Japanese

Title	地域包括ケア病棟における訪問看護師と連携した効果的な退院支援のあり方
Subtitle	原著
Authors	川久保砂奈江1), 田辺満子2)
Authors (kana)
Organization	1)朝日大学病院, 2)岐阜県立看護大学 機能看護学領域
Journal	岐阜県立看護大学紀要
Volume	23
Number	1
Page	13-24
Year/Month	2023 / 3
Article	原著
Publisher	岐阜県立看護大学
Abstract	「要旨」本研究では, 地域包括ケア病棟において, 患者・家族が少しでも長く地域で希望する療養生活が送れるよう訪問看護師(以下, Ns)と入院早期からの連携協働を基盤とした, 患者の生活に合わせた効果的な退院支援のあり方を検討することを目的とした. 研究方法は, (1)退院支援の現状を病棟Nsと他職種に質問紙調査を実施した. 加えて地域の訪問Nsと共に事例検討会を開催した. 結果から効果的な退院支援の4つの方策を導き, 退院支援フローチャート, 退院支援シートを修正した. (2)修正したシートを用いて退院後に訪問看護を利用する患者3名に退院支援を実践し, 患者が退院後, 訪問Nsとの同行訪問を実施した. (3)病棟Ns, 訪問Ns, 多職種に質問紙調査を実施し取り組みを評価した. 結果, (1)質問紙では【院内外の多職種との連携とずれの調整】をする事等, 検討会では【多職種が患者・家族の思いを共有し, 同じ気持ちで意思決定支援する】事等の必要性が示された. (2)では, 修正シートを用いて病棟Nsが主体となり, 入院から1週間以内に患者情報を収集し, 院内外の多職種でカンファレンスを重ね, 患者・家族の意向と退院後の生活に合わせた退院支援を実践した. その結果, 患者・家族から【在宅で必要な医療処置に対する丁寧な指導が受けられた】と満足感や安心感が語られた. (3)の結果【入院中から退院後の生活を意識しイメージする】【入院前を含め具体的にADLを確認し必要な介護を検討する】等の意識の変化が確認できた. 以上より, 地域包括ケア病棟における訪問Nsと連携協働した退院支援のあり方として, (1)入院早期に連携して退院支援を実践するため共通のツールをもって体制を保証する, (2)病棟Nsが主体となり, 訪問Nsと患者・家族の意向や在宅生活情報を共有する, (3)アセスメントの視点や実践状況を十分理解し退院後も継続できるような支援方法を検討する, (4)院内外の多職種で目標や方針を統一してチームで退院支援を進めることが効果的である.
Practice	看護学
Keywords	地域包括ケア病棟, 訪問看護師, 退院支援, 継続看護, 多職種連携, community-based integrated care ward, discharge support, continuous nursing, multidisciplinary collaboration, home-visit nurses

English

Title	The Effectiveness of Discharge Support in Collaboration with Home-Visit Nurses in Community-Based Integrated Care Wards
Subtitle
Authors	Sanae Kawakubo1), Michiko Tanabe2)
Authors (kana)
Organization	1)Asahi University Hospital, 2)Management in Nursing, Gifu College of Nursing
Journal	Journal of Gifu College of Nursing
Volume	23
Number	1
Page	13-24
Year/Month	2023 / 3
Article	Original article
Publisher	Gifu College of Nursing
Abstract	[Abstract] In the community-based integrated care ward, collaboration with home-visit nurses beginning from the early stage of hospitalization can allow patients and their families to spend their desired recuperation time in the community. This study aimed to examine the ideal effective discharge support based on patients' lifestyles. This study used three research methods: "Ward nurses and other staff took a questionnaire survey to elucidate the status of and issues with discharge support, and to determine necessary improvement measures. A case review meeting was held with the local home-visit nurses in charge of readmitted patients and the ward's multidisciplinary staff. We derived four measures for effective discharge support, in addition to revising the discharge support flow chart and form." "Using the modified form, we provided discharge support and accompanied three patients who had home-visit nursing following discharge." "We performed a questionnaire survey for the ward nurses, visiting nurses, and other professionals to evaluate their efforts." The process of discharge support can be improved by coordinating nursing care, collaborating with multidisciplinary staff, and adjusting gaps. The case review meeting revealed the patients' and families' needs to share their feelings with medical professionals, who mediate their decision-making. The case review meeting also revealed the concerns of patients and their families between the ward and the community. Using the modified form, ward nurses led multiple conferences with multidisciplinary staff within a week of admission, and provided of discharge support according to the patients' and families' wishes and lifestyles. During post-discharge visits, the patients and their families expressed a sense of satisfaction and security, notably the careful guidance on medical treatments. Following the application of these strategies, the ward nurses demonstrated changes in awareness (e.g., thinking about a patient's life after discharge, comprehensively confirming ADL, including ADL before hospitalization, and considering nursing care). Based on the above, the following discharge support measures should be implemented in collaboration with home-visit nurses: "Ensuring a system for collaborative discharge support at the early stage of hospitalization," "ward nurses playing a leading role in sharing information about the patient's and family's wishes and at-home lifestyle information with home-visit nurses," "considering the support that can be continued even after discharge from the viewpoint of assessment and practice," and finally, "promoting discharge support as a team by unifying goals and policies among multiple professionals inside and outside the hospital."
Practice	Nursing
Keywords	community-based integrated care ward, discharge support, continuous nursing, multidisciplinary collaboration, home-visit nurses

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