以健康信念模式探討醫學中心新生兒病房護理人員施行早產兒疼痛控制措施之現況及其相關影響因素

Abstract

背景：早產兒因器官功能的不成熟，出生後需密集且持續觀察，甚至接受侵入性的檢查與治療，護理人員除維持其生命徵象穩定外，更應避免檢查與治療過程產生的疼痛對早產兒造成的不良影響。近年來，早產兒疼痛控制議題愈發受到重視，如何適當施行疼痛評估及減除早產兒的疼痛之方法，已有大量文獻可供參考，然而臨床上對於早產兒疼痛控制仍不理想。 目的：本文旨在探討 (一) 臺灣醫學中心新生兒病房護理人員執行治療處置種類、 施行疼痛控制措施現況；(二) 探討臺灣醫學中心新生兒病房護理人員對於早產兒接受治療處置時所產生疼痛之自覺感受性、嚴重性程度；(三) 護理人員對於施行疼痛控制措施之自覺利益、自覺障礙程度；(四) 護理人員對其所處環境中，關於早產兒疼痛控制的行動線索存在與否之評定；(五) 探討研究對象之人口學特質、對於疼痛影響早產兒之自覺感受、嚴重性、行動利益及行動線索與施行疼痛控制措施的相關性。 設計：本研究自106年12月30日至106年7月於國內四間醫學中心新生兒病房進行收案，採用橫斷性相關性研究，研究對象為新生兒病房護理人員，以自擬之自填式結構式問卷進行資料收集，問卷包含「護理人員基本資料及單位特性」、「疼痛控制健康信念量表」、「疼痛控制之現況」等三部份，資料以統計套裝軟體SPSS 22.0建檔及進行資料分析，以描述性統計分析參與研究者之調節因素、個人信念、行動線索與施行疼痛控制之現況；以獨立t檢定 (Independent Sample T-test)、皮爾森積差相關係數 (Pearson’s Correlation)、單因子變異數分析 (one-way ANOVA) 呈現參與研究者調節因素、個人信念及行動線索與疼痛控制介入現況相關性；以線性迴歸 (Linear Regression) 分析及階層線性模式 (Multilevel linear models) 探討護理人員個人信念及施行早產兒疼痛控制措施之重要影響因子。 結果：本研究於四間醫學中心新生兒病房收案，共納入159位護理人員，研究發現醫學中心新生兒病房護理人員 (1) 自覺介入常見治療處置對早產兒所產生疼痛感受程度為中度偏向嚴重（總分為0-10分， Mean  SD=5.02.3分至9.0 1.7分）；(2) 自覺介入常見治療處置對早產兒所產生疼痛之影響程度集中於短期影響，認為待疼痛感停止後影響可停止；(3) 施行疼痛控制措施之環境控制項目其執行百分比為七成以上、非藥物式疼痛控制項目執行百分比最低接近六成、藥物式疼痛控制執行百分比位於五成左右；(4) 由階層線性模型統計結果可知，在環境控制部份，行動線索 (p≤0.01) 為其重要影響因子；非藥物式疼痛控制方面則有醫院單位別 (p≤0.01)、自覺嚴重性 (p≤0.01)；自覺感受性 (p≤0.01) 及自覺行動障礙 (p<0.05) 則影響藥物式疼痛控制措施。 結論及建議：本研究顯示護理人員對早產兒執行檢查及治療處置時，大多能提供環境控制及至少一項以上非藥物式介入，然而在藥物式疼痛控制部份僅有五成。在護理人員執行早產兒疼痛控制部份的相關因素，除年資、單位類別、護病比之外，自覺嚴重性、自覺感受性及行動線索亦擔任重要角色，可知護理人員對於早產兒疼痛認知的衝擊及執業單位所提供相關可用資源，會影響其施行疼痛控制行為的品質。根據上述結果，建議未來在新生兒病房可增加相關疼痛課程以期增加護理人員對早產兒接受處置時產生的疼痛強度，以及此疼痛造成的影響程度之認知，建立常規給藥規範、設置專職負責疼痛照護護理人員，使護理人員介入早產兒疼痛控制施行情形更臻完善。

Background: After birth, preterm infants must be intensively observed and treated with a large number of invasive procedures for their immature organs, nurses in addition to maintaining the stability of their vital signs, but also to avoid the adverse effects from procedure pain. In recent years, pain control issues in preterm infants are becoming more important, but although numerous of references can be referred to, pain control for premature is still not ideal in clinical. Subjects: The purpose of this study was to investigate nurses in neonatal centers or neonatal intensive care units how to select the pain control strategies when they provide the invasive procedures in preterm infants, and use the Health Belief Model to analyze the related factors between nurses’ perceived seriousness, perceived susceptibility, perceived benefit, perceived barriers, cues to action and implementation of pain control strategies. Method: We included 159 nurses who met the inclusion criteria from four neonatal centers or neonatal intensive care units in Taiwan medical center. A structured questionnaire developed by researchers was utilized including Staff Basic Information and Nursing Unit Characteristics, Health Belief Scale of Pain Control, Prevalence of Pain Control. Data were analyzed by descriptive statistic and inferential statistics including t-test, one-way ANOVA, Pearson product-moment correlation, Linear regression and Multilevel linear models. Results: The results showed that (1) nurses’ perceived susceptibility of pain was moderate to severe (total score were 0-10 points, Mean  SD = 5.0 ± 2.3-9.0  1.7); (2) the degree of perceived seriousness in the procedure of preterm infants affected by the impact of short-term impact; (3) the percentage of implementation of pain control strategies in preterm infants of the environmental control project was over 70%, pharmacological pain control exacutive rate was close to 60%, and nonpharmacological pain control was about 50%, and (4) from the Multilevel linear models of the results, the action cues have a marked impact on environmental control (P≤0.01), the hospital/unit class (P≤0.01) and perceived seriousness were highly affected with nonpharmacological pain control, and perceived seriousness (P≤0.01) , perceived barriers (p <0.05) affect the pharmacological pain control measures. Conclusion: This study shows that nurses can implementate environmental controls well and at least one of the above nonpharmacological pain controls when performing examinations or treatment of preterm infants, but only 50% of the pharmacological pain controls. In addition to the age, unit, nurese-to-patient ratio, nurses’ perceived susceptibility, perceived seriousness and cues to action also play an important role in the nurses to carry out of the preterm infants’ pain control factors. We can see the impact of nurses on the cognitive impact of premature infants and the relevant resources provided by the unit will affect the quality of their pain control behavior. It should be added cues to action in hospitals, including hold the relevant pain course in order to increase the awareness of the conscious, establish routine about the administration of drug, and set additional responsibility Nurse Practitioner for pain control field, consciously serious care of the nurses, expect the implementation of pain control in preterm infants more perfect.