がん患者のACPにおける看護支援の構成要素とその影響要因

The Components and Influencing Factors of Nursing Support on Advanced Care Planning for Cancer Patients

要旨

　本研究の目的は，がん患者のACPにおける看護支援の構成要素とその影響要因を明らかにすることである．ACPの概念分析と面接調査の結果をもとに，個人属性9項目，ACPの看護支援55項目，ACPの認識11項目からなる自記式質問紙を作成した．無作為抽出した全国の病院，訪問看護事業所147施設で，経験年数5年以上の看護師に質問紙を配布し，回収は対象者からの個別投函とした．2018年6月1日から9月30日に質問紙1,354部を配付し，798部の回答が得られ（回収率58.9％），780部を有効回答とした（有効回答率97.7％）．データは因子分析と重回帰分析を行った．

　看護支援の構成要素として【対話に基づく確かな情報共有】【患者の今後の希望の探求】【終末期に備えた取り決め】【患者の意向の擁護】【患者の生き方の理解】【ケアへの患者の価値観の反映】【継続的な取り組み】が抽出された．また，ACPの看護支援の影響要因として，今後の治療や意向について患者に繰り返し確認するのは当然であるという認識やACP研修受講回数，訪問看護事業所，ACPの体制整備などが正の影響を及ぼし，外来やACPの知識不足・コミュニケーション能力不足などが負の影響を及ぼしていることが示された．

　本研究で抽出された7つの構成要素は，がん患者のACPへの看護実践における有用な指標になると考えられる．

　The purpose of this study is to clarify the components and influencing factors of nursing support on Advanced Care Planning (ACP) for cancer patients.

　A questionnaire was developed based on ACP concept analysis and interview surveys. It consisted of nine items related to personal attributes, 55 items regarding ACP support, and 11 items about nurses' recognition of ACP. Hospitals and stations for visiting nurse services were randomly selected nationwide, and 147 of them consented to participate in this research. The questionnaire was sent to nurses at the organizations with no less than five years of experience and collected via mail individually. Between June 1 and September 30, 2018, 1,354 copies of the questionnaire were distributed. 798 responses (response rate of 58.9%) were received, and 780 of them were valid (effective response rate of 97.7%). Factor analysis and multiple regression analysis were employed to analyze the data.

　The factor analysis yielded the following seven factors as the components of nursing support for cancer patients in ACP: “appropriate sharing of information through dialogue,” “exploration of patients' wishes for their end of life,” “arrangements for end of life,” “advocacy of patients' wishes,” “understanding of how patients have lived,” “reflecting patients' values regarding care,” and “continuous effort.” The multiple regression analysis demonstrated that the following factors had a positive effect on nursing practice in ACP: “nurses' recognition of the need to confirm patients' intentions for future treatment and care repeatedly based on the assumption that their feelings can fluctuate,” “the number of times attending ACP training,” “stations for visiting nurse services,” and “establishment of the ACP system.” In contrast, the following factors had a negative impact: “outpatient services,” “inadequate knowledge about ACP,” and “lack of communication skills.”