こころのケア場面における臨床判断の構造と特性

Structure and Characteristics of Clinical Judgment in Psychosocial Nursing Care

はじめに

　看護者が用いる技術のうち，こころのケア技術に関しては心理学の諸知識が紹介されてはいるものの，医療補助技術や生活行動援助技術に比べて，看護独自の技，知識としてはまだ未熟な開発段階と言わざるをえない。萱間（1991）や上泉（1994），菅原（1993），添田（1994）らは，周辺学問から借用した知識の適用ではなく，実際の臨床の場から実践的知識やケア技術を明らかにしようと試みている。これらはそれぞれ異なる臨床領域からの結果であるが，共通して言えることは，看護者の行なうこころのケアは，意図的に場を設定して行なうというよりも，むしろ，日常的に診療の補助や生活行動の援助をしながら行なわれているところに特徴があるということである。したがって，どのような看護場面にもこころのケアは内包されていると言えるだろう。

　しかしながら，逆に“診療の補助や生活行動の援助をしながら”という特徴が看護者の行なうこころのケアを見えにくくさせており，技の洗練や教育，適正な報酬などを困難にしている。ともすれば，看護者自身さえも，日常的に行なっている看護行為とこころのケアを分離してとらえていることがあり，こころのケアをしているとは意識化しにくい状況を作り出している。

　The purpose of this study was to identify the structure and characteristics of clinical judgment in psychosocial nursing care.

　In this study, an inductive qualitative approach was used. Subjects were a convenient sample of nurses who have more than 5 yearse xperience and agreed to participate in this research. Data was collected through semistructured interviews. Data was recorded on a tape and transcribed, then analyzed based on Grounded Theory Approach.

　Subjects: the number of subjects were consisted of 38 nurses. The average age and duration of clinical experience was 36.6 years old and 12.6 years. Result: three constructions of clinical judgment were extracted; 1)judgment content, 2)judgment criteria, and 3)monitoring.

　Nurses made clinical judgments on information input. This input was processed as the content of clinical judgment and also two dimensions; judgment related to care situations and to care planning. Judgment related to the care situation included the following content; emotional condition, illness trajectory, activity of daily living, social support and predictability of future conditions. Judgment related to care planning included the following content; potential strength (power) among the patient, nurses, and the nursing team; the relationship between the patient and nurses and between the patient and the nursing team; strategyand direction of care.

　The second construction of clinical judgment was criteria. Nurses made clinical judgments according to the 4 criteria which were professional knowledge, past experience, patient characteristics, and personal experience.

　The third construction of clinical judgment was monitoring. This means reliable clinical judgment requires monitoring and feedback.

　Three types of clinical judgment among nurses were identified; flexible type, progressive type, intuitional type and protocol type.

　Discussion: The dynamics and characteristics of clinical judgment were discussed to promote ability of clinical judgment among nurses. This study propose a model of clinical judgment in psychosocial nursing care setting.