背景與目的：根據醫策會資料顯示，精神專科醫院病人跌倒事件佔病人安全事件第二位；精神疾病病人心智狀態異常、意識混亂、認知功能障礙等，都是加重跌倒的危險因子;本研究探討台灣南部某精神科專科醫院住院病人跌倒發生原因與改善成效，及護理人員參與行動研究後賦權感受與防跌成效的差異。
方法：以回溯性收集病人安全通報次級資料庫跌倒相關資料，橫斷式資料自2014年至2016年之每年1月1日至6月30日共445件；資料歸納包含跌倒病人屬性、跌倒當下的狀態、跌倒原因歸類、跌倒傷害嚴重度等，以及行動研究參與者賦權感受。採用SPSS18.0 for Windows統計軟體進行量性資料分析處理，以敘述性統計、卡方檢定、獨立樣本t檢定進行分析；再採用行動研究法探討不同屬性病人介入防跌計畫之成效，螺旋循環式行動研究步驟包括，在實務中尋找問題點、收集資料釐清情境、發展行動策略及分析反思與類化。
結果：精神科住院病人跌倒重要因素中，診斷以Schizophrenia佔整體跌倒病人之49.8%為最多，跌倒病人年齡50歲以上居多；跌倒主要原因，以「生理因素」為最多佔57.9%，第二是精神症狀影響或病人自我保護能力不足；執行改善策略後成效輕度損傷病人數由40.4%降至6.9%，無損傷的病人數由59.6%提升至93.1%；護理人員防跌教育衡量，成績80分以上者佔98%成效良好；賦權感受調查結果，實驗組與對照組在工作上自我決策與工作上的影響力平均值比較達到統計上顯著差異，幾項病人跌倒之主要相關因素呈現逐年改善之變化。
結論：行動研究法的特質包含，研究是基於實務工作者意識到實務上出現問題、透過研究來直接改善狀況；本行動研究提供個案醫院病人跌倒問題以科學、系統、持續循環性的方式，區分不同屬性病房確認真正原因再擬定改善策略，研究參與者依照實務狀況分析及再評值，是組織內為自己的專業實踐的研究。

Research background and purpose: According to the Joint Commission of Taiwan information, mental hospital patients fall events ranked second among patient safety index; mentally ill patients with abnormal mental status, confusion, cognitive impairment, are risk factors of the fall incidents; This study explored the causes and the improvement of hospitalized patients' falls in a psychiatric hospital in southern Taiwan and the differences in the outcomes of knowledge improvement and empowerment of nurses after they engage in prevention education.
Methods: We collected information on the fall of patient safety information sub-database retrospectively, and the number of cross-sectional data was 445 from January 1 to June 30 of each year from 2014 to 2016. The data were summarized as falling patient attributes and falling The current state, the main reason for the fall and the classification of the secondary causes, the severity of the falls, etc., and the empowerment of paramedics participating in the anti-drop education outcomes and participating in the action research. Data analysis and statistical methods were conducted by SPSS18.0 for Windows statistical software for quantitative data processing, narrative statistics, chi-square test, independent sample t test analysis of relevant content; and then use the action research to explore different properties of patients interventional anti-fall plan Effectiveness, spiraling action research steps include finding problems in practice, collecting information to clarify situations, developing action strategies and analyzing reflection and categorization.
Results: Among the most important factors of fall in psychiatric inpatients, 49.8% were diagnosed with Schizophrenia and those who the age 50 were mostly affected. The main reason for the fall was "physiological factors" accounting for 57.9% of the total, and the second was psychotic symptoms or patients Self-protection ability is insufficient; After implementation of the improvement strategy, the number of mild injury patients decreased from 40.4% to 6.9%, the number of non-injury patients increased from 59.6% to 93.1%; Nursing staff dropped to education after the measure of 80 points or more 98% of them performed well; Empowerment felt the survey results, the experimental group and the control group in the work of self-decision-making and work on the impact of the average comparison to achieve statistically significant differences.
Conclusion: The characteristics of action research included, research outcome is problem-based practitioners appear to realize on their own practice, to improve directly the situation through research; this action to provide case study in a hospital patient falls on problem solving, science, system , Continuing the cycle of the way to distinguish between the different attributes ward to identify the real cause and then to develop strategies to improve the study participants in accordance with the actual situation, with education led by colleagues, so the main factors related to the fall of several patients are showing improvement year by year.

致謝 Ⅰ
摘要 Ⅱ
ABSTRACT Ⅲ
目錄 Ⅴ
表目錄 Ⅶ
圖目錄 Ⅷ
第一章前言 1
第一節研究背景與動機 1
第二節研究目的 5
第二章文獻探討 6
第一節精神科住院病人跌倒因素與現況 6
第二節醫療機構對不同原因的跌倒預防做法 15
第三節行動研究方法與醫療照護實務運用 22
第四節醫療機構行動研究的倫理考量與信效度 27
第三章研究方法 29
第一節研究情境與資料蒐集 29
第二節問卷設計 33
第三節資料處理與分析 36
第四節行動研究流程 40
第四章研究結果 43
第一節第一階段行動準備 43
第二節第二階段行動執行 51
第三節第三階段行動反思 59
第五章結論、討論及建議 72
第一節結論與討論 72
第二節限制與建議 77
參考文獻 81
附錄一 86
附錄二 88
附錄三 89
附錄四 90
附錄五 91

Albrand G, Munoz F, Sornay-Rendu E,DuBoeuf F &Delmas PD.(2003) Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study. Bone, 32,78-85.
Altrichter, H., Posch, P., and Somekh, B. (1993), Teachers investigate their work:
A introduction to the methods of action research, London: Routledge.
Conger, J. A. & R. N. Kanungo (1988) “The empowerment process: Integrating theory and practice,” Academy of Management Review, 13, No.1, pp.471-482.
Coghlan, D., & Brnnick, T. (2001). Doing action research. London:Sage Publication.
Chiarelli PE, Mackenzie LA, Osmotherly PG.: Urinary incontinence is associated with an increase in falls: a systematic review. Aust J Physiother 2009; 55: 89-95.
Feldman, A (2007) Validity and quality in action research. Educational Action Research, 15(1),21-32.
Gallagher JC, Rapuri PB, Smith LM(2007). An age-related decrease in creatinine clearance is associated with an increase in number of falls in untreated women but not in women receiving calcitriol treatment. J Clin Endocrinol Metab 2007; 92: 51-8.
Guse, C. E. &Porinsky, R. (2003). Risk factors associated with hospitalization for unintentional falls : Wisconsin hospital discharge data for patients aged 65 and ovwe. Medical Journal, 102(4), 37-42.
Goodridge D, Marr H(2002). Factors associated with falls in an inpatient palliative care unit: an exploratory study . Int J Palliat Nurs, 8(5),48-56.
Grabiner, M. D., Owings, T. M., & Pavol, M. J.(2005). Lower extremity strength plays only a small role in determining the maximum recoverable lean angle in older adults.The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 60(11),
Hartikainen S, Lonnroos E, Louhivuori K(2007).Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci MedSci .62(11),72-81.
Hartholt KA, van der Velde N, Looman CW .(2010).Trends in fall-related hospital admissions in olderpersons in the Netherlands. Arch Intern Med ,170, 905-11.
Kemmis, S., & McTaggart, R. (2000). Partipatory action research. In N.K. Denzin & Y.S. Lincoln(eds.), Handbook of qualitative research. London Sage Publication.567-605.
Koepsell TD, Wolf ME& Buchner DM.(2004). Footwear styleand risk of falls in older adults. J Am Geriatr Soc, 52(1), 495-501.
Kemmis, S., and Mctaggart, R. (1997), The Action Research Planner (3rd ed.),Deakin University Press, Victoria, Australia.
Lee JE, & Stokic DS.(2008).Risk factors for falls during inpatient rehabilitation. Am J Phys Med . 87(3),41-53.
Lavsa SM, Fabian TJ, Saul MI, Corman SL,Coley KC.(2010). Infl uence of medications and diagnoses on fall risk in psychiatric inpatients. Am J Health Syst Pharm ,1274, 80.
Rolfe, G. (1998). “Reflexive action research,” in Expanding nursing knowledge understanding and researching your own practice, Boston:Butterworth-Heinemann, 171-213.
Rosendahl E, Lundin-Olsson L, Kallin K, et al:Prediction of falls among older people inresidential care facilities by the Downton index.Aging Clin Exp Res 2003;15:142-7.
Stewart, R., Richards M., Brayne, C. & Mann, A. (2001) Vascular risk and cognitive impairment in an older British, African-Caribbean population.Journal of the American Geriatrics Society, 49(3), 263-269.
Rubenstein LZ, Josephson KR, Osterweil D(2002).Falls and fall prevention in the nursing home.Clin Geriatr Med.12:881-902.
Sieri, T., & Beretta, G.,(2004). Fall risk assessment in very old males and females living in nursing homes. Disability and Rehabilitation, 26(12), 718-723.
Tinetti ME, Speechley M& Ginter SF., (1998) Risk factors for falls among elderly persons living in the community. N Engl J Med. 319(17), 1-7.
Thurman DJ, Stevens JA, Rao JK: Quality Standards Subcommittee of the American Academy of Neurology: Practice parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70: 473-9.
Tilling LM, Darawil K, Britton M: Falls as a complication of diabetes mellitus in older people. J Diabetes Complications 2006; 20: 158-62.
Schensul, J. J. (2009). Community, culture and sustainability in multilevel dynamic systems intervention science. American Journal Community Psychology, 43, 241-256.
Winter, R , & Badley, G. (2007). Action research and aiernic writing: A conversation. Educational Action Research, 15(2), 253-270.
Wallis, S. (1998). Changing practice through action research. Nurse Research, 6(2), 5-15.
Young, L. (2006). Participatory action research (PAR): A research strategy for nursing? Western Journal of Nursing Research, 28(5), 499-504.
Yokoya, T., Demura, S., & Sato, S. (2008). Fall risk characteristics of the elderly in exercise class. Journal of Physiological Anthropology, 27(1), 25-32.

向肇英、李介至、林碧珠(2012)。影響老年人身心健康之相關因素探討。新臺北護理期刊，14(1)，7-16。
李麗花、羅惠敏、林麗娟、鐘蝶起、李茹萍（2006）。精神科住院病人跌倒因素探討。志為護理，5(1)，78-82。
李宗育、陸鳳屏、詹鼎正(2014)。老年人跌倒之危險因子、評估、及預防。內科學誌，25，137-142。
林小玲、溫明寰、陳玉枝(2010)。跌倒危險評估量表準確度之研究。醫護科技期刊，12(1)，47-59。
林淑芬、高毓秀(2008)。機構高血壓老人預防跌倒行為相關因素之探討。健康促進與衛生教育學報，29，99-117。
林茂榮、黃慧芬(2008)。老人跌倒之預防介入策略。台灣衛誌，l.27(6)，447-460。
洪鈴雅、 張家豪、 蔡虔祿(2013)。運動訓練對老年人跌倒風險之探討。健康生活與成功老化學刊，5(1)，28-33。
洪一仁、廖慧伶、李明輝(2013)。藥物與老人跌倒。醫學與健康期刊，2(1)，9-16。
范懿文、王文秀(2010)。應用行動研究法探討組織成功導入CMMI 之個案研究。11，25-40。
陶蕃瀛(2004)。行動研究：一種增強權能的助人工作方法。應用心理研究，23，33-48。
張惠琳、樓亞洲、陳立奇(2009)。預防藥物相關之跌倒。北市醫學雜誌，6(5)，77-85。
陳惠芳、洪嘉徽(2006)。員工知覺薪酬公平與賦權對組織承諾影響之研究。東吳經濟商學學報，P5(03)，235-262。
陳玉枝、郭淑瑜、林麗華、簡淑芬(2008)。實施護理人員跌倒防範教育對跌倒事件知識、態度及行為之探討。護理雜誌，25(1)，12-19。
陳美碧、劉淑言、曾淑君、侯菊驪、李秀如(2010)。住院老年精神病人跌倒因子分析—回溯性病例對照研究。榮總護理，27(4)，394-401。
曾志傑、蘇碧玉、黃信得、張玉坤、戴月明（2013）。Risk Factors for Inpatient Falls at a Mental Hospital。臺灣精神醫學，27(2)，131-139。
曾堯人、顏兆熊(2010)。老人跌倒之風險評估與預防。當代醫學，37(5)，46-52。
曾彥閔、蔡春玉、林子鈺(2006)。藥物相關的跌倒。醫院藥學，23(1)，84-86.
楊瑞珍、陳美燕、黃璉華(2001)。行動研究法的概念及其在護理的應用。醫護科技學刊。3(3)，244-254。
楊榮森(2008)。老年人的跌倒與骨折預防。台灣老年醫學暨老年學雜誌，3(2)，78-90。
楊博仁、林惠文、楊宜慎、陳俊傑、陳宣志、汪正青、顏啟華、徐千剛、李孟智(2012)。台灣地區老人跌倒之預測因子探討。老人醫誌，5(1)，65-78。
潘世尊(2011)。論行動研究論文審查上的一些問題。當代教育研究。19(4)，41-77。
黎家銘、張皓翔、李世代、陳晶瑩(2012)。長期照護機構住民的跌倒預防。台灣醫學，16(5)，538-543。
顧艷秋(2010)。某醫學中心住院病人跌倒傷害及其相關因素探討。長庚護理，21(3)，287-297。
詹美芳、張淑苑、陳靜芳、林志堅、李淑華（2011）。降低精神科急性病房住院病人跌倒發生率專案。榮總護理，28(3)，308-313。
蔡燿州、陳政友、蔡明世（2010）。嘉義縣某地區醫院護理之家及精神病房慢性住院病人跌倒傷害嚴重程度相關因素研究。健康促進暨衛生教育雜誌，30，87-108。
蔡玉梅、郭倩琳、鄭夙芬(2010)。臨床護理人員執行實證實務影響因素之探討。護理暨健康照護研究，6(2)，79-88。
葉莉莉(2010)。參與式行動研究法及其應用。新臺北護理期刊，12(2)，59-67。
羅元婷、羅慶徽、朱明若、許佩蓉、張俊喜、林金定(2007)。老人跌倒防制策略之探討。台灣老人保健學刊，13(1)，14-28。
盧孳艷、林雪貴、張碧芬（2003）。女性主義參與式研究法在護理研究之應用‧護理雜誌，50(2），57-60。
盧孳艷、楊舒琴、陳秋芳（2003）。批判反思研究法及其應用‧護理雜誌，50（6），51-54。
財團法人醫院評鑑暨醫療品質策進會（2014年8月1日）。病人安全通報系統年度報表。取自http：//www.tpr.org.tw/index03.php?getid=year