ホスピス・緩和ケア病棟のがんと認知症を併せもつ患者の看護における困難と対処過程

Stress and Coping of Nurses Caring for Cancer Patients with Dementia Hospitalized in the Hospice or Palliative Care Units

要旨

　本研究の目的は，ホスピス・緩和ケア病棟（以下，緩和ケア病棟）に勤務する看護師が，認知症とがんを併せもつ患者の看護において抱く困難と対処過程を明らかにすることである．

　緩和ケア病棟において，認知症とがんを併せもつ患者の看護経験がある看護師12名を対象に半構造化面接を行い，エスノグラフィーの手法を用いて分析した．

　その結果，看護師は，認知症とがんを併せもつ患者の看護について〈今までのやり方が通じずやっかいに感じる〉困難をもち，〈培った経験を活かしつつやれるケアを試行錯誤する〉ことで対処していた．この対処を支える気構えは〈苦痛を緩和して穏やかさを得ることに徹するしかない〉であった．対処の結果，看護師は〈諦めなければ認知症の特徴を捉えた緩和ケアの実践ができる〉感覚を得ていた．一方で〈尽力してもケアや薬剤の効果の実感が得られない〉と感じる看護師も存在し，〈最期は看護の重点を家族に移す〉対処をとった．いずれも最期は，〈家族と信頼関係を築き家族の満足いく看取りとなる〉という困難と対処過程が明らかとなった．

　認知症とがんを併せもつ患者の看護において看護師の困難を減じるためには，ケアの成果の実感がもてるよう認知症のBPSDとせん妄について学ぶことや，院内外の他職種と協働できる体制整備の重要性が示唆された．

　This study aimed to identify stress and coping of nurses caring for cancer patients with dementia who are hospitalized in the hospice and Palliative Care Unit (PCU).

　Semi-structured interviews were conducted involving 12 nurses with experience in providing care for cancer patients with dementia in the PCU. The obtained data was analyzed using an ethnographic approach. From the results, 12 categories were extracted, and the following types of stress and coping issues were identified: 1. The nurses had experienced stress over the care of cancer patients with dementia, and felt〈difficulties when standard nursing care plans couldn't be applied〉. To cope with the stress, they〈had developed and practiced various types of care based on their clinical experiences〉. 2. Their coping methods were based on〈focusing on relieving pain and providing patients with a peace of mind〉. 3. Finding ways to cope resulted in the nurses feeling as follows:〈if we don't give up, it is possible to offer appropriate palliative care based on the traits of dementia〉. On the other hand, some nurses〈had failed to achieve effective care and medication despite their efforts〉, and so such nurses〈had chosen to shift the focus of care from patients to families in end-of-life care〉. Irrespective of this,〈families were satisfied with the end-of-life care and created trusting relationships with the nurses〉.

　In order to reduce the stress of nurses caring for patients with dementia, it is important for them to acquire knowledge of delirium or behavioral and psychological symptoms of dementia to help them achieve effective care, and establish a system to promote cooperation with other healthcare professionals working outside hospitals.