護生對個案報告之認知、態度及其書寫滿意度之研究

個案報告(Case Report)是護理病人之經驗報告，不論是體生實習或臨床N3護理人員，均須撰寫個案報告，以呈現照護病人之經驗能力。個案報告之進行過程包含了：選擇病人、查證文獻、收集資科、執行護理措施及資料分析。本研究對象為對中部某學院護理科五專部五年級全體學生，學生均己修過個案報告習作及臨床實習之學分，利用全體學生集會時，先給予說明問卷之目的及填寫注意事項，採立意取樣並賦予問卷調查。所收集之資料經檢視處理後即進行編碼登錄，輸入電腦後予以分析統計，使用方法包括平均值、標準差、百分比、單因子變異數分析( One way ANOVA)等。經統計得知，護主在個案報告的認知上，以參考資料格式及文獻考查之整理組織答對率最高，護理計劃評值答對率最低，全部內容之答對率為71.96%；遇到困難時最常與護士討論的31.3%；最少與老師討論；護生書寫個案報告收穫最多為內科；在個案報告書寫態度方面，自我要求越高、書寫過程是越容易及書寫後成就感越高者，其書寫滿意度越高，學生認為書寫個案報告可學習許多專業知識，並藉由資料的搜集，對個案的觀查照顧會更好；個案報告書寫後之滿意度方面，個性越趨向內控者，且書寫過程困難度越低，其書寫滿意度越高。據此統計研究之重要結論，應可提供相關醫療機構、護理學校及實習指導老師，在考量護生實習期間對個案報告書寫輔導之指引。

關鍵字

個案報告；認知；態度；滿意度

並列摘要

The purpose of this study was to investigate nursing students'cognition attitude and satisfied degree about case report writing.Cognition ,attitude and satisfied degree scales were used as the investigating tool. Purposive sampling data was collected through interview. The findings showed that the percentage of the cognition right answers was 71.96%. This study revealed the following findings : the person who like to discuss was clinical nurse. The more difficulty course to write was psychiatric nursing and gain more was medical nursing.The more internal direction of locus control and feel easy writing ,the more satisfied of her case report. The results could be a reference for the department of medical treatment , nurse school and the clinical instructor establishing standard guideline and promote nursing students in case report writing. Writing case report can learn more professional knowledge and take good care to client.