建構緩和安寧療護服務模式於長照機構之行動研究

Abstract

【背景與目的】 臺灣社會快速進入高齡化階段，失能老年人數量逐年攀升，機構照護需求亦隨之增加。入住機構的老年住民多為潛在或現存的安寧緩和照護對象，然而，目前機構內的安寧緩和照護方式主要以個體為單位，缺乏系統性與整合性照護。現行服務模式導致具有安寧緩和需求的住民，無法及時獲得所需的安寧照護，影響其生活品質和末期照護的整體效果。因此，本研究旨在探討現行長照機構內所適合的安寧緩和照護模式，透過行動研究進行：(1) 探索護理之家發展安寧緩和照護模式之歷程與重要關鍵要素、(2) 發展以長照機構整體為實施對象的安寧緩和照護模式、(3) 找出長照機構適切之安寧緩和療護品質指標並檢視其可應用性 【方法】 本研究採用行動研究方法，研究過程分為四個主要階段：初始期、行動期、反思期和成果期。初始期主要進行機構概況調查與需求分析，確立研究目標與範疇，並建立研究團隊與相關利害關係人之間的溝通機制。行動期則著重於設計與實施行動方案，包括以下幾個主要方面：(1) 末期醫療決策意向，針對住民及其家屬進行末期醫療決策的意向調查，了解其對安寧緩和療護的態度和需求，並制定相關決策指導原則；(2) 長照安寧緩和共同照護，建立跨專業團隊，強化醫療、護理、社工及心理等多方面的合作，推動安寧緩和照護的整合性服務模式，確保住民在生理、心理、社會及靈性方面獲得全面的照護；(3) 安寧緩和教育，針對機構內工作人員進行系統性的安寧緩和照護教育訓練，提升其對安寧緩和照護理念及實務操作的理解與技能，並提高其照護品質和專業素養；安寧緩和照護規範與流程制定，根據研究過程中所收集的數據與經驗，制定並完善機構內的安寧緩和照護規範與操作流程，確保其符合住民需求和機構實際運作情況。在行動期結束後進入反思期，透過對行動方案的實施結果進行回顧與分析，識別成功經驗與存在問題，並進一步調整和改進方案。最後，成果期主要是對研究結果進行總結與評估，並將成功的安寧緩和照護模式加以推廣應用，期望能在臺灣長期照護機構內廣泛實施，從而提升住民的生活品質和末期照護品質。 【結果】 本研究採用行動研究方法，旨在發展出適合臺灣長照機構合適的安寧緩和照護模式。長照安寧緩和照護發展歷程(STREAM)，包含以下部分：(1) 系統性評估(System Assessment)：對現有照護體系進行安寧緩和執行現況與資源等評估；(2) 發揮敏感度(Sensitivity)：覺察及理解表層下的社會互動、情感反應與理解他人情緒與反應，以此適時的調整行動計劃目標與策略量；(3) 制行動計劃(Tailor Made Plan)：根據安寧照護需求及機構特性，共同制定行動計畫；(4) 調整與更新行動計畫(Redefining the Way)：理解參與成員的執行經驗與感受，評值安寧照護行動計劃的成效；(5) 引導參與及賦權增能(Empower People)：引導參與者與自身生命中照護或安寧的經驗連結，建立空間促使參與成員表達對安寧照護執行的經驗等；(6) 在脈絡中行動(Action in Context)：在住民家屬、工作人員、機構所屬社區脈絡下行動；(7) 使改變成真(Make Change Happen)：確保行動方案的有效執行與持續改進，以小目標的成功持續累積蛻變的能量。透過這些步驟，建立可落實的安寧緩和照護行動方案，推動安寧緩和照護在長期照護機構中的應用，提升住民的安寧緩和照護品質。 【結論】 行動研究發展出的本土化安寧緩和照護模式，在實際應用中取得顯著成效。系統評估階段發現現有照護體系中存在的缺陷，根據住民與機構的需求，量身定制照護方案，重塑照護方式，改善傳統模式，賦能人員提升了機構工作人員的專業能力和服務品質。在情境中的行動階段，實施了改進措施，並在促成改變的過程中確保方案的有效執行和持續改進。此安寧緩和照護模式更具系統性與整合性，期望未來在國內推展長照安寧緩和照護時，可提供實踐經驗與理論參考依據。

【Background and Purpose】 Taiwanese society is rapidly entering an advanced stage of ageing, with the number of disabled, elderly individuals steadily increasing, leading to a growing demand for institutional care. Many elderly residents in these facilities are potential or current candidates for palliative care; however, the existing approach to palliative care within these institutions primarily focuses on individual cases, lacking systemic and integrated care. This lack of a comprehensive care model results in residents with palliative care needs being unable to receive timely care, negatively impacting their quality of life and the overall effectiveness of end-of-life care. Therefore, this study aims to explore appropriate palliative care models within long-term care institutions through action research, focusing on developing a systemic and integrated approach. The objectives are to investigate the process and critical factors in developing palliative care models in nursing homes, develop a palliative care model implemented across the entire long-term care institution and identify appropriate quality indicators for palliative care in long-term care institutions and evaluate their applicability. 【Methods】 This study employs an action research methodology organised into four main phases: the Initial Phase, the Action Phase, the Reflection Phase, and the Outcome Phase. During the Initial Phase, an institutional overview survey and needs analysis are conducted to establish research objectives and scope and develop communication mechanisms between the research team and relevant stakeholders. The Action Phase, a collaborative effort, focuses on the design and implementation of action plans, encompassing the following key areas: 1. End-of-Life Medical Decision-Making Intentions: This involves conducting surveys on the intentions of residents and their families regarding end-of-life medical decisions to understand their attitudes and needs concerning palliative care. Based on these findings, relevant decision-making guidelines are formulated. 2. Integrated Palliative Care in Long-Term Care: A comprehensive, multidisciplinary team is established to enhance collaboration among medical, nursing, social work, and psychological professionals. This aims to promote an integrated service model for palliative care, ensuring that residents receive comprehensive care across physical, psychological, social, and spiritual dimensions. Palliative Care Education: Systematic palliative care education and training are provided to staff within the institution, aiming to enhance their understanding and skills in palliative care concepts and practices, thereby improving the quality of care and professional competence. 3. Development of Palliative Care Standards and Procedures: Based on data and experiences collected throughout the research process, institutional palliative care standards and operational procedures are developed and refined to ensure they meet residents' needs and align with the institution's operational realities. Following the Action Phase, the Reflection Phase involves an ongoing review and analysis of the action plans' outcomes, identifying successful practices and existing challenges, and making further adjustments and improvements to the plans. Finally, in the Outcome Phase, the research findings are summarised and evaluated, with the successful palliative care models being promoted for broader application. The ultimate goal is to facilitate widespread implementation in long-term care institutions across Taiwan, thereby enhancing residents' quality of life and end-of-life care. 【Results】 This study employs an action research methodology to develop a palliative care model suitable for long-term care institutions in Taiwan. The development process of long-term care palliative care, referred to as STREAM, includes the following components: 1. System Assessment: This involves evaluating the current state of palliative care implementation and available resources within the existing care system. 2. Sensitivity: This step focuses on recognizing and understanding the underlying social interactions, emotional responses, and the ability to perceive others' emotions and reactions. These insights are used to appropriately adjust the action plan's goals and strategies. 3. Tailor-Made Plan: A customised action plan is jointly developed based on the institution's specific characteristics and palliative care needs. 4. Redefining the Way: This involves understanding the participants' experiences and feelings during implementation and evaluating the effectiveness of the palliative care action plan. 5. Empower People: Participants are guided to connect with their own experiences related to care or palliative situations. A space is created to encourage members to share their experiences in implementing palliative care. 6. Action in Context: Actions are taken within the context of the residents' families, staff, and the wider community associated with the institution. This approach fosters a sense of community and shared commitment to improving palliative care. 7. Make Change Happen: This step ensures the effective execution and continuous improvement of the action plan. Small successes gradually build momentum for broader transformation, instilling a sense of optimism and hope for the future of palliative care in long-term care institutions. Through these steps, a practical palliative care action plan is established, promoting the application of palliative care in long-term care institutions and enhancing the quality of palliative care provided to residents. 【Conclusions】 The localised palliative care model developed through action research has achieved significant results in practical application. During the system assessment phase, deficiencies within the existing care system were identified, creating customised care plans tailored to the needs of residents and institutions. This approach reshaped traditional care methods and improved them, empowering staff by enhancing their professional competencies and the quality of services provided. In the action-in-context phase, improvement measures were implemented, ensuring the effective execution and continuous refinement of the plan throughout the change-facilitation process. With its practical benefits, this palliative care model is more systematic and integrated, offering valuable practical experience and theoretical reference for the future promotion of palliative care within long-term care institutions domestically.