臺灣住宿式長期照顧服務機構文化變革可行性評估-以機構經營者觀點探討

The Feasibility Assessment of Culture Change in Long-term Care Institutions in Taiwan - Perspectives from the Chief Executive Officers

蔡雅雯(Ya-Wen Tsai)

指導教授 ： 陳雅美

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2021年)

https://doi.org/10.6342/NTU202103223

摘要

研究背景：
依據國發會推估臺灣2026年將邁入超高齡社會，政府積極依主流文化及國際趨勢推動社區及居家式長期照顧服務(以下簡稱長照服務)。近五年老人長期照顧機構(以下簡稱長照機構)使用率不斷提升。由此可見長照機構在臺灣的長照服務中扮演不可或缺的角色。長照機構品質是各國重視且困擾的議題，臺灣以評鑑制度來管控長照機構品質，但良莠不齊。而美國自1970年開始有一連串，為了提升長照機構去機構化的照顧，發展以使用者為中心的照顧模式文化變革(Culture Change)，改善了美國長照機構照護品質，並發展出「文化變革特點(Artifacts of Culture Change)自評表」，讓長照機構經營者可以自我評值變革的達成率。本研究將以經營者角度，透過翻譯「文化變革特點(Artifacts of Culture Change)自評表」，進行臺灣文化變革(Culture Change)的重要性與可行性探討。
研究目標：
1. 瞭解臺灣長照機構經營者對於臺灣長照機構文化變革重要性及可行性間之關係
2. 瞭解臺灣長照機構經營者之特性對於臺灣長照機構文化變革看法之關係
3. 瞭解臺灣長照機構經營者對於臺灣長照機構文化變革之看法
研究方法：
調整美國長照文化變革特點自評表，從原79題改為51題，分為六個面向(照護面、環境面、家庭和社區面、領導面、工作場所面、工作人員面)，各面中各題皆分為重要性及可行性，並個別以五分法請經營者填寫。問卷最後提供開放式欄位自由填寫，不可行或非常不可行之原因。問卷透過三位專家(包含長照業者及學者)進行表面效度檢測。請15位未來可能的機構經營者填寫，預試整體信度Cronbach's α大於0.7。依據臺長照機構類型及各縣市資源比例，進行兩個層次的分層隨機抽樣，抽300家機構，進行經營者匿名橫斷性調查研究。以相關矩陣檢測、獨立樣本T檢定、複迴歸分析、座標圖，分析經營者特性、重要性、可行性三者間之關聯性。以內容分析法，將質性回饋進行分類和彙整。
研究結果：
回收率23%，其中一般護理之家44.1%、養護型機構38.2%。整體問卷實測信度Cronbach’s α達0.9以上，內在同質性高。六個面向為：第一生活類(包含照護面、環境面、家庭和社區面)，第二經營類(機構領導面、工作場所面、工作人員面) 個面向重要性及可行性Cronbach's α介於0.70~0.90之間。經營類面向重要性或可行性平均分數皆大於生活類面向。重要性及可行性平均照護面都最低、工作人員面都最高。以各題之重要性及可行性平均分數，畫出座標圖，並以中位數作為輔助線劃分四個象限，45%題項位於重要且可行的第一象限、41%題項位於不重要且不可行的第三象限。被認為最重要也最可行的前三題皆為工作場所面，包含「專業有分工」、「嘉許優良員工」、「鼓勵員工能力提升」。而經營者回饋較不可行的原因，最多為「機構方便性」，其次為「長輩功能與個人偏好」提及最多。經營者對各面向之重要性及可行性平均分數皆為顯著正相關。其中「家庭和社區面」的重要性和另外3個面向之可行性；「環境面」及「工作場所面」的可行性分別和另外3個面向重要性顯著中度正相關(r > 0.5 , p <0.001)，可見關聯性高於其他面向間。經營者特性與其對於各面向之看法無顯著相關。
討論與建議：
從研究結果中可以看出，經營者認為生活類比經營類不重要且不可行，這與國外發展文化變革的目的與研究結果相佐，可見臺灣長照機構經營者仍舊偏向傳統機構式照顧。但提升(1)經營者對於家庭和社區面的重視程度、(2)環境面和工作場所面的可行性，有助於推動臺灣整體文化變革，因此可以成為政策推展的優先方向。長照機構以長者為中心的照顧理念，對於經營者而言多半仍處於概念及表面宣導，未來臺灣發展文化變革建議從其覺得可行的面向政策優先。也可透過經營者在意的評鑑制度及財務資源觀點來提升台灣機構的文化變革。

關鍵字

長期照顧 ； 以使用者為中心 ； 長照機構照護品質 ； 長照文化變革 ； 可行性評估

並列摘要

Background
According to the National Development Council’s estimation, Taiwan will enter a super-aged society in 2026, for which the government is actively promoting community and home-based long-term care services (hereinafter referred to as long-term care services) in accordance with mainstream culture and international trends. In the past 5 years, the utilization rate of long-term care institutions for the elderly (long-term care institutions) has been increasing. This shows that long-term photography institutions play an indispensable role in Taiwan’s long-term photography services. The quality of long-term care institutions is an important issue in many countries. Taiwan uses an evaluation system to control the quality of long-term care institutions, but institutions’ quality still in different level. In the United States, there has been a series Culture Change since 1970. To improve the deinstitutional care of long-term care institutions, Culture Change has developed a user-centered care model, improved the quality of care in long-term care institutions in the United States, and established the “Artifacts of Culture Change,” allowing the operators of long-term care institutions to self-evaluate the achievement rate of changes. From the perspective of an operator, this study will provide a discussion on the importance and feasibility of Taiwan’s Culture Change through the translation of the “Artifacts of Culture Change.”
Objectives
1. Understand the relationship between the importance and feasibility of cultural change among managers of long-term care institutions in Taiwan.
2. Understand the relationship between the characteristics and their perspectives regarding cultural change among managers of long-term care institutions in Taiwan.
3. Understand the perspectives regarding cultural change among managers of long-term care institutions in.
Methods
The Artifacts of Culture Change of American long-term care from the original 79 to 51 questions, were divided into six aspects (care, environment, family and community, leadership, workplace, and staff). Each question in the face was divided into importance and feasibility, and the operator was asked to fill it out in five points. At the end of the questionnaire, open-end fields were provided to be filled freely . The questionnaire was tested for surface validity by three experts (including long-term care providers and scholars). Fifteen possible future institutional operators filled in the questionnaire, and the overall pretest reliability Cronbach’s α was greater than 0.7. According to the type of agency responsible for the supervision of the office and proportion of resources in each county and city, two-level stratified random sampling was conducted, and 300 institutions were selected to conduct an anonymous cross-sectional survey of operators. The correlation between the characteristics, importance, and feasibility of the operators with correlation matrix testing, independent sample T verification, multiple regression analysis, and coordinate graphs was tested. Content analysis to classify and aggregate qualitative feedback was used.
Discussion and suggestions
The research results showed that the operators believe that the life analogy management category is not important and unfeasible, which is in line with the purpose of developing cultural changes abroad and research results. It was presented that the operators of long-term care institutions in Taiwan still prefer traditional institutional care. However, increasing (1) the importance that operators place on the family and community and (2) the feasibility of the environment and workplace will help promote the overall cultural change in Taiwan, so it can be a priority for policy promotion. The long-term care institution’s elder-centered care concept is still mostly conceptual and superficial to the operators. In the future, Taiwan’s development of cultural reform proposals will give priority to policies that they think are feasible. It is also possible to enhance the cultural change of Taiwanese institutions through the evaluation system and financial resources that the operators care about.

並列關鍵字

Long-term care ； user-centered ； care quality of long-term care institutions ； cultural change of long-term care ； feasibility evaluation

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