@phdthesis{oai:niigata-u.repo.nii.ac.jp:02000205,
 author = {清野, 由美子},
 month = {2022-01-07, 2022-01-07},
 note = {Ⅰ．研究背景 摂食嚥下障害は精神疾患患者の9～42%が合併するとも言われ，抗精神病薬をはじめとする向精神薬の有害反応や精神症状の影響が指摘されている。精神科病院における肺炎の多くが高齢者の誤嚥性肺炎と考えられ，救命できたとしても禁食による低栄養や安静臥床に伴うADLの低下を招きQOLに影響を及ぼす。ところが，我が国の精神病床の91.8%を占める民間立の精神科病院の中で嚥下機能評価およびリハビリテーションに関して専門的な支援が可能な施設は皆無に近く，看護師の摂食嚥下障害支援への関心の低さが指摘されている。これまで，摂食嚥下障害をもつ患者への対応に課題を抱える精神科病院において，看護師および多職種が誤嚥性肺炎予防についてどのように考え，どのようなケアを提供しているかというケア提供者から見た誤嚥性肺炎予防の実態は明らかにされていない。また，このような環境で入院生活を送る患者の誤嚥性肺炎リスクの影響要因は未だ解明されておらず，必要な支援に関する検討が不足している。誤嚥性肺炎は，現場のケアにより予防可能な疾患である。食べたら誤嚥性肺炎が起こるのではなく，「ケア不足がゆえに誤嚥性肺炎が起こる」とも言われる。本論文では，精神科病院における誤嚥性肺炎予防のケアに着目し，臨床現場の現状を明らかにした上で，精神疾患患者の食べることを支える支援を検討する。Ⅱ．目的および方法 本論文は，以下の3つの研究により構成される。研究1：目的は，精神科看護師が体験している誤嚥性肺炎予防に関する看護ケアを明らかにし，食べることの支援に向けた示唆を得ることである。2016年7月から11月，某県内20か所の精神科病院のうち16か所の病院の病棟看護師55名を対象に，1グループ2～5名/1施設とするフォーカスグループインタビューを計16回行い，得られたデータを質的帰納的に分析した。本研究は，新潟大学研究倫理審査委員会の承認(第144号)を受けて実施した。研究2：目的は，精神科病院のNSTメンバーが誤嚥性肺炎予防を踏まえて提供するケアの現状と課題を明らかにし，食べることを支えるチームアプローチへの示唆を得ることである。2017年9月から12月，某県内20か所の精神科病院のうちNSTを有する8か所のNSTメンバー31名を対象に，1グループ3～5名/1施設とするフォーカスグループインタビューを計8回行い，得られたデータを質的帰納的に分析した。本研究は，新潟大学研究倫理審査委員会の承認(第2017-0123号)を受けて実施した。研究3：目的は，精神科病院入院患者における誤嚥性肺炎リスクの影響要因を明らかにし，予防に向けた支援への示唆を得ることである。2018年7月から12月，某県内1か所の精神科病院入院患者約400名のうち病棟内食堂で食事摂取可能な者100名を対象に，誤嚥性肺炎リスク評価により判定した低リスク群と中等度リスク群との2群に分け，統計学的検討を行った。本研究は，新潟大学研究倫理審査委員会の承認(第2018-0022番)を受けて実施した。Ⅲ．結果および考察 研究1：精神科看護師は，有効な資源の少なさや精神疾患をもつ人に特有の【精神科における誤嚥性肺炎予防ケアの困難】があるために，誤嚥性肺炎予防において，食事の見守りの徹底に象徴される【目前の誤嚥・窒息リスクを回避したいという強い思いに基づくケア】を提供していた。一方では，入院生活を送る精神疾患患者にとって食はQOLの重要な要素であることから，【食べることのQOLを志向したケア】に取り組んでいた。また，日々の看護業務の一環として，【誤嚥性肺炎予防に有効とされる日常生活援助】に努めていた。さらに，限られた環境の中で最大限のケアを提供するために，【精神科医療の強みを活かすチームケア】を取り入れていた。食べることを支えるために，精神科看護の経験知を活用し，院内多職種と協働で包括的なアセスメントやケアに取り組むことの必要性が示唆された。研究2：精神科病院NSTメンバーは，【経口摂取に伴う誤嚥の防止】のために精神疾患をもつ人に特徴的な摂食嚥下障害への対応や食形態等の調整を行い，NST活動の主軸となる栄養管理，ミールラウンド，経口摂取への移行に代表される【栄養状態・体力の改善】，口腔ケアを励行することで【不顕性誤嚥による肺炎の回避】に努めていた。【食べることにつなげるチーム医療】では，病院スタッフへのコンサルテーションを担い，医療職として職務の遂行に取り組んでいた。課題として，食事場面や食形態の調整，嚥下機能のアセスメントや訓練をはじめとする【摂食嚥下障害への対応における困難】や，栄養管理，薬物療法，作業療法等の【精神科NST活動における困難】が明らかとなった。食べることを支えるチームアプローチとして，NST本来の力や各専門職の強みを活かしつつ，部署・職種の枠を超えた柔軟な多職種連携を行うことが重要であると示唆された。研究3：精神科病院の病棟内食堂で食事摂取が可能な入院患者における誤嚥性肺炎リスクに影響する因子は，入院期間，BMI，PEF，RSSTであった。誤嚥性肺炎予防に向けた支援として，これらの数値に着目しながらアセスメントを行うとともに，栄養状態や呼吸機能，嚥下機能の維持改善を目指す取り組みが必要であると考える。, Ⅰ．Research background Dysphagia is said to be associated with between 9 and 42 per cent of psychiatric patients. Adverse reactions to and psychiatric symptoms from psychotropic drugs such as antipsychotics have been implicated. Most pneumonia in psychiatric hospitals seems to be aspiration pneumonia that occurs among elderly patients, and even if life can be saved, the condition causes malnutrition due to fasting and a decrease in ADL due to resting, which affects QOL. While private psychiatric hospitals account for 91.8% of psychiatric beds in Japan, virtually none of these can provide specialized support for evaluation and rehabilitation of dysphagia. Attention has also been drawn to the lack of interest in dysphagia support by nurses. To date, in psychiatric hospitals that have problems in dealing with patients with dysphagia, the aspiration pneumonia prevention situation has not been clarified from the point of view of care providers i.e. the attitude of nurses and other professionals to aspiration pneumonia prevention and what sort of care they provide. Moreover, the factors that influence the risk of aspiration pneumonia in patients who live in hospital in such an environment are not yet clear and the question of necessary support has not been sufficiently examined. Aspiration pneumonia is a disease that can be prevented by on-site care. It would seem that it does not occur through eating; instead “aspiration pneumonia occurs due to lack of care.” In this paper, we focus on the care required for aspiration pneumonia in psychiatric hospitals, clarify the current state of clinical practice, and examine support for helping mentally ill patients to eat. Ⅱ．Purpose and method This paper consists of the following three studies. Study 1: The purpose was to clarify nursing care for aspiration pneumonia prevention as experienced by psychiatric nurses and to obtain suggestions for helping patients to eat. From July to November 2016, we conducted a total of sixteen focus group interviews with 55 ward nurses in sixteen of twenty psychiatric hospitals in Prefecture A in groups of two to five people per hospital. The data obtained were analyzed qualitatively and inductively. This study was carried out with the approval of the Niigata University Research Ethics Review Committee (No. 144). Study 2: The purpose was to clarify the current situation and issues relating to care provided by Nutritional Support Team (NST) members of psychiatric hospitals for the prevention of aspiration pneumonia, and to obtain suggestions for a team approach to support eating. From September to December 2017, we conducted a total of eight focus group interviews with 31 NST members from eight of twenty psychiatric hospitals with nutritional support teams in Prefecture A. There were three to five people per group and per hospital. The data obtained were analyzed qualitatively and inductively. This study was carried out with the approval of the Niigata University Research Ethics Review Committee (No. 2017-0123). Study 3: The purpose was to clarify the factors influencing the risk of aspiration pneumonia in patients admitted to a psychiatric hospital and to obtain suggestions for support aimed at its prevention. From July to December 2018, 100 patients who could take their meals in the ward cafeteria in a psychiatric hospital with approximately 400 patients in Prefecture A, were divided into a low risk group and a medium risk group on the basis of an aspiration pneumonia risk assessment and a statistical study was conducted. This study was carried out with the approval of the Niigata University Research Ethics Review Committee (No. 2018-0022). Ⅲ．Results and Discussion Study 1: Because of the lack of effective resources and since “aspiration pneumonia preventive care in a psychiatric ward involves particular problems,” psychiatric nurses have provided aspiration pneumonia prevention “care based on their eagerness to avoid the risk of pulmonary aspiration or suffocation happening before their eyes” using measures such as careful monitoring during meals (i.e. food, etc. “going down the wrong way”). On the other hand, since food is an important element of QOL for mentally ill patients who are hospitalized, they have been working on “prioritized QOL in terms of food.” In addition, as part of daily nursing care, they provided “everyday living support that they considered to be effective in preventing aspiration pneumonia.” Furthermore, in order to provide maximum care in a limited environment, they have adopted “team care that made the most of the strengths of psychiatric medical care.” It was suggested that to help patients eat, experience and knowledge of psychiatric nursing should be used in order to work on comprehensive assessment and care in collaboration with various hospital occupations. Study 2: NST members of the psychiatric hospital deal with prevention of the dysphagia associated with mentally ill people by “preventing them from swallowing down the wrong pipe” while taking in food orally, and adjusting meal patterns. Through nutritional management, which forms the lynchpin of NST activities, meal rounds, and “improvements in physical strength and nutritional status” represented by the transition to oral intake, as well as through scrupulous oral care, the NST members have endeavored to “avoid food going down the wrong way while nobody notices.” Those involved in “eating-related team care” were responsible for consultation with hospital staff and endeavored to perform their duties as medical professionals. The issues clarified were “difficulties in dealing with dysphagia” such as adjustment of meal settings and eating patterns, and assessment of and training in the swallowing function; and “difficulties in psychiatric NST activities” such as nutritional management, drug therapy, and occupational therapy. As a team approach to support eating, it seemed important to carry out flexible multidisciplinary collaboration that transcends the boundaries of departments and occupations while utilizing the original strengths of NST and the strengths of each specialty. Study 3: Hospitalization period, BMI, PEF, and RSST were factors that affected the risk of aspiration pneumonia in inpatients who were able to eat in the ward cafeteria of a psychiatric hospital. To support the prevention of aspiration pneumonia, it was suggested that assessment must be carried out while paying close attention to these values and that efforts were required to maintain and improve nutritional status, respiratory function, and swallowing function., 新大院博(保)甲第40号},
 school = {新潟大学, Niigata University},
 title = {精神科病院における誤嚥性肺炎予防のケアに関する研究},
 year = {}
}