Takako Tsutsui

本研究では,住み慣れた地域で3年間,介護サービスを利用しながら,生活を継続していた要介護高齢者に着目し,彼らが利用していたサービス(サービスの組み合わせ)と要介護状態の変化との関係を分析した.要介護度の変化としては,改善及び悪化に着目し,悪化群と改善群に特徴的なサービス(サービスの組み合わせ)モデルについて検討した.分析には,2015年6月以降に利用を開始し,2018年6月までに利用を終了した居宅の介護サービス利用者12,003名のうち,6ヵ月以上継続して,介護サービスを利用していた要介護1-4の利用者8,029名を対象とし,利用期間によって,短期利用群,長期利用群の2群に分けた.この2群別に,AIの一分野として,1980年代から研究されてきたベイジアンネットワークを用い,要介護度の変動と利用サービスの関係を示すモデルを作成した.研究の結果,要介護度の改善に資するサービスや,悪化と関連するサービスが示された.さらに,利用期間の長さによって,同一の利用サービスであっても,要介護の変動への影響が異なることが明らかにされた.ただし,本分析には,利用者の年齢,傷病の有無,手段的日常生活動作項目などの基本情報,医療サービスの種類や量,環境因子などの情報は反映されていない.このため,今後の課題としては,因果を説明できる要素を含めた分析をさらに行い,これを踏まえたモデルの構築を検討すべきと考えられた.(著者抄録)

COVID-19によるパンデミックは,人々の生活に大きな変化をもたらしただけでなく,自殺や孤立死,家族内のDV,虐待等といった深刻な社会問題を顕在化させた.とくに自殺や孤立死の背景には,加速化する単独世帯の増加があると考えられる.本稿では,単独世帯の増加と,これを背景とした「孤立死」や孤独に関する課題について,実証データを基に取り上げる.また日本では,孤独や孤立に関しては,データが不足していたため,実効性のある対応が不十分であったことを述べる.しかしながら,これらの課題は,血縁,地縁が希薄化した現代社会の中で必然的に発生したものであり,我々の社会は,これらの解決に際し,社会生活を送るためのスキルをRe-skillingするための新たな社会サービスを必要としていること,これを学校教育だけでなく,生活の場で学習できる環境を構築することが喫緊の課題であることを論じる.(著者抄録)

目的:生活介護,就労継続支援B型サービスを利用していた障害者群別に,それぞれのサービス利用開始前のWHO-DAS得点と基本属性等の生活状況等の差異を明らかにすることを目的とした.方法:WHO-DAS 2.0の36項目版(代理人評価)による調査を生活介護の利用者68名,就労継続支援B型の利用者31名に実施した.また,この2種類のサービス利用者群別の基本属性,WHO-DASの得点を比較分析した.さらに,各サービス利用の有無を目的変数とし,対象者の属性及び6領域7種類のWHO-DAS領域別得点を説明変数とした多重ロジスティック回帰分析を実施した.結果:利用サービスによる性別や知的障害の有無には有意差はなかったが,生活介護の利用者群の年齢は,就労継続支援B型サービス利用群よりも30歳未満の割合が高かった.また,生活介護利用群は,特別支援学校出身者が有意に多かった.さらに,生活介護利用群は,親との同居率が高く,交際・婚姻経験がないものが多かった.障害等級は,生活介護利用群のほうが,重度(A,1級)の者が多く,障害支援区分も3以上の者が多かった.考察:WHO-DASの領域別得点は,すべての領域で生活介護利用群のほうが,就労支援B型利用群よりも有意に高く,支援を要する状態となっていた.現行の利用サービスの選定には,一定のルールがあることが示唆された.結論:WHO-DASは,ICFの中の「参加と活動」に関する生活機能を評価するアセスメントツールである.本研究の結果からは,これまで臨床的知見により決定されていたサービスを利用者の開始前のWHO-DASの得点値を利用することで当該障害者にとって,より適切なサービスを選択できる可能性が示された.(著者抄録)

看護必要度による患者の評価情報は,患者が罹患している多くの疾患名からの情報ではなく,医師以外の臨床家が直観的に患者像を想定できる情報を得ることができるものとして,有用とされている.看護必要度はすでに87万床以上の病床で評価されて続けていることから,項目の一部を使い,病院から地域への情報連携に活用しようという動きも始まっている.これは,多くの地域の臨床家にとって,看護必要度による患者把握の利便性が高いことが認識されてきたことによる.本稿では,まず,看護必要度の活用にあたり,理解しておくべき基本的な考え方を述べながら,看護必要度の開発経緯から今日までの診療報酬制度における活用実態を示す.次に,多職種連携に際して提供されている疾病に係る情報に加え,看護必要度による情報を活用することで,患者にとって,より適切なケアを継続的に提供できる,新たなケアシステムを構築できる可能性があることを論じた.(著者抄録)

看護必要度は,主に看護師が患者評価のために使用してきた尺度であるだけでなく,多職種協働の推進に活用できる有効なマネジメントツールである.本研究では,看護師の属性及び職位別の看護必要度データの活用意向を明らかにし,この結果から,今後の研修プログラムのあり方を考察することを目的とした.方法として,一般社団法人日本臨床看護マネジメント学会が実施した「2020年度ステップアップ研修」参加者の1,975名に対し,協力が得られた1,265名のデータ(回収率64.1%)を用い,病床,職位別等の分析を行った.職位による活用意向に有意差が示されたのは,入院患者の受入れ病棟の決定,看護師の要員算定,傾斜配置,病棟の再編成・病棟の増減で,いずれも看護部長,看護師長等の看護管理者の活用意向が有意に高かった.一方,業務分析・業務改善,多職種連携,退院調整に関しては,看護管理者とスタッフレベルとの有意差は無く,どの職位でも活用意向が高いことがわかった.以上の様な活用意向が示されたことは,従来の職位に連動した看護管理だけではなく,職位に関わらず,全ての職位のマネジメントスキルを向上させる必要を示唆している.加えて,新たなテーマとして多職種連携や退院調整のスキル向上が求められていると考えられた.今後は,スタッフレベルと地域の多職種との看護必要度データの利用による連携スキルに資する教育を推進し,地域連携へ寄与することが期待されている.(著者抄録)

目的:多職種連携が看護必要度のデータを価値あるケア情報やサービスへと変化させ,有効的に利用できるかを検証することを目的とした先行研究を系統的にレビューし,看護必要度の活用に際しての課題を整理した.方法:医学中央雑誌Webを使用し2022年8月検索)「看護必要度」と「多職種」及び看護必要度の評価に関わる職種である,「理学療法士,作業療法士,言語聴覚士,医師,事務職員,薬剤師,ソーシャルワーカー,介護福祉士,管理栄養士,歯科衛生士,放射線技師,検査技師,臨床工学技士,ケアマネジャー」の各職種名称を検索語として組み合わせた.結果と考察:検索の結果,解説,会議録,座談会等を扱った文献を除外すると,原著論文は57件となった.これらから看護必要度を用いた多職種連携の推進に関する研究動向として相応しいと考えられた12件をもとに,以下の知見を得た.看護必要度が診療報酬に導入された2002年当初から看護必要度と多職種に関する研究は報告されていたが,2016年の診療報酬改定を契機に看護必要度を用いた多職種連携を図るための評価システムが試行されていた.また,看護必要度は多職種において既に業務量評価,看護必要度評価における精度改善チーム医療等に活用されていた.結論:看護必要度は,これまで看護職員が主となった研究が多数,報告されてきたが,多職種が看護必要度のデータやシステムを業務に活用している事例が示されつつあることが明らかになった.(著者抄録)

BACKGROUND: A growing number of older adults require complex care, but coordination among professionals to provide comprehensive and high-quality care is perceived to be inadequate. Opportunities to gain the knowledge and skills important for interprofessional collaboration in the context of geriatric care are limited, particularly for those already in the workforce. A short-term training programme in interprofessional collaboration for health and social care workers in the Philippines was designed and pilot tested. The programme was devised following a review of the literature about geriatric care education and group interviews about training needs. The objectives of this paper are to introduce the training programme and to evaluate its influence on attitudes and readiness to collaborate among participants using both quantitative and qualitative methodologies. METHODS: A total of 42 community health workers and 40 health institution workers participated in the training in July 2019. Quantitative indicators were used to evaluate attitudes towards and readiness for collaboration before and after the training. Content analysis was performed of responses to open-ended questions asking participants to evaluate the training. A convergent parallel mixed-methods design was applied to determine the patterns of similarities or differences between the quantitative and qualitative data. RESULTS: Significant improvements were seen in scores on the Attitudes Towards Health Care Teams Scale among community health (P < 0.001) and health institution (P < 0.001) staff after the training. Scenario-based case studies allowed participants to work in groups to practise collaboration across professional and institutional boundaries; the case studies fostered greater collaboration and continuity of care. Exposure to other professionals during the training led to a deeper understanding of current practices among health and social care workers. Use of the scenario-based case studies followed by task-based discussion in groups was successful in engaging care professionals to provide patient-centred care. CONCLUSIONS: This pilot test of in-service training in interprofessional collaboration in geriatric care improved community and health institution workers' attitudes towards such collaboration. A 3-day training attended by health and social care workers from diverse healthcare settings resulted in recommendations to enhance collaboration when caring for older adults in their current work settings.

The objective of this study was to evaluate the efficacy of an in-service, short-term training program in improving the attitudes toward, and readiness and activities for collaboration among community health workers (CHWs) in a primary care setting in the Philippines. A randomized controlled trial was adopted dividing participants into an intervention (n = 42) and a control group (n = 39). Attitudes toward, and readiness and activities for collaboration were measured using three standardized scales before and at 6 months after the training. A significant difference (p < 0.001) was observed in the Attitudes Toward Health Care Teams Scale (ATHCTS) scores between pre- and post-test in the intervention (6.3 ± 8.3 [Mean ± SD]) and control groups (0.7 ± 8.2). Multivariate linear regression analysis showed an independent positive association between the intervention and greater improvement in the ATHCTS score (Coefficient β = 6.17; 95% CI = 0.82, 11.53; p = 0.03) at follow-up, after adjustment for age, years in current occupation, and social support role of participants. The results demonstrated the efficacy of the intervention for improving the attitudes of CHWs toward collaborative practice in the care of older adults.

本研究は,管理栄養士による看護必要度項目の認知や,その活用に関わる現状を明らかにし,多職種連携の推進に資する方策を検討することを目的とする.方法は,4施設の急性期病院に勤務する33名の管理栄養士を対象とし,自記式質問紙調査を実施した.この結果,25名から回答を得た(回収率は75.8%).結果は看護必要度の院内研修受講経験は,25名全員が「なし」であった.栄養に関わる業務上で看護必要度の項目やそれに関わる情報を確認したことが「ある」は15名,「ない」は10名であった.また,入院患者の栄養ケアを実践する際に「一般病棟用の重症度,医療・看護必要度Iに係る評価票」の項目を用いたことがあるかについて,その利用頻度をリッカート5点尺度で測定した.この結果,栄養ケアの実践にて活用する患者情報として,「食事摂取の介助状況」,「抗悪性腫瘍剤の有無」,「褥瘡の有無」,「放射線治療の有無」,「診療・療養上の指示が通じるか,通じないか」等が示された.これは看護必要度の情報が栄養管理業務にも利用できうる可能性を示したものと考えられた.ただし,看護必要度の情報を栄養士が利用し,多職種チームとして,院内でのケアを具体的に実践するためには,連携が進んでいない職種への看護必要度に関わる教育,研修が必要となると考えられた.(著者抄録)

Abstract This study was aimed at clarifying the awareness in national registered dietitians of nursing care intensity items, and current practice relating to these items, and at examining ways to contribute to the promotion of multi-occupational collaboration. A self-administered questionnaire survey was conducted for 33 national registered dietitians working in four acute care hospitals. Responses were obtained from 25 subjects (response rate, 75.8%). Results showed that "None" of all 25 subjects had experience of participating in an in-hospital training course related to nursing care intensity items. Subjects who had ever checked the nursing care intensity evaluation items and information related to these items in nutritional practice numbered 15, and 10 had never checked them. In addition, we looked at whether the evaluation item "Evaluation form on the severity and the necessity of medical care / nursing I for general ward" was used in the practice of nutritional care with hospitalized patients, and rated the frequency of use using the 5-point Likert scale. Results showed that patient information utilized for nutritional care included "status of meal intake assistance", "treatment with an antineoplastic agent", "presence of a pressure sore", "presence of radiation treatment", "communicability of instructions from staff on medical treatment/ care of the patient", and other factors. It was suggested that information on nursing care intensity items could be used for nutritional management work as well. However, it is necessary to provide education and training related to nursing care intensity items for occupations in which multi-occupational collaboration has not yet been promoted, so that nutritionists use information on nursing care intensity evaluation, and practice hands-on in-hospital care as members of a multi-occupational team.

The purpose of this paper is to review the research trend in foreign countries related to <patient classification system< which has become a main theme internationally in the medical system, and to examine new patient classification system necessary for the patient value improvement and clinical nursing management as a basis of this operation.As a method, the search for previous studies was conducted mainly by searching for keywords related to patient classification in PubMed and Cinahl-databases, and two journals, Journal of Advanced Nursing and Journal of Nursing Management, were complemented by searching for papers directly related to the keywords.The patient classification system is not the first-generation system aimed only at proper assignment of nurses at the beginning, but the development of the fourth-generation system which includes many elements of hospital management such as cost management of services and medical supplies has been started. As a result of the research, it was shown that the introduction experience of over 10 years of the national level of nursing care intensity evaluation which is rare internationally brings about advantage in the mechanism which collects the evaluation data on the patient disease state which is necessary for the system construction, training on this information collection, retention of the motivation of the provider.Therefore, the development of a disease classification system for fourth-generation patients utilizing this advantage and the realization of clinical nursing management that raises the value of patients based on this system are urgent issues in the future.

BACKGROUND: The psychological care of abused children in the child protection system is an urgent issue in Japan. Child abuse has a serious impact on children's emotion and behavior, but there is virtually no evidence about how child abuse affects sleep, which is closely related to behavioral and emotional control. In this study, we sought to identify sleep habits and suspected sleep disorders among abused children and adolescents admitted to residential care facilities in Japan and to investigate their association with emotional and behavioral problems. METHODS: The study targeted 273 abused children and adolescents (age range: 4 to 15 years) who had been admitted to a residential care facility in Japan. They were assessed by physicians and other personnel at facilities with expertise in childcare and abuse. Respondents completed a brief sleep questionnaire on the incidence of problematic sleep habits and suspected sleep disorders as well as a questionnaire on emotional and behavioral issues. RESULTS: Approximately 40% of the abused children and adolescents had some sleep-related symptoms at bedtime and waking, and 19% had suspected sleep disorder. Abused children with emotional and behavioral problems had a significantly higher incidence of suspected sleep disorders than abused children without such problems, and this incidence was particularly high among those with antisocial behavior and depressive behavior. Our predictive model also showed that antisocial behavior and depressive behavior were significant predictors of suspected sleep disorders. CONCLUSION: Careful assessment and appropriate therapeutic intervention for sleep disorders are required in abused children and adolescents with emotional and behavioral problems.

Introduction: Japan has the largest percentage of elderly people in the world. In 2012 the government implemented a community-based integrated care system which provides seamless community healthcare resources for elderly people with chronic diseases and disabilities. Methods: This paper describes the challenges of establishing a community-based integrated care system in 1974 in Mitsugi, a rural town of Japan. This system has influenced the government and become the model for the nationwide system. Results: In the 1970s, Mitsugi's aging population was growing faster than Japan's, but elder care was fragmented among a variety of service sections. A community-based integrated care system evolved because of the small but aging population size and the initiative of some local leaders of medical care and politics. After the system took effect, the proportion of bedridden people and medical care costs for the elderly dropped in Mitsugi while it continued to rise everywhere else in Japan. Mitsugi's community-based integrated care system is now shaping national policy. Conclusion: Mitsugi is in the vanguard of Japan's community-based integrated care system. The case showed the community-based integrated care system can diffuse from rural to urban areas.

The establishment of the Japanese community-based care system was (first) presented in the report of the National Council on Social Security System Reform in August of 2013. Since then, each function aims at supporting the lives of the elderly people in their homes and local communities where they feel attached by dividing and/or sharing (various) care tasks. This system includes the concept of community-based care in addition to that of integrated care, which is designed to support elderly individuals with chronic health conditions and ensure their independent lives after discharge from hospitals by delivering services tailored to those individual's conditions. This integrated care is considered to contribute to the sustainability of the health system by moderating the demands of unnecessary hospitalizations and expensive emergency services and to support maintaining the quality of life of individuals to reach a high level of independence and satisfaction in their lives. In this article, I will explain the position of the Japanese community-based care system in the context of health services integration. Meanwhile, I intend to clarify the international problems with health services integration and to give insights into their solutions by reviewing previous worldwide studies. From international reviews of previous studies, integration and coordination of health services are found to be considered problematic on the international level as well. In order to facilitate integration of health services, we suggest establishment of an integrative service delivery model through systematic organization of integration frameworks (horizontal/vertical and linkage/coordination/full integration). From the domestic trends in Japan, with the prospect of further division of roles in each function in the service delivery system, it is necessary to clarify the care management process including patient admission and discharge from hospitals in order to achieve seamless care management for people with care needs. Moreover, in order to strengthen this management function, it is necessary to develop a practical tool to support better information sharing across different health care sectors. At the same time, municipal governments are expected to support this type of initiative from multiple aspects.