加護病房護理人員對使用呼吸器病人鎮靜照護的知識程度、角色認知與非計畫性氣管內管拔除之相關性探討

背景：非計畫性氣管內管拔除（Unplanned endotracheal tube extubation, UEE）是加護病房最常見的意外事件，也是重症單位醫療品質重要的指標（方、方、方，1999；陳、曾、黃、鄭，2006）。Chevron等人（1998）研究發現躁動不安病患，未使用鎮靜劑引起非計畫性氣管內管拔除率為5%~15.9%。而目前持續性鎮靜照護已是加護病房使用呼吸器病人之常規治療，通常在醫師開立醫囑後，由護理人員根據經驗判斷鎮靜的成效再隨時按需要來調整劑量，因此護理人員對用藥時機、藥物作用、副作用之辨識與處理、評估藥物成效及調整劑量之知識能力，對鎮靜治療的療效有關鍵性的影響。目前關於護理人員鎮靜知識之調查，大都是採自我主觀報告，缺乏對護理人員鎮靜知識程度及其對鎮靜照護角色認知之客觀評估。目的：本研究旨在探討加護病房護理人員對使用呼吸器病人鎮靜照護的知識程度、角色認知與非計畫性氣管內管拔除之相關性探討。方法：採橫斷式、相關性的問卷調查設計，研究對象為南部二所醫學中心166名加護病房護理人員，包含前驅試驗(確定問卷信、效度)及正式調查。採結構式量表，包括基本屬性、鎮靜照護知識（藥物作用、評估工具、照護指引）、角色認知與非計畫性氣管內管拔除等進行資料收集，共計發出209份問卷，回收192份問卷，扣除未填寫完整的問卷，共計有效問卷166份，以SPSS14.0中文套裝軟體進行資料分析。結果：（1）加護病房護理人員鎮靜藥物作用知識標準化得分為63.10，屬於中下程度；鎮靜評估工具知識標準化得分為48.40，屬於低等程度；鎮靜照護指引知識標準化得分81.00，屬於良好程度；（2）鎮靜照護角色認知標準化得分為65.70，屬於中下程度認同；（3）不同工作單位、不同進階層級、不同鎮靜照護經驗頻率、是否參加鎮靜照護相關研習或在職教育在鎮靜照護知識程度有顯著性差異（χ2 =38.97，p < .01；χ2 =10.20，p < .01；χ2 =9.08，p < .05；Z =－2.23，p < .05）；年齡與藥物作用、評估工具知識呈現正相關（r = .327，p < .01；r = .317，p < .01）；加護年資與藥物作用知識呈現正相關（r = .161，p < .01）；（4）不同工作單位在鎮靜照護角色認知有顯著性差異(χ2 =27.59，p < .01）；年齡與鎮靜照護角色認知呈現正相關（r = .182，p < .01）；（5）不同工作單位在非計畫性氣管內管拔除有顯著性差異(χ2 =23.81，p < .01）；非計畫性氣管內管拔除與年齡、藥物作用、照護指引知識呈現負相關（r =－.191，p < .05；r =－.248，p < .01；r =－.181，p < .05）（6）影響非計畫性氣管內管拔除的顯著預測因子為工作單位、照護指引知識，解釋非計畫性氣管內管拔除的總變異量為11.7%。研究結果將可協助臨床護理人員清楚並了解自己在鎮靜照護上的角色認知，並可做為加護病房鎮靜照護教育與知識評核的基礎，提升護理人員專業知識及對重症病患的照護品質。

關鍵字

鎮靜照護知識程度；角色認知；非計畫性氣管內管拔除

並列摘要

Background: Unplanned endotracheal tube extubation (UEE) is the most common accident in the intensive care units, and served as an important indicator for quality care (Square, Square & Square, 1999 ; Chen, Zeng, Huang & Zheng, 2006). Research showed that the rate of unplanned endotracheal tube extubation among restless patients without proper sedation was about 5% to 15.9% (Chevron et al., 1998). Continuous sedation treatment has become a common regimen for critical patients with a ventilator. Nurses are mainly responsible for the sedative medication dose adjustment after physician’ prescriptions. Therefore, nurses' knowledge level regarding sedative medication indications, side effects and patient assessment has a huge impact on the success of sedation treatment. However, in the past nurses' knowledge level was not measured in an objective way. No research ever studied nurses' perceptions regarding their roles in the patient sedation. Purpose: The purpose of this study was to explore the relationship between ICU nurses' knowledge level regarding sedations on patients with a ventilator, perceptions of nurses' role and UEE. Method: This study was a cross sectional correlational survey study. A total of 166 ICU nurses from two medical centers in southern Taiwan was chosen. There were two phases in this study: (a) pilot study for establishing the reliability and validity of instruments; (b) the survey. A total of 209 questionnaires were sent out, and 192 questionnaires were returned. Among those, a total of 166 questionnaires was completed and valid. A structured scale, including basic properties, sedation care knowledge (sedative drug effects, sedation assessment tool, and sedation care guidelines), perceptions of nurses' role, and the frequency of UEE, was used for data collection, and SPSS14.0 Chinese software package for data analysis. The results showed: (1) nurses had a moderate-low knowledge level in sedative medications with a standardization score of 63.10 ; low knowledge level in the sedation assessment tool with a standardization score of 48.40; and a good knowledge level the sedation care guideline with a standardization score of 81.00; (2) nurses perceptions regarding their role on sedation was within the range of less agreeable and with a standardization score of 65.70; (3) the sedation knowledge level was significantly different among different work units, different advanced levels, different frequencies of sedation care experience, and between with or without taking sedation care conference course or continuing education (χ2 = 38.97, p < .01; χ2 = 10.20, p < .01; χ2 = 9.08, p < .05; Z =- 2.23, p < .05); age and sedative drugs knowledge level, assessment tools knowledge level showed a significantly positive correlation (r = .327, p < .01; r = .317, p < .01) ; and intensive care seniority and sedative drug knowledge level showed a positive correlation (r = .161, p < .01); (4) nurses perceptions on sedation roles were significantly different among different work units (χ2 = 27.59, p < .01); age and the role perceptions were positive correlation (r = .182, p < .01); (5) The frequency of UPE was negatively correlated with age, the knowledge level of sedative drugs, and sedation guidelines (r =-.191, p < .05；r =-.248, p < .01; r =-.181, p < .05) ; (6) different work units and the knowledge level of sedation guidelines were significant predictors for the frequency of UEE. Two variables explained about 11.7% of the variance. Findings can help ICU nurses aware the needs to improve their knowledge level on sedation regimen. Also the findings can serve as the basis for future planning of on-job education and for evaluating clinical practice to ensure better quality of care for critical patients.