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系統識別號 U0026-2207201401014800
論文名稱(中文) 護理人員面對「生命末期」癌症病人照顧之態度與行為
論文名稱(英文) Nurses’ attitudes and behavior toward end-of-life care for terminally ill cancer patients
校院名稱 成功大學
系所名稱(中) 護理學系
系所名稱(英) Department of Nursing
學年度 102
學期 2
出版年 103
研究生(中文) 林承霈
研究生(英文) Cheng-Pei Lin
學號 t26004029
學位類別 碩士
語文別 中文
論文頁數 163頁
口試委員 指導教授-趙可式
口試委員-馮瑞鶯
召集委員-顏家瑞
中文關鍵字 態度與行為  護理人員  癌症末期病人  生命末期照護 
英文關鍵字 attitudes and behavior  nurses  terminally ill cancer patients  end-of life care 
學科別分類
中文摘要 背景:惡性腫瘤是全球目前主要死亡原因之一,在台灣自民國71年起更連續31年高居十大死因之首,不僅是影響全球,也是影響台灣人死亡的最重要原因之一,且比例有逐年增加趨勢。癌症病人在疾病進展至臨終的過程中,可能會出現虛弱疲憊、疼痛、排尿障礙、呼吸困難、譫妄等症狀,大多數病人在這段期間都需要在醫院接受醫護人員的治療與照護,再加上社會變遷,死亡地點由家中逐漸變更為醫院,臨床護理人員便成為照顧生命末期病人之第一線人員。多數臨床護理人員面對生命末期病人照顧時常不知所措,並產生恐慌、害怕、憂鬱等情緒,進而影響個人與專業之發展,間接降低護理品質,更有人因此離開職場,故此議題值得深究。
研究目的:探討臨床護理人員面對「生命末期」癌症病人照顧(End-of-life care, EOL care)時之態度與行為。
研究方法:本研究為一描述相關性研究,以方便取樣選取133位國立成功大學附設醫院照顧過生命末期癌症病人之護理人員為對象,依據Ajzen(1985)提出之計畫行為理論(Theory of planned behavior, TPB)為研究架構,設計出自擬式問卷「生命末期照護能力量表(End-of-life Care Competence Scale, EOLCCS)」以測量護理師對EOL care之態度與行為,包含臨床決策知識、臨床處置行為、瀕死症狀知識、信念、正向態度與意願等六個次量表。運用描述性統計、單因子變異數分析、相關分析及複線性回歸分析探討護理人員面對EOL care之態度與行為現況,並了解個人特質、專業特質、過去經驗對護理人員EOL care之態度與行為的影響,且調查護理人員對於EOL care之資源需求、單位支持/重視程度、挫折因應策略為何,最後檢驗計畫行為理論TPB是否適用於本研究。
研究結果:共發出150份問卷,回收145份,回收率96.7%,刪除不符合研究納入條件12人,有效問卷為133份。受試護理師多為女性且未婚,擁有大學學歷,年齡平均30歲,護理工作年資平均8年,護理層級多為N2,其「臨床決策知識題」平均分數為2.93分(標準差=1.02,範圍:1-5分),約63.7%之受試護理師達到及格標準(3分以上);在「臨床處置行為題」平均分數為3.49分(標準差=1.15,範圍:0-6分),約45%之受試護理師達到及格標準(4分以上)。其中在處置行為題影響護理師提供不適切EOL care之原因有:(1)護理師想法與實際作法不一致(2)護理師多按照醫囑執行護理照護,缺乏獨立批判性思考能力(3)EOL care知識、觀念與實際處置不夠正確、熟練。在「瀕死症狀知識題」平均得分為3.39分(標準差=1.24,範圍:0-5分),大多數(80.1%)受試護理師能達到及格標準(3分以上),其中以鏡面舌(60.9%)與臨終脫水(42.1%)答對率最低。針對護理人員提供EOL care之意願進行調查,發現約有36%(28.6%~41.4%)的護理師在不利於執行EOL care條件下仍願意執行EOL care。護理人員之個人特質中的「年齡」、「婚姻」、「學歷」,專業特質中的「護理年資」、「護理層級」、「工作單位」、「教育訓練」,過去經驗中的「是否在安寧病房工作過」、「是否常常照顧癌末病人」等為影響EOL care臨床照護能力之重要因子,但大多都僅在知識與技能層面(臨床決策知識、臨床處置行為、瀕死症狀知識)有顯著改變,對於情意層面(信念、正向態度與意願)幾乎無差異,由此可見情意上的培養遠比技能知識的建立困難,未來應加強情意方面的訓練。以「護理層級」分析知識與技能層面表現,發現能力未與層級成正比,N3表現最好;以「工作單位」分析知識與技能層面表現,結果安寧病房之護理師得分最高(Mean = 4.5~5.4分),婦科病房之護理師得分最低(Mean = 2.0~2.9分)。調查護理人員對EOL care課程主題需求,發現「溝通技巧」為大多數人認為第一順位主題(31.6%);提升生命末期癌症病人照護品質之要素上,「增加護理照護人力」為多數人認為的第一
順位要素(38%);單位支持/重視EOL care之調查結果以安寧病房得分最高(Mean = 4.10-4.60分),兒科病房得分最低(Mean = 1.43-3.86分)。當護理人員執行EOL care遇到挫折時的因應策略以「與同事分享並尋求支持」最多(34.3%),可見建立團體討論會與同儕支持的重要性。運用計畫行為理論檢驗本研究,發現單就「意願」無法預測EOL care行為,必須加上「自我覺知之行為控制(Perceived behavioral control)」才能達到預測(F = 16.49, p < 0.001, R2 = 20.2%)。
結論:期望此研究結果能增加護理領域之背景知識,做為未來護理教育和臨床新進人員在職教育設計之參考,以增進臨床護理人員生命末期照護之知識、態度與行為,提升照護品質,並且讓護理行政管理者能做適度的人力調配與病房設備建置,提供良好且適合提供EOL care之工作環境。最後本研究結果能成為EOL care之背景知識並針對相關議題更深入探究,發展台灣本土化EOL care體系。
英文摘要 SUMMARY
The purpose of this study is to investigate nurses’ attitudes and behavior toward end-of-life (EOL) care for terminally ill cancer patients. The study applied a descriptive correlational research design. Choose 133 nurses from medical center in southern Taiwan as participants, use EOLCCS questionnaire as research instrument to collect data, and analyze how personal characteristics, professional characteristics, past experience affect attitudes and behavior toward EOL care by descriptive statistics, one way ANOVA, correlation and multiple linear regression. The results showed that personal characteristics, professional characteristics, past experience only can increase their knowledge and skills but not belief, positive attitude and intention. Moreover, it is found that “knowledge and skills “ and “nursing level” are not in direct proportion, nurses who at N3 performed the best. Nurses worked in hospice ward performed the best (Mean = 4.5-5.4) and who worked in gynecology ward performed the worst (Mean = 2.0-2.9) in the knowledge and skill level. This study reveals that we should design more EOL care training programs which are according to clinical situation for clinical nurses, and affective teaching should be included to increase their belief and attitude toward EOL care. Finally nurses can increase their EOL care competence and elevate the quality of EOL care.
Key words: attitudes and behavior, nurses, terminally ill cancer patients, end-of life care


INTRODUCTION
Cancer has been the leading cause of death in Taiwan and the world. There are more and more people die because of cancer. Before their death, most of them need to be hospitalized for the symptomatic control, (e.g., pain, fatigue, dyspnea, delirium, etc.), and because the time and social environment changes, there are more and more patients die in the hospital. The number of deaths attributable to cancer is continuing to increase in hospital. Therefore, nurses will be the key person to care the terminally ill cancer patients. Nurses will feel anxiety, stress, helpless when caring end-of-life patients, and the quality of nursing care and demission rate will be influenced by their attitudes and experiences toward end-of-life care. So this is an important issue to be discussed. The purpose of this study is to investigate nurses’ attitudes and behavior toward end-of-life (EOL) care for terminally ill cancer patients.

MATERIALS AND METHODS
Choose a medical center in southern Taiwan as a research field. And selects 133 nurses as participants by applying convenience sampling , then collect information by structure questionnaire named “End-of-life Care Competence Scale (EOLCCS)”, which with 6 subscales, “Clinical decision knowledge”, “clinical treatment”, “pre-dying identification”, “belief”, “positive attitude”, “intention to care” . Analyze how personal characteristics, professional characteristics, past experience affect attitudes and behavior toward EOL care by descriptive statistics, one way ANOVA, correlation and multiple linear regression, and then investigate the nurses’ needs of resource for EOL care, units support of EOL care, coping strategies for frustration on doing EOL care, finally test the suitability of the theory of planned behavior on this research.

RESULTS AND DISCUSSION
This research has send out 150 questionnaires, took back145 questionnaires, response rate is 96.7%, and deleted 12 nurses’ questionnaires which didn’t meet the inclusion criteria, a total of 133 questionnaires were used for analysis. Most nurses were female, and unmarried with a mean age of 30. Most of them have university degrees, with a mean nursing working year of 8, nursing level at N2. The average score of “ Clinical decision ” is 2.93 (SD = 1.02, range: 1-5), there were 63.7% nurses can reach the passing score ( 3 point); the average score of “ Clinical treatment ” is 3.49 (SD = 1.15, range: 0-6), there were 45% nurses can reach the passing score ( 4 point).The reason nurses couldn’t provide EOL care appropriate are (1) Thinking and actual behavior were not consistent (2) Always by order to do nursing care, lack of critical thinking (3) Not familiar with the knowledge and treatment of EOL care. The average score of “Pre-dying sign knowledge” is 3.39 (SD = 1.24, range: 0-5), most (80.1%) of the nurses can reach the passing score ( 3 point) , “Mirror tongue” and “Terminal dehydration” are two concepts nurses were not familiar with. There were 36%(28.6%~41.4%)nurses would like to provide EOL care in the unfavorable condition. Nurses’ personal characteristic (eg. age, marriage status, education level), professional characteristic (eg. nursing working years, nursing level, work unit, special training) and past experience (eg. work at hospice wards, care the terminally ill cancer patients often) only can increase clinical decision knowledge, clinical treatment, pre-dying identification but not belief, positive attitude and intention to care. Choose “nursing level” as a factor to analyze nurses’ clinical decision knowledge and clinical treatment, it is found that “clinical decision knowledge and clinical treatment “ and “nursing level” are not in direct proportion, nurses who at N3 performed the best; Choose “working unit” as a factor to analyze nurses’ clinical decision knowledge and clinical treatment , the result showed that nurses worked in hospice ward performed the best ( Mean = 4.5-5.4), nurses worked in gynecology ward performed the worst (Mean = 2.0-2.9). “Communication skill” (31.6%) is the most needed courses for nurses, and increase “manpower of nurses”(38%) is the most important key impact factor for providing appropriate EOL care. Hospice wards provide the most support of EOL care ( Mean: 4.10-4.60); Pediatric wards provide the least support of EOL care (Mean:1.43-3.86). The coping strategies of most nurses when they suffering with setback is “Share with colleagues and get support”(34.3). EOL care behavior cannot be predicted only by “Intention”, it must to add “Perceived behavioral control” into the regression model to successfully predict EOL care behavior in TPB (F = 16.49, p < 0.001, R2 = 20.2%).

CONCLUSION
The research result is expected to enhance the nursing professionals’ caring skill as well as to increase the knowledge base through integrating and analyzing the data of nurses’ attitudes and experiences toward end-of-life care for terminally ill cancer patients . Then design a education programs or training programs based on the result for EOL care class in nursing schools and hospital units. And nursing administration staff can manage manpower properly and create an appropriate environment for providing EOL care. Finally, based on this research, more and more related research can be conducted, then integrate the findings to develop a local EOL care system.
論文目次 目錄
摘要 ..................................... II
Abstract ................................. V
致謝 .................................... VIII
表目錄 ................................... XI
圖目錄 ................................... XII
附件目錄 ................................. XIII
第一章 緒論 ............................... 1
第一節 研究背景 ............................ 1
第二節 研究動機與重要性 ...................... 3
(一) 本研究對護理人員的重要性 ................. 3
(二) 本研究對臨床護理照護體系的重要性 .......... 3
第三節 研究者的生命經驗 ...................... 4
第四節 研究目的 ............................. 5
第五節 研究問題 ............................. 5
第六節 名詞定義 ............................. 6
(一) 生命末期癌症病人( Terminally ill cancer patients) ......................................... 6
(二) 生命末期照護( End-of-life care, EOL care) ........................................... 6
(三) 護理人員面對生命末期照護之態度(Nurses’attitudes toward EOL care) .....................................8
(四) 護理人員面對生命末期照護之行為(Nurses’ behavior toward EOL care) .................................... 9
第二章 文獻查證 ............................. 10
第一節 計畫行為理論(Theory of planned behavior, TPB) .......................................... 10
(一) 計畫行為理論(Theory of planned behavior, TPB) .......................................... 10
(二) 計畫行為理論於健康照護行為研究上之應用成效 ........................................... 11
第二節 生命末期照護 ........................... 12
(一) 台灣生命末期照護之發展歷程與現況 ............ 12
(二) 台灣生命末期照護之困境 .................... 13
第三節 護理人員面對生命末期照顧之衝擊與態度 ....... 14
(一) 護理人員之社會人口學與生命末期照顧態度之影響 .. 14
(二) 護理人員面對生命末期照顧之心理壓力 .......... 15
(三) 護理人員面對生命末期照顧之態度對工作經驗之影響.. 15
第三章 研究方法與材料 .......................... 19
第一節 研究設計與架構 .......................... 19
(一) 研究設計 ............................... 20
(二) 研究場域 ............................... 20
(三) 研究參與者 ............................. 20
(四) 取樣方法 .............................. 20
(五) 研究工具 ............................... 21
(六) 研究的嚴謹度確保(Rigorous) .............. 33
(七) 資料收集方法 ............................ 39
(八) 預期收案時間 ............................ 40
(九) 研究架構-1 .............................. 41
(十) 研究架構-2 .............................. 42
第二節 研究倫理考量 ............................. 43
第三節 資料分析 ................................ 47
第四章 研究結果 ................................ 49
第一節 前驅測試結果 ............................. 49
第二節 正式研究結果 ............................. 51
第五章 討論 .................................... 91
第一節 研究結果與過去文獻比較及所產生的新知識 ......... 91
第二節 研究優勢(Research strength) ............ 109
第三節 研究限制 ( Limitation ) ................. 110
第四節 研究結果應用與未來研究方向(Implication) ... 111
第六章 結論 ................................... 114
參考文獻 ..................................... 115

表目錄
表一 正式問卷計分方式 .......................... 30
表二 專家內容效度指標(CVI) ..................... 51
表三 社會人口學特徵 ............................ 52
表四. 過去生死相關教育經歷 ..................... 53
表五. 過去影響生命末期照顧之經驗 ................. 54
表六 護理人員面對EOL care之態度與行為描述性分析結果 . 56
表七 個人特質、專業特質與各次概念間之關聯 .......... 56
表八-1臨床決策知識題─臨終脫水答題情況 ............. 57
表八-2臨床處置行為題─臨終脫水答題情況 ............. 58
表八-3臨終脫水臨床決策知識與臨床處置行為之比較 ...... 59
表八-4 臨終脫水處置行為題選擇持續給予人工營養與水分之理由 ... 59
表八-5臨終脫水處置行為題選擇必須減少人工營養與水分之理由 .... 60
表八-6臨終脫水處置行為題選擇不再給人工營養與水分之理由 ...... 60
表八-7臨床處置行為題─淋巴水腫按摩答題情況 ................ 61
表八-8 淋巴水腫按摩處置行為題選擇會執行淋巴水腫按摩之理由 ... 62
表八-9淋巴水腫按摩處置行為題選擇不會執行淋巴水腫按摩之理由 .. 62
表八-10臨床決策知識題─不延長瀕死期之升壓劑使用答題情況 .... 63
表八-11臨床處置行為題─不延長瀕死期之升壓劑使用答題情況 ..... 64
表八-12不延長瀕死期之升壓劑使用決策知識與實際處置行為的比較 .. 64
表八-13 不延長瀕死期之升壓劑使用─選擇停止使用升壓劑之理由 ... 65
表八-14不延長瀕死期之升壓劑使用─選擇仍持續使用升壓劑之理由 .. 66
表八-15 臨床決策知識與處置行為題─臨終病人導尿管更換 ....... 67
表八-16 臨終病人導尿管更換─選擇重新更換留置導尿管之理由 .... 67
表八-17臨終病人導尿管更換─選擇移除導尿管,視情況單次導尿之理由 ... 68
表八-18臨終病人導尿管更換─選擇續放留置導尿管之理由 ........... 69
表八-19臨床決策知識與處置行為題─癌末病人便秘處置 ........... 69
表八-20臨床處置行為題─病人家屬哀傷撫慰 ................. 71
表九-1 瀕死症狀知識題第一題:瀕死嘎嘎音答題狀況 ........... 72
表九-2瀕死症狀知識題第二題:鏡面舌答題狀況 ............. 73
表九-3瀕死症狀知識題第三題:荔枝眼答題狀況 .............. 73
表九-4瀕死症狀知識題第四題:臨終脫水答題狀況 .......... 74
表九-5瀕死症狀知識題第五題:陳式呼吸答題狀況 .......... 74
表十-1 未提供足夠硬體(設備)與軟體(人力)設備情況下願意提供EOL care之意願 75
表十-2未提供生命末期照顧相關訓練情況下願意提供EOL care之意願 ... 76
表十-3單位不支持與重視生命末期照顧情況下願意提供EOL care之意願 . 76
表十-4機構制度未給予護理人員特殊誘因情況下願意提供EOL care之意願 77
表十一 性別、婚姻狀態與各次構念間關係 ........................78
表十二 宗教信仰與各次構念間關係 ........................... 78
表十三 最高學歷與各次構念間關係 ............................ 79
表十四 護理層級與各次構念間關係 ......................... 80
表十五 單位科別與各次構念間關係 ........................ 81
表十六 三年內是否參加訓練與各次構念間關係 .............. 82
表十七 是否在血腫科/安寧病房工作過與各次構念間關係 ....... 83
表十八 照顧癌末病人/至親好友癌末經驗與各次構念間關係 ..... 83
表十九 照顧癌末病人頻率與各次構念間關係 ................ 84
表二十 EOL care相關資源需求 ........................ 85
表二十一 EOL care因應策略 ......................... 86
表二十二 工作單位對EOL care重視/支持程度 ............ 87
表二十三 意願、自我覺知之行為控制預測行為之複線性回歸 ....89
表二十四 態度、主觀規範、自我覺知之行為控制預測意願之複線性回歸 .. 90

圖目錄
圖一:疾病進展至死亡軌跡圖(Trajectory of disease progress) ...................... 2
圖二:預估病人的存活期 ............ 2
圖三:相關醫療種類的分類概念圖 ..... 8
圖四:計畫行為理論 理論架構 ....... 11

附件目錄
附件一 國立成功大學醫學院附設醫院人體試驗委員會同意臨床試驗證明書 ........ 125
附件二 國立成功大學醫學院附設醫院人體試驗委員會同意計畫修正證明書 ........ 126
附件三 成大護理研究生至成大醫院護理部各單位進行論文研究申請表 ............... 127
附件四 研究同意書 .......... 128
附件五 專家效度名單 ......... 131
附件六 研究問卷專家效度指引 .. 132
附件七 專家效度題目修正表 .... 143
附件八 正式研究問卷 ........ 155
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