初期情報収集とその活用方法の検証

Evaluation of the Methods Used to Collect and Apply Initial Information

　筆者らは，看護師が行う初期アセスメント段階における情報収集場面を調査し，看護師が収集した情報の意味とその活用方法について考察した．筆者らは，看護師が患者の入院後24時間以内に行う情報収集場面に同行し，非参加型観察法で観察しフィールドノートを作成した．また看護師に，情報収集の経過について半構造的面接法で面接した．そして，フィールドノートと面接内容を合わせて逐語記録を作成し，帰納的な分析を行った．実務経験4年以上の看護師5名が，それぞれの患者6名に行った情報収集の過程で繰り返し出てくるパターンには，「第一印象検証型情報収集過程」，「納得型情報収集過程」，そして「収集項目順守型情報収集過程」があった．また，看護師の情報収集に対する姿勢は「看護診断を導く」という目的限定型であり，「情報を何に，どう生かそう」という多角的視点をもたない援助者主導型であった．

　Conditions under which nurses collect information during their initial assessments were investigated. In addition, the significance and application of the information collected were evaluated. Researchers accompanied nurses while they collected information within 24 hours of patient admission. Researchers used a non-participatory observation method and detailed field notes, and interviewed nurses about the process of information collection using a semi-structured interview. Based on field notes and interview outcomes, a transcript was created, and inductive analysis was performed. Five nurses, each with more than four years working experience, collected information from six patients. Repeatedly observed patterns during the information collection process included “impression-based information collection”, “satisfaction-based information collection”and “questionnaire-based information collection”. The attitude of nurses toward information collection could be classified as a limited-objective type, which lacks diversified views about the purpose and application of the information.