糖尿病教育における看護師の教育スタイル自己評価ツールの開発 : 看護師が自己評価する実践の実態から証明する教育の特徴

取得学位 : 博士（保健学）, 学位授与番号 : 医博甲第1945号 , 学位授与年月日 : 平成20年3月22日, 学位授与大学 : 金沢大学, 審査結果の報告日 : 平成20年2月22日, 主査 :稲垣 美智子 , 副査 :泉 キヨ子, 塚崎 恵

糖尿病教育における看護師の教育スタイルの解明

【目的】糖尿病教育に携わる看護師が教育スタイルを自己評価する評定尺度を開発し、看護師の糖尿病教育スタイルの実態および教育スタイルと教育背景や実践現場の環境等との関連を明らかにする。【方法】金沢大学医学倫理審査会にて承認を得、糖尿病患者教育に携わっている全国の看護師を対象に、2005年7-9月にアンケート調査を行った。独自に作成した看護師の教育スタイル自己評価票(54項目)、対象者の背景および実践環境に関する質問票、一般性自己効力感尺度を用いデータ収集を行った。【結果および考察】分析可能なデータは1096であった。54項目の自己評価票の回答を因子分析した結果、20項目においてある程度の妥当性と信頼性を確認でき、「看護師の糖尿病教育スタイル自己評価ツール」を活用できる可能性が見出された。またK-means法によるクラスタ分析を行った結果、3つにクラスタ化され得点分布の特徴とグループ間の得点の相対的比較から、「深入りしないタイプ」「熱くのめりこむタイプ」「冷静で距離をおきつつ要はおさえるタイプ」と命名した。「熱くのめりこむ」「冷静で距離をおきつつ要はおさえる」をあわせた半数以上の看護師の教育スタイルはある程度安定していると考えられた。看護職種内や他職種との連携感など環境のとらえ方は「熱くのめりこむ」において最も肯定的で、「深入りしない」では最も肯定感が低かった。「深入りしないタイプ」は糖尿病看護経験は浅く糖尿病療養指導士有資格者は少なく、自己効力感が最も低く自信がないといった「熱くのめりこむタイプ」とは対照的であった。4割以上存在する「深入りしないタイプ」の看護師に対し、他のタイプへ変化させる教育を行うことによって糖尿病に携わる看護師全体の実践能力を向上させる可能性が考えられた。その介入方法として「看護師の糖尿病教育スタイル自己評価ツール」を活用できるよう、項目を精選し看護師への教育介入へ向け検討していく方向性が示された。This study was carried out for the purpose of developing a scale for the self-evaluation of teaching style by nurses involved in diabetes education, clarifying the status of the diabetes education styles of nurses, and examining the relationship among education styles, educational background and environment at the actual sites of education.A questionnaire survey was carried out targeting nurses implementing education for diabetes patients throughout Japan from July through September, 2005 after obtaining approval from the Kanazawa University medical ethics committee. Data was collected via a self-evaluation instrument (54 items) specifically designed for the education styles of nurses, a survey of background and practical environment of subjects, and a general self-efficacy scale.There were 1,096 items of analyzable data. As a result of the factor analysis of responses to the 54-items self-evaluation instrument, a certain degree of validity and reliability were observed in 20 items, sh owing the potential of utilization of the self-evaluation tool for the diabetes education styles of nurses. As a result of cluster analysis by the K-means method, data was clustered into 3 groups: namely, "the type of nurses who do not become very involved," "the type of nurses who get deeply involved," and "the type of nurses who teach important points calmly while keeping a good distance" according to the characteristics of score distribution and the relative comparison of scores among groups. The educational styles of more than half of the nurses combining "the type of nurses who get deeply involved" and "the type of nurses who teach important points calmly while keeping a good distance" were thought to be stable to some extent.There is believed to be potential for improvement of the practical ability of all nurses involved in diabetes patients by providing education to "the type of nurses who do not become very involved," a number which accounts for 40% or more of all nurses, that causes them to change to the other types of nurses. In order to do so, this study suggests the need to improve the items utilized in the self-evaluation tool for the diabetes education styles of nurses for educational intervention toward the nurses.研究課題/領域番号:16592141, 研究期間(年度):2004-2006出典：「糖尿病教育における看護師の教育スタイルの解明」研究成果報告書　課題番号16592141 (KAKEN：科学研究費助成事業データベース（国立情報学研究所）)　　　本文データは著者版報告書より作

2型糖尿病性腎不全患者の肯定感尺度

Purpose : The objectives of the present survey were set as follows : 1. To prepare a positivity scale for type-2 diabetic renal failure patients for the psychological construct of “Belated conviction of having worked hard to take care of oneself ” medical-care perception, which was a result reached inductively in the previous study. 2. To elucidate the relationships of the position on the positivity scale with QOL and duration of diabetic nephropathy treatment for type-2 diabetic renal failure patients. Methods : An interview- and questionnaire-based survey was carried out with 70 type-2 diabetes patients with renal failure． The answers to questions about 12 items relating to the psychological construct of the “I will overcome my regrets” medical-care perception were evaluated by factor analysis. The validity of the scale was tested using the GSES scale, and the correlation coefficient. With respect to the characteristics of the positivity scale, QOL is determined using the KDQOLSFTM1.3 scale, and its correlation with duration of diabetic nephropathy treatment is obtained using the correlation coefficient. Results : The outcome was that the three parameters that made up the scale in this research were factors, and were the same as the items in the previous qualitative research. Reliability was confirmed on the basis of the internal consistency of the three parameters. The concurrent validity was confirmed on the basis of significant correlation between the GSES scale and the positivity scale. Both the positivity scale and quality of life (QOL) showed significant positive correlations with the following parameters in the KDQOL-SFTM1.3 scale : social functioning, emotional wellbeing, general health perception, burden of kidney disease, and sleep. Discussion : The ability to hold the “Belated conviction of having worked hard to take care of oneself ” medical-care perception resulted in favorable QOL after introduction of dialysis. In addition, for high-level medical-care perception, it is necessary to recognize the condition as diabetic nephropathy, and to undergo treatment, for a significant period. 目的：帰納的に導き出した先行研究結果である、「遅ればせながらできるだけ頑張ったと納得する」療養認識の構成概念から糖尿病性腎不全患者の肯定感尺度を作成する。また、肯定感尺度とQOLおよび糖尿病性腎症療養期間との関係を明らかにする。方法：２型糖尿病性腎不全患者７０名に面接式質問紙調査を行った。質問は、【後悔を収め る】療養認識の構成概念１２項目であり、因子分析により、尺度とする３項目の構成を確認した。尺度の妥当性としてGSES尺度を用いて相関係数で検定した。療養認識の特徴は、QOLをKDQOL－SFTM１３. 尺度を用い、糖尿病性腎症療養期間との関係を相関係数を用いて導いた。結果：肯定感尺度とする３項目は、質的研究結果と同様の項目で因子となった。３項目の内的一貫性による信頼性（ ＝０７. ０）が確認された。また、自己効力感尺度と正の相関により併存妥当性があった。QOLについては、KDQOL－SFTM１３. 尺度において社会生活、心の健康、全体的健康感、腎疾患による負担、睡眠において有意な正の相関があった。糖尿病性腎症療養期間とも正の相関がみられた。考察：「遅ればせながらできるだけ頑張ったと納得する」という療養認識が低いよりも高いほうが透析導入後もQOLが良好である。また、その療養認識を高く持つには、糖尿病性腎症として認識して療養する期間が必要と言えた。Thesis of Matsui, Kiyoko / 松井 希代子 博士学位論文(金沢大学 / 大学院医薬保健学総合研究科

糖尿病ケアにおける看護師のソーシャルスキルおよび批判的思考態度の実態と糖尿病教育スタイルとの関係

本研究の目的は、糖尿病看護に携わっている看護師のソーシャルスキルおよび批判的思考 態度の実態と看護師の糖尿病教育スタイルとの関係を明らかにすることである。糖尿病教育 スタイルとは、糖尿病看護に携わっている看護師の患者教育における意識や行動の特徴であ り、3 つのスタイルで識別される。 糖尿病看護に携わっている看護師を対象に自記式質問紙調査を実施した。223 施設に質問 紙を送付し、返送された1115 名中、有効回答848 名（有効回答率76.0%）を分析対象とした。 基本属性、ソーシャルスキル9 下位尺度27 項目、批判的思考態度4 下位尺度33 項目、糖尿 病教育スタイル自己評価18 項目について調査した。 その結果、あてはまるとの回答が80% 以上だった項目は、ソーシャルスキルでは皆無で あり、批判的思考態度においてもわずか４項目であった。また、批判的思考態度においては、 年齢、糖尿病看護経験年数、CDEJ、糖尿病看護認定看護師と相関がみとめられた。しかしソー シャルスキルにおいて相関のみとめられたのは糖尿病看護経験年数のみであった。また、糖 尿病教育スタイルとこれら2 つのスキルとの相関においては、いずれも生活心情がみえてい るスタイルとの正の相関が最も高かったが、批判的思考態度の下位尺度「証拠の重視」にの み相関はみとめられなかった。 以上より、看護師のソーシャルスキルおよび批判的思考態度の自己評価は高いとはいえな いことが明らかになった。また、資格よりむしろ糖尿病看護経験年数がスキルの高さに関与 する可能性が示された。さらに、これら2 尺度の得点と最も相関が高かった生活心情がみえ ている教育スタイルがのぞましいことが確認された

血液透析治療を受ける 2 型糖尿病患者の「社会力」を測定するための新しい尺度

Purpose:When beginning dialysis treatment, patients with type ２ diabetes face a need to build new relationships, as support receivers, with the people close to them, who become support givers. Taking as our base “social competence”, i.e. the ability to connect with people and build society, we created a social competence scale for Japanese patients with type ２ diabetes receiving dialysis. This study tested the reliability and validity of the scale. Method:This is a cross-sectional study that focuses on Japanese　patients with type ２ diabetes receiving dialysis (n=１６３, males=１２１, females=４２). The mean age of the patients was ６５.１±１０.３ (range ４４-９１). The mean duration of dialysis was ６.０±４.７ years (range ０.５-２５). Our data were analyzed using exploratory factor analysis, criterion related validity, and reliability testing.Results:The final version of the social competence scale for patients with type ２ diabetes receiving dialysis was composed of ５ factors, with ３２ items. All ３２ items had a Cronbach’s α of ０.８９, with a total distribution of ４９.０５%. The scale showed a significant correlation with KiSS-１８.Conclusion:This study suggests that a social competence scale for Japanese patients with type ２ diabetes receiving dialysis may be used as an essential tool for nurses in assessing the relationships between patients and those close to them. Also, by clarifying the constituent factors of social competence in patients with type ２ diabetes receiving dialysis, the study enables nurses to develop education programs for patients to cultivate their social competence. The study therefore facilitates the provision of better care in practical clinical care settings

CPAP 使用者のアドヒアランスの性質分けの試み〜「使用率」と「使用日の平均使用時間」による4 群比較〜

[Aim] The definition of good adherence to continuous positive airway pressure (CPAP)therapy for obstructive sleep apnea syndrome (OSA) is a utilization rate of ≥70% and amean usage time on usage days of ≥ 4 hours, and users who deviate from this definitionare regarded as having poor adherence. Personalized guidance is required to improve theadherence of users with poor adherence. Hence, a more detailed classification is neededrather than simply classifying users as having poor and good adherence. Thus, this studyaimed to clarify the significance of classification of adherence into four groups based onthe two indices of utilization rate (%) and mean usage time (hours).[Method] This study examined CPAP users at the CPAP specialist outpatient departmentfrom October to November 2016. In total, 535 patients were included, and informationon CPAP adherence, physical data at initial consultation, and data on motivation forconsultation were collected. The survey period was set as 2 months. The CPAP userswere divided into four groups, and a 4-group comparison was conducted on factors thataffect adherence, using the χ ² test, the Kruskal-Wallis test, and the pairwise method.The utilization rate was set as the vertical axis and the mean usage time on usage dayswas set as the horizontal axis to create a scatter plot. The four segments were created byintersecting the axes with the values of “70%” and “4 hours”, with the top right set asthe good adherence group “≥70%/≥ 4 hours”; moving counterclockwise, the next segmentswere set as the insufficient adherence time group “≥70%/<4 hours,” poor adherence group“≤70%/<4 hours,” and insufficient adherence days group “<70%, ≥ 4 hours.”[Results] The good adherence group (n=393) accounted for 70% of users; the remaining30%, conventionally classified together as users with poor adherence, were distributed intoinsufficient adherence time group (n=31), poor adherence group (n=49), and insufficientadherence days group (n=62). No significant differences in sex or residual AHI wereobserved, but significant difference was observed in age, usage history, and BMI betweenthe good adherence group and poor adherence group. The percentage of patients withhypertension was significantly different between the good adherence group and insufficientadherence days group. There was a significant difference in the percentage of patientswho sought consultation due to subjective symptoms between the insufficient adherencedays group and insufficient adherence time group. The percentage of patients who soughtconsultation due to a recommendation by a company medical checkup showed a significantdifference between the good adherence group and insufficient adherence days group.[Conclusion] These results suggest that adherence can be divided into four groups basedon utilization rate and mean usage time on usage days, and that these classifications maybe helpful for constructing a guidance management system that emphasizes personalizedguidance systems

２ 型糖尿病患者における医療者との関係構築スキル尺度の開発および信頼性と妥当性の評価

Background and Purpose: To prevent interruption of diabetic care, it is necessary for patients with type 2 diabetes mellitus (T2DM) to build good relationships with medical staff. It is important that both patients with T2DM and medical staff strive for the common goal of good diabetes control. Therefore, measures capable of considering more concrete skills specific to patients with T2DM than the existing scale are required. Here, a skill scale for patients with type 2 diabetes mellitus to build relationships with medical staff was developed, and its reliability and validity were verified.　Methods: As a theoretical framework for our scale, we used the 50-item list of social skills for adolescents created by Goldstein et al. We created 76 items based on a previous study, interviews with nurses specializing in diabetes care, and our own clinical experiences. The content validity and surface validity were verified, and we carefully selected 56 items for use in the scale. All items were evaluated using a 5-point Likert scale. Valid responses to the questionnaire were obtained from 262 Japanese patients with T2DM. Exploratory factor analysis was performed to verify the construct validity. The 18-item Kikuchi Scale of Social Skills (KiSS-18) was used to investigate the criterion-related validity. The content validity index (CVI) was used to assess of content validity. The skill scale scores between the continuous diabetes care group and those with a history of diabetes care interruption were compared to determine the known-groups validity. Cronbach’s alpha, item-total correlations, and good-poor analysis were used to determine the internal consistency of the scale.　Results: Our scale contained four factors and 36 items based on exploratory factor analysis: “problem-solving skills” (Factor 1), “coping skills” (Factor 2), “communication skills” (Factor 3), and “feelings-consciousness skills” (Factor 4). The four factors of this scale together had a cumulative contribution ratio of 56.12%, and construct validity was confirmed. The correlation coefficient with KiSS-18 was r = 0.590, and was significant (p < 0.01). The item-level content validity indexes ( I-CVIs) of the scale were 0.80 – 1.00, the scale-level content validity index ( S-CVI/Ave) was 0.95: CVI exceeded the standard. The total score of the scale was significantly lower for patients with a history of diabetes care interruption (p < 0.01). The Cronbach’s alpha coefficient of the four factors for the 36 items was 0.960, while that of the factors was 0.791 – 0.960. Item-total correlation analysis indicated that all items were significantly correlated (r = 0.313 – 0.798, p < 0.01), and good-poor analysis indicated that all items showed a significant difference (p < 0.001).　Conclusions: This study confirmed the reliability and validity of a new scale for patients with T2DM in Japan. This scale could be useful to support patients with T2DM.背景・目的：糖尿病の通院中断予防には、患者と医療者が良好な関係を築けるようなスキルを高めることが必要である。 2 型糖尿病患者と医療者は良好な糖尿病コントロールの維持を共通目標とし、両者の努力が重要である。これより、 2 型糖尿病患者には既存尺度よりも特有で具体的なスキルを考慮した尺度が必要と考えた。本研究は 2 型糖尿病患者における医療者との関係構築スキル尺度を開発し、信頼性と妥当性を検証することを目的とした。　方法：本尺度の理論的枠組みには、ゴールドステインらの作成した若者のための社会的スキルを用いた。先行研究、糖尿病看護に携わる看護師への面接、研究者の臨床経験を基に 76 項目を作成した。その後、内容妥当性と表面妥当性を検証し、原案 56 項目を作成した。全項目は 5 段階のリッカート尺度で評価した。日本の 2 型糖尿病患者 262 名の有効回答を得た。データは探索的因子分析を行った。妥当性の検討として、基準関連妥当性はKiSS-18、内容妥当性は内容妥当性指標 (CVI) を用い、既知集団妥当性は通院中断経験の有無と尺度得点の比較を行った。信頼性の検討はクロンバックα、I-T 相関分析、G-P 分析を行った。結果：探索的因子分析により 4 因子 36 項目を抽出した。 4 因子は、「問題解決スキル」、「対処スキル」、「コミュニケーションスキル」、「感情自覚スキル」と命名した。本尺度の累積寄与率は56.12%であった。KiSS-18との相関係数は0.590と有意な相関であった（p < 0.01）。 CVI は各項目 0.80 〜 1.00、尺度全体 0.95 と基準を上回っていた。通院中断経験者は尺度総得点が有意に低かった（p < 0.01）。尺度全体のクロンバックα係数は 0.960 であった。全項目において、I-T 相関分析は有意な相関であり (r = 0.313 〜 0.798, p < 0.01)、G-P 分析では有意差が得られた（p < 0.001）。　結論：本研究は日本の 2 型糖尿病を持つ患者において信頼性と妥当性のある尺度と確認できた

初期教育時における2 型糖尿病患者の療養心構え評価尺度の開発

Education for patients with newly diagnosed type 2 diabetes is important because it canhelp to reduce the risks of complications by encouraging strict blood glucose control fromthe earliest stages of the disease. In education for newly diagnosed type 2 diabetes, it isimportant for patients to develop a deep understanding of having diabetes along with anattitude toward preparing for medical treatment. Moreover, an index is needed to evaluatewhether patients receiving such education after diagnosis are properly prepared for life asa diabetes patient. This study was performed to develop a scale for evaluating recuperationattitude at the time of education for patients with newly diagnosed type 2 diabetes.Twenty-four items were created for the draft scale by referring to previous research andHerzberg’s motivation-hygiene theory, which was then administered to 174 patients withtype 2 diabetes. Exploratory factor analysis yielded four factors with 16 items: undertakingrecuperation as a diabetes patient (Factor 1), looking back on a poor diet and trying tofix it (Factor 2), trying to study diabetes comprehensively (Factor 3), doing what can bedone now (Factor 4). The cumulative contribution of these factors before rotation was65.58%, indicating good construct validity. Significant and positive correlations were foundbetween this scale and the Self-Efficacy Scale for Diabetes Self-care and the JapaneseTranslated “The Summary of Diabetes Self-Care Activities Measure”; thus, the criterionrelatedvalidity was secured. The average item-level content validity index (S-CVI/Ave)was 0.90, indicating good content validity. Finally, the internal consistency was securedwith a Cronbach’s α coefficient of 0.86. Overall, the reliability and validity of this scalewere confirmed. This scale can be used to evaluate recuperation attitude at the time ofeducation for patients with newly diagnosed type 2 diabetes

成人２ 型糖尿病患者の類型化した信頼の様相と病気の不確かさの認知およびセルフケア行動の関連

Purpose: This study was performed to quantitatively verify the relationships among the“trust state” of patients with type 2 diabetes, recognition of disease uncertainty, and selfcarebehavior.Method: The present study based on Mishel’s theory of uncertainty in illness had a crosssectionalsurvey design. A questionnaire was developed to identify the state of trust. Thestudy population consisted of adults with type 2 diabetes. A total of 204 questionnaireswere distributed, and 125 completed questionnaires were recovered (response rate 61%).Participants had an average age of 53.6 (SD 9.6) years and included 71 men (62.8%) and42 women (37.2%). State of trust, awareness of disease uncertainty, and self-care behaviorwere evaluated using the questionnaire. To classify the state of trust, the factor structurewas confirmed by exploratory factor analysis of the state-of-trust questionnaire. One-wayanalysis of variance and multiple comparisons were used to examine each relationship.Results: The number of items in the state of trust questionnaire was changed from tento six. As a result of the promax rotation of the main factor method, the following threefactors were extracted: “wants compatible doctors,” “trusts doctor easily,” and “receivemedical care at one’s own convenience.” Cluster analysis using factor scores of six itemsand three subscales from the state of trust questionnaire created four clusters. Thenumbers of participants per cluster were as follows: cluster 1 (high scores for “wantscompatible doctors” and “trusts doctors easily”), 22 (19%); cluster 2 (low scores for“wants compatible doctors,” “trusts doctors easily,” and “receive medical care at one’sown convenience”), 18 (16%); cluster 3, (low score for “wants compatible doctors,” butnot for “trusts doctors easily”), 21 (19%); cluster 4 (lower score for “trusts doctors easily”than “wants compatible doctors”), 52 (46%). For each of the four clusters for the state oftrust, the mean total score of uncertainty in illness perception was not equally distributed.Therefore, Welch’s test was performed, which revealed significant differences in self-carebehavior and meals between clusters 1 and 4 (p < 0.0001).Conclusion: The high rate of meals in cluster 1 suggested that creating a state of trust, i.e.,“wants compatible doctors” and “trusts doctors easily,” is important in nursing. Educationfor diabetes patients should consider their state of trust