發展胎兒死亡事件之照護模式—行動研究法之應用

Abstract

胎兒死亡常是突發且無法預期的，對於一個期待新生兒的家庭而言，此是一件憾事，它會衝擊與此事件有關的人，包括婦女家庭、以及護理人員。我國的文化仍視胎兒死亡為不可言說的禁忌，許多醫護人員未覺知自身的哀傷，也不知道該如何自我調適，更沒有合適的方法引導婦女表達哀傷，因此發展一個適合我國文化的照護模式已是刻不容緩。但要發展一個合適的照護模式需要先了解胎兒死亡事件婦女的經驗、調適及其對照護的期望；也要能了解提供照護的護理人員她們在照顧這些婦女的感受、自我調適、所提供的照護內容，以及她們認為若能做甚麼就可以提升照護品質? 因此本文分成三部分探討： 第一部分深入探討婦女的經驗、調適與照護期望，研究者以觀察-會談法收集十位婦女的資料，將互動過程寫成行為過程記錄，請二位研究對象檢視研究結果是否符合其感受，確認研究結果能得到類似經驗者的共鳴，資料之計分者內在信度為88.7%；計分者間信度為81.2%。經內容分析且依產前、待產、產後的時間序得到的結果是：婦女在胎兒死亡事件的經驗為：「胎兒突然死亡的衝擊」、「失去所愛的心痛」、「意外的退奶經驗」、及「學習放下與再生」；她們的自我調適方式是：「多方確認胎兒死亡的證據」、「詮釋胎兒死亡的意義」、「確認胎體受到妥善安置」、及「促進家庭和諧與生活回復正常」；她們對照護的期望是：「相關資訊的提供」、及「提供一個關懷的環境」。研究者也以敘事方法，依事先擬定之訪談指引訪談唯一一位同意接受敘事訪談的婦女，了解其經歷事件的始末。 研究的第二部分是探討護理人員在照護胎兒死亡事件的感受、調適、所提供的照護，以及對理想照護的建議，研究者利用訪談指引以個別及小組訪談方式，所有訪談皆有錄音，在事後謄寫成紙本，以內容分析法萃取出主題，其計者分者內在信度為87.8%，計分者間信度為80.8%，上述資料皆依Lincoln & Guba (1985)之內容真實性(credibility)、可轉移性(transferability)、一致性(confirmability)，及中立性(dependability)來提升內容的值得信賴度。結果發現：護理人員於照護胎兒死亡事件之感受有二大主軸：哀及怕，她們會為胎兒，以及為母親感到哀傷而出現「哀」的感受，因「對死亡的先存態度」、「害怕胎兒遺體」、及「擔心說錯話」而產生「怕」的感受；以及因「應對困難與挫折感」、「繁忙工作及專業形象的限制」而有「無力感」；她們的自我調適方式包括「努力將自己與事件隔開」，及「尋求支持」；她們多半用自己的方法提供照護措施，包括「給她一個空間療傷」、及「嘗試提供照護」；護理人員覺得提升照護品質的是：「照護越早介入越好」、以及「強化護理人員的照護能力」，可以使婦女得到更好的照護。 第三部份即依婦女及護理人員的資訊進行行動研究，以確認所擬定的照護模式是護理人員能提供且符合婦女的照護需求，照護開始的時間儘可能提早到婦女來門診尋求確認胎兒狀況的時候，每一次行動研究循環都參考婦女及家屬的建議，在與包括單位護理長、專科護理師、以及實際提供照護者的小組成員的反思及討論後，依據醫院政策及執行可行性進行修改，產生下一次的模式內容，經過四次循環，已確定方向，再以一位產房開始接觸的婦女進行照護，確認此照護模式亦能適於產房開始照護的婦女，經過小組確認照護模式定案，並由專科護理師接手運作一次。 本研究結果發現主責照護者，可以應用領航護理師概念，傾聽特定族群的感受與期望，提供衛生教育等資訊，並進行跨部門或跨單位之聯繫溝通，使其照護更具連續性及一致性。研究結果所產生的臨床實務建議，包括理解婦女的感受，對哀傷的婦女及家屬多予關懷，在其情緒慌亂的時候給予陪伴及理解，說明待產及胎兒處理流程，提供選擇，產後依個別狀況提供產後退奶及產後生理變化之資訊等措施，都能有助於改善婦女的負向情緒。在護理教育部分則建議將婦女及護理人員的經驗感受、調適、對照護的期望納入養成教育及在職教育，透過了解他人及自我了解，以及具體的處理方式以利提升照護能力。 本研究的貢獻包括發展胎兒死亡事件之照護模式，不僅符合這類婦女與家人的需求，也提供各醫院產科單位一個可行的專業照護流程；此外，本研究採取觀察-會談法收集資料，發現此種方法可適用於少話、被動，且不容易有後續接觸機會的哀傷族群，敘事方式雖限於只有一位婦女同意參與，但也能藉其故事理解其感受，並使其能在說故事的過程中宣洩其哀傷，研究結果看到領航護理師角色在此族群的重要性，亦可作為未來護理專業另一個拓展空間的參考。

Fetal death is often sudden and unpredictable, and is devastating to a family expecting a newborn. Fetal death has an impact on anyone involved in this event, including the woman’s family and nursing personnel. In the culture in Taiwan, fetal death is still regarded as an ineffable taboo. Many medical and nursing personnel do not perceive their own sorrow, neither do they know how to adjust themselves or use appropriate approaches to guide women to express sorrow. Therefore, there is an urgent need to develop a nursing program suitable for the culture in Taiwan. However, in order to develop an appropriate nursing program, it is necessary to understand women’s experiences of fetal death events, as well as adjustments and expectations regarding nursing care. In addition, it is necessary to understand the feelings, self-adjustments, and care content of the nursing personnel providing care to these women, as well as how to improve care quality as perceived by them. Therefore, this study is divided into 3 parts: Part 1 is the in-depth investigation of women’s experiences, self-adjustments, and expectations towards nursing care. This study used participant observations as “obser-view” to collect the data of 10 women, and documented the interactive process as process recordings. This study invited 2 subjects to inspect whether the research results are consistent with their feelings, and confirm that people with similar experiences can resonate themselves with the research results. Regarding the data scoring, the intra-rater reliability is 88.7%, and the inter-rater reliability is 81.2%. The results of content analysis are as follows: women’s experiences of fetal death events are: “impact of sudden fetal death,” “heartbreak for the loss,” “accidental experience of postpartum lactation suppression,” and “letting go of the past and looking forward to the reborn.” Their self-adjustments are, as follows: “multi-confirmation of the evidences of the fetus death,” “interpreting the meaning of the death of a fetus,” “making sure that the fetal remains are properly handled,” and “regaining normal life.” Their expectations towards nursing care has two aspects: “provision of related information” and “providing a environment with caring ,” including the provision of independent space to avoid recalling sorrow, notification of information on examinations and handling of fetal remains, provision of information on prevention of a similar event, and follow-up on women’s postpartum lactation suppression and uterine involution. Part 2 is the investigation of the feelings, self-adjustments, nursing care providing to the women, and suggestions for the ideal care of nursing personnel in fetal death events. This study used interview guidelines to perform individual or group interviews, which were all recorded. After the interviews, this study converted the interview content into transcripts, and used content analysis to extract the themes. The intra-rater reliability is 87.8%, and the inter-rater reliability is 80.8%. The content credibility, transferability, confirmability, and dependability of Lincoln and Guba (1985) were used to improve the reliability of the data. The research results showed that: nursing personnel’s feelings about fetal death are mainly divided into two parts: sorrow and fear. They feel sorrow for the fetus and mother. They feel fear because of their “existing attitude towards death,” or because they are “afraid of fetal remains,” “worried about saying anything wrong,” and their feel “helplessness.” Their self-adjustments include: “endeavoring to separate themselves from the event” and “seeking support.” They usually use their own approaches to provide care measures, including “providing the woman with a healing space” and “trying to provide care.” The nursing personnel suggest that the approaches to improve care quality are: “early intervention of care” and “strengthening nursing personnel’s care ability.” Part 3 is the action research conducted according to the information of the women and nursing personnel to confirm that the developed care model can be provided by nursing personnel, and it meets the care needs of women. The start time of care should be as early as the moment when women come to the outpatient clinic to confirm fetal status. The cycles of each action research were developed according to the suggestions of women and their family members. After the reflections and discussions of the head nurse, nurse practitioners, and team members who actually provide care, this study modified the care model according to hospital policy and the feasibility of implementation to develop the next model content. After 4 cycles, the direction was ascertained. The nursing personnel provided care to women from contact at delivery in order to ensure that this care model applies to women starting to receive care at the delivery room. After the confirmation of the care model by the team, nurse practitioners operated it in person. This research results showed that, primary caregivers can use the concepts of navigator nurse to listen to the feelings and expectations of specific populations, provide health education, and implement inter-sectoral or inter-unit communications to provide continuous and consistent nursing care. The suggestions on clinical practice generated from the research results include: to understand women’s feelings, to provide more care to women and family members who feel sorrow, to provide companionship and understanding when they are in emotional chaos, to explain the procedures of labor and processing of fetal remains, to provide choices, and to provide the information of postpartum lactation suppression and physiological changes according to individual conditions. The said measures all are beneficial to the improvement of women’s negative emotions. In terms of nursing education, it is advised to include the experiences, feelings, adjustments, and expectations towards care of women and nursing personnel into general education and in-service education. In this way, nursing personnel’s care ability can be improved through the understanding of others and selves, as well as specific handling methods. This research contribution is the development of a nursing program for fetal death events, which not only meets the needs of women and their family members, but also provides the Division of Obstetrics of various hospitals with feasible professional care procedures. Moreover, this study used “obser-view” to collect interview data, and found that this method only applies to populations in sorrow who are short-spoken and passive, and cannot be contacted afterwards. Although only one woman agreed to participate in the narrative method, her feelings could be understood through her story. In addition, the story-telling process enabled her to vent the emotion of sorrow. The research results showed the importance of the role of navigator nurse in this population, and can be provided as reference for future expansion spaces of nursing professionals.