養護型住宿式長照機構專業團隊合作經驗之探討─以護理人員、照顧服務員及社會工作人員為例

Abstract

住宿式長照機構是我國正式長照服務體系裡發展最久的服務類型，其中又以養護型機構數量為最多，但機構內的專業團隊整合照顧卻經常受文獻指出尚未成熟且有待進步。然而，既有文獻缺乏進一步對養護型住宿式長照機構專業團隊合作現況與困境有深入探究。爰此，本研究旨在探討養護型住宿式長照機構內的護理人員、照顧服務員與社工人員在專業團隊合作上之現況、遭遇如何之困難與因應策略，以及對理想的專業團隊合作之期許。本研究藉由質性研究深度訪談法，並以立意抽樣為主，滾雪球抽樣和網路徵詢為輔，訪談6家不同規模與不同專業背景主任的養護型住宿式長照機構內的護理人員、照顧服務員與社工人員，共18位受訪者，並以主題分析法進行資料整理。 研究結果指出，1.養護型機構專業團隊合作現況，以「有品質的照顧」為團隊共享的知識結構。三種專業人員在合作過程皆發揮同等重要、缺一不可的角色與功能，而團隊合作中的非正式互動關係能夠促進專業團隊緊密相依的凝聚力。此外，不同規模與不同專業背景主任的機構專業團隊系統運作機制及心智共享方式呈現不同樣貌。雖然機構專業團隊整合照顧發展較過往有著持續進步，但小型機構兼任社工人員由於缺乏適足人力，因此專業深度仍難以發展。2.養護型機構專業團隊在內部微視層面遭遇溝通協調時間安排與意見整合上的困難，以及夾在不同立場之間的兩難。因應策略則就溝通協調問題，團隊採取個別商討或請有決定權之主管介入協調，而針對夾在兩難困境，團隊通常採取秉持專業價值之角色立場予以回應。在機構管理層級的居間層面則面臨人力吃緊且業務量沉重影響團隊討論深度有限。在機構外部體系的鉅視層面則遇到團隊平時的付出努力難以在評鑑中展現或被肯定。而在居間層面與鉅視層面之困難，由於涉及組織管理與上級監督單位，因此團隊成員通常採取自我調適作為因應。惟特別的是，當團隊面臨鉅視層面的挑戰，會激發出團隊患難見真情，使團隊成員展現出團隊認同與凝聚力。3.養護型機構專業團隊對理想的合作期待，在內部微視層面包含專業團隊成員能在合作過程中充分投入並確實發揮專業角色與功能、專業團隊合作要能夠回應成員們內在心理需要受到鼓勵與支持的需求。在機構管理層級的居間層面則包含機構管理層能透過適足人力與制度規劃來支持專業團隊合作及發展。在機構體系之外的鉅視層面則包含專業團隊與內外部系統溝通能夠互信交流與共享暢通，以及能夠結合通訊科技在專業團隊合作上運用。 研究建議以促進專業團隊共享心智為基礎，提出：1.機構專業團隊成員在團隊合作中遇到的難題宜尋求團隊共同解決、重視專業團隊合作照顧過程中向不同領域專業人員徵詢意見。2.機構管理者應重視專業團隊合作過程中的正式與非正式互動交流、配置適足的專業人力、結合照顧科技應用於機構專業團隊合作。3.政策制定者應強化與實踐機構評鑑制度的輔導功能、從法令制度加強對小型養護機構兼任社工專業人力之發展與重視、增加不同專業領域共同參與的專業團隊合作訓練。4.未來研究者可進一步探索專業團隊系統外的力量如何影響團隊內部之運作，以及系統內外如何心智共享地合作，並探討更多元等第類型機構與更多不同專業背景團隊成員之合作經驗。

Among the variety of types of the long-term care service system in Taiwan, the development of institutional services are the longest. In addition, the amount of nursing institutions are the most of all categories of institutional services. However, many literatures pointed out that the integrated care in nursing institutions were immature and needed improvement, but lacking for the deep exploration of current conditions and difficulties which inter-disciplinary teams faced in the process of collaboration in nursing institutions. Therefore, the aim of this study was to explore current conditions, difficulties, coping strategies and expectations which nurses, care aides, and social workers experienced in the inter-disciplinary teamwork of nursing institutions. This qualitative study was conducted by purposive sampling as the mainly sampling method and supplemented by snowball sampling and internet referral, using in-depth interviews with 18 participants including nurses, care aides and social workers from 6 nursing institutions which had different size and professional background of the manager. Data was analyzed by thematic analysis. Findings included as followed: 1. About current conditions of inter-disciplinary teamwork in nursing institutions, “caring with good quality” is the shared knowledge structure in inter-disciplinary teams. Nurses, care aides and social workers are all essential and play their unique roles in the process of collaboration. Moreover, informal interaction between team members can enhance cohesion of inter-disciplinary teamwork. Furthermore, mechanisms of system collaboration and ways to share mental are various in inter-disciplinary teams which had different size and professional background of the manager. Although the development of integrated care in nursing institutions is more progressive than the past, manpower of part-time social workers in small size nursing institutions is still insufficient; as a result, the development of social work profession in small size nursing institutions is difficult to be mature and deep. 2. About difficulties of inter-disciplinary teamwork, at inter-disciplinary teams as a micro level, one is that time to discuss and opinions are inconsistent, the other is that the dilemma of different standpoints. Coping strategies is that facing discussion problems, inter-disciplinary teams discuss separately or consult with the manager. Facing dilemma problems, they stand in the professional position to react. At institutional management as a mezzo level, inter-disciplinary teams confront manpower shortages and heavy workloads; thus, the depth of discussions is limited. At outer systems as a macro level, inter-disciplinary teams face that everyday efforts which team members engage in do not be showed in institution evaluation and be identified by judges. Due to difficulties at mezzo and macro levels are related to superior management or the authorities, inter-disciplinary teams often adopt self-adjustment to react. Especially, encountering macro-level difficulties, inter-disciplinary teams would be aroused cohesion and identification with teams. It makes team members hang together. 3. About expectations of inter-disciplinary teamwork, at inter-disciplinary teams as a micro level, inter-disciplinary teams expect that team members can fully involve in collaboration and play their own unique roles. Besides, inter-disciplinary teamwork should fulfill the need that team members want to be supported and encouraged. At institutional management as a mezzo level, inter-disciplinary teams hope that managers can support the development of inter-disciplinary teamwork through employing adequate manpower and planning mechanism. At outer systems as a macro level, inter-disciplinary teams desire that they can interact and communicate honestly and reliably with inner and outer systems; furthermore, new communication technologies can be applied to the process of inter-disciplinary teamwork. According to research findings, suggestions which are based on promoting mental shared of inter-disciplinary teamwork are as followed: 1. For inter-disciplinary team members, problems which are occurred during the process of collaboration should be solved by the team, and team members should value consultation with other disciplinary team members during the process of collaboration. 2. For institutional managers, they should value formal and informal interaction during the process of inter-disciplinary teamwork, employ adequate manpower, and introduce innovative care technologies into inter-disciplinary teamwork. 3. For the authorities, they should strengthen the function of fostering of institution evaluation, reinforce the development of part-time social workers in small size nursing institutions through legislation, and increase training for inter-disciplinary teamwork. 4. For future researchers, they can explore ways in which outer systems influence inner systems and in which they collaborate and share mental. Besides, understanding experiences of inter-disciplinary teamwork from more different grade of nursing institutions and inter-disciplinary team members are recommended.