助産実践を記録する判断理由や状況に関する探索研究

Exploration for Reasons and Situations for Recording Midwifery Practice

要旨

　目的：本研究では、分娩担当の助産師が何を記録する、またはしないのか、その判断理由や記録するに至った状況を探ることを目的とした。

　方法：対象者は、正常分娩介助を担当した助産師11名である。データ収集は、担当した産婦の分娩第1期から第4期までの助産実践の内容のうち何を記録に残し、何は記録しないか、その記録の要否を決めさせる理由と実践場面や状況等について半構成的面接法を行った。そして、Berelsonの内容分析の方法に基づき分析を行った。

　結果：実践内容を記録する理由や状況は【助産師の役割・責務遂行】【実践結果に対する満足度やインパクト】等の6カテゴリに集約された。実践内容を記録しない理由・状況は、【他の助産師との認識の共通性】【同時に行われた複数の実践内容】等の3カテゴリに集約された。

　結論：助産師が記録に残した理由・状況では、ケアや処置等の対象に変化や効果がみられた実践等であった。逆に実践しても記録しなかったのは、助産師間で当然と考える実践内容、一つのケア等に副次的に生じた実践であった。

Abstract

　Purpose: In this study, the authors aim at, for what midwives in charge of delivery record and do not record, exploring reasons for their judgment and situations that lead to the recording action.

　Method: The subjects for this study were 11 midwives in charge of assisting normal delivery of babies. For data acquisition, we performed semi-structured interview for reasons for which they decided the necessity for the records and practice scenes or situations, among midwifery practice contents from the first to the forth delivery periods of the midwives in charge.

　Result: Reasons for and situations of recording the practice content were categorized into six items such as [Fulfilling role and duty of an midwife], [Satisfaction and impact for the practice result] and so on. Reasons for and situations of not recording the practice content were categorized into three items such as [Commonality in cognition with other midwives], [Plural practice contents performed at the same time] and so on.

　Conclusion: Reasons for and situations of recording the practice content were from practice in which changes and effects were seen in the subjects for care or treatment. On the other hand, reasons for and situations of not recording the practice content are from practice content that is regarded as matter-of-course actions by midwives and that occurred subsidiary with one care.