腦部損傷病患照顧者出院前壓力感受與情緒反應探討

Abstract

本研究為橫斷式描述性相關研究，研究目的在探討主要照顧者在腦部神經損傷病患出院前的壓力感受與情緒反應相關因素。以立意取樣方式，於北部某醫學中心神經內外科病房收集63位腦部神經損傷病患之主要照顧者，運用結構性問卷包含腦部損傷患者主要照顧者壓力感受問卷、流行病學憂鬱量表（CES-D）、情境焦慮量表（SAI）、病患與照顧者的基本資料表與照顧資源問卷，與照顧者面對面親自訪談進行收集資料。研究對象所照顧的腦部損傷病患疾病多以腦部梗塞為主，平均為65.38歲，男性，屬輕度腦部損傷，巴氏指數平均為13.33分；主要照顧者平均年齡為48.69歲，多數為女性、高中職學歷、已婚、為病人的配偶、與病患感情還不錯、自覺健康狀況普通、平均照顧時數為14.44小時。將所得資料進行描述性統計與推論性統計分析。研究結果如下： 一、照顧者於病患出院前自覺有輕度到中度的壓力感受、65.1%的人具有憂鬱傾向。 二、照顧者在病患出院前最擔心的前十項壓力事件順序為：「病況再次發生變化」、「害怕病人死亡」、「花費增加、支出增加」、「缺乏照顧人力」、「害怕病人跌倒」、「不會處理病人突發問題」、「不清楚病患未來狀況，無法做好後續照顧計畫的規劃」、「幫病人抽痰」、「就醫往返不方便或困難」、「害怕自己照顧能力不好」。再經文獻概念分析，將本研究照顧者壓力感受歸納為四個構面，依序為病況變化之醫療處置、經濟及資源不足、直接照顧困難及照顧病人對自己與家人的影響。 三、照顧者照顧時數越長、面對病人出院之準備度越差，以及護理人員提供出院前之護理指導完成率越低，則整體壓力感受越大。此三變項可解釋照顧者壓力感受10%的變異量。 四、病患意識狀況越差、出院時病患身上所具有的管路越多；照顧者教育程度越低者、對病患照顧技能純熟度越不熟練、無法找到照顧諮詢的人來解決照顧問題、護理人員提供出院前之護理指導完成率越低，與照顧者的整體壓力感受越大，照顧者越有憂鬱傾向。這些變項共可解釋照顧者憂鬱反應38.9%的變異量。其中，「照顧者的整體壓力感受」為最具預測力的變項。 五、病患發病前為家中主要經濟來源者；照顧者教育程度越低者、對病患照顧技能純熟度越不熟練、無法找到照顧諮詢的人來解決照顧問題、護理人員提供出院前之護理指導完成率越低，與照顧者的整體壓力感受越大，照顧者的焦慮反應越高。這些變項共可解釋照顧者焦慮反應42%的總變異量。而「照顧者的整體壓力感受」為最具預測力的變項。 故建議在未來臨床護理實務方面，瞭解此類病患出院前主要照顧者的壓力感受，規劃提供一系列完善的護理指導方案並提高護理指導完成率，使照顧者可以經由增強整體照顧能力，認識與瞭解相關社會資源的運用，降低其出院前的壓力感受，進而降低憂鬱與焦慮。

This study uses a cross-sectional design with a descriptive correlation approach. The main purpose of this study is to investigate the primary caregiver’s stress perception and emotional response with brain damaged patients at pre-discharge. A purposive sample of 63 primary caregivers were face-to-face interviewed through structured questionnaires in a neurological and neurosurgical units at a medical center in northern Taiwan, including Questionnaire for Primary Caregiver’s Stress Perception, Center for Epidemiologic Studies Depression Scale (CES-D), State Anxiety Inventory (SAI), basic information about patient and caregiver, and Questionnaire for Caregiver’s Resource. Brain infarction is the most common disease among all brain damaged patients cared by these subjects. The mean age of patients is 65.38, male with mild brain damage, and the mean score of Barthel Index is 13.33. The mean age of primary caregivers is 48.69. Most of the caregivers were female, married, patient’s spouse, with high school background, having a good relationship with patients, ordinary health status on his/her own initiative, and the average care time is 14.44 hours. The results show: 1.The degree of primary caregiver’s stress perception before patient discharge was mild to moderate. 65.1% of them have tendency toward depression. 2.The top 10 stress events that the caregiver worried about are: “patient condition changes again”, “patient will dead after discharge”, “expenditure increase”, “short of caring manpower”, “fear of patient falling down”, “can’t handle the unexpected problems”, “unable to make a good plan because patient’s status is unclear in the future”, “suction for the patient”, “inconvenient or hard to go to hospital”, “inadequate care ability”. After that, we separate caregiver’s stress perception into 4 categories by using concept analysis, which are “medical treatment when patient’s status is changed”, “financial burden and short of resource”, “difficult to provide direct care”, and “the influence of caring patient upon caregiver and caregiver’s family members”. 3.The longer care time for caregiver, the less readiness for patient’s discharge, and the lower completion rate of nursing instruction from nursing staff before discharge, and the larger degree of stress perception would be. These 3 independent variables can explain 10% variance at the caregiver’s stress perception level. 4.The worse patient conscious level, the more tubes on patient at discharge; the lower level education for caregiver, the worse caregiver’s mastery in caring patient; fewer people can be found to counsel on solving caring problems, the lower completion rate of nursing instruction before discharge, the higher overall stress perception of caregiver, and the more tendency toward depression on caregiver. These independent variables can explain 38.9% variance in caregiver’s depression scale. Among them, the “caregiver’s stress perception level” is the strongest predictor. 5.These items will cause caregiver with higher degree of anxiety and can explain 42.0% variance of caregiver’s anxiety scale: “patient takes most responsibility for family income before being sick”, “lower education level of the caregiver”, “worse caregiver’s mastery”, “caregiver unable to find counselors to solve caring problems”, “low completion rate of receiving information and care training from nursing staff before discharge”, and “high caregiver’s stress perception level”. The “caregiver’s overall stress perception level” is the strongest predictor. In clinical nursing practice, this study recommends understanding the primary caregiver’s stress perception before patient discharge, providing a complete and better nursing plan to increase the completion rate of nursing instruction. These can help the caregiver to lessen his/her stress perception and further decrease his/her depression and anxiety through strengthening overall care ability and understanding how to utilize social resources.