兒童友善醫療的現況與需求——由學齡前期住院兒童的觀點及行為來探討

背景：近年兒童友善醫療逐漸成為各國兒科醫療的照護共識，且將兒童的觀點和經驗納入醫療計畫的規劃及成效評值普遍被認為十分重要。兒童作為身心較為脆弱的族群，學齡前期的兒童尤其容易因住院壓力受到傷害，但由於其理解及表達能力上的限制，現有之文獻較缺乏自學齡前期兒童觀點了解其需求和期望，及對兒童友善醫療現況的評值之研究。目的：由學齡前期住院兒童的觀點及行為來探討目前友善醫療臨床施行的現況，並了解其對兒童友善醫療的期望和需求。方法：以質性研究為主，量性研究為輔，運用混合研究方法之聚合平行設計，採立意取樣選擇個案。在2021年10月至11月間共有11組年齡介於3–6歲之學齡前期兒童及其父母參與研究。透過半結構式訪談、臨床觀察及量表蒐集研究資料。訪談時研究者會提供白紙、彩色筆、色紙及角色圖卡等表達性創作工具作為訪談之輔助工具，並讓兒童自由選擇使用與否；臨床觀察中，研究者採觀察者及參與者的角色型態觀察兒科醫療執行的臨床情境；量表使用經過良好信、效度檢查共27題項的兒童住院之行為量表，以一般焦慮、分離焦慮、睡眠焦慮、飲食紊亂、攻擊行為及冷漠退縮等六個面向，評估兒童住院之行為變化。研究資料採用內容分析法將質性資料進行有系統的歸類和分析，並使用SPSS for Mac 28.0版套裝軟體進行量性資料的統計分析。結果：共歸納出三個主題，分別為：一、住院兒童仍為人，此主題描述以下三個重點：(1)尊重兒童的身體自主能增加其對於醫療行為的掌控感和配合度，且年齡較小兒童的自主性在臨床上更容易被忽視，因此較易表現出攻擊行為、(2)兒童受限於COVID-19疫情的防疫規範、疾病狀況和身上管路等原因，認為住院是不自由且無聊的、(3)兒童希望面對醫療時身心都是被準備好的，且無過去就醫經驗的兒童較容易出現睡眠焦慮；二、住院兒童仍為兒童，此主題描述了以下三個重點：(1)以兒童為中心對兒童而言是更為友善的、(2)住院兒童的疼痛問題並未獲得良好控制、(3)住院過程中應滿足兒童娛樂、陪伴及安撫等特殊需求；三、聽見兒童的聲音，描述兒童對於不同醫療角色的距離及恐懼感受的差異和來源，以及兒童對醫院顏色及裝飾物的重視。目前臨床兒童友善醫療施行現況上，在尊重兒童自主及參與自身醫療的權利、醫療人員的直接和有效溝通、滿足兒童陪伴和娛樂需求等方面仍有改善空間。此外，本研究期間正逢台灣COVID-19疫情，其對兒童友善醫療產生的衝擊，影響到兒童感覺住院不自由及陪伴和娛樂需求的不滿足。結論：建議未來可透過跨病房的交叉訓練、跨領域的案例討論會及教育課程，加強醫療人員對不同年齡層兒童的適性照護和溝通技巧，並強化其尊重兒童基本權利的概念，以提供更為友善的兒科醫療照護。此外，在醫院針對傳染病的防疫規劃時，應同時將兒童之身心需求納入考量，盡可能以較少限制的手段達到防止病毒傳播的相同目的。本研究結果可提供未來醫療人員在教育與實務上的建議，並作為未來規劃更完善兒童友善醫療計畫的參考，以提升兒科醫療照護的品質，增進兒童的健康與福祉。

關鍵字

兒童友善醫療；學齡前期兒童；住院；護理照護；混合研究方法

並列摘要

Backgrounds: Child-friendly healthcare has become consensus in pediatric healthcare settings over the world in recent years, and taking children’s perspectives and experiences into consideration is accepted to be important for planning and evaluating health services provision also. Children are vulnerable population, while preschool age children are particularly vulnerable to the effects of stress during hospitalization, limited ability in understanding as well as expressing their feelings. Studies in past generally excluded either views of investigating their needs, expectations on child-friendly healthcare or evaluating child-friendly healthcare services. Purposes: To explore preschool-aged hospitalized children's needs, expectations and experiences in child-friendly healthcare from the perspective of children as well as their behavioral responses to medical interventions. Methods: This study was explored mainly via qualitative research and synergistically via quantitative research. A convergent parallel mixed-methods research was conducted to recruit purposive samples of eleven preschool children (aged 3–6) and of their parents in both October and November, 2021. Multiple data collection methods were used, including semi-structured interview, clinical observation and the Post Hospitalization Behavior Questionnaire. During the interview, the expressive art tools, such as blank paper, color pencils, colored papers and character picture cards were provided, and children were encouraged to express their thoughts in ways they prefer. During the clinical study, the researcher observes the pediatric clinical situation by the role of observer-as-participant. The 27-item Post Hospitalization Behavior Questionnaire, a well-validated instrument, was used to measure children’s behavior changes across 6 categories. i.e., general anxiety, separation anxiety, anxiety about sleep, eating disturbances, aggression toward authority, and apathy/withdrawal. The qualitative data were analyzed using content analysis, and the quantitative data were analyzed with SPSS for Mac 28.0. Results: Three themes relating to children’s views of child-friendly healthcare were exported from this study. They were summarized in the followings: (1) Hospitalized children are as human and it contained three issues. The first issue described that children consider independence and freedom are important, and expect to be well-prepared regardless physically or mentally as facing medical treatment. About this clinical situation, the younger children were more ignored and more suffered. Therefore, they are more aggressive behaviors in younger hospitalized children. The second issue was that hospitalized children felt boring and unfree due to both many life support lines in their bodies and many restricted regulations for preventing COVID-19 epidemic. The third was that hospitalized children hope to be well prepared before facing the medical needs. Sleep anxiety were more detected in this diseased children who admitted in hospital at first time in their life. (2) Hospitalized children as children. This theme contained three points also. The first is that hospitalized children-centered could be friendlier in the resources and medical cares. Point two described that their disease-related pain seemed not to be well faced and controlled. The final described the resources and medical cares about special needs on play, companionship, and been well pacified for diseased-children in hospitalization. (3) Listening to children's voices, children described different feelings of distance and fear among different medical roles. This theme also described children’s thoughts on the colors and decorations in hospital. Current clinical practice of child-friendly medical care were limitedly reported on respecting children's rights what there were of being unforced and of participating in their own medical care. Direct and effective communication and children's needs on companionship or entertainment were all deficient in current clinical practice of child-friendly medical care. In addition, this study was conducted in the period of Covid-19 pandemic, and this pandemic has impacts on child-friendly medical care such as affecting children's feelings in lack of freedom and unsatisfied needs on companionship and entertainment during hospitalization. Conclusion: Cross training, multidisciplinary case conference and courses are recommended to improve healthcare workers in using appropriate care and communication skills based on children’s development characteristics, in strengthening their concept of respecting children’s rights, and in providing a friendlier pediatric caring settings in final. Besides, stakeholders in hospital should take hospitalized children’s needs into consideration even though setting limits due to the prevention of virus spread. This research supports on providing educational and practical advice for future medical practitioners, and can serve as a reference for planning and improvement of child-friendly medical programs in the future, so as to improve the quality of pediatric medical care and enhance children's health and well-being.