台灣安寧舒適量表之跨文化適應及驗證

Abstract

研究背景與動機：安寧緩和療護是健康照護中很重要的一環，它提供預期餘命有限的病人全面性的支持，強調全人照護。雖然「舒適」在安寧緩和療護及護理中一直是重要概念，然而過去對末期患者的照護品質評估多以特定症狀或生活品質為主，鮮少直接測量「舒適」。Kolcaba博士於1991年始對舒適進行深度的分析，並提出舒適理論，認為舒適是一護理照護介入的正向結果，並進行了一系列研究，針對不同族群，包括末期及安寧病人，發展舒適量表，提供全方位的舒適度評估。然而，「舒適」在台灣臨床上仍以質性呈現為主，少有具體化的量測；Kolcaba博士的安寧舒適量表（Hospice Comfort Questionnaire, HCQ）也尚無中文版本可使用，更缺乏本土族群的參考數據。 研究目的：本研究旨在發展台灣版安寧舒適量表，進行量表翻譯、調整及心理計量分析。 研究方法：本橫斷性研究自2023年5月到2024年5月，於台灣北部某醫學中心，依量表翻譯指引之六步驟進行：正向翻譯、第一次整合、盲化的回覆翻譯、第二次整合、預試及認知訪談、及完整的心理計量檢測。前四個步驟由雙語及安寧緩和專家完成，而預試及量表心理計量分析步驟，邀請臨床專家並招募安寧緩和病人參與。統計法運用描述性統計並驗證信效度，包含內在一致性信度、內容效度及建構效度等。其中，收斂效度使用Functional Assessment of Chronic Illness Therapy─palliative care（FACIT-pal-14）生活品質量表驗證。 研究結果：根據7位安寧緩和專家及30位病人之預試結果修訂24題HCQ，其題項內容效度指標範圍從0.857-1、整體量表內容效度指標平均為0.988。心理計量檢測階段共納入120位受試者資料，平均年齡為67.22歲（SD = 12.26），90.0%的受試者（n = 108）為末期癌症病人。整體量表Cronbach’s α為0.862。HCQ和FACIT-pal-14呈顯著正相關（ρ= 0.834, p < 0.001）具備良好收斂效度；且能夠區分不同緩和預後量表（F = 4.339, p = 0.015）及不同經濟壓力感受（t = 3.805, p < 0.001）之病人。探索性因素分析萃取七個因素，可解釋63.791%的總變異量，根據臨床經驗及舒適理論最終歸納為五個舒適情境：靈性、心理、社會文化、環境及身體舒適，調整量表為23題之台灣安寧舒適量表（Taiwan Hospice Questionnaire, THCQ），Cronbach’s α為0.866，可解釋總變異量> 50%。此外，本土安寧緩和病人之平均舒適度（以標準化分數表示）為中度（67.10分, SD = 15.66），而五個舒適情境當中又以靈性（54.60分, SD = 22.91）及心理（61.20分, SD = 24.40）舒適度最低。 結論：本研究依本土特性調整生成THCQ，THCQ為一簡明且具備足夠信效度的舒適量測工具，可供未來臨床及研究使用。本研究亦初探本土接受安寧緩和療護的病人之舒適結構，顯示靈性及心理照護為本土安寧緩和病人重要之舒適構成因素，其相關照護需獲得更多的重視。

Background Hospice care is a critical component of healthcare, providing comprehensive support to patients with limited life expectancy and emphasizing holistic care. Although ‘comfort’ is one of the most crucial concepts in hospice and nursing c are, the assessment of care quality for terminal patients has primarily focused on specific symptoms or quality of life rather than measuring ‘comfort’. Dr. Kolcaba viewed comfort as a positive outcome of nursing interventions and developed Comfort Theory as well as the Hospice Comfort Questionnaire (HCQ). However, in clinical practice, comfort is still mostly observed qualitatively, rather than being systematically measured. Additionally, HCQ has not yet been translated into Chinese, and there is a lack of reference data for Taiwanese local populations. Objective To develop a Taiwan version of the Hospice Comfort Questionnaire, involving the translation, adaptation, and psychometric analysis of the scale. Methods From May 2023 to May 2024, this cross-sectional study was conducted at a medical center in northern Taiwan. The study followed the six-step instrument translation guideline of cross-cultural health care research: forward translation, first synthesis, blind back-translation, second synthesis, pilot testing and cognitive debriefing, and full psychometric testing. Bilingual and hospice care experts were involved in the initial four steps, while clinical experts and terminally-ill patients participated in the pilot and psychometric testing. Descriptive statistics and tests of reliability and validity, including internal consistency reliability, content validity, and construct validity, were employed. The Functional Assessment of Chronic Illness Therapy─palliative care (FACIT-pal-14), commonly used for measuring quality of life, was employed to confirm convergent validity. Results Based on feedback from seven palliative care experts and the results of a pilot test involving 30 patients, the 24-item HCQ was revised.. Content validity indices (I-CVI) ranged from 0.857 to1 with an average scale content validity index (S-CVI) of 0.988. Psychometric testing was conducted using data from 120 participants, with a mean age of 67.22 (SD = 12.26), and 90.0% were diagnosed with terminal cancer. The overall Cronbach’s alpha coefficient was 0.862. A significant positive correlation was found between HCQ and FACIT-pal-14 (ρ = 0.834, p < 0.001), indicating good convergent validity. Moreover, the questionnaire effectively differentiated between patients with different Palliative Prognostic Index scores (F = 4.339, p = 0.015) and financial burden (t = 3.805, p < 0.001). Exploratory factor analysis extracted seven factors, explaining 63.791% of the total variance. These factors were clinically and theoretically consolidated into five comfort contexts: spiritual, psychological, sociocultural, environmental, and physical comfort. The revised 23-item Taiwan Hospice Comfort Questionnaire (THCQ) had a Cronbach's alpha of 0.866, explaining more than 50% of the total variance. The average comfort level for the local patients receiving hospice care, expressed as a standardized score, was moderate (67.10, SD = 15.66), with spiritual (54.60, SD = 22.91) and psychological (61.20, SD = 24.40) comfort levels being the lowest among the five contexts. Conclusion This study modified HCQ to form THCQ, resulting in a concise and psychometrically sound tool for measuring comfort, suitable for both clinical and research applications. The study also explored the comfort structure among local patients receiving hospice care, highlighting that spiritual and psychological care are crucial components of comfort for Taiwanese patients, indicating a need for greater attention in these areas.