病棟看護師の終末期がん患者の在宅に向けた退院支援と緩和ケアの知識・実践・困難感および今後を予測した看護実践との関連

The Relationship Between Ward Nurses Discharge Support for Home Care of Terminal Cancer Patient and Palliative Care of Knowledges, Practices, Difficulties, and Predicted Nursing Practices

要旨

　【目的】病棟看護師による終末期がん患者の在宅に向けた退院支援と緩和ケアの知識・実践・困難感，今後を予測した看護実践との関連を明らかにする．

　【方法】東北地方の2県に限定したがん診療拠点病院等7施設の看護師を対象に，基本属性，今後を予測した看護実践，緩和ケアに関する医療者の知識・実践・困難感評価尺度，在宅の視点のある病棟看護の実践に対する自己評価尺度の質問紙調査を行った．分析は，記述統計，因子分析，各変数間の相関を求め，緩和ケアの知識・実践・困難感，今後を予測した看護実践が在宅の視点のある病棟看護実践に影響を与えるモデルを設定しパス解析を行った．

　【結果】対象338名に調査用紙を配布，有効回答は116名である．在宅の視点のある病棟看護実践は，緩和ケアの「せん妄」「患者・家族中心のケア」「疼痛」「コミュニケーション」と「予測される事態を地域医療者と共有」の5観測変数によって適合度指標が高い十分に受容できるモデルが構築された．そのなかで，緩和ケアの実践「せん妄」と「患者・家族中心のケア」「予測される事態を地域医療者と共有」の3観測変数は，在宅の視点のある病棟看護実践の58.3％を説明した．

　【考察】在宅の視点のある病棟看護実践に直接関連した緩和ケアの実践の「せん妄」と「患者・家族中心のケア」は，「患者・家族」と「生活」に視点をおいたケアが求められ，これら2つが終末期がん患者の在宅に向けた退院支援において重要と考える．

　Objective: This study clarified the relationship between discharge support from ward nurses for the homecare needs of terminal cancer patients (including the associated knowledge/practice/difficulty of palliative care) and predicted nursing practices.

　Methods: Participants included nurses from seven facilities (including cancer hospitals) from two prefectures in the Tohoku region. Questionnaires were distributed containing self-assessment scales related to the ward nursing practice with a focus on the home perspective. Retrieved data were subjected to a variety of analysis methods, including descriptive statistics, factor analyses, variable correlations, a model established to determine the level of discharge support according to palliative care knowledge/practice/difficulty, and a covariance analysis on the predicted level of nursing practice.

　Results: The survey form was distributed to 338 nurses, and valid responses obtained from 116 nurses were included in the analysis. Results indicated that five factors were related to ward-nursing practices from the home perspective i.e., palliative care practices: Delirium, patient/family-centered care, pain, communication, and share-predicted situations with community health care providers. A valid model with a high-degree index was thus constructed. A total of 58.3% of such practices were explained by the three factors of “practical palliative care practice: Delirium,” “practical palliative care practice: Patient/family-centered care,” and “share-predicted situations with community health care providers.”

　Discussion: The two factors of “delivery” and “patient/family-centered care” were directly related to discharge support for required stay-at-home care focusing on the “life” of “patient/family” in the palliative care practice. These two factors are considered highly important.