臺灣博碩士論文加值系統

背景：多數病人寧願在自己家中臨終，然而病人仍多數在醫院臨終。但近年由於高齡化、高醫療給付制度，健保給付的住院天數限制及癌症末期與八大類慢性疾病均納入居家安寧療護健保給付範圍，因此居家安寧療護是逐漸成為重要且日漸增加的照護模式。然而居家安寧療護之家屬照顧者的主觀生活歷程經驗如何?家屬照顧者對於生病末期家人的居家安寧療護準備度如何?較少本土性之探討。
研究目的：研究分為三階段：(一)探討居家安寧療護之主要家屬照顧者的生活歷程經驗;(二) 建構居家安寧照顧準備度量表(The Readiness of Home-Beased Palliative Care Scale, RHPCS)(以下簡稱RHPCS)，並評值信度及效度。(三)探討主要家屬照顧者之RHPCS及其預測相關因素
研究方法：研究分為三階段：(一) 以一對一深度訪談北部某區域級醫院社區收案至分析飽和；(二) 依據第一階段質性研究結果，建構RHPCS的信度及效度；(三) 相關性研究法。收案樣本為北部某醫院中心社區居家安寧療護之主要家屬照顧者。
研究內容及結果：第一階段共有22位家屬平均年齡59.7歲(45-76歲)。其照顧之病人有癌症7位、非癌症15位，已接受居家安寧服務時間為二個月至2年8個月，以持續比較法分析訪談資料，分析結果如下：〝家屬對居家安寧療護具共識〞情況下，即開始〝全心全意居家陪伴照護其生命末期的親人〞的生活歷程。在此歷程中，主要家屬照顧者出現的互動行為類屬包括：〝學習居家照護的基本技能〞、〝安排分擔和輪替以減輕照護的負擔〞、〝為即將死亡的家人做準備〞、〝協商即將死亡的家人從醫院回到家〞、〝隨侍在側，提供不插管的基本生命維持之舒緩生活〞，家屬照護者常保持自我鼓勵以關懷、毅力和耐心來保持其心境與生活適應。第二階段建構「居家安寧照顧準備度」量表的信度及效度，共收集103位居家安寧療護之主要家屬照顧者，平均年齡61.17歲；效度方面：專家效度CVI值為0.95；驗證性因素構面分析以 15 題項與次量表構面之模式為良好適配，次量表構面分別命名為「親情維繫與共識」、「居家照護技能與臨終準備」、「安排分擔和輪替」、「隨侍在側處理緊急及舒緩照顧」，發展的一系列模式指標(統計檢定量)，絕對適配檢定指數、增值適配檢定及精簡適配檢定結果皆達標準，各潛在變項負荷因素構面負荷量介於.78-.90 之間，顯示模式基本適配度良好，整體模式適配度指標方面，絕對適配度中，RMR= .021、SRMR=.074；增值適配檢定方面 NFI=.90、CFI=1.00、IFI=.91；簡效適配檢定方面 PNFI= .72，皆達適配標準；同時效度則以照顧者支持需求評估量表(The Carer Support Needs Assessment Tool, CSNAT)經翻譯及反翻譯中文版(Chinese version)進行相關係數檢定，顯示CSNAT量表與本量表呈現正相關(相關係數=.919達顯著相關，P＜.0001)。總量表之信度 Cronbach'sα係數為.928，次量表構面之信度分別為:親情維繫與共識(.859)、居家照護技能與臨終準備(.879)、安排分擔和輪替 (.875)、隨侍在側處理緊急及舒緩照顧(.860)，顯示有良好的信、效度。第三階段: 103位主要家屬照顧者之居家安寧照顧準備度介於大多準備至充分準備之間，與以下因素成相關：體重、BMI、主要家屬照顧者職業、病人有無接受外籍或本國籍看護的服務及與親屬的關係；其解釋之總變異量為23.4%，(F值為4.878，p=.000 )，達顯著水準。次量表構面對居家安寧照顧準備度總分的解釋變異量為92.9%(F值=321.893，p=.000) ，達顯著水準。
建議：居家安寧主要家屬照顧者應有全方位的準備應具備，兼具身、心、靈及社會(資源運用等)及親人死亡文化習俗等各面向的準備。「居家安寧照顧準備度」量表，具良好的信效度，未來可運用居家安寧療護相關實務及研究。此外，對於體重過重者，親屬的關係ヽ疾病別及有無接受看護的服務等提供參考照顧家屬身心評估之準備與篩檢。

Background：Most patients prefer to die at their own homes due to the increased issues of aging, high medical payment system and limitation of hospitalization days. Therefore, Home-based palliative care is becoming more and more important. Terminal cancers and eight chronic diseases are covered in palliative care that can be paid by Health for All Insurance. Home-based palliative care model that is getting more and more important and is on the increase gradually. However, being the family caregivers, what are their subjective life experiences? In regard to the home-based palliative care for the terminally-ill patients, what is their family members’ readiness? Few local studies conducted it as yet. It is crucial to promote home-based palliative care by paying attention to the family caregiver’s subjective values and readiness.
Purpose: The research is divided into three phases: (1) Exploring the main family caregivers’ life experiences of home-based palliative care; (2) constructing the reliability and the validity of the “Home-based Palliative Care Readiness scale” (RHPCS (3) Exploring the main family caregivers’ readiness for home-based palliative care, the related factors and its prediction.
Method: The three phases applied the following research methods: (1) A qualitative study was conducted on the basis of grounded theory; (2) Scale development and investigation; (3) Correlational Study.
Result: Phase I: In total, 22 Primary Family caregivers aged 45-76 years participated in in-depth interviews. The data were analyzed using the constant comparative method.
“Being with the terminally-ill family member with whole heart and provide home care” was the core category for describing and guiding the life process of Primary Family caregivers. During this process, “Family consensus-
Home-based palliative care” was identified as antecedent condition. Once women felt these types of discomforts, they began “Being with the terminally-ill family member with whole heart and provide home care.” This process was marked as a life cycle by action and interaction among the categories of “Learning the basic skills of home-based care”, “Reducing the burden by sharing and
rotating the care”, “Preparing for the upcoming death for the patient”, “Negotiating
to return home for the dying patient”, and “Being by the patient’s side and ensuring
a comfortable life with basic life support and no intubation”. Finally, most family
caregivers keep self-encouragement- care, perseverance and patience to maintain
their state of mind and the adaptation to life. Phase II: the
average age of 103 main family caregivers aged 61.17 years accepting home-based
palliative care is recruited to proceed with RHPCS to construct reliability and
validity testing. On the aspect of validity: Expert Validity CVI value is 0.95;
Confirmatory Factor Analysis (CFA) adapts 15 questions to the four factors, which are
categorized into subscales: “Family Relationship Maintenance and Consensus”, “Home-based Palliative Care Techniques and End-of-life Preparation, “Arrangement of Sharing and Rotating for the caregivers”, and “Standby on Emergency and Palliative Care”. This series of model indicators (test statistic), absolute fit measure index, incremental fit test, and parsimonious goodness-fit test (PGFI) have all reached the standards. Each latent variable has a value of 0.78 – 0.90 in factor loadings, which means the basic fit test is optimal, and the absolute fit test index of the general model fit indicator is moderate, with a RMR of 0.021, SRMR of 0.074. As for the incremental fit test, the NFI value is 0.90, CFI value is 1.00, while IFI value is 0.91. The parsimonious fit index has a value of 0.72 in PNFI, which have all reached the standards. At the same time, the validity is evaluated by the Carer Support Needs Assessment Tool (CSNAT), which is translated and back translated into a Chinese version. The result is a value of 0.919 (P<0.0001), which shows a positive correlation of CSNAT with the scale. The prediction of validity, RHPCS and the subscales may jointly predict the variance of 93.0%, with the R-square value of 0.971 for the preparation of home-based palliative care. As for reliability test, the Cronbach’s α coefficient of the scale is 0.928, and the subscales are 0.859 for “Family Relationship Maintenance and Consensus”, 0.879 for “Palliative Care Techniques and End-of –life Preparation”, 0.875 for “Arrangement of Sharing and Rotation for the caregivers”, 0.860 for “Standby on Emergency and Palliative Care”, which shows that RHPCS has good validity and reliability. Phase III: 103 family caregivers showed RHPCS is correlated to the following factors: weight, BMI, the career, whether or not the patient is accompanied by a hired caregiver, and also the relationship of the patient with his/her family and relatives. Significant level was the total variance explained is 23.4% (F value=4.878, p=0.000). The relationship of the subscales structure to the total score of the RHPCS. Significant level was the total variance explained is 92.9% (F value = 321.893, p = .000).
Suggestions:
The main family caregiver responsible for the palliative care of patient should have comprehensive readiness of physiological, psychological, social, and cultural custom readiness for the family member’s death. RHPCS is a reliable and valid tool for health providers to make an assessment for patients accepting palliative care, which includes factors. It provides a way to understand to what degree the main family caregivers are prepared for the patient’s accepting home-based palliative care. This can also be applied to pre-assess for discharge, evaluation for the new case of home-based palliative care. The predictors of RHPCS include weight, BMI, relationship status with the patient, illness of the patient, whether or not the patient accepts a hired local or foreign caregiver, and so they can be used for reference to assess and screen the readiness of family caregivers who are taking care of the patient.

摘要…………………………………………………………………………….……..i
目次…………………………………………………………………………….……iv
表次…………………………………………………………………………….……vi
圖次…………………………………………………………………………….…..viii
第一章 緒論
第一節 研究背景、動機及重要性………………………………………….……..1
第二節 研究目的………………………..………………………………….……..5
第三節 研究問題…………………………………..……………………….……..5
第四節 名詞界定……………………………..…………………………….……..6
第二章 文獻探討
第一節 居家安寧療護知識的進展……………………………..………….……..7
第二節 居家安寧療護的概念………………………………….…………….….13
第三節居家安寧療護之照顧者的照顧準備度相關實證..…………….…….….22
第三章 研究方法
第一節 研究設計……………………….………………………………….…….31
第二節 研究架構………………………………………….……………….…….32
第三節 第一階段質性研究…………………………………………….…….….32
第四節 第二階段建構RHPCS的信度及效度.……………………………...….38
第五節 第三階段相關性研究法………………………………….……………..46
第六節 倫理考量………………………………………….………………….….47
第四章 研究結果
第一節 居家安寧療護主要家屬照顧者之生活歷程經驗..…………………….48
第二節 建構RHPCS，並評值信度及效度….…………………….…..…….…61
第三節 RHPCS驗證性因素分析….…………………….…..………….………83
第四節 主要家屬照顧者人口學特性、RHPCS及效標量表之描述.……........87
第五節 主要家屬照顧者之RHPCS及其預測相關因素………………...…….99
第六節 RHPCS次量表分數對總分的預測力…….………………..………….112
第五章 討論
第一節 居家安寧療護之主要家屬照顧者的生活歷程經驗討論…………….115
第二節 建構RHPCS，並評值信度及效度(和CSNAT之差異，國情文化
不同)討論………………………………………..……………….122
第三節 RHPCS編制討論……………….……..……………………………....124
第四節 主要家屬照顧者之照顧準備度及其預測相關因素討論………...…..129
第六章 結論、建議與研究限制
第一節 生命末期病人照顧者居家安寧療護之照顧經驗……….……..…..137
第二節 RHPCS發展及其信、效度檢定………………….….….....….……138
第三節 探討主要家屬照顧者之居家安寧照顧準備度及其預測相關因素….140
第四節 研究應用與建議………………………………………….…............141
第五節 研究限制..……………..………………………………….…..…......142
參考文獻
中文部分…………..…………………………………………………….............143
外文部分………………..……………………………………………….…........146

附錄
附錄一 前驅性質性研究……..………………….……………………...…..…..162
附錄二 專家效度審查表……………………..………………………......…......207
附錄三 RHPCS之專家效度名單(按姓氏筆畫排序)……………….…..….......209
附錄四 連續性變項常態分佈檢定結果.……………………….…….……..….210
附錄五 The Carer Support Needs Assessment Tool (CSNAT)使用授權書....….215

表次
表4-1 主要家屬照顧者之人口學特性.……………………………….….....…...49
表4-2 病人疾病特性………….…………………………………….………..…..50
表4-3 準備度次量表依質性訪談結果說明….……………………………...…..61
表4-4 RHPCS專家效度暨建議…………………….…………………………….67
表4-5 RHPCS次量表及題項適配結果……………………..…………..…..……69
表4-6 RHPCS題項分析-專家效度……………………..…………….…………..71
表4-7 RHPCS……………….……………………….………………………….…73
表4-8 CSNAT………………………………………………………………..….....76
表4-9-1 RHPCS與CSNAT之Pearson’s相關檢定(n=30)….………………….. 77
表4-9-2 RHPCS與CSNAT之Pearson’s相關檢定(n=103)……………………..77
表4-10-1 RHPCS與次量表對準備程度之變異量解釋力(n=30)………………. 78
表4-10-2 RHPCS與次量表對準備程度之變異量解釋力(n=103)………………78
表4-11-1 RHPCS內部一致性(Cronbach's α)…………………………………..80
表4-11-2 RHPCS各題項內部一致性(Cronbach's α)…………………………..80
表4-12 RHPCS各題項次量表相關因素分析........................................................83
表4-13 RHPCS次量表親情維繫與共識各題項相關因素分析............................84
表4-14 RHPCS次量表居家照護技能與臨終準備各題項相關因素分析............84
表4-15 RHPCS次量表分擔和輪替各題項相關因素分析……………….……...84
表4-16 RHPCS次量表隨侍在側處理緊急及舒緩照顧題各項相關因素分析....84
表4-17 RHPCS驗證性因素分析各題項與次量表整體模式適配度指標……....86
表4-18主要家屬照顧者人口學特性……………………………………………..88
表4-19 RHPCS與CSNAT得分分析…………………………………….……….91
表4-20 RHPCS各題項得分分析………………………………………………….93
表4-21 RHPCS各題項得分之描述性統計分析.....................................................95
表4-22 CSNAT各題項得分分析………………………………………………….97
表4-23 CSNAT各題項得分之描述性統計分析………….………........................98
表4-24 RHPCS總分與CSNAT總分之相依樣本t檢定.......................................99
表4-25 主要家屬照顧者人口學連續性變項常態分佈檢定…………………....100
表4-26主要家屬照顧者人口學特性與RHPCS總分相關分析………………..101
表4-27 主要家屬照顧者人口學特性與準備度次量表之相關分析....…………105
表4-28 主要家屬照顧者BMI與疾病之相關性分析………..............................107
表4-29 主要家屬照顧者人口學特性對準備度之總分、次量表預測之逐步
迴歸分析………………………………..………………..….……….109
表4-30 RHPCS次量表分數對總分之逐步迴歸分析……..………….…..…......112
表4-31 RHPCS次量表各題項分數對總分之逐步迴歸分析…………………...113

圖 次
圖3-1 研究流程……………………………………………………………………31
圖3-2質性概念架構..................................................................................................37
圖3-3信效度檢定流程….…………………………………………………………39
圖4-1 主要家屬照顧者之照顧經驗概念架構圖……….........................................51
圖4-2直方圖暨標準化常態機率圖..........................................................................79
圖4-3 RHPCS驗證性因素分析結果…………………………..…........................86
圖5-1 CSNAT與概念架構比較……………………………………… .………….123
圖5-2 CSNAT與RHPCS比較圖…………… ……………………….…………..124

中文部分
中央健康保險署( 2014，1月27日)‧新聞發布，「在地善終」不再遙不可及，健保自103年元月起，新增社區安寧療護服務納入健保給付．取自https://www.nhi.gov.tw/News_Content.aspx?n=A7EACB4FF749207D&sms= 587F1A3D9A03E2AD&s=6B2C44A62273A313
中央健康保險署( 2015，1月23日)．(1) 安寧緩和醫療條例相關法條及相關同意書及\意願書‧取自https://www.nhi.gov.tw/Content_List.aspx?n=67D59157C6CF1314&topn=D39E2B72B0BDFA15
中央健康保險署( 2017，2月23日)‧安寧療護(住院、居家、共照及社區)網路查詢服務‧取自https://www.nhi.gov.tw/Content_List.aspx?n= 46505DE49DF0A
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