推開醫療機構的大門－嘉義市護醫人員居家照護經驗

Abstract

本論文試圖解釋隱藏於家庭再生產功能的老人照護需求，其照護資源公共化的現象與影響，文中雖未曾直接切入老人及其家庭照顧者作為研究對象，而是以提供居家照護的護醫人員的照護經驗，來呈現照護資源如何「以老人為中心」流動，而社區照護如何在「家」場域落實。 研究方法是質化取向之深度訪談法與參與觀察法，以居家護理師與往診醫師為研究對象，強調照護是一個地理脈絡的經驗，故要了解照護改變至社區或家的意義，便要探索新的照護脈絡如何生產、如何運作，期望在目前文獻探討非正式照顧者和正式照護人員之間的需求與供給關係之外，補充正式的、組織的照顧者進入家場域工作的照護情境，以呈現專業實踐過程。 家領域提供完整的情境脈絡，醫用者的個體性與獨特性得以展現，醫療專業者得以觀察與聽見更細微的線索，例如身體所透露的生命歷程、老人對自身疾病獨特的診療方式、照顧者的憂苦歡喜以及疾病帶來脆弱、焦慮與無助的感受，醫用者的經驗和感受比以前更加受到重視，「反思的專業者-充權的使用者」在特定的家場域、透過互動情境與互動內容的維繫，於醫用雙方過程中被實現出來。 呈現健康和地方之間的關係與經驗時，誰得到什麼？在哪裡？提出缺乏公共化的面向是很重要的，在整個控制家戶資源和決定政策和執行的結構中，提供居家照護的專業者、老人和家庭照顧者皆位於附屬的、末端的結構地位，要轉化現行對責任和成本的安排，付費的居家醫療照護就是一個在公領域與私領域之間的中介面向，可以用來促進承認家庭和國家是不可分割的事實，探索正式照顧者如何理解他們的角色和責任，正式照顧運作時的經驗與態度，都會有助於了解政策如何轉變為實際運作，藉由「照護工作實際涉入情形」，再概念化「家庭照護是什麼」「社區照護是什麼」，再政治化長期照護。

This paper explores healthcare for the elderly in the context of the reproductive function of the home as well as the impact of healthcare resources going public. While the paper does not feature the elderly and home caregivers as the research subject, it constructs the picture of how healthcare resources circulate around the elderly and how community healthcare is realized in the context of home through presenting the actual work experience of the home healthcare provider. This qualitative-oriented research adopts methods such as in-depth interview and participant observation. A small group of home healthcare nurses and house call doctors constitutes the research subject. As healthcare is closely related to the geographical context, it is essential to explore the creation and operation of the new healthcare network in order to understand how the transformation of healthcare affects the community and the home. In addition to reviewing existing literature on the supply-demand balance for both professional and amateur caregivers, this paper constructs the picture of the legal, organized caregiver working in the context of home. The home provides a complete context, allowing the individuality and uniqueness of the patient to unfold. The home healthcare providers are given the convenience of observing the patient up-close, detecting tiny threads of clues such as the patient’s physical health as shown in the appearance, the unique means of self-treatment adopted by elder patients, the feelings of the caregiver, and the senses of weakness, anxiety, and helplessness that come along with the illness. The experience and feelings of the patient are given more consideration than before. The relationship between “the reflective professional” and “the empowered user” is realized through interaction in the context of home. In presenting the relationship between health and the location factor, two interesting questions emerge: Who gets what? And where? It is important to highlight the absence of the public dimension. Professional home healthcare providers, the elderly, and home caregivers are situated in the bottom layer of the pyramid of policy-making, policy implementation, and the allocation of household resources. Paid home healthcare serves as an interface between the public and private domains, transforming existing arrangement of duties and costs and promoting the recognition of the fact that the home and the nation are inseparable. Through exploring how legal caregivers come to realize their roles and duties, as well as their experience and attitude toward work, the paper develops a better understanding of how policies are implemented. The focus of research shifts from the actual operation of home care, then to the conceptualization of “home health care” and “community care,” and finally to the political context of long-term healthcare.