介護老人保健施設における看護職，介護職，リハビリテーション職，および支援相談員の在宅支援行動

Home Assistance Activities Performed by Nurses, Care Workers, Rehabilitation Workers, and Support Counselors at Geriatric Health Services Facilities

抄録

　目的は，介護老人保健施設（老健）における看護職，介護職，リハビリテーション（リハ）職，および支援相談員（相談員）の在宅支援行動を明らかにすることである．施設長が在宅支援を施設の方針として明示し，組織的に取り組んでいる3施設において，各職種1人計12人に半構成的面接調査を行い，質的帰納的に分析した．各職種は利用者・家族の在宅生活との連続性を意識して利用者の心身状態を整え，家族と信頼関係を構築し，入所後の利用者と家族の関係性および家族の状況を随時判断しながら，協働して家族の意思決定を支援していた．相談員は老健の役割と支援内容を説明し，家族の状況に即して意思決定を促し，看護職は利用者と家族の在宅生活への最善を尽くしたケア内容と結果を家族に説明し，介護職は利用者の在宅復帰への意欲を支持し，家族の主体的な在宅介護に向けて支援し，リハ職は利用者のADL改善と家族の介護負担軽減をすり合わせてリハ目標を決定していた．

　The objective is to elucidate the home assistance activities conducted by nurses, care workers, rehabilitation (“rehab”) workers, and support counselors at geriatric health services facilities (“roken”). Three facilities where the director has clearly indicated an institutional policy for home assistance and where there is systematic institutional involvement in home assistance were selected for the study. Semi-structured interviews were conducted with a total of 12 participants, one of each profession from each of the three facilities, and qualitative data was subsequently analyzed with an inductive approach. Workers of each occupation collaborated and prepared their client mentally and physically to continue living at home with his/her family, and built trust with the family. They also constantly assessed the relationship between the family and client as well as the family's condition after the client joined the facility, while also providing the family with comprehensive support in decision-making. Workers of each occupation acted characteristically for their respective positions: counselors explained the role of “roken” as well as the content of assistance provided by “roken”, and prompted continuous decision-making based on each family's situation, nurses explained the content of optimal care for the clients to be living at home with family members as well as subsequent results to the family; care workers provided clients with support on their desire to return home, and family members with assistance for active home care; rehab workers determined the rehab objectives with consideration for both improvement in ADL of clients and reduction in the burden of care on family members.