麻醉科預立特定醫療流程之觀點探討:質性研究

Abstract

背景：因應台灣麻醉專科護理師制度化，推動「預立特定醫療流程（pre-established medical processes, PMPs）」乃確保適法性與病人安全之關鍵；同時，臨床上亦逐漸關注如「可信賴專業活動（entrustable professional activities, EPAs）」等客觀授權機制的發展。本研究旨在探討麻醉臨床團隊對於執行 PMPs 之真實觀點、對相關授權工具的接受度，以及可能面臨之系統性障礙。 方法：本研究採質性研究設計，以立意取樣招募 21 位來自不同層級醫院之核心關係人，包含麻醉醫師、麻專師主管與一般麻專師。資料蒐集運用深入半結構式訪談；資料分析則採取「歸納與演繹並行」取徑：先透過反思性主題分析（reflexive thematic analysis, RTA）執行歸納、編碼與主題萃取，繼以實施研究綜合框架（Consolidated Framework for Implementation Research, CFIR）為理論架構，對實務障礙進行演繹剖析與系統性討論。 結果：文本分析結果歸納出四大核心主題：一、從「口頭默契」到「法理保障」的轉型陣痛，凸顯法規保護網與傳統臨床慣性間之拉扯；二、流程制定的理想與現實落差，揭示跨職類權力角力及「技術別」與「症狀別」任務之標準化困境，並伴隨「臨床僵化」與盲目「治療數據」的隱憂；三、EPAs 作為評核工具的信賴與侷限，指出評核實務易流於「文書作業化」及「人情信任」，且單一標準的評核框架易引發資深人員之專業認同剝奪與心理抗拒；四、行政推動與整合的關鍵因素，證實科部領導者之支持與消弭「資訊孤島」現象為制度落地之樞紐。 結論：落實 PMPs 與相關客觀授權機制（如 EPAs），實為一場牽涉資源、文化與權力分配的系統性變革。欲達兼顧病人安全與學習成效之實質授權，應揚棄單向規範，轉向「系統性賦權」。具體優化策略建議包含：「先易後難」的漸進式推行與任務分層、建構在地化跨職類總結性授權機制、落實資訊系統無縫接軌，以及實施分層教育以滿足不同年資人員之內在動機。

Background: With the institutionalization of anesthesia nurse practitioners in Taiwan, the implementation of pre-established medical processes (PMPs) is crucial for ensuring legal compliance and patient safety. Simultaneously, there is growing clinical attention to the development of objective authorization mechanisms, such as entrustable professional activities (EPAs). This study aims to explore the genuine perspectives of clinical anesthesia teams regarding the implementation of PMPs, their acceptance of related authorization tools, and the potential systemic barriers they may encounter. Methods: This qualitative study employed purposive sampling to recruit 21 core stakeholders across varying hospital levels, including anesthesiologists, NANP supervisors, and general NANPs. Data were collected through in-depth semi-structured interviews. Data analysis followed a hybrid inductive and deductive approach: reflexive thematic analysis (RTA) was initially used for inductive coding and theme extraction, followed by the application of the Consolidated Framework for Implementation Research (CFIR) as a theoretical framework to perform a deductive analysis and systematic discussion of implementation barriers. Results: Textual analysis yielded four core themes: 1. The transitional pains from "implicit verbal agreements" to "legal protection," highlighting the tension between the regulatory safety net and traditional clinical inertia. 2. The discrepancy between idealized protocol design and clinical reality, exposing interprofessional power dynamics and the inherent challenges of standardizing "skill-based" versus "symptom-based" tasks, while also highlighting the latent risks of "clinical rigidity" and the detrimental tendency to blindly "treat the numbers." 3. The trust and limitations of EPAs as an assessment tool, indicating that assessment practices easily devolve into "mere paperwork" and "interpersonal trust," and that a single-standard assessment framework often triggers a sense of professional identity deprivation and psychological resistance among senior staff. 4. The key factors of administrative promotion and integration, confirming that the support of department leaders and the elimination of "information silos" are pivotal for successful institutional implementation. Conclusions: Operationalizing PMPs and related objective entrustment mechanisms, such as entrustable professional activities (EPAs), is essentially a systemic paradigm shift that implicates resource allocation, organizational culture, and power dynamics. To achieve substantive authorization that balances patient safety and learning outcomes, institutions must transition from unidirectional regulations toward "systemic empowerment." Specific recommended optimization strategies include: a stepwise implementation approach paired with task stratification, the establishment of localized, interprofessional summative authorization mechanisms, the seamless integration of information systems, and the adoption of stratified education to foster the intrinsic motivation of personnel across varying levels of seniority.