「成人患者の利益・権利を守るアドボカシー」に関する看護師の意識

Abstract

背景 現在の医療現場において,真に患者の意思決定に基づく医療サービスが提供されているのかという問いかけから,患者と接する時間が長く身近にいる看護師は何ができ何をしなければならないのか(看護の役割)を探求するために,看護師が患者の権利や人権をどのように認識し実際に係わっているか,また,最近看護職の間で使われているアドボカシーの用語について,その用語の持つ意味や構成概念についてどのように理解しているかを明らかにしていく必要がある。目的 看護が行うアドボカシー(nursing advocacy)の概念を実践看護師の視点から検討し,アドボカシー概念の意味するもの,その概念が構成している価値観を明確にし,「患者のアドボケイトとしての看護の役割」を考え,さらにアドボケイトという役割を担うことへの課題を明らかにするための基礎データとして,臨床で働いている看護師のアドボカシーについての意識と経験の現状を把握するために調査を行った。方法 Davisらが開発し,看護師24名を対象にパイロット・スタディーを行った質問票を,一部改変し追加した質問票を用いてアンケート調査を行った。対象は近畿圏内の緩和ケア病棟を持っている300床以上の病院で働いている臨床経験5年以上の看護師365名である。結果 7割の看護師はアドボカシー実践を行っていた。「患者が苦しんでいるとき」,「患者や家族への病状説明が不十分」な時に,「患者と医師のパイプ役」,「医師に再説明の依頼」,「不明点/疑問点の医師への確認」など,医師に向けての行動が多かった。アドボカシー実践を促進する職場環境は,「患者中心の看護」,「看護スタッフ間の協力の精神」で,逆に「ゆとりある業務」,「医師はあくまで同僚」が実践の場で欠如していた。患者の権利については,看護師の意識や理想は全体的に高いが,病院において実際に守られているあるいは看護師が現実に係わっている状況とは差があった。また,患者の意思決定を促進するのに必要な患者本人の情報や看護・治療計画に参加する権利は守られていない傾向にあった。フライの看護師アドボカシーモデルに基づく25項目の権利の選定は妥当であり、この理論は支持された。結論 アドボカシーに関する概念のより明確な定義づけをするためには,看護師全般に渡るさまざまな実証的研究を重ねながら,諸理論の照合と検証が必要である。

Background In response to a question whether medical services are provided truly based on patients' own decision in current clinical settings, what can and should nurses do as health care provides who work close to patients for long hours? To understand nurses' roles, we need to study how nurses are aware of and address issues concerning patients' rights. We also need to clarify how nurses understand the meanings and concepts of terms recently used among them in practicing advocacy. Objective I conducted a survey to study the concept of nursing advocacy from a practice nurse's point of view. The purposes were: 1) to understand roles of nurses as patient advocates by clarifying the meaning of the concept of advocacy and values centered on the concept; and 2) to collect information about awareness concerning advocacy among nurses working in clinical settings and their experience in practicing advocacy, which will shed light on their responsibilities as patient advocates. Method I used a questionnaire form with some revisions and additions to the one developed by Davis et al. for a pilot study in 24 nurses. The subjects for my survey were nurses with five or more years of clinical experience at hospitals with 300 or more beds and with a palliative care unit within the Kinki region. Results Seventy percent of the respondents had experience of serving as patient advocates, mostly to address issues in relation to doctors, such as easing patients' suffering, providing patients and/or their family with sufficient explanation about their disease conditions, serving as a mediator between patient and physician, requesting the doctor to provide an explanation again to the patient, and seeking doctor's clarification about unclear points and doubts. In workplaces where nurses were motivated to pursue advocacy efforts, "patient-centered nursing care" was provided and "cooperative spirit among nursing staff" was cultivated. What lacked in their workplaces were "an environment with less pressure" and the concept that "doctors and nurses are on an equal footing." While awareness and ideal of patients' rights among nurses were generally high, there was a difference between the ideal and actualities. There was a tendency that the confidentiality of personal information about patients and the right of patients to participate in planning treatment and care were not protected. The selection of 25 rights of patients based on a nursing advocacy model by Dr. Fry was proved appropriate and her theory was supported. Conclusions To define the concept of advocacy, we need to conduct empirical research covering a broad range of nursing activities, based on which comparison and verification of theories should be made.