探討護理之家護理師及照顧服務員於照護生命末期住民的經驗與感受

Abstract

背景：護理之家的住民多是患有多重慢性疾病、失能或高齡的長者。對於這些長期居住於護理之家的多數住民來說，也是生命結束前的最後居所。因此，如何在護理之家提供生命末期照護，儼然是一重要議題。然而，在現有的護理之家中，護理團隊通常由護理師和照服員(以下簡稱照服員)組成，他們的主要職責是提供失能住民的日常生活照顧。因此，當住民進入生命的最後階段時，護理團隊(以下指包含護理師和照服員)在生命末期照護的決策、症狀管理和舒適照護等都將面臨重大挑戰。基於此，本研究目的為探討護理之家護理團隊在照護生命末期住民時的實際經驗和內心感受，以增進長期照護人員對於提供生命末期照護的實踐與理解。 方法：本研究為一運用現象學理論之質性研究，自2020年12月01日至2023年02月28日期間，立意取樣於桃園某地區醫院附設之2家護理之家。運用半結構式訪談指引，透過一對一的入深度訪談，了解受訪者在生命末期照護的經驗與感受，利用錄音轉而謄錄為逐字稿，並撰寫反思日誌，依據受訪內容摘錄意義單元進行資料分析，當訪談資料已無新類別或概念再出現時，即視為研究資料飽和，停止收案。 結果：受訪者共有54位，分別為護理師34位，照服員20位，平均年齡為39.52歲，多為女性50人（92.59%），教育程度主要為大學（53.70%）。依據訪談結果歸納五個主題(themes)依序為「面對死亡現身」、「遭逢照護困境」、「調整照護行動」、「超越照護挑戰」及「學習生死課題」，共衍生12項次主題(subthemes)，其中7個次主題是聚焦於經驗層面，而另5個次主題則聚焦於感受層面。研究發現護理團隊在生命末期照護中扮演著核心角色，首先是面對住民在生命終點階段的不確定性和照護困難，其次是護理團隊需要學會靈活調整照護行動與策略，超越末期照護的挑戰，包括加強實務訓練的準備和轉化情緒勞務的感受，再其次是透過末期照護的經驗，受訪者經歷了專業成長的轉變，從常規日常照護逐步轉變至能夠實踐生命末期照護，使住民能在一個安詳且熟悉的環境中完成生命旅程。 討論與結論：本研究提供了對護理之家生命末期照護經驗的全面理解，突顯了護理之家末期照護專業實踐中所面臨的多層面挑戰與成長機會，包含在照護生命末期住民過程中的直接經驗，揭示了溝通技巧、症狀管理以及照護策略調整等多方面的挑戰，運用這些經驗對於改進末期照護實踐具有重要意義，此外，護理團隊起初所面臨的道德困擾、照護壓力和情緒勞務等負面感受，後續也衍生了專業助人和自我成長的正面轉化，理解照護過程中感受的轉變，也有助於增進照護者的心理調適能力。因此依據研究結果，強調提升末期照護品質需增強照護教育、實踐準備及心理情緒支持，並且提高文化敏感度，以應對多樣的家庭背景和需求，護理團隊能夠更細膩地回應末期住民與家屬的照護需求，實現住民的善終願望，並提升護理服務的整體品質。

Background: Residents in nursing homes frequently contend with a complex array of chronic illnesses, disabilities, or the challenges of advanced age. For many individuals, the nursing home represents their final place of residence as they approach the end of life. Consequently, the provision of end-of-life (EOL) care in such facilities is a critical concern. Within these settings, nursing staff—comprising primarily nurses and nurse aides—are tasked with attending to the daily needs of residents with disabilities. This responsibility becomes considerably more complex as residents approach the final phase of their lives, presenting the nursing staff with significant challenges in making informed decisions, managing symptoms, and ensuring comfort in EOL care. Therefore, the purpose of this study was to explore the practical experiences and inner perceptions of nursing staff in caring for residents at the end of life to understand the provision of EOL care. Methods: This study was qualitative research utilizing phenomenological theory, conducted from December 1, 2020, to February 28, 2023. Purposeful sampling was conducted at two nursing homes affiliated with a hospital in the Taoyuan area. Semi-structured interview guides were used to conduct one-on-one in-depth interviews, aiming to understand participants' experiences and perceptions about EOL care. Interviews were recorded and transcribed verbatim and reflective journals were written. Data analysis involved extracting meaningful units based on the interview content. Data collection ceased once no new categories or concepts emerged, indicating that the research data had reached saturation, and no further cases were collected. Results: There were 54 participants in total, comprising 34 nurses and 20 care workers, with an average age of 39.52 years. The majority were female, accounting for 50 individuals (92.59%), and the predominant level of education was university (53.70%). Based on the results, five main themes were identified as "Facing the emergence of death," "Encountering Care Dilemmas," "Adjusting Care Actions," "Surpassing Care Challenges," and "Learning Life and Death Issues," generating a total of 12 subthemes. Among these, seven subthemes focused on the experiential aspect, while the other five centered on the perceptual aspect. This study reveals, firstly, that the nursing staff plays a pivotal role in EOL care, facing the uncertainty and care difficulties of residents in the final stages of life. Secondly, it highlights the need for the nursing staff to learn to flexibly adjust their care actions and strategies to surpass the challenges of EOL care, including the burdens of insufficient practical training preparation and emotional labor. Furthermore, through the experience of EOL care, nursing staff undergo a transformation in professional growth, transitioning from routine daily care to being capable of implementing EOL care, enabling residents to complete their life's journey in a familiar environment. Conclusions: This study provides a comprehensive understanding of the experiences in end-of-life care within nursing homes, highlighting the multifaceted challenges and growth opportunities faced in professional practice. It encompasses the direct experiences of caring for residents at the end of their lives, revealing various challenges in communication skills, symptom management, and care strategy adjustments. Utilizing these experiences is crucial for improving end-of-life care practices. Additionally, the initial negative impacts of moral distress, caregiving pressure, and emotional labor on the care team eventually transformed into positive experiences of professional helping and personal growth. Understanding these shifts in feelings during the care process also helps enhance caregivers' psychological adjustment abilities. Therefore, based on the study results, it is emphasized that improving the quality of end-of-life care requires enhanced care education, practical preparation, and psychological and emotional support. Increasing cultural sensitivity to address diverse family backgrounds and needs is also essential. This enables the care team to respond more delicately to the needs of terminal residents and their families, fulfilling residents' end-of-life wishes and improving the overall quality of care services.