Japanese

Title	患者と家族の思いに沿った退院支援 その3 - 退院支援の実践上の課題の明確化及び改善に向けた方策の考案 -
Subtitle	原著
Authors	加藤由香里
Authors (kana)
Organization	岐阜県立看護大学 地域基礎看護学領域
Journal	岐阜県立看護大学紀要
Volume	22
Number	1
Page	15-26
Year/Month	2022 / 3
Article	原著
Publisher	岐阜県立看護大学
Abstract	「要旨」 本研究では, 患者・家族の思いを中核として退院支援の課題を明らかにし, 退院支援の実践の改善に向けた方策を考案することを目的とする. X病院の看護職が, 事例検討と地域資源担当者及び退院支援を先駆的に行う病院の退院調整看護師への調査結果を踏まえ, X病院の退院支援の課題を検討する. 次に, X病院の退院支援の課題を基盤として, モデル病棟とした地域包括ケア病棟の看護職等が, 自部署の退院支援の課題及び改善の方策を考案する. 地域包括ケア病棟の退院支援の課題は, 【(課題1) 患者の思いを聴き受け止める】【(課題2) 家族自身のことを聴き受け止める】【(課題3) 看護師が患者・家族の生活をイメージし生活の要望に沿った支援をする】【課題4 (修正) 患者・家族が生活をイメージできるように関わる】【課題5 (修正) 患者・家族の生活に必要な情報を地域資源担当者と共有し退院後の生活を検討する】であった. また, 改善の方策として〈転床日に患者から, 現在困っていること, 心配なこと, 入院前の生活, 生活の中で楽しみにしていること, どのように暮らしたいかについて聴く〉〈患者と家族のどちらの生活や要望も尊重した患者・家族の生活について, 患者, 家族, 多職種で話し合う〉〈退院後も継続する生活上のケア・医療的な処置について患者・家族とゴールを話し合い, 判断力と自信が持てるよう看護の意図を示し具体的に支援する〉〈入院中の患者の生活の様子, 家族の生活・介護状況の詳細を地域資源担当者と共有し, 退院後のリスクや残された課題を検討する〉等の13の方策が考案された. 明確にされた退院支援の課題は, 支援事例の患者・家族の思いの聴き取りを中核とし, 様々な地域資源担当者等からの聴き取り, X病院の様々な部署の看護職が検討した課題を基盤としており, どの部署にも共通する課題であると考えた. 今後は明らかになった退院支援の課題改善の方策を実践に適用し, 評価していく必要がある.
Practice	看護学
Keywords	退院支援, 病棟看護師, 患者と家族の思い, 課題改善の方策, discharge support, ward nurses, patient and family thoughts, measures to improve issues

English

Title	Discharge Support based on the Thoughts of Patients and Their Families : Part 3 - Clarification of Issues in the Practice of Discharge Support and Devising Measures for Improvement -
Subtitle
Authors	Yukari Kato
Authors (kana)
Organization	Community-based Fundamental Nursing, Gifu College of Nursing
Journal	Journal of Gifu College of Nursing
Volume	22
Number	1
Page	15-26
Year/Month	2022 / 3
Article	Original article
Publisher	Gifu College of Nursing
Abstract	[Abstract] This study identifies issues in discharge support with focus on the thoughts of patients and their families, and to devise measures to improve discharge support practices. For the study, nurses at X Hospital examined the issues in discharge support at X Hospital, based on case studies and the results of a survey of community resource officers and discharge coordination nurses in hospitals that pioneer discharge support. Furthermore, we examined the issues of discharge support in the community-based comprehensive care wards used as model ward, and devised measures to improve their practices. Based on the case studies and survey results, we identified the issues in discharge support in community-based comprehensive care wards. The issues are as follows: [Task 1: Listening to and accepting the patient's thoughts and feelings]; [Task 2: Listening to and accepting the family's thoughts and feelings]; [Task 3: Nurses imagining the life of the patient and their family and providing support according to the patient's life needs]; [Task 4 (modified): Help patients and their families to imagine a new life for themselves]; [Task 5 (modified): Connect patients and their families to community resources that can provide the information necessary for their lives and help patients consider their lives after discharge] To improve these discharge support-related issues, the following thirteen measures were devised: "On the day of transfer, ask patients about their current problems, concerns, life before hospitalization, what they are looking forward to in life, and how they want to live;" "Discussions among patients, families, and multidisciplinary professionals about the lives of both patients and families that respects their needs;" "Discuss goals with patients and their families regarding daily care and medical treatment to be continued after discharge, and promote understanding of nursing intentions and provide specific support so that patients can exercise judgement and confidence;" "Share details of the patient's life and the family's living and caregiving situation with community resource personnel during hospitalization to discuss risks and remaining challenges after discharge." The issues identified for discharge support were deciphered by listening to the opinions of patients and families in the supported cases, and to various people in charge of community resources, and the issues discussed by nurses in various departments of X Hospital, so they are considered to be common issues. In the future, it will be necessary to apply the measures to address the issues of discharge support and evaluate them.
Practice	Nursing
Keywords	discharge support, ward nurses, patient and family thoughts, measures to improve issues

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