HIROSHI ONO

【目的】看護小規模多機能型居宅介護(以下,看多機)は,訪問看護・介護,通所,宿泊サービスを臨機応変に組み合わせ,医療ニーズにも対応するという多様な機能をもつため,既存の看護提供施設とは異なる能力が求められると考えられる。看多機でのより質の高い看護を展開できるような行動指標の開発を目指し,本研究では,研究者らが先行研究にて明らかにした看多機看護師のコンピテンシーについて,定量的な内容妥当性の検討を行うことを目的とした。【方法】2020年9月時点の全看多機で勤務している看護師に対し,自記式質問紙調査を実施した。質問内容は看多機看護師のコンピテンシー(8カテゴリー,48サブカテゴリー)についての重要性であり,記述統計を行った。【結果】国内全看多機の看護師498人へ調査票を配布し217人から回答を得,回収率は36.5%であった。48サブカテゴリーのうち,ほぼすべての項目において9割以上の人が「とても重要」「重要」と回答し4点満点中,平均値3.4点以上でったため,重要であるという評価であった。特に,【その人や家族の強みを引き出し生活に取り入れる】【個々に合わせ臨機応変にケアを創造する】【命をまもる】【最期まで「生きる」を支える】【その人を地域で支えるチームをつくる】は,複数の項目において,平均値3.8点以上と高い点数であった。【結論】先行研究で抽出し専門家により精錬された8カテゴリー,48サブカテゴリーからなる看多機看護師のコンピテンシーについて定量的な内容妥当性が確認された。療養者を取り巻く家族や地域のあり方が多様化する中で,最期まで住み慣れた場所で暮らしていくためには,看護師が中核となり療養生活を支える役割があることが確認された。(著者抄録)

Introduction: The purpose of this study was to clarify the relationship between the available service information on small-scale multifunctional in-home nursing care (KANTAKI) and its operational status via text mining. Methods: We obtained nationwide textual information on KANTAKI from the Nursing Care Service Information Disclosure System and the Ministry of Health, Labour, and Welfare, and analyzed the characteristics of the word usage using KH Coder. The number of users and employees and the implementation of services were compared among the facilities that used terms relating to medical dependency and end-of-life care, which are KANTAKI characteristics, and with other facilities. Results: The facilities that used terms relating to medical dependency and end-of-life care showed significantly more users requiring nursing care level 5 and more full-time nursing staff than those not using such terms. Moreover, regarding service provision, the rate of procedures was significantly higher in 11 of 12 items, except for stoma. Conclusion: The facilities that use terms relating to medical dependency and end-of-life care in their information have more users and provide a greater variety of services. In the future, educational support is required to enable facility managers to understand the services and translate them into their work.

背景・目的:本研究では,先行研究において抽出された看護小規模多機能型居宅介護(以下,看多機)で働く看護師に求められるコンピテンシーの内容と,実際に看多機で働く看護師の優れた看護実践から,コンピテンシーの内容妥当性を検討することを目的とした.方法:看護師や施設管理者11名を対象にフォーカスグループインタビューを2回実施し,コンピテンシー評価指標(大項目・小項目)案の内容妥当性を検討した.結果:その人の希望に沿いながら「生きる」ための支援を重視するという意見から【看取りを支える】は【最期まで「生きる」を支える】に修正された.また【その人を支えるチームをつくる】は,平時から地域資源を活用する必要性の指摘を受けて【その人を地域で支えるチームをつくる】に修正された.家族の介護負担を軽減する支援の重要性から【家族を支える】が新たに追加された.変更のなかった【その人の生活の中で歩み寄りを続ける】【その人や家族の強みを引き出し生活に取り入れる】【個々に合わせ臨機応変にケアを創造する】【命をまもる】【その人の居場所をつくる】と合わせ,大項目は8つとなった.小項目の妥当性についても検討と修正した結果,37項目から48項目となった.考察:フォーカスグループインタビューでは利用者だけでなく家族支援が望まれていた.本調査を経て,看多機で働く看護師のコンピテンシーが精錬され,内容妥当性は確保された.(著者抄録)

Introduction Various stressors have been identified in patients in the intensive care unit (ICU), including postoperative pain, ventilatory management, and nursing care. However, sedated patients are less responsive, and nurses have difficulty capturing their stressors. Objective To investigate patient stress caused by nursing care performed in the ICU on sedated patients based on changes in physiological indices. Methods We observed nursing care performed on patients with postoperative esophageal cancer under sedation in the ICU. This included endotracheal suctioning and turning, the time required for the care, and the patients’ behavioral responses. Information on arousal levels, autonomic nervous system indices, and vital signs were also obtained. The changes in indicators before and after care were then compared and analyzed. Results There were 14 patients in the study. The mean age of the patients was 68 years. Ninety-nine scenes of nursing care were observed, and in six of these, additional bolus sedation was administered because of the patient's significant body movements. In endotracheal suctioning, no significant changes were observed in all indicators. In turning, vital signs changed significantly, and when both were continued, all indicators changed significantly. Conclusion Our study found that different types and combinations of nursing care may cause different stresses to the patients. Moreover, the autonomic nervous system indices may be more likely to react to stresses in a variety of nursing care, while arousal levels may be more likely to react to burdensome stresses. If the characteristics of these physiological indicators can be understood and effectively utilized during care, it may be possible to better identify and reduce patient stress during sedation management.

Background Japan is a superaging society unparalleled in the world. Elderly people who need medical care do not receive adequate support in the community. As a new service to address this issue, a small-scale multifunctional in-home care nursing service called Kantaki was created in 2012. Kantaki, in collaboration with a primary physician, operates 24 hours a day and provides various nursing services (home visits, home care, day care, and overnight stays) to older people living in the community. The Japanese Nursing Association is working hard to promote this system; however, its low utilization rate is an issue. Objective This study aimed to determine factors influencing the utilization rate of Kantaki facilities. Methods This was a cross-sectional study. A questionnaire on the operation of Kantaki was sent to all administrators of Kantaki facilities operating in Japan from October 1 to December 31, 2020. A multiple regression analysis was used to determine factors associated with a high utilization rate. Results Responses from 154 of the 593 facilities were analyzed. The average utilization rate for all valid responding facilities was 79.4%. The average number of actual users and the break-even point were almost equal, resulting in little surplus profit from facility operations. A multiple regression analysis showed that factors that had a significant impact on the utilization rate included the break-even point, a surplus of users relative to the break-even point (ie, the margin of revenues), the number of months in office of the administrator, the type of corporation (ie, nonprofit), and Kantaki’s profit from operating home-visit nursing offices. The break-even point, a surplus of users relative to the break-even point, and the number of months in office of the administrator were robust. In addition, support for reducing the burden on family helpers, a service sought by the system, significantly and negatively affected the utilization rate. In the analysis that removed the most influential factors, the cooperation of the home-visit nursing office, Kantaki’s profit from operating the home-visit nursing office, and the number of full-time care workers were significantly related. Conclusions To improve the utilization rate, managers need to stabilize their organization and increase profitability. However, a positive relationship was found between the break-even point and utilization rate, suggesting that simply increasing users did not contribute to cost reduction. Moreover, providing services that meet the needs of individual clients may result in lower utilization rates. These results, which are inconsistent with common sense, reflect the divergence between the assumptions underlying the system’s design and actual conditions. To solve these issues, institutional reforms, such as an increase in nursing care fee points, may be necessary.

【目的】健やかな地域生活を促進するためのプログラムへの参加高齢者に対する,COVID-19の感染拡大防止対策の影響と,それによって生じた身体状況及び生活状況の変化を明らかにすることである。【方法】プログラム開始前,プログラム実施6ヵ月後,再開時の3回分の評価が揃っている参加高齢者13名(全員女性,平均年齢80.5歳)を対象とし,身体状況の計測値と生活状況の変化について分析した。【結果】プログラム開始前,プログラム実施6ヵ月後,再開時の比較で,体重,骨密度,2ステップテスト値に有意な変化が確認された。体重は51.4kg,49.1kg,51.2kgと変化し(p=.013),介入前と再開時の比較に減少が認められた。また,骨密度は66.0g/cm2,76.0g/cm2,73.2g/cm2と変化し(p=.013),介入前と介入6ヵ月後の比較で上昇が認められ,2ステップテスト値も0.9,1.1,1.0と変化し(p=.018),介入前と介入6ヵ月後の比較で上昇が認められた。また,生活上の変化として「体調に問題ない」と「外出を控えた/頻度が減少した」の回答者数は同数だったが,その半数に「足腰の弱りを自覚する」状況があり,転倒や骨折による入院に至ったケースもあった。【結論】本研究の結果より,COVID-19の感染拡大による半年以上の健やかな地域生活を促進するためのプログラム休止は,参加高齢者の外出頻度を低下させ,運動機能に影響を与えたことが分かった。高齢者にとって低下した運動機能を引き上げることは容易ではなく,骨折など受傷に伴う入院は廃用性症候群を引き起こす可能性もある。今後は感染対策下であっても,高齢者の活動の場を確保できるような新たな交流方法を整備するとともに,地域で生活する高齢者に持続的にアプローチできる支援活動が必要である。(著者抄録)

This study evaluated the effectiveness of a life-enhancement program designed to focus on dining conditions in welfare facilities for seniors living in Japan. Effectiveness was specifically evaluated based on whether improvements were achieved in (1) nutritional status, (2) oral health, (3) frequency of fever, and (4) vitality of appetite across three sites. As part of a comprehensive-care initiative that began with dining support, the program consisted of two main components: (1) a 3-month intensive program comprised of (a) collective experiential learning for residents and staff (including nutritionists, nurses, and physiotherapists) and (b) a tailor-made individual program for residents followed by (2) a 3-month continuation program. Participants included 168 individuals (31 males and 137 females) from a total of three facilities (average age was 85.9 [60-104] years). Results showed that the intensive program significantly improved nutritional status (e.g., BMI, caloric intake, and water intake; P < 0.000-0.005) and tongue movement (P < 0.000) while significantly reducing dental-plaque and tongue-coating indices (P < 0.000). Significant improvements were also achieved for degree of appetite and vitality indices (P < 0.000-0.001). However, incidences of fever were not reduced. These findings indicate that the program effectively improved nutritional status, oral health, vitality, and appetite. However, these effects did not sufficiently remain once the program was finished, thus suggesting the need for a continuous intervention.

The aim of this study is to determine the effect of food consistency on health and related factors among residents in welfare facilities for seniors (n = 227; mean age, 86.2 ± 8.0 years; 78.9% female). Residents who ate regular food had a lower incidence of fever during the 3-month period (p < 0.001) and consumed more calories (1325.97 ± 220.2 kcal) than those who ate chopped (1125.0 ± 256.8 kcal), paste (1122.0 ± 288.5 kcal), and gastric tube food (812.5 ± 150.7 kcal) (p < 0.001). Modifying a resident's food by making it softer and finer did not reduce the incidence of choking. Logistic regression analysis (backward elimination method) revealed four factors related to eating regular food: vitality index, appetite, number of remaining teeth, and choking frequency. Causal relationships were not obtained because this was a cross-sectional study. The findings of this study suggest that a regular consistency of food positively influences the health of older individuals.

[Background] To promote an integrated community care system, the Japanese government created a multifunctional long-term care service model called Kantaki in 2012, aiming to provide a combination of services such as short-stay, day-care, and home visit by aides and/or nurses to meet various client needs. However, it is unclear how well this model has been utilized and accessed throughout Japan.[Objective] This study aimed to understand the distribution status of Kantaki through a secondary analysis of information on its operations and population trends released by public institutions.[Methods] The study determined the number of Kantaki, Shotaki (a service that is similar to the Kantaki model except it does not provide home visit service by nurses), and visiting nurse stations from the Ministry of Health, Labour and Welfare website registry. Population trend information was collected from the national census. Statistical processing included a correlation analysis using descriptive analysis and Spearman's correlation coefficient.[Results] As of December 31, 2018, there were 479 Kantaki operations throughout Japan. The mean number of Kantaki operations by prefecture was 10.19 ± 10.51. Of the municipalities, 233 (13.5%) out of 1,724 had Kantaki operations available. The number of Shotaki (.765), number of visiting nurse stations (.747), population (.703), population density (.513), and the rate of aging (-.442) were found to have a significant correlation with the number of Kantaki operations present.[Discussion] The number of Kantaki operations showed a large variation across regions, with a higher prevalence in population-dense urban areas, and lower prevalence in regions with a high aging rate. This reveals the distribution model is unrelated to the elderly population, who can be potential clients, and must be affected by other reasons such as staffing issues and operating costs. To promote Kantaki throughout Japan, such operational issues should be analyzed further.

[Objective] More than two decades have passed since the situation-specific theory (SST) was proposed. This literature review analyzes changes in the number of SST-related articles, their contents, methodologies, and sources for the construction. This study aimed to clarify the developing process and prospects in future SST constructions.[Methods] Using the CINAHL, PubMed, and ICHUSHI databases, we searched for papers in English with the key words of "situation-specific theory" and "situation-specific theories" and those words translated in Japanese. Eighty-eight articles were found and screened. At the end, fifty articles were to be reviewed, and they were sorted by year of publication and contents. Additionally, articles reporting SST construction were analyzed for the theory constructing methodologies and sources used for the constructions.[Results] All articles were classified into the following six categories: theory development, concept analysis, clarification of theory sub-concepts, theory testing, research based on theoretical framework, and review/commentary. The number of published articles is increased every year. The review of these articles revealed that constructions of SST were validated and utilized as research frameworks, and SST has been contributing to the construction of knowledge in the field of nursing science. SSTs were constructed in 23 articles, all of which focused on restricted phenomena in particular fields or subjects. The integrative approach was the most commonly employed for construction methods; however, other methods were found in some articles. The sources frequently used for the constructions were preexisting theories, research findings, and literature reviews, whereas practical experiences were rarely used as the sources.[Conclusion] Based on the increase in constructions of STT, utilization of SST as frameworks, and validation of the theory, the awareness of SST will grow in the field of nursing science. As construction methods other than the integrative approach are emerging, additional SSTs should be constructed with a broader range of approaches.

目的 超高齢社会の到来に伴って、疾患や加齢等により安定した経口摂取が困難な患者が多くなり、食支援を必要とする高齢者は急増しているが、在宅ケアの要である訪問看護師が主体的に取り組む食支援に関する研究は少なく、ほとんどが事例報告である。そこで本研究では在宅での生活支援の中で、訪問看護師がどのような食支援を行っているのか、その実際を明らかにするために調査を行った。方法 食を支援するための具体的な看護実践を明らかにすることを目指しているため、調査対象は食への支援を積極的に展開している訪問看護ステーションに勤務している訪問看護師とした。この訪問看護師に対して、グループインタビューを行った。インタビューデータより食支援の内容を読み取り、類似性に従って分類した。結果および考察 5名の訪問看護師からデータが得られた。生活支援の中での食支援として、食支援を積極的に行っている訪問看護師は「その人らしく生きる食支援」を行っていた。訪問看護師が行う食支援は【食に対する看護師の思い】を根底におきつつ、療養者と家族の意思を尊重することを基盤にしてケアを行っていた。そして、在宅ケアの特徴を踏まえて【高度なアセスメント】【食に対する全人的なケア】【包括的な食支援のための多職種連携】【連続的な評価】という取り組みを展開していた。(著者抄録)

【目的】「食」を切り口として包括的なケアを進めることで生活全般に波及することをねらい「食からはじめる生活支援プログラム」を作成した。本研究は、その効果と継続性に関して評価することを目的とし、1)栄養摂取状態、2)口腔健康、3)発熱頻度、4)意欲・食欲の改善が入居者にみられるかを明らかにした。【方法】研究協力者は一特別養護老人ホーム入居者(入居者)および入居者のケアに直接かかわる施設スタッフ(介護職、栄養士、看護師、理学療法士等)とした。プログラム内容は、3ヵ月間の1)集中プログラム:入居者各自についての(1)テーラーメイド個人プログラムと(2)集団体験学習プログラム(入居者対象および施設スタッフ対象を各月1回計3回)、続く3ヵ月間の2)継続プログラムからなる。介入の効果と継続性を検討するため、介入開始前、介入3ヵ月後、介入6ヵ月後(終了時)、介入終了6ヵ月後において、以下の項目を比較した。1)栄養摂取状態(BMI、摂取カロリー量、水分摂取量、食形態)、2)口腔健康状態(現在歯、齲歯、義歯、処置歯、歯垢、舌苔、舌機能)、3)調査前3ヵ月の発熱頻度、4)意欲(Vitality index)、食欲。4回分の調査記録がある入居者について分析を行った。本研究は兵庫県立大学看護学部・地域ケア開発研究所研究倫理委員会の承認をうけ実施した。【結果・考察】研究協力入居者は100人(男性24人、女性76人)、平均年齢は83.6歳(60〜101歳)であった。1)栄養状態には有意な変化がみられ、摂取カロリー(p=0.005)、水分摂取(p=0.000)、食形態(p=0.003)のいずれの項目も介入前と比較し介入6ヵ月後にかけ改善する傾向にあったが、介入終了6ヵ月後には元に戻る傾向にあった。2)口腔清掃の状況を示す歯垢や舌苔では、介入前と比較し、介入3ヵ月後、介入6ヵ月後、介入終了6ヵ月後と有意に改善した。3)発熱の頻度は有意な変化がみられ(p=0.019)、介入前と比較して介入3ヵ月後は有意に低下した。4)食欲は有意な変化がみられ(p=0.000)、介入前と比較し、介入3ヵ月後、介入6ヵ月後は有意に増進したが、介入終了6ヵ月後には減少した。Vitality Indexは有意な変化がみられ(p=0.000)、介入前と比較し、介入3ヵ月後は有意に増加したが、介入終了6ヵ月後には減少した。【結論】本プログラムは、栄養状態、口腔健康、発熱頻度、意欲や食欲の向上に効果があると考えられたが、介入終了後その効果は続かず、継続的に介入を行っていく必要性が示唆された。(著者抄録)

【目的】高齢者の食事の物性に関しては誤嚥防止の観点からしか十分な関心が払われていない。普通食は咀嚼を要するので、唾液分泌を促し免疫や口腔衛生に貢献し、また廃用性萎縮の防止や咀嚼嚥下機能の維持増進が期待できる。そこで、本研究は、1)食形態は肺炎の発生と関連があるか、2)食形態は栄養状態と関連するか、3)食形態とムセは関連するか、4)普通食摂取を可能にする要因は何か、という4つの研究疑問を解くことを目的とした。【方法】調査対象は一特別養護老人ホーム入居者80人(男性13人、女性67人)、平均年齢88.7歳であった。調査項目は、1)食形態(普通食、軟菜、キザミ食、ペースト食、胃瘻)、2)健康状態(要介護度、認知症高齢者の日常生活自立度、既往歴、発熱、BMI、摂取カロリー量、水分摂取量、食欲、ムセの頻度、Vitality index)、3)口腔状態(現在歯数、義歯数、う歯、咬合、舌機能)であった。本研究は兵庫県立大学看護学部研究倫理審査委員会の承認をうけ実施した。【結果・考察】1)食形態は肺炎の既往や発熱と有意な関連があった。過去3ヵ月間の発熱は、普通食摂取者25人中5人(20.0%)に対し、ペースト食摂取者22人中12人(54.5%)、胃瘻16人中10人(62.5%)と多かった(p=.045)。2)食形態は栄養状態と関連した。平均摂取カロリー量は、普通食(1320.5±231.9Kcal)、キザミ食(1209.2±231.9Kcal)、ペースト食(1150.0±211.0Kcal)、胃瘻(809±153Kcal)であった(p=.000)。3)食形態とムセは有意な関連はみられなかった。軟らかで細かい食形態であってもムセは改善しなかった。4)ロジスティック回帰分析(変数減少法)の結果、普通食摂取に有意に影響したのはVitality index、食欲、咬合状態の3項目であった。【結論】本研究は横断的研究であるため、因果関係に言及することはできないが、本研究の結果は咀嚼を要する食形態は、良好な健康状態と関連すると考えられた。(著者抄録)

© 2015, Springer Japan. All rights reserved. Aspiration pneumonia is the leading cause of death among the elderly. Modified-texture foods, i.e., foods with altered consistency, are recommended in order to maintain both normal swallowing and adequate nutrition, which is also expected to reduce aspiration pneumonia, when elderly people are suspected to suffer from disorders of eating and/or swallowing. However, it is reported that overly-restrictive diets have been provided to most residents given modified-texture diets. Furthermore, there is scant empirical evidence of the medical effectiveness of food texture-modification. Little attention has been paid to the effect of the consistency of food substances, as well as the ability of mastication, on general health. Our cross-sectional studies showed that eaters of regular foods have lower incidences of pneumonia and fever, while those eating modified-texture, i.e., softer and finer, foods have higher incidences of pneumonia and fever. In this review, the effects of interventions for prevention of aspiration pneumonia were overviewed then the impact of the consistency of food substances on the health of the elderly and the direction of further research was discussed.

The effect of the consistency of food substances on health has not been assessed. The ingestion of food substances which require mastication promotes salivary secretion and oral function, which may in turn lead to a lower incidence of aspiration pneumonia. Thus, this study aims to reveal the importance of ingesting regular solid food and inquires into the condition associated with ingesting regular food.The subjects were 225 Japanese residents (47 males and 178 females; age, mean 87.9years) in welfare facilities for seniors. The following data were obtained from the facility's records: 1. consistency of food substances and their caloric intake, 2. their general health status 1) BMI, 2) medical record, 3) cognitive function. Their oral health status was checked by dentists.Eaters of regular food had a lower incidence of pneumonia (16.7%) than chopped food (28.6%), paste food (58.3%) and gastric-tube fed residents (57.1%). This may be because of the higher calorific intake of eaters of regular food (mean+/-SD; 1378.0 +/- 206.9 kcal) compared to chopped food (1282.7 +/- 193.5), paste food (1189.6 +/- 324.4kcal) and those gastrostomy tube fed residents (812.5 +/- 150.7kcal) (ANOVA, p<0.001). Eaters of regular food had better dental occlusion, better oral function and better cognitive function.Since this was a cross-sectional study, it was not possible to ascertain causal relationships. However, the results suggest that the consistency of food substances which require mastication has some influence in lowering the incidence of aspiration pneumonia of the elderly.

術後精神障害とは手術を受けたことを契機に生じた様々な精神症状の総称である。症状の特定が難しいため、その発見と対処には個々の精神機能の特徴を理解して状態のアセスメントを行うことが重要である。術後精神障害の多くは意識障害に包括された症状であり、観察には覚醒水準に加えて、見当識や注意に現れる意識内容の変容という視点が重要となる。せん妄は術後によく生じる精神障害であり、低活動型せん妄は目立たないため発症を見逃すことが多い。医療者は術後患者に精神機能低下が生じていることを前提に精神機能評価を行い、精神機能の状態に合わせた環境整備やケアを行う必要がある。そして患者の行動に対して興味を持つことが、術後精神機能障害を早期に発見、予防をしていくことにつながると考える。(著者抄録)