevent visitors of high-risk Covid-19 exposures from entering the hospital. During the visitation, some general person-to-person transmission prevention measures are implemented, such as wearing face-masks, performing hand hygiene, maintaining appropriate social distance etc (Chu et al., 2020). Since visitors do not need to enter the ICU, extra personal protective equipment (PPE) for visitors, such as a gown or overall, is not required. Visitors are only required to wear face-masks, the same requirement as in public areas in the hospital. It avoids visitor’s risk of infection caused by inappropriate donning and doffing and reduces the use of PPE. And after the visitation, disinfection measures are performed to the whole room. 3 FAMILY-CENTRED MODERATE RESTRICTIVE VISITATION In the family-centred moderate restrictive visitation programme, family-centred is reflected in family-led appointment and participation in important medical decisions. Firstly, we have set up a separated communication room outside the ICU, equipped with an intranet computer with the Hospital Information System and a large-screen video phone connected to the bedside extension, a wireless handcar videophone, via intranet as well. Secondly, a simple visitation appointment system is built on an online survey tool. Their family members are able to make appointments in advance online. And the everyday appointments are scheduled automatically. No additional human resource is required in arranging the appointments. In the meanwhile, the visitation limits of “no more than one visitor per patient at a time” are achieved by the online appointment system. Reservations are open to all families with visiting needs from 13:30 to 17:00 every day. The visiting time is limited to <30 minutes for each family. During the visitation, the appointed families are invited separately to stay in the communication room accompanied by the charge nurse on duty. The charge nurse is required to re-assess the health codes, symptoms and SARS-CoV-2 test results. The position of the charge nurse during visitation is also needed before the pandemic, but the content of the responsibility is altered. In the 30-minute time, the charge nurse would briefly introduce the condition and treatment progress of the patient and let the family communicate with the patient via live video calls. The video calls are done using a secure system via the hospital intranet, and the leakage of the patient’s private information is somehow prevented. The charge nurse would also explain to the family when they were confused with the information they received from the video calls. In many cases, family members of ICU patient, usually the ones authorized, are involved in medical decision-making. In the family-centred moderate restrictive programme, families are allowed to enter the communication room in the hospital and the face-to-face communication between family and ICU team is preserved. The ICU team is able to use all accessible patient information in the intranet computer to let the family fully understand the treatment progress, and to assist the family with informed consent. Please find the figure of a diagram of the Family-centred Moderate Restrictive Visitation Program in the separate file, in which the programme is introduced in depth by illustration. Behind the video call, the members of the whole ICU team are involved in the programme. When the charge nurse keeps the family accompanied in the visitation room during the video call, the care team would cope with the patient by bedside as needed. And in special cases, the patient’s doctor in charge would communicate with the family in the visitation room. All members are part of the programme, help to build the communication bridge between critically ill patients and their families, and deliver the family-centred care. Overall in the Family-centred Moderate Restrictive Visitation Program, both in-person and virtual visitation are included. Family visits are opened to the greatest extent in the acceptable limits under the corona-virus crisis. In a 19-month-time practice since 2020, we gradually obtained the understanding of the patients and their families. In cases of some low-compliance patients, the family even became part of the ICU team in persuading the patient to better cooperate with the care team. In our experience, no matter what kind of techniques are used, the ICU team is always the best communication bridge between critically ill patients and their families. And in the proposed programme, the ICU team supports both the family and the patient from both sides of the video calls, helping the family understand the situation of the patient and the patient coping with their treatment. 4 CONCLUSION The proposed Family-centred Moderate Restrictive Visitation Program in this study broadens the boundaries of family communication in ICUs in the context of COVID-19 pandemic, which gives a new thought on adapting the nursing management to the Post-Covid “new normal.” The new normal Covid-19 is here to stay, and the world cannot be isolated forever. Post-Covid “new normal” is on its way to come. New rules in nursing management are going to be considered under the concern of the normal COVID-19 pandemic. AUTHOR CONTRIBUTIONS Shulan Yang and Huijuan Zhang were the major contributors in writing and revising the manuscript. All authors read and approved the final manuscript. ACKNOWLEDGEMENTS None. CONFLICT OF INTEREST The authors declare that they have no competing interests. ETHICAL APPROVAL Not applicable. Open Research DATA AVAILABILITY STATEMENT Data sharing not applicable to this article as no datasets were generated or analyzed during the current study. REFERENCES Chu, D. K., Akl, E. A., Duda, S., Solo, K., Yaacoub, S., Schünemann, H. J., & COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors (2020). Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: A systematic review and meta-analysis. Lancet (London, England), 395(10242), 1973– 1987. https://doi.org/10.1016/S0140-6736(20)31142-9CrossrefCASPubMedWeb of Science®Google Scholar Klop, H. T., Nasori, M., Klinge, T. W., Hoopman, R., de Vos, M. A., du Perron, C., van Zuylen, L., Steegers, M., Ten Tusscher, B. L., Abbink, F. C. H., Onwuteaka-Philipsen, B. D., & Pasman, H. R. W. (2021). Family support on intensive care units during the COVID-19 pandemic: A qualitative evaluation study into experiences of relatives. BMC Health Services Research, 21(1), 1060. https://doi.org/10.1186/s12913-021-07095-8CrossrefPubMedWeb of Science®Google Scholar Liu, X., Humphris, G., Luo, A., Yang, M., Yan, J., Huang, S., Xiao, S., Lv, A., Wu, G., Gui, P., Wang, Q., Zhang, Y., Yan, Y., Jing, N., & Xu, J. (2021). Family-clinician shared decision making in intensive care units: Cluster randomized trial in China. Patient Education and Counseling. Google Scholar Mistraletti, G., Giannini, A., Gristina, G., Malacarne, P., Mazzon, D., Cerutti, E., Galazzi, A., Giubbilo, I., Vergano, M., Zagrebelsky, V., Riccioni, L., Grasselli, G., Scelsi, S., Cecconi, M., & Petrini, F. (2021). Why and how to open intensive care units to family visits during the pandemic. 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在回顾老年人照护者虐待倾向评估工具的基础上,综述了照护者虐待倾向的相关影响因素,旨在为认知障碍老年人护理的实践和科学研究提供参考.

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