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研究生:陳鳳音
研究生(外文):Chen Feng-Yin
論文名稱:機構式長期照護的品質及其相關影響因素
指導教授:吳淑瓊吳淑瓊引用關係
指導教授(外文):Wu Shwu-Chong
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:衛生政策與管理研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2002
畢業學年度:90
語文別:中文
論文頁數:118
中文關鍵詞:機構式長期照護品質因素
外文關鍵詞:institutionallong term carequalityfactors
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為促進對國內長期照護中機構式照護的品質,本研究主要目的在探討國內的機構住民照顧品質,並進一步探討影響住民照顧結果之相關因素。研究架構主要參考Donabedian(1966)所提出的結構(structure)、過程(process)、結果(outcome)之品質管理理論模式,並探討機構的結構與過程二方面品質對照顧結果的影響。研究資料來自民國87-89年衛生署委託吳淑瓊教授主持之「機構式長期照護品質評估指標之建立」研究計畫,研究樣本包含十家護理之家及養護機構,由其中抽取297位住民,結果完成243位住民之評估,據以進行分析。研究資料係以外來專家評估機構整體品質,以該機構內護理人員來評估住民在前後三個月間共二次的健康情形的方式進行。
本研究最終目的是想瞭解住民在機構中得到的照顧結果,並希望檢驗機構結構面品質中的機構特質、工作人員組成、機構環境、機構住民組合等四個變項,及服務過程品質中的生活照顧服務、專業醫療照護服務、住民權益、管理程序、活動安排等五個變項對照顧結果品質之影響,又將住民因素放入分析模式中做為控制。照顧結果之測量包含:身體功能、失禁情形、認知功能、憂鬱症狀、意外事件、壓瘡及尿道感染等七項;將前四項歸為以住民為分析單位的住民功能改變結果,後三項歸為以機構為分析單位的機構照顧不良結果。
本研究除描述性分析外,另以雙變項分析來檢定機構結構與服務過程品質中各變項與照顧結果的關係,並以多變項分析來探討影響照顧結果的因素。研究結果如下:
1.本研究所選取機構中,在結構面品質以環境的舒適性的表現較差,如提供穩密環境及家庭化佈置等,在過程面品質則以住民權益的維護,如尊重住民隱私及自我決定權,及對住民的個別化管理程序,如住民約束及飲食規範表現較差。
2.以依變項照顧結果來看:在住民功能改變結果方面,在前後三個月間的變遷不多,生理功能變差的(46.1%)較變好的(27.6%)為多,精神功能變好的(38.3%)較變差的(26.7%)為多。在機構照顧不良結果中,各機構發生率分佈在0.07-0.24之間,十家機構的平均發生率為0.15,若與平均發生率做比較,高於及低於平均的各有五家機構。
3.在住民功能改變結果與各項因素的關係中,以t-檢定(t-test)及單因子變異數 (one-way ANOVA)分析後發現:機構大小、佔床率、住民數與病服員數比率、機構內住民插氣切管比率等四項與住民生理功能得分改變情形有顯著相關;但只有管理程序一項與住民精神功能得分改變情形有顯著相關。
4.在機構照顧不良結果與各項因素的關係中,以無母數檢定之曼-惠特尼U檢定(Mann-Whitney U test)及克-瓦二氏單因子等級變異數(Kruskal-Wallis)分析後發現:因機構數太少,並無任何因素呈現顯著相關,但結構面品質及過程面品質中,都有較大的相關性存在(0.05<p<0.5);從其分佈的趨勢可發現,結構面因素中,住民數與病患服務員數的比率較低、專業人力資格符合項目較少、環境的安全性及舒適性表現較差、醫療設備的完整性較差的、住民完全依賴比率較低的,較易發生照顧不良的結果;過程面因素中,生活照顧及專業醫療照護服務表現較差的、管理程序表現較好的,較易發生不良照顧結果。
5.在多變項分析中,以線性複迴歸分析生理及精神功能改變二個模式,在置入相同變項,並控制其他因素之影響力後發現:
(1)生理功能變化迴歸模式之解釋力為14.8%,有多項結構面因素與生理功能變化有顯著相關(p<0.05),其中機構體系為護理之家、機構床數較多的大型機構、住民數與護理人員人數比較多、專業人力資格較符合、機構環境的安全性較差、醫療設備完整性較差、機構內住民插鼻胃管的比率越高、住民身體功能完全依賴程度越嚴重的,住民生理功能越易變差。
(2)精神功能變化迴歸模式之解釋力為10.6%,並無任何變項與精神功能的改變有顯著相關,但有許多結構面因素中的變項與精神功能變化仍有較大差異性存在(0.05<p<0.5),其中機構體系為養護機構的、床數越小的、住民數與病患服務員人數比率較大、機構內住民插鼻胃管的比率較大、住民性別為男性、子女數較少、疾病穩定度較差,住民精神功能較易變差、住民數與護理人員人數比率較小的,住民精神功能較易變差。
由本研究結果可知,機構在環境穩密性與家庭化佈置、對住民隱私及自我選擇權利的維護、及個別化管理的表現上仍有待加強,服務提供者應針對這幾方面再做努力。另外,研究結果也發現許多結構面品質都會對照顧結果有影響,可見目前機構設置標中對結構面品質的規範是很重要的,若要再放寬標準,便會對住民權益造成威脅,是絕不容許的。最後,也建議決策者可針對本研究結果中影響照顧結果的重要因素來加強評核,以保障機構內住民的權益與福利。
In order to improve the quality of care in long-term care (LTC) facilities in Taiwan, this study was aimed at investigating the care in domestic institutions, and to examine important factors which affect the outcome of care. The framework of the study is based on Donabedian’s (1966) quality management model, examining the institute for the influence of structural and process quality factors on the outcome of care. Data in this study are from the project “Development of Nursing Home Quality indicator in Taiwan”, 1998~2000, conducted by Doctor Shwu-Chong Wu. The survey was done in 10 long-term care facilities. There were 297 residents in the LTC facilities sampled, and the assessment of 243 residents was accomplished for further analysis. The data of the facility quality were from experts’ evaluation, and the data of health condition of the residents were collected by nurses in these facilities.
The purpose of the study is to realize the outcome of care received by the residents in LCT facilities, and to examine the factors which affect the outcome, including structure factors (facility character, the compose of workers in the facility, the facility environment, and the compose of residents), and process factors (the service of life care, the service of professional care, the right of the residents, the procedure of management, the arrangement of activities). Also, resident factors were put into the analysis model as control factors. The measure of the outcome includes 7 variables: physical function, incontinence, cognition function, depression symptoms, accidents events, bedsore and urinary infection. The first four variables can be generalized as the outcome of resident’s functional change, while the later three can be generalized as the outcome of poor care in the facilities.
In addition to the qualitative analysis, bivariate analysis is applied to examine the effect of the variables of structure and process on the outcome of care. Multiple variable analysis method is used to examine the factors in determining the outcome of care. The major findings are presented below:
1. For the quality of structure, the facilities selected in the study do not work well regarding environmental comfort, such as in providing private space and homelike decorates. As for the quality of process, the facilities do not work well in valuing rights of residents, such as privacy and self-decisions; neither in individual procedures of management, such as restrains and food.
2. In view of the variables which determine the outcome of care, the outcome of resident’s function does not change obviously during the three months: physical function deteriorated in 46.1% and improved in 27.6% of the samples, while mental function improved in 38.3% and deteriorated in 26.7% of the samples. The prevalence of outcome of poor care in the selected 10 facilities ranged between 0.07 and 0.24, with the mean value of 0.15. There were five facilities each with higher and lower prevalence than the mean value.
3. As for the relation between the outcome of residents’ functional change and factors of structural and process quality, from the results of t-test and one-way ANOVA analysis, it showed that the physical function of the residents changed with four variables, i.e. facility size, bed occupation, the ratio of resident and nurse aid, and the percentage of residents with the usage of trachea tubes in the facility. However, mental function changed with only one variable, i.e. the procedure of management.
4. The results of Mann-Whitney U test and Kruskal-Wallis analysis showed that no variables structural and process quality has significant effect on the outcome of poor management. However, the factors of structural and process quality are still related to the outcome of poor care in the facilities. The structural and process factors still exist some relations with the outcome of care(0.05<p<0.5).
5. The linear multiple regression method was applied to analyze residents’ functional change in both the physical and mental functions. The major results were showed below:
(1) The regression model of physical function change can explain 14.8% of the model. If the facility type is a nursing home, the facility size is larger, the ratio of residents to nurses is larger, the workers in the facility are more professional, the environment security is worse, or the percentage of dependent residents in the facility is lager, the physical function of the residents in the facility will deteriorate easier.
(2) The regression model of mental function change can explain 10.6% of the model, but no variable is significantly related to the change of mental function.
Our findings showed that the facilities in our study should strengthen themselves in environmental privacy, homelike decorates, the right of self-choice of the residents, and individual management. In addition, the result of our study showed that the outcome of care was indeed affected by the quality of structure. It is thus obvious that regulation on structural quality is very important in setting a LTC facility. Therefore, if we continue to make the standard even looser, the rights of these residents who live in the facility will be seriously threatened. Finally, in order to ensure the rights of the residents in LTC facilities, decision makers are strongly suggested to strengthen the evaluation on the facilities especially in the factors which affect substantially the outcome of care.
致謝 I
中文摘要 II
英文摘要 IV
目錄 VI
圖表目次 IX
第一章 前言 1
第一節 研究動機 1
第二節 機構品質的意涵與面向 2
第二章 文獻探討 3
第一節 機構照護品質的發展 3
第二節 機構品質的意涵與面向 5
(一)結構指標 6
(二)過程指標 7
(三)結果指標 7
第三節 機構品質指標 8
第四節 影響結果品質的因素 9
(一)結構面因素 9
1.機構特質 9
2.機構環境 10
3.工作人員組成 11
4.機構住民組成 11
(二)過程面因素 12
1.專業照護 12
2.一般照顧 12
3.機構管理程序 13
(三)住民因素 13
1.基本人口學 13
2.健康情形 14
第三章 研究方法 19
第一節 研究架構 19
第二節 研究假設 20
(一)機構結構面因素會影響住民的照顧結果 20
1. 住民的照顧結果會因機構特質不同而有差異 20
2. 住民的照顧結果會因機構的工作人員組成而有差異 20
3.住民的照顧結果會因機構環境不同而有差異 20
4.住民的照顧結果會因機構住民組合不同而有差異 20
(二)機構過程面因素會影響住民的照顧結果 21
第三節 研究對象 21
(一)研究機構 21
(二)研究樣本 21
第四節 研究工具 22
(一)問卷設計 22
1.文獻整理 22
2.深度訪談 22
3.焦點團體法 22
4.德菲法專家效度預測 22
(二)信效度測試 23
1.效度檢定 23
2.信度檢定 23
第五節 資料收集過程 23
第六節 研究變項 23
(一)結構面變項 24
(二)過程面變項 24
(三)住民特質變項 25
(四)照顧結果變項 26
第七節 資料分析方法 28
第四章 研究結果 47
第一節 資料回收情形 47
第二節 研究對象特性 48
(一)機構特性 48
1.機構結構特質 48
2.服務過程特質 49
(二)住民特性 50
1.基本人口學特質 50
2.入住時間 51
3.健康狀況 51
第三節 機構照顧的結果 51
(一)照顧結果之分布情形 52
1.功能改變的結果 52
(1)身體功能 52
(2)失禁情形 53
(3)認知功能 53
(4)憂鬱症狀 54
2.照顧不良的結果 54
(1)意外事件 54
(2)壓瘡情形 54
(3)尿道感染情形 55
(二)前後二次照顧結果的變遷情形 55
1.功能改變的結果 55
2.照顧不良的結果 55
第四節 住民功能改變的結果與機構結構、服務過程、
住民特質因素間的關係 56
(一)機構結構因素與功能改變結果的關係 56
(二)服務過程因素與功能改變結果的關係 58
(三)住民特質與住民功能改變結果的關係 59
第五節 照顧不良的結果與機構結構、服務過程的關係 60
(一)機構結構因素與照顧不良結果的關係 60
(二)服務過程與照顧不良結果的關係 60
第六節 住民健康改變結果與結構、過程因素,住民特質
之多變項關係 61
(一)機構結構、服務過程、住民特質與住民生理功能改變的關係 61
(二)機構結構、服務過程、住民特質與住民精神功能改變的關係 62
第五章 討論與建議 105
第一節 重要結果討論 105
(一)研究對象特性 105
(二)機構品質 105
1.機構結構品質 105
2.服務過程品質 106
3.照顧結果品質 106
(三)影響結果品質的因素 107
1.住民功能改變結果之影響因子 107
2.機構照顧不良結果之影響因子 109
第二節 研究限制 109
(一)研究對象之限制 109
(二)研究變項之限制 110
第三節 建議與應用 111
(一)研究上的建議 111
(二)研究結果之應用 111
第六章 參考文獻 113
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(二) 英文部份
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