護理人員對兒童安寧緩和療護溝通障礙與自信心之探討

Abstract

研究目的：現今醫療的進步，救治及延長了許多患有急、重、難、罕疾病病童的壽命，但當醫療到達極限、死亡無可避免時，多數的父母直到病童臨終前都未談論過兒童安寧緩和療護相關議題，另一面，大部分的醫療人員認為在照顧末期兒童時沒有得到足夠的支持，進而對於兒童末期照護溝通備感壓力且缺乏自信。有效溝通是安寧緩和療護的基石，但大多兒童安寧緩和療護相關研究都著重於症狀治療，較少針對護理師在與病童及家屬溝通末期照護之議題進行探討，因此，本研究的目的在了解兒科護理人員對兒童安寧緩和療護溝通的障礙與自信心，並探討及其相關因素。 研究方法：本研究採用量性研究中之描述性相關性研究設計(descriptive-correlational research design)，翻譯並使用結構式自填問卷「安寧緩和療護溝通障礙評估量表」、「安寧緩和療護溝通自信評估量表」做為本研究之主要研究工具，在正式進行資料收集前，依Mapi Research Institute所提出三階段語言翻譯驗證方法進行翻譯及完成內容效度檢定。自2024年3月至2024年8月以國立臺灣大學醫學院附設醫院兒童醫院兒科病房之280位兒科護理師為研究對象進行橫斷性資料收集，共納入211位 (75%) 兒科護理人員參與本研究及完成資料收集。最後以SPSS統計套裝軟體進行資料建檔與分析，並以多元回歸 (Multiple regression) 探討護理人員之兒童安寧緩和療護溝通障礙及自信之相關因子。 研究結果：在「安寧緩和療護溝通障礙評估量表」、「安寧緩和療護溝通自信評估量表」之信效度測試方面，歷經五位專家進行兩輪之審查後，全量表的內容效度指數 (scale-level content validity index, S-CVI) 及每道題項的內容效度指數 (item-level content validity index, I-CVI) 均大於.9，顯示量表具有良好之內容效度。以探索式因素分析量表的因素結構，結果顯示「安寧緩和療護溝通障礙評估量表」包含四個構面，分別為「醫師與主管對護理師參與安寧緩和醫療照護討論支持度」、「角色功能不確定感」、「時間不足」、「安寧緩和療護照護結果與感受」；而「安寧緩和溝通自信評估量表」可分為三個構面，分別為「執行安寧療護角色功能自信程度」、「與醫師溝通與傳達照護需求自信程度」、「評估、辨識、回應家屬疾病了解程度及情緒困擾之信心」，可解釋之變異量分別為68.81%及65.69%。信度方面全量表及各面向Cronbach α介於.79-.92之間，顯示「安寧緩和療護溝通障礙評估量表」與「安寧緩和療護溝通自信評估量表」均具有良好之內在一致性。 在研究目的之分析結果方面，85.8%之受試者認為病人家屬和醫師共同討論病人預後及照顧目標很重要，但大部分的受試者「不曾」或「很少」(分別佔29.4%與43.1%，總共72.5%，) 出席緩和醫療護照護 (Palliative Care) 家庭會議。在「安寧緩和療護溝通障礙」方面，受試者所感受到的溝通障礙之分平均值為2.76分 (給分範圍1-5分)，其中以「角色功能不確定」(分量表平均值3.39分)及「時間不足」 (分量表平均值3.09分) 之障礙較高。在「安寧緩和療護溝通自信心」方面，受試者平均自評得分為2.46分 (給分範圍1-5分)，量表得分平均值皆低於3分。進一步分析兒科護理師之安寧緩和療護溝通障礙與自信之影響因素，影響安寧緩和療護溝通障礙之主要因素包括：臨床疾病相關討論執行頻率(β值介於-.68至-.15)、兒童安寧照護經驗 (β值介於-1.23至-.13)；影響安寧緩和療護溝通自信之主要因素為臨床疾病相關討論執行頻率 (β值介於.07至.48)、醫師與主管對護理師參與安寧緩和醫療照護討論支持度障礙， (β值介於-.25至-.13)、角色功能不確定感(β值介於-1.27至-.13)。 結論：本研究顯示兒科護理人員面臨中等程度的安寧緩和療護溝通障礙及安寧緩和療護溝通自信不足。影響安寧緩和溝通障礙的重要因素為「兒童安寧照護經驗」、「臨床疾病相關討論執行頻率」；影響安寧緩和療護溝通自信的主要因素為「臨床疾病相關討論執行頻率」、「醫師與主管對護理師參與安寧緩和醫療照護討論支持度」及「角色功能不確定感」等三項因素。基於本研究結果，建議未來可藉由增加臨床安寧緩和療護跨域討論會及模擬教育訓練課程，同時營造支持護理師參與安寧緩和療護溝通之臨床環境，以提升護理人員安寧緩和療護溝通自信及整體兒童安寧緩和療護照護品質。

Objective:Advances in healthcare have significantly prolonged the lives of children with acute, critical, complex, and rare diseases. Nevertheless, once treatment reaches its limits and death becomes inevitable, most parents avoid discussing pediatric palliative care (PPC) with their children until the terminal phase. Meanwhile, many healthcare providers report insufficient support when caring for terminally ill children, leading to stress and a lack of confidence in end‑of‑life communication. Effective communication is the cornerstone of palliative care. However, existing research on PPC has predominantly focused on symptom management, whereas literature on nurses’ communication regarding terminal care with patients and families remains scarce. The purpose of this study was to explore the communication barriers perceived by pediatric nurses during PPC, assess their self‑confidence in end‑of‑life communication, and identify related factors. Methods:Using a descriptive-correlational research design, this study employed two structured, self‑administered questionnaires (i.e., the Palliative Care Communication Barriers Scale and Palliative Care Communication Self‑Confidence Scale) as the primary research instruments. Using the three‑stage process proposed by the Mapi Research Institute, both questionnaires were translated, and their content validity was examined prior to data collection. Subsequently, from March to August 2024, a cross‑sectional survey was conducted among 280 pediatric ward nurses at the National Taiwan University Children’s Hospital. Among them, 211 (75%) completed the data collection process and were enrolled in the study. Data were compiled and analyzed using SPSS statistical software. Multiple regression analyses were performed to identify factors associated with communication barriers and self‑confidence in PPC. Results:After two rounds of reviews by a panel of five experts, both the Palliative Care Communication Barriers Scale and Palliative Care Communication Self‑Confidence Scale demonstrated superior content validity, with their scale level (S CVI) and item level content validity indices (I CVI) exceeding 0.90. In terms of construct validity, an exploratory factor analysis revealed that the Palliative Care Communication Barriers Scale comprised four dimensions, namely “physician and supervisor support for nurseinvolvement in palliative discussions,” “role uncertainty,” “insufficient time,” and “outcomes and feelings toward palliative care.” Alternatively, the Palliative Care Communication Self‑Confidence Scale comprised three dimensions, namely “confidence in performing palliative nursing roles,” “confidence in communicating care needs with physicians,” and “confidence in assessing, recognizing, and responding to families’ disease understanding and emotional distress.” Collectively, these domains explained 68.61% and 65.69% of the variance, respectively. Cronbach’s α for the total scales and each subscale ranged from 0.79 to 0.92, indicating high internal consistency between the two questionnaires. The survey results revealed that 85.8% of the study participants agreed that joint discussions between families and physicians about prognosis and care goals were important. However, most participants “never” or “rarely” (29.4% and 43.1%, respectively, totaling 72.5%) attended palliative care family meetings. On the Palliative Care Communication Barriers Scale, the mean score for perceived communication barriers was 2.76 (range: 1-5), with higher scores observed for “role uncertainty” (mean: 3.39) and “insufficient time” (mean:3.09).On the Palliative Care Communication Self‑Confidence Scale, the mean score for self‑confidence was 2.46 (range: 1-5), with the mean scores of all subscales below 3. Further analyses of factors affecting pediatric nurses’ palliative care communication barriers and self-confidence . Factors associated with communication barriers include the frequency of clinical disease‑related discussions (β = -0.68 to -0.15) and prior PPC experience (β = -1.23 to -0.13). The main factors influencing confidence in palliative care communication include the frequency of clinical disease-related discussions (β=0.07 to 0.48), perceived barriers due to lack of support from physicians and supervisors for nurses’ involvement in palliative care discussions (β= -0.25 to -0.13), and communication barriers related to role uncertainty (β= -1.27 to -0.13). Conclusions:This study revealed that pediatric nurses experience moderate communication barriers and insufficient confidence when engaging in PPC.” Key factors influencing communication barriers were “prior PPC experience” and the “frequency of clinical disease‑related discussions.” Factors influencing self‑confidence included the “frequency of clinical disease‑related discussions,” “physician and supervisor support for nurses’ involvement in palliative discussions,” and role uncertainty. Based on the findings of this study, it is recommended that future efforts focus on increasing interdisciplinary palliative care discussions and simulation-based training programs. Additionally, creating a supportive clinical environment that encourages nurses to participate in palliative care communication may help enhance their confidence and improve the overall quality of PPC.