臺灣博碩士論文加值系統

台灣兒童安寧概念發展已三十多年，護理人員對安寧療護的認知與態度確實影響安寧療護工作之推動。如何和不同年齡層的瀕死病童及擁有著不同故事的家屬溝通，是兒科臨床工作人員的一大挑戰。本研究目的在探討瞭解：一、護理人員在照顧瀕死兒童與病童及家屬的溝通歷程之內容及感受；二、護理人員在照顧瀕死兒童與病童及家屬的護理人員溝通歷程之想法及技巧建立經驗，以探討護理人員在照護瀕死兒童中的溝通經驗。本研究法採用質性研究法，以立意取樣方式收案，運用自擬半結構式訪談指引和錄音筆作為研究工具，採取深度訪談方式，再以主題分析的方式進行資料歸納分析。
本研究共收案16位護理人員，獲得研究結果之主題為「上善若語」，可再分為二個次主題，分別為「逆語」及「順語」。
逆語可再分為三個類別，分別為「忽略自我的覺察」、「難以突破的桎梏」及「臨床照護的困境」。「忽略自我的覺察」可分為四個次類別，分別為（一）害怕自我的揭露；（二）無限循環的挫折；（三）無法宣洩的壓力；（四）不當結痂的傷口。「難以突破的桎梏」，此類別又可包含四個次類別，包括：（一）安寧訓練的落差；（二）不被信任的感覺；（三）急慢病房護病比；（四）不易轉換的情緒。「臨床照護的困境」則包含四個次類別，分別為（一）過往經驗的不足；（二）陪伴技巧不熟悉；（三）溝通技巧不成熟；（四）教學氛圍不友善。
順語則分為三個類別，分別為「順勢而為的成長」、「提高自我價值感」以及「開啟蛻變的鑰匙」。「順勢而為的成長」又可再分為三個次類別，包括：（一）實戰經驗的累積；（二）被迫成長的無奈；（三）隨機應變的能力。「提高自我價值感」，又可再分為三個次類別，包括：（一）學習自我的肯定；（二）找尋工作的價值；（三）他人肯定的意義。「開啟蛻變的鑰匙」，又可再分為八個次類別，包括：（一）提升自我的知識；（二）透視憤怒的背後；（三）掌握陪伴的策略；（四）跨領域的醫療共識；（五）團隊共善的氛圍；（六）臨床教師的角色；（七）同儕支持的意義；（八）護病共好的要素。
本研究結果期望能廣泛運用於護理教學及實務中，並能幫助護理專業人員面對與瀕死兒童溝通所遇到的障礙及擬具策略有實質的貢獻。

關鍵字：護理人員、瀕死、兒童、溝通經驗。 

The concept of children's palliative care in Taiwan has developed more than 30 years. The awareness and attitude of nursing staff on palliative care have indeed affected the promotion of palliative care. How to communicate with dying children of different ages and family members with different background is a challenge for pediatric clinical staff.
The purpose of this study was to explore:1. The content and feelings of the communication process of nursing staff in caring for dying children and their families; 2. The experience in building ideas and skills of nursing staff on how to communicate with dying children and their families. This research method adopted the qualitative research method, which includes the method of purposive sampling, using the self-designed semi-structured interview guide and the digital voice recorders as the research tools. Using in-depth interviews to understand and the interviews were transcribed and analyzed using thematic analysis.
A total of 16 nursing staff were selected and the theme of the research findings was " Dialogue is the best care ", which can be further divided into two sub-themes, namely " Negative Dialogue "and " Positive Dialogue "
Negative Dialogue can be further divided into three categories, namely, "Ignoring Self-Awareness", "Difficult to Break Through" and "Difficulties in Clinical Care". "Ignore Self-Awareness" can be divided into four sub-categories, namely (1) Fear of Self-Disclosure; (2) Frustration in an Infinite Circle; (3) Pressure to Vent; (4) Improper Scarring Wounds . "Difficult to Break Through," this category can be divided into four categories, including: (1) the Gap in Hospice Palliative Training; (2) the Feeling of Being Untrusted; (3) the Ratio of Care to Illness in the Ward; (4) Not Easily Convertible Emotions. The "Difficulties of Clinical Care" can be divided into four sub-categories, namely (1) Lack of Past Experience; (2) Unfamiliar Companion Skills; (3) Immature Communication Skills; (4) Unfriendly Teaching Atmosphere.
Positive dialogue can be further divided into three categories, namely, "Growth as the Experience Gained", "Improving the Sense of Self-Worth" and "Turning on the Key to Change". "Experience Accumulation" can be divided into three sub-categories, including: (1) the Accumulation of Actual Combat Experience; (2) the Helplessness of Forced Growth; and (3) the Ability to Adapt to the Situation. "Improve the Sense of Self-Worth", and then extract three sub-categories, including: (1) the Affirmation of Self Learning ; (2) Finding the Job Value ; (3) the Affirmation from Others. "Open the Key to Change" can’t be divided into to eight more categories, including: (1) to Improve Self-Knowledge; (2) to See Behind the Anger; (3) to Master the Strategy of Companion; (4) Cross-Disciplinary Medical Consensus; (5) Good Team Atmosphere; (6) Role of Clinical Teachers; (7) Significance of Peer Support; (8) Elements of Good Care.
The results of this study are expected to be widely used in nursing teaching and practice, and can be of substantial help and contribute while of facing the communication of dying children.

Keywords : nursing staff, dying, children, communication experience.

致謝 i
中文摘要 iii
Abstract v
第壹章 緒論 1
第一節 研究背景與動機 1
第二節 研究問題 4
第三節 研究目的 5
第四節 名詞解釋 6
第貳章 文獻查證 7
第一節 台灣安寧緩和護理教育現況 7
第二節 兒童臨終照護重點與困境 9
第三節 臨床溝通的意義與重要性 14
第參章 研究方法 18
第一節 研究設計 18
第二節 研究場域與對象 19
第三節 研究資料收集與紀錄 20
第四節 資料收集與分析 23
第五節 研究嚴謹度 25
第六節 研究倫理 28
第肆章 研究結果 29
第一節 受訪者之基本資料 32
第二節 上善若語 34
第三節 忽略自我的覺察 35
第四節 難以突破的桎梏 40
第五節 臨床照護的困境 44
第六節 順勢而為的成長 48
第七節 提高自我價值感 51
第八節 開啟蛻變的鑰匙 55
第伍章 討論 65
第一節 上善若語 66
第二節 護理人員被剝奪的悲傷 70
第三節 護理瀕死養成教育不符職場需求 73
第四節 無時無刻的挑戰 75
第陸章 結論與建議 77
第一節 研究者自身處境及研究探問形成之反思 78
第二節 重要研究發現 80
第三節 護理實務或教育上的意涵和應用 82
第四節 研究限制及未來研究方向 87
參考文獻 88
中文文獻 88
英文文獻 92
附件 97
附件一 人體試驗委員會同意書 97
附件二 訪談指引 99

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