透視骨盆腔檢查的醫護病互動--第一部份：從婦女病患的角度探討骨盆腔檢查的經驗;第二部份：以行動研究促進骨盆腔檢查的醫護病互動

Abstract

【背景與目的】 骨盆腔檢查是許多女人的共同經驗：在陌生的醫療診間，面對陌生的器械與醫護人員，赤身裸露，雙腿跨於內診台支架上，承受侵入性檢查。有許多文獻指出負向評價或經驗，如暴露隱私的困窘、害怕、焦慮，以及身體的不舒適或疼痛、感到低微且赤裸、無防衛性、易受傷害等，或醫師或檢查者所呈現的態度是否輕視態度、譴責、願意溝通、解釋、提供資訊皆影響她們的感受。然而婦女病患骨盆腔檢查的正負向經驗，很多範圍是與醫護人員的行為有關。至今，國內很少有研究在探討醫護人員行為對婦女病患骨盆腔檢查經驗的影響，加上在目前此種「唯我」、「獨尊」、「理所當然」父權體制的意識下所建構的醫療體制，女性身體在醫療環境中的遭遇經驗是ㄧ種「無權力與被控制」的處境。因此本研究目的分兩部份，第一部份是從婦女病患觀點，瞭解她們在經歷骨盆腔檢查過程中所關注的醫護人員行為。第二部份是根據這些事實的發現，哪些醫護人員的行為使婦女病患產生負向經驗，透過行動研究，研究者與醫護人員(實踐者)是平等夥伴關係、共同討論，互相學習之下，使醫護人員的行為朝向婦女病患所期望的骨盆腔檢查之醫護病互動，並塑造「以婦女病患為尊」及親善的婦產科門診環境。 【方法】 本研究分兩部份進行資料收集，第一部份採立意取樣，於中部某醫學中心、區域醫院與地區醫院婦產科門診，以重要事件技巧(CIT)為方法，進行資料收集，將訪談的32位婦女病患資料，並使用Atlas.ti 5.0版軟體進行分析。第二部份以行動研究的四階段：事實的問題(確認問題)、計劃、行動，和評值為研究方法，根據第一部分婦女病患的負向經驗為事實的問題，延攬地區與區域醫院的醫護人員參與行動研究，擬定三個行動目標，透過婦女病患的問卷與訪談的評值，瞭解醫護人員執行骨盆腔檢查的情形，共執行三次行動研究，反覆回饋與修正的過程，改善醫護病互動，以符合婦女病患的需求。問卷資料使用SPSS 10.0版統計套裝軟體，採百分比方式進行資料分析，也將訪談婦女病患和醫護人員的資料轉成逐字稿，並整理與分析。 【結果】 第一部分研究結果歸納出醫護人員執行骨盆腔檢查的行為，使婦女病患產生的正/負向經驗，有44種行為、4個次類別、2個類別和1主題。兩類別為：一、被瞭解為人的個體，包含被尊重/不被尊重、被關注與投入/被忽略需求。二、產生信心，包含掌控情境/不確定感、被支持/未被支持。從這些不同事件所組成的行為敘述，其背後隱藏著婦女病患的需求—期望醫護人員能秉持有一種助人關係的內涵與原則。 第二部分透過行動研究過程，研究者與醫護人員在彼此平等關係下，共同討論與分享，行動中隨時反思，藉由婦女病患三次的反覆評值，以瞭解醫師行為的調整、護人員行為的改變及環境改善的狀況：1.醫師行為的調整，彰顯了尊重婦女病患的具體操作：(1) 從詢問「我現在要幫妳做檢查」至嚐試詢問「我現在要幫妳做檢查，妳準備好了嗎?」，讓婦女病患覺得很有安全感，有被重視感覺與尊重、有機會提問並與醫師互動。(2)有的醫師可以接受無小布簾，檢查時能與婦女病患面對面互動。(3)會徵求婦女病患同意，允許其他醫師進入內診間見習。2. 護理人員行為的改善上，婦女病患感受到從沒有提供身體披覆到重視身體隱私的維護；張貼內診流程圖，讓她們清楚流程，減少對流程的不確定感；對初次檢查者會先解釋內診流程，使其先有心理準備；護理人員會介紹內診環境及引導上下內診台，若是有檢查經驗者，至少會詢問是否需要幫忙；會馬上清除內診台上前位婦女病患所遺留下的污物；會詢問是否使用內診台上小布簾，使其有自主權。若是醫師無法接受不圍布簾者，則告知婦女病患「我現在要幫妳圍起」，與婦女病患有互動機會；請婦女病患腳平放於內診台等待醫師檢查，減少尷尬與不舒適。3. 環境的改善上，鴨嘴污物桶從無蓋到有蓋桶子，減少婦女病患看到大量鸭嘴的緊張與不安；內診環境的圍簾從不緊密缺乏隱私至緊密有隱私感。 【結論】 本研究結果顯示從婦女病患的角度瞭解醫護人員的哪些行為使她們產生正負向的經驗，瞭解其負向經驗後，透過行動研究在實際的臨床婦產科情境中進行醫護病互動的改善，也可做為醫護人員執行最佳實務—骨盆腔檢查的指引，及婦產科醫師實習前必讀與熟稔的素材，促使婦女病患有正向經驗與避免負向經驗的產生，除可適用於臨床實務與教學的參考外，可推廣行動研究於臨床實務者，增加實務者自主獨立的研究，以改善實務，朝向以婦女病患為中心的照護。

【Background and purpose】 The pelvic examination (PE) is a common experience facing with the majority of women. Women patients’ positive and negative experiences in connection with the PE are, to a large extent, connected to the physicians’ and nurses’ behaviors and attitudes. Nowadays, few studies focus on exploring this area. In addition, Taiwanese medical system is primarily dominated with paternalistic physician-patient relationships, indicating that the physician has centrality, superiority and authority. Thus, this study was divided into two parts. The first part of the study was to understand their experiences concerning physicians’/nurses’ behavior in the situation of the PE from women patients’ perspective ; the second part of the study was to improve physician-nurse-patient interaction and increase quality of care in PE through action research based on women patients’ negative experiences, 【Subjects and methods】 The qualitative approach was used in the first part of the study. Thirty-two women were asked to describe their positive and negative experiences while receiving the PE and what they perceived as critical for the PE procedures. Data were analyzed with the critical incident technique (CIT). The second part of the study used the four phases of this action research project, including fact-finding, planning, action, and evaluation. According to the fact-finding about women patients’ negative experiences, the researcher, physicians and nurses discuss the action objective together, leading to the consensus objectives. Also, an action research group was established in the local, the region hospital. Then an action research was formed with participants and collaborative physicians and nurses. Research adopted 3 cyclical processes and revised action aimed to improve physician-nurses-woman patient interaction and meet women patients’ need. Questionnaire data was analyzed using SPSS 10.0 and descriptive interviews were transcribed verbatim for analysis. 【Results】 The results of the first part of the study consisted of 44 categories of behaviors, four subcategories, two categories [acknowledged as a person and created confidence], and one main theme [a helping relationship]. Women patients perceived positive experiences, including being respected, being in control, being engaged, and being supported. On the contrary, women patients also described negative experiences, including not being respected, feeling uncertain, needs being neglected, and not being supported. Through understanding the meaning behind women patients’ experiences indicated that the women were to expect physicians/nurses hold a helping relationship of connotation and principle. The result of the second part of the action research emphases the involvement of the researcher and participants [physicians and nurses] in the process of involvement, collaboration, and reflection in action. Through 3 cyclical processes to evaluate changes or adjust in physicians’ and nurses’ behaviors, and change environment in the obstetric and gynecological outpatient department. First, the physicians’ behaviors were changed or adjusted, including (1) physicians were willing to once again ask for permission by saying, “Are you ready?” This made women patients feel respected, relaxed their body, and increased interaction with physicians. (2) Physicians also could choose not using a curtain, and (3) ask whether to permit the other physicians to come into the examination room to learn PE skills. Second, concerning the nurses’ behaviors was changed, including, nurses assessed whether a woman understood a PE procedure and asked whether to she preferred a curtain or not; Nurse needed to clean examination table right now when woman patient finish a pelvis exam; If the physician was used to utilize a curtain, a nurse told “I will utilize the curtain for you.” and interacted with the woman patient; If women patient was waiting for the physician for a long time, the nurse needed to put her legs on the examination table or sit on the side of examination table; Nurses also designed a PE procedure protocol to increase women patients’ awareness of the procedure. Third, an examination room was changed to increase privacy and added a cover so that speculums would not be seen in the garbage can in order to decrease women patients’ tension. 【Conclusions】 The conclusion of the first part of the study showed that these women patients had positive experiences when their physicians acknowledged them as persons and facilitated the procedure to create confidence. When physicians/nurses hold a helping relationship with women patients, women patients were more likely to be acknowledged as a person and created their confidence. If physicians and nurses followed the above suggestions, then they could create women-friendly clinics. The conclusion of the second part of the study was to promote physician-nurse-woman patient interaction and to decrease women patients’ discomfort in the PE procedure. These findings can be incorporated into medical and nursing education and used as a valuable reference for those training to become obstetric and gynecological physicians or nurse. The results were also regarded as best practice guidelines in an obstetric and gynecological outpatient department. We also suggested nurses or physicians to expand action research to practice, enhancing the focus of woman patient-oriented practice Keywords: pelvic examination, women patients, experience, physician-nurse-patient interaction, qualitative study, action research, a helping relationship