The research on the establishment of community care system in remote areas for elderly people promoting health and not requiring long-term care

本研究的目的是通过在两个偏远地区(A：农村、人口减少和大雪地区，B：A：海岛)的行动研究，确定护士在偏远地区为促进健康且不需要长期护理的老年人建立社区护理体系的作用和方法。他们是在边远地区医疗辅助医院工作的护士，在边远地区诊所工作的护士，以及市政公共卫生护士。研究人员和护士继续召开会议，研究解决老年人问题的方法，并实践护理活动。研究结果表明：1.支持边远地区老年人认识到健康促进和预防的重要性，管理健康状况，保持独立性的必要性变得明显。此外，老年人在获得A区各种服务方面需要支持。一个制度的问题是，它是一项因资源短缺而难以使用的服务，以及现有资源因护士短缺而无法发挥作用。在B区，密集的人际关系对前者产生了影响。诊所护士和公共卫生护士合作的重要性变得显而易见。为了加强他们的合作，在海关举行了一次会议是有效的。护士的角色是为需要健康管理的病人提供预防性支持。公共卫生护士的作用是制定以必要的最低限度的资源提供卫生服务的方法，利用互助力量，促进对老年人的非正式支持的功能。医院护士的角色是支持出院，让老年人可以住在家里。

The purpose of this study was to identify role and approach of nurses which establish the community care system in remote areas for the elderly promoting health and not requiring long-term care by action research in two remote area (A : a rural, depopulation and heavy snowfall area, B : a island). They were the nurses who works in the support hospital for medical care in remote areas, the nurses who works at a clinic in remote areas, and municipality public health nurses. Researchers and nurses continued holding a meeting, considered the approach which solves the problem of the elderly, and practiced nursing activities. This was accomplished by analyzing description of the process.The findings showed :1. The necessity of supporting the elderly who live in remote areas to recognize the importance of health promotion and prevention, to manage health condition, and to maintain independence became clear. In addition, the elderly needed the support for accessing to various service in A area.2. The problems of a system were that it is the service which is hard to use by shortage of resources, and that the present resources are not functioning by the shortage of nurses. In B area, dense human relations had influenced the former.3. The importance of cooperation of a clinic nurse and a public health nurse became clear. In order to strengthen their cooperation, it was effective to have held a meeting in custom.4. A nurse's role is preventive support to the patient who needs health management. A public health nurse's roles are to devise the approach to provide health services by necessary minimum resources, to utilize mutual help power, and to facilitate the function of informal support for elderly people. A hospital nurse's role is supporting discharge so that elderly people's can live at home.