재가장기요양기관 방문간호사의 방문간호 체험

Abstract

노인장기요양보험 재가급여 중 유일한 의료서비스인 방문간호는 간호사가 방문간호지시서에 따라 대상자의 가정을 방문하여 간호, 진료보조, 요양에 관한 상담 등을 제공함으로써 간호의 영역을 확장하는 계기가 되었다. 본 연구는 재가장기요양기관 방문간호사의 방문간호 체험의 의미와 본질을 탐구하기 위해 van Manen의 해석학적 현상학 연구방법론을 적용하였다. 연구 참여자는 방문간호 경력 1년 이상인 10명의 방문간호사들로 목적적 표집과 편의 표집, 눈덩이식 표집 방법을 통해 선정하였다. 자료 수집은 2017년 1월 7일부터 2018년 10월 12일까지 진행되었으며, 연구 참여자와의 면담은 방문간호 체험에 대한 새로운 진술이 더 이상 나오지 않는 포화시점에 이르기까지 총 23회에 걸쳐 이루어졌다. 자료 분석은 van Manen이 제시한 해석학적 현상학 방법론에 근거를 두고 전체론적(holistic) 방법과, 선택적(selective) 방법, 그리고 세분법(detailed)을 사용하였다. 연구 결과, 재가장기요양기관 방문간호사의 방문간호 체험은 8개의 본질적 주제와 27개의 하위주제로 도출되었다. 본질적 주제는 ‘대상자 및 보호자와 의 소통에 힘씀’,‘간호에 협조적이지 않은 보호자를 대하며 마음 고생함’,‘주도적으로 대상자 간호를 계획하고 수행함’,‘축적된 간호지식과 기술을 대상자 간호에 쏟아 부음’,‘효과적인 간호수행을 위해 다양한 인적자원과 협력함’,‘방문간호를 수행함에 있어 제도적 한계를 실감함’,‘내 환자라는 책임감을 가지고 의료인으로서의 소명을 다함’,‘방문간호사로서 보람을 느끼며 오래도록 일하고자 함’이다. 연구 참여자들은 대상자 및 보호자와의 소통과 신뢰를 바탕으로 대상자 중심으로 간호를 수행하였고, ‘내 환자’라는 책임감에서 모든 간호지식과 기술을 대상자 간호에 쏟아 부었다. 그러나 참여자들은 제한된 간호시간, 불합리한 수가체계 등의 제도적 한계로 원하는 만큼의 간호를 제공하기 어려웠고, 간호에 협조적이지 않은 보호자로 인해 어려움을 겪기도 하였다. 그럼에도 불구하고 대상자의 건강상태가 호전되는 모습에, 대상자 및 보호자가 보내는 지지 및 감사에 방문간호사로서의 보람을 느끼며 방문간호사의 길을 오래도록 가겠다고 다짐하였다. 본 연구는 재가장기요양기관 방문간호사의 방문간호 체험을 해석학적 현상학 연구방법을 적용하여 보다 생생하고 깊이 있게 탐구하였다는데 의의가 있다. 본 연구결과는 방문간호사에 대한 이해의 폭을 넓히고 방문간호사의 실무능력 및 업무 만족도 향상을 위한 구체적 방안을 마련하는 데 기초자료로 활용될 수 있을 것이다.;South Korea has implemented long-term care insurance beginning in July 2008 to satisfy the new welfare demands generated by social changes such as the aging population and nuclearization of the family. Home-visiting nursing, the only medical service among the in-home benefits of long-term care insurance, refers to visits by long-term care providers such as nurses to the homes of beneficiaries to provide nursing assistance in medical treatment, convalescence counseling, or oral hygiene according to the instructions of physicians, dentists, or Korean medical doctors. Home-visiting nursing became an opportunity to increase the professionalism of nurses and expand the scope of nursing by extending nursing, which has been mostly performed in hospitals, to patients’ own homes. Home-visiting nursing was also found to be helpful for the management of physical and mental health of the elderly individuals who have limited accessibility to medical facilities due to the distances or the diseases that make them bedridden, reduce the stress of the primary caregiver and family, and contribute to the reduction in medical expenses and hospitalization rates in the case of long-term use. The present study used van Manen’s hermeneutic phenomenological approach to investigate the meaning and nature of the nursing of visiting nurses of home-based long-term care service centers. A total of 10 home-visiting nurses working in Seoul and Gyeonggi-do Province for one year or more were recruited through purposive and snowball sampling and participated in the present study. Data collection was conducted from January 7, 2017 to October 12, 2018. A total of 23 in-depth face-to-face interviews with 10 participants were conducted until the saturation point at which there was no new information on their nursing experience. Data analysis was performed using holistic, selective, and detailed methods based on the hermeneutic phenomenological approach suggested by van Manen (2014). The analysis resulted 8 essential themes and 27 themes as the lived experience of visiting nurses of home-based long-term care service centers. The 8 essential themes were as follows: (1) Making efforts to interact with the patients and their caretakers; (2) Nurses having difficulty in interactions with uncooperative caretakers; (3) Planning and performing autonomously nursing centered on the patient; (4) Nursing patients utilizing all nursing knowledge and skills accumulated through nursing experiences; (5) Cooperating with various community human resources for effectively caring for patients; (6) Realizing the limitations of the support system in performing work as a visiting nurse; (7) Following the calling of medical personnel by taking responsibility for 'my patient'; (8) Pledging oneself to career-long work, feeling reward as a visiting nurse.' The participants were building relationships of trust as they were empathizing with patients' pain and communicating with patients and their guardians. Also, with the realization of the need for educating the guardians and caregivers regarding the continuity of nursing, the nurses were devoting themselves to their education. The participants derived achievement motivation from the fact that they could provide self-directed nursing according to their autonomous judgment while they continuously studied to cope with various types of diseases. Furthermore, they made efforts to establish cooperative relationships at the local level to efficiently support the patients. The participants experienced various types of difficulties during their home-visiting nursing while facing the reality of in-home benefits, which is biased toward home-visit care. Above all, it was at times difficult to use high-quality treatment material and perform nursing care under a tight schedule because nursing had to be provided within a set time and the medical insurance benefits. In addition, patients and their guardians sometimes misunderstood that nurses were pursuing their interests only, and uncooperative behaviors of guardians often created difficulties for the nurses. The participants were, however, aware of their role as the only health care provider covered by the in-home benefits of the long-term care insurance, and they made their best efforts to fulfill the responsibilities with a sense of accountability towards their own patients. They tried to assess patients’ health status and provide customized nursing services accordingly based on their long clinical experience and expertise. They also made efforts to manage patients’ health so that patients could maintain their current health at home without visiting hospitals or facilities. They were proud that their patients’ health improved, and the support of patients and guardians expressing gratitude for their nursing services was rewarding for them and thus the participants wanted to continue home-visiting nursing. In conclusion, the present study has its significance in helping to understanding the role and importance of visiting nurses of long term care insurance through an in-depth investigation of the nursing experience of visiting nurses of home-based long-term care service centers. The findings of the present study may contribute to the preparation of measures to improve the clinical competence and job satisfaction of visiting nurses by examining issues and difficulties experienced at visiting nursing sites. It may also contribute to the preparation of practical measures to improve the quality of home-visiting nursing by broadening its understanding and recognition.