Kawasaki Yuko, Nii Manab, Nishioka Eina
College of Nursing Art and Science, University of Hyogo, Hyogo, Japan.
Department of Electronics and Computer Science, University of Hyogo, Hyogo, Japan.
Healthc Inform Res. 2024 Oct;30(4):364-374. doi: 10.4258/hir.2024.30.4.364. Epub 2024 Oct 31.
This study was performed to examine the content of decision-making support and patient responses, as documented in the nursing records of individuals with cancer. These patients had received outpatient treatment at hospitals that met government requirements for providing specialized cancer care.
Nursing records from the electronic medical record system (in the subjective, objective, assessment, and plan [SOAP] format), along with data from interviews, were extracted for patients receiving outpatient care at the Department of Internal Medicine and Palliative Care and the Department of Breast Oncology. Data analysis involved simple tabulation and text mining, utilizing KH Coder version 3.beta.07d.
The study included 42 patients from palliative care internal medicine and 60 from breast oncology, with mean ages of 70.5 ± 12.2 and 55.8 ± 12.2 years, respectively. Decisions most frequently regarded palliative care unit admission (25 cases) and genetic testing (24 cases). The assessment category covered keywords including (1) "pain," "treatment," "future," "recuperation," and "home," as terms related to palliative care and internal medicine, as well as (2) "treatment," "relief," and "genetics" as terms related to breast oncology. The plan category incorporated keywords such as (1) "treatment," "relaxation," and "visit" and (2) "explanation," "confirmation," and "conveyance."
Nurses appear crucial in evaluating patients' symptoms and treatment paths during the decision-making support process, helping them make informed choices about future treatments, care settings, and genetic testing. However, when patients cannot make a decision solely based on the information provided, clinicians must address complex psychological concepts such as disease progression and the potential genetic impact on their children. Further detailed observational studies of nurses' responses to patients' psychological reactions are warranted.
本研究旨在检查癌症患者护理记录中记录的决策支持内容和患者反应。这些患者在符合政府提供专门癌症护理要求的医院接受了门诊治疗。
从电子病历系统中提取以主观、客观、评估和计划（SOAP）格式记录的护理记录，以及来自访谈的数据，这些数据来自内科与姑息治疗科以及乳腺肿瘤学部门接受门诊护理的患者。数据分析包括简单列表和文本挖掘，使用KH Coder 3.beta.07d版本。
该研究包括42名来自姑息治疗内科的患者和60名来自乳腺肿瘤学的患者，平均年龄分别为70.5±12.2岁和55.8±12.2岁。最常做出的决策涉及姑息治疗病房入院（25例）和基因检测（24例）。评估类别涵盖的关键词包括：（1）与姑息治疗和内科相关的“疼痛”“治疗”“未来”“康复”和“家庭”等术语，以及（2）与乳腺肿瘤学相关的“治疗”“缓解”和“遗传学”等术语。计划类别包含的关键词如：（1）“治疗”“放松”和“就诊”，以及（2）“解释”“确认”和“传达”。
在决策支持过程中，护士在评估患者症状和治疗路径方面似乎至关重要，帮助他们就未来治疗、护理环境和基因检测做出明智选择。然而，当患者无法仅根据提供的信息做出决策时，临床医生必须处理诸如疾病进展以及对其子女潜在的基因影响等复杂的心理概念。有必要对护士对患者心理反应的应对进行进一步详细的观察性研究。
