看護記録の認知に関する発話分析―「看護記録の教育」に向けた内容の検討

A Protocol Analysis of Cognitive Aspects in the Production of Nursing Record in Search of a Metacognitive Teaching Method

要旨

　本研究は，看護過程での思考の証しともいえる看護記録を取り上げ「看護記録の教育」のあり方について検討するため，認知心理学の知見と関連づけながら，次の3点を明らかにすることを目的とした．

（1）看護記録の認知に関する概念構成を提案する．（2）看護学生と看護婦の看護記録に関する認知を（1）に基づき比較検討することで，記録の認知に影響を及ぼしている要因と，記録の認知に関する問題点を指摘する．（3）（2）の結果より，看護教育への示唆を明らかにする．

　調査1では，グループインタビューを実施し，看護学生18名と看護婦12名を対象に，看護記録に関する発話内容を，記録の認知に関する概念カテゴリーにそって分析した．その結果，看護記録の認知に影響を及ぼしている3つの要因が明らかとなった：（1）情報伝達の認識，（2）メタ認知の働き，（3）記録様式のもつ問題点，である．

　調査2では，個人インタビューを実施し，看護学生4名を対象に，個性を記述することによって分析した．その結果，臨床実習記録の認知に関する3つの問題点が明らかとなった：

（1）記録の意義の理解，（2）自己内対話型の認知，（3）読み手の分析，である．

　これらの結果から，看護教育への示唆として，記録をモニターし看護過程を内省するメタ認知能力を高めるためには，情報伝達の必要性を学生に十分に認識させた上で読み手を分析的に捉える力を育成していくことが重要であることを指摘した．

Abstract

　This study proposes a teaching method for writing a nursing record based on findings in cognitive psychology. In the discussion ; (1) we clarified how the concept of cognition could be conceptualized in a nursing record, (2) we attempted to identify factors that might influence a nursing record and thus locate problems that might occur in the cognitive process of writing a nursing record, (3) we investigated how to teach writing a nursing record.

　In the first research, 18 nursing students and 12 nurses were selected as subjects and grouped into focus groups for interview. The obtained data were analyzed. The results of the analysis revealed the following three influential factors in the cognitive process of writing a nursing record ; (1) communicating and sharing information with its reader, (2) what may be called “matacognitive activities”, (3) external problems caused by the writing format.

　In the second research, 4 nursing students were selected and interviewed individually. The obtained data were analyzed qualitatively. We found from the data that there are three types of problems in recording during their clinical practicum ; (1) problems caused in the process of understanding what the record actually means, (2) problems caused in the internal dialectical process, (3) problems caused in the recognition or comprehension of the record on the part of the reader.

　As a conclusion, it is necessary to promote “metacognition” through reflection and monitoring. To effectively communicate through a nursing record, it is important to recognize how the reader of a nursing record may comprehend the record before the writer composes it.