以病患與家屬為中心的出院準備工具發展與驗證

Abstract

研究背景: 台灣是全球老化趨勢相當快速的國家之一，伴隨著高齡人口遽增，長期照護需求因應增加，特別是連接起急性照護和長照的出院準備服務。 目前西方國家已發展出些許以病患為中心的出院準備工具，讓病患在住院的期間就能一步一步的了解所需的資訊以及照護模式。但是台灣至今所擁有的評估工具大多是以專家角度出發的評估表單，而且並未進行有信效度的檢測，目前缺乏一個以病患與家屬為中心的評估工具。 研究目的: 發展適合台灣以病患與家屬角度出發的出院準備評估問卷，並測量此工具的信效度，探討此工具與一個月後健康狀況與出院準備滿意程度的相關性。 研究方法: 本研究採問卷調查研究法，根據Ya-Mei Chen等人2019年發表的Development of a Patient- and Family-Centered Care Discharge Planning Tool專家會議結果，繼續進行兩輪的德菲法調查，預計發展一個出院準備評估工具(patient-and-family centered discharge planning, PFC-DP)以及後續追蹤問卷(Follow-up PFC-DP questionnaire, FU- PFC-DP)，之後以所發展的問卷作先導測試，並針對問卷內容做信效度檢測。 以訪員使用問卷面訪的方式，於台灣彰化縣衛生福利部彰化醫院進行工具測試，對於年齡50歲以上，住院天數等於或超過五天以上的病患進行資料的收集。符合條件的病患於住院期間進行出院準備問卷的填寫，若出院日期滿30天，則開始進行電話追蹤。 研究結果: 第一回合德菲法問卷題項共31題，27題具有共識（I-CVI ≧ 0.8），4題未達共識（I-CVI: 0.50-0.73），追蹤題項共12題，其中5題未達共識（I-CVI: 0.67-0.77）。第二回合德菲法問卷題項共33題，29題具有共識（I-CVI ≧ 0.8），4題未達共識（I-CVI:0.65-0.77），追蹤題項共17題，其中4題未達共識（I-CVI: 0.65-0.77）。 參與本研究的病患共200位。有66.5%的病患年齡大於65歲且約48.5%的病患是男性。各構面的清楚程度（或困難程度、擔心程度、同意程度、好壞程度、滿意程度）之Cronbach’s α值範圍介於0.71至0.95，另外，是否需要更多協助之Cronbach’s α值範圍介於0.93至0.98，結果顯示各構面下的題目之間具有良好的一致性。之後進行驗證性因素分析，將自我照顧資訊需求構面的第5題刪除，第14、15題合併，並拆成身體恢復的資訊和衛教資訊兩個構面，也刪除社會支持構面的擔心與同意程度。最後出備問卷(PFC-DP)有六個構面，共27題，電訪追蹤問卷(FU-PFC-DP)維持16題。 最後檢驗工具可以預測的結果，發現所有構面的清楚程度(或困難程度)和需要更多協助程度都有顯著相關；個人照護、行動能力、家事活動的困難程度越高，出院後的再住院次數會更多，而自我照護、行動能力、生活品質以及家人的生活品質會越差。另一方面，衛教資訊、行動能力、家事活動、社會支持需要更多協助的程度越高，出院後會越不能遵從醫療人員的指示進行照顧，而身體恢復的資訊需求和衛教資訊越不需要更多協助，對醫院提供的生活與照顧指導會越滿意。 結論與建議: 無論是出備問卷(PFC-DP)還是電訪追蹤問卷(FU-PFC-DP)皆達到良好的信效度，因此建議可以在醫院使用這份工具，補足台灣從專業角度做的出備缺乏的部分，除了讓病患學習對自己準備出院之重要部分，也同時使醫療人員根據此工具評估結果去加強病患的出備。

Background: Taiwan is one of the fastest ageing countries. With the rapid growing older population, the demand for long-term care has increased, especially the discharge planning, which links acute care and long-term care. At present, western countries have developed patient-centered tools for discharge planning, so that patients can understand the required information and care plan step by step during their stay at the hospitals. However, most of the discharge planning assessment tools in Taiwan were developed for health care professional use only and no tool properties were examined. No patient-and family-centered tool was available in Taiwan. Objective: This study was aims to create a patient and family-centered discharge assessment tool that was suitable for Taiwanese older adults and pilot tested this tool’ properties. In addition, explore the correlation between this tool and health outcomes and discharge satisfaction a month later. Method: This study adopted a questionnaire survey method, and based on the results of Development of a Patient- and Family-Centered Care Discharge Planning Tool published by Ya-Mei Chen et al. in 2019. We conducted two rounds of Delphi survey and expected to develop a discharge assessment tool, which is patient-and-family centered discharge planning(PFC-DP) and Follow-up PFC-DP questionnaire(FU-PFC-DP). In the end, we examined the tool properties, including reliability and validity. We pilot tested these tools in the Changhua Hospital, Ministry of Health and Welfare and follow up patients a month after patients were discharged from the hospital. Patients aged 50 years and over, with hospital stays of five days or more were included for the study. Eligible patients fill out the discharge assessment tool during their stay at the hospital, and the researcher contacted the patients by phone after 30 days following their discharge. Result: In the first round, there are 31 questions in the PFC-DP, 27 of which have consensus (I-CVI≧0.8), 4 questions have not reached consensus (I-CVI: 0.50-0.73). In addition, there are 12 questions of FU-PFC-DP, 5 of which have not reached consensus (I-CVI: 0.67-0.77). In the second round, there are 33 questions in the PFC-DP, 29 of which have consensus (I-CVI≧0.8), 4 items have not reached consensus (I-CVI: 0.65-0.77). There are 17 items in FU-PFC-DP, 4 of which have not reached consensus (I-CVI: 0.65-0.77). A total of 200 patients participated in the study. 66% of patients were 65 years old and over, and about 48.5% of patients were male. The internal consistencies of the tools’ clearness (or the degree of difficulty, the degree of agreement, or the degree of satisfaction) has reached Cronbach’s alpha ranging from 0.71 to 0.95. On the other hand, the degree of unmet need (needing more support) has reached Cronbach’s alpha ranging from 0.93 to 0.98, which means there is good agreement among items within each domain. After conducting series of confirmatory factor analysis, we deleted question 5 in the domain of self-care information needs, merged questions 14 and 15, and divide the domain into two domains as the health recovery related information needs and the health education information needs. In addition, the degree of worry or agreement of social support domain was deleted. There were 27 questions in the final questionnaire (PFC-DP), and 16 questions in the follow-up questionnaire (FU-PFC-DP). The predictive validity of the PFC-DP showed that that the clearness (or difficulty) of all domains were strongly associated with the degree of needing more support. What’s more, the more difficulty of the domain of personal care, mobility, and household activities, the higher number of hospitalization after discharge, and the lower self-care ability, mobility, quality of life and family quality of life. On the other hand, the more unmet needs in the domains of health education information needs, mobility, household activities, social support needs more help, the more difficulty to follow the instructions from medical staff after hospital discharge. The lower unmet needs in domain of health recovery information needs and information of health education needs less help, patients and families perceived higher satisfication with the education provided by practitioners in the hospital. Conclusion and Recommendation: Both PFC-DP and FU-PFC-DP have achieved good reliability and validity. It is recommended that these tools can be used in the hospital to supplement professional perspective discharge planning in Taiwan. Not only did patients learn about the necessity of preparing hospital discharges, but health professionals may also use the data to improve their patients’ discharge preparation.