臺灣職能治療師的共享決策知識、態度與行為之初探

Abstract

研究背景：共享決策 (shared decision-making, SDM) 係一種重視個案與醫療人員合力參與決策過程的醫療決策模式。SDM對醫療人員或職能治療師 (occupational therapist, OTs) 的價值在於SDM符合現代醫療的主流價值 (以病人為中心與實證醫學)、尊重個案參與醫療決策的權利，並且可改善醫病關係與治療遵從度。先前研究已顯示醫療人員的知識程度可能影響其態度與行為，然此三者之關聯性目前並無明確定論。雖然現今臺灣醫療界已開始推廣SDM並致力於將SDM應用於日常醫療實務中，但臺灣醫療人員的SDM行為現況與其前導因子 (知識與態度) 的實證研究仍相當缺乏 (包含臺灣OTs)。瞭解臺灣OTs的SDM行為概況及前導因子應有利於改善臺灣OTs的SDM行為。然而，臺灣OTs的SDM行為概況及前導因子皆未知以致於不利改善臺灣OTs的SDM行為，故調查臺灣OTs的SDM行為概況及前導因子應具研究需求與價值。 研究目的：本研究目的共有二項：1.調查臺灣OTs的SDM知識、態度及行為概況；2.檢驗臺灣OTs的SDM知識、態度及行為之關聯性。 研究方法：本研究採用橫斷式研究 (cross-sectional study) 及方便取樣 (convenience sampling) 之研究設計，並以網路問卷調查臺灣OTs對SDM的知識、態度及行為。知識層面評量是否知道SDM及自覺對SDM的熟悉程度。態度層面評量8項態度因子，即：決策角色偏好、概念認同性、個案不適用性、臨床適用性、臨床不實用性、預期結果、自我效能以及採用動機，其中決策角色偏好以控制偏好量表 (Control Preferences Scale, CPS) 評量，而其他7項SDM態度因子則根據其他學者之研究成果彙整相關評估項目來評量。行為層面評量決策採用模式及SDM執行程度，其中決策採用模式以改良版控制偏好量表 (modified version of Control Preferences Scale, CPSpost) 調查，而SDM執行程度以醫療人員版共享決策問卷 (Shared decision-making Questionnaire-physician version, SDM-Q-Doc) 評量。 研究結果：在SDM行為方面，198位臺灣OTs中約為46.0%採用SDM，而SDM-Q-Doc的指數平均為71.9分。在SDM態度方面，臺灣OTs中約有70.7%偏好採用SDM，約有97%認同SDM概念，約有32.4%認為SDM不適用於多數個案/家屬，約有86.9%認同SDM適用於OT臨床工作情境，約有21.7%認為SDM缺乏臨床實用性，約有69.7%預期SDM具備正向成果效益，約有89.9%具備執行SDM的自我效能，約有83.3%具備學習並採用SDM的意願/動機。在SDM知識方面，臺灣OTs約有65.2%聽過SDM，而整體SDM熟悉程度約為4.2分。在關聯性方面，決策採用模式與其決策角色偏好為中度相關(σ=0.36)，與其他7項SDM態度因子為低度相關(σ=-0.16-0.24)。SDM執行程度與概念認同性(σ=0.58)、臨床適用性(σ=0.50)、自我效能(σ=0.67)、臨床不實用性(σ=-0.49)、結果預期性(σ=0.30)及採用意願/動機(σ=0.48)為高度或中度相關，而與個案不適用性(σ=-0.15)及決策角色偏(σ=0.03)則為低度相關或無相關。是否聽過SDM與採用動機為低相關(σ=-0.13)，而與其他7項SDM態度因子(σ=-0.06-0.03)及與決策採用模式(σ=-0.01)及SDM執行程度(0.00)則為無相關。SDM熟悉程度與自我效能(σ=0.15)、採用動機(σ=-0.11)、決策採用模式(σ=0.12)及SDM執行程度(σ=0.12)為低度相關，而與其他6項SDM態度因子則為無相關 (σ=-0.09-0.07)。 研究總結：臺灣OTs的SDM採用比例接近5成，整體SDM執行程度約為中度，對SDM態度多數為正向態度，6成以上聽過SDM，而整體SDM熟悉程度約中度偏低。在關聯性方面，SDM行為與SDM態度為低度到高度相關，而SDM知識與SDM態度及SDM行為則為低相關或無相關。本研究應有助於臨床及研究人員瞭解臺灣OTs的SDM知識、態度與行為之現況以及影響其SDM知識、態度與行為之關鍵因子，且應可作為未來臨床教學與SDM推廣之實證依據。由於本研究仍有些許不足之處，因此，建議未來以本研究的相關不足之處為基礎來繼續釐清SDM相關議題。

Background: Shared decision-making (SDM) is one kind of medical decision-making model that emphasizes the cooperation between clients and clinicians during the medical decision-making process. Although Taiwanese medical society has tried to promote SDM and to integrate SDM into clinical practice, the evidence-based research on the status of SDM behavior and its antecedents (knowledge and attitudes) of Taiwanese medical personnel is still quite lacking (including Taiwanese OTs). Understanding the SDM behavior and its antecedents of Taiwanese OTs should help improve the SDM behavior of Taiwanese OTs. However, the status of SDM behavior and its antecedents of Taiwanese OTs are unknown, which is unfavorable to improve the SDM behavior of Taiwanese OTs. Therefore, the survey of SDM behavior and its antecedents of Taiwanese OTs should have research needs and values. Purpose: There are two aims of this proposal. First, to overview Taiwanese OTs’ knowledge, attitudes, and behavior of SDM. Second, to recognize the correlations between Taiwanese OTs’ knowledge, attitudes, and behavior of SDM. Methods: This is a cross-sectional study using a convenience sampling design. This study surveys Taiwanese OTs about their knowledge, attitudes, and behavior of SDM by using the selfmade online questionnaire. The knowledge domain includes whether OTs know about SDM and the level of familiarity of SDM. The attitudes domain includes 8 factors, such as preferred role in decision-making, SDM concept agreement, clients’ inapplicability, clinical applicability, clinical impracticality, expected outcome, self-efficacy to implement SDM, and motivation to use SDM. Thereinto, this study use the Control Preferences Scale (CPS) to investigate Taiwanese OTs’ preferred role in decision-making, and use the questionnaire based on other scholars’ study to evaluate the other seven attitude factors. The behavior domain includes the utilization of decision-making model and the degree of SDM behavior. The utilization of decision-making model is investigated by modified version of Control Preferences Scale (CPSpost), and the degree of SDM behavior is surveyed by the Shared Decision-making Questionnaire-physician version (SDM-Q-Doc). Results: There are 198 Taiwanese OTs in this study samples. The proportion of utilizing SDM is about 46.0%, and the general degree of SDM behavior was 71.9. The proportion of preferring SDM is about 70.7%. The proportion of agreement with SDM concept is about 97%. The proportion of agreement with client’s applicability of SDM is about 67.6%. The proportion of agreement with clinical applicability of SDM is about 86.9%. The proportion of agreement with clinical practicality of SDM is about 78.3%. The proportion of positive expectation of SDM results is about 69.7%. The proportion of who has self-efficacy to implement SDM is about 89.9%. The proportion of who has motivation to learn/ adopt SDM is about 83.3%. The proportion of who have heard of SDM is about 65.2%, and the general level of SDM familiarity is about 4.2. With regards to the correlations, there is a moderate correlation between utilization of decision-making model and preference of decision-making role (σ=0.36), and there are low correlation between utilization of decision-making model and the other 7 attitude factors (σ=-0.16-0.24). The degree of SDM behavior are highly or moderately correlated with concept agreement (σ=0.58), clinical applicability (σ=0.50), self-efficacy (σ=0.67), clinical impracticality (σ=-0.49), expected outcome (σ=0.30) and motivation (σ=0.48), and are lowly or not correlated with clients’ inapplicability (σ=-0.15) and preference of decision-making role (σ=0.03). Whether OTs know about SDM is lowly correlated with motivation (σ=-0.13), and are not correlated with the other 7 attititude fators (σ=-0.06-0.03), utilization of decision-making model (σ=-0.01) and the degree of SDM behavior (σ=0.00). The level of familiarity of SDM are lowly correlated with self-efficacy (σ=0.15), motivation (σ=-0.11), utilization of decision-making model (σ=0.12) and the degree of SDM behavior (σ=0.12), and are not correlated with the other 6 attitude factors (σ=-0.09-0.07). Conclusion: The proportion of utilizing SDM in Taiwanese OTs is close to 50%. The general degree of SDM behabior is moderate. The general attitudes toward SDM are mostly positive. More than 60% of Taiwanese OTs has heard of SDM, and the general level of SDM familiarity is moderately low. With regards to the correlations, SDM behavior are lowly to highly correlated with SDM attitudes. SDM knowledge are lowly or not correlated with SDM attitudes and SDM behavior. This study investigates the SDM knowledge, attitudes, and behaviors of Taiwanese OTs and examines the relevance of SDM knowledge, attitudes, and behaviors. It should help clinical and researchers understand the current state of SDM knowledge, attitudes, and behaviors of Taiwanese OTs and the key factors impact on SDM knowledge, attitudes and behavior. This study should be used as the empirical basis for future clinical teaching and SDM promotion. As there are still some limitations in this study, it is recommended continuing to investigate the relevant SDM-related issues based on the shortcomings of this study.