「回歸社區」：臺北市一所醫院精神科慢性病房思覺失調症病人出院經驗之質性研究

背景與目的：讓更多的慢性精神病人出院回歸社區生活，是許多國家精神醫療發展的趨勢，而臺灣仍有相當數量的病人居住於慢性精神科病房，其住院期間長，且出院後再住院率高，病人與家屬對從慢性病房出院會有許多擔憂及不安。國內較缺乏從病人觀點闡述出院經驗的相關研究，本研究希望能從病人的角度了解在慢性病房接受復健後出院回到社區的主觀經驗，面臨了何種挑戰，以及回歸社區的有利因素。方法：採用質性方法中的訪談研究法進行研究，針對曾住過精神科慢性病房六個月以上後出院，生活在社區的思覺失調症病人。使用架構分析法分析訪談資料，探討病人生命經驗及出院前後的相關因素。結果：本研究共訪談了八位病人。運用包含個人、人際、社區與醫院的多層次架構來理解病人的出院經驗。在主觀經驗方面，出院後病人開始體會要能回顧學習經驗、尋求社會支持並讓自己更有彈性去磨合；與住院不同的是要學會自我管理、融入多元的人際互動；而面對自身疾病角色常是自我污名，且須面對身體的老化、退化；家庭階段的改變、跟自身社會角色的重新定位；病人在出院前往往對出院後的生活沒有想像，面對環境的變動會有不安，但在逐漸適應後開始可以有放下跟放鬆的感覺，對過日子開始有另一層的體悟，歸於平淡的康復過程就是生活。關於回歸社區的挑戰，在個人層次，病人面臨自我照顧能力不足、症狀的縈繞跟干擾、經濟負擔增加，與學習能力受限；人際層面會面臨家庭的適應與監控、復健場域人際相處與活動適應的難題、職場適應，及社區參與的侷限性；而與醫院的連結方面，會發生門診功能有限，以及慢性病房原有的社會支持因出院而結束；在面對社區多元的資源時，病人經常有不知如何連結、利用，以及不符使用資格的狀況。有利於回歸社區的因素包括：住院中的復健經驗及出院安排能協助銜接出院生活、家屬的生活管理及經濟支援、復健場域中老師的復健訓練及疾病管理與活動的協調、職場中的輔導支持、社會福利資源能提供基本生活經濟援助，而宗教是生命各階段促進社會融入的穩定力量。結論：出院回歸社區是一種生活經驗重整與社會網絡重新建立的過程，面對在個人、人際、醫院與社區不同層次的挑戰，重要的有利因素包括在住院中的出院準備，以及家屬、復健場域、職場與社會福利的適當支援，以及宗教信仰。將來協助病人回歸社區的政策，應考慮提供某種個人化的服務，在考量病人主觀經驗與需求的情況下，因應多層次的挑戰與整合，與輔助病人串聯起多元的社區資源。

關鍵字

社區；臺北市；精神科；慢性病房；思覺失調症；出院；質性研究

並列摘要

Background and Purpose： Many countries have adopted the mental health care policy to assist more patients with chronic mental illness to be discharged from hospital and return to the community. However, a substantial number of patients with chronic mental illness are still treated in chronic psychiatric ward in Taiwan, with long duration of hospitalization and high re-hospitalization rates. Patients and family have a lot of concerns and anxieties toward discharge from chronic psychiatric ward. Nevertheless, there is a lack of local studies investigating patients’ experiences of leaving hospital and returning to the community from the patients’ perspectives. This study was aimed to understand patients’ subjective experiences about returning to the community after receiving rehabilitation treatment in the chronic psychiatric ward, with a focus on challenges faced by the patients and factors facilitating the process. Methods： This is a qualitative study based on interviews with patients with schizophrenia who stayed in the chronic psychiatric ward for more than six months and then were discharged and lived in the community. We used framework analysis approach to analyze the data, exploring patients’ experiences and factors associated with discharge before and after the patients left hospital. Results： A total of eight patients were interviewed. A multilevel framework was developed to incorporate patients’ experiences and factors associated with post-discharge adaptation at the individual, interpersonal, community, and hospital levels. The patients’ experiences included several themes, including i) the development of the ability to reflect on past learning experiences, seek social support, and enhance personal flexibility to adapt to the post-discharge life; ii) to learn about managing own daily life and interpersonal interaction; iii) to face the challenges of self-stigma, aging, and deterioration of functions; iv) to adapt to the changes in family structure and personal social role; v) to develop the understanding of the recovery process as an integral part of life and start to enjoy a relaxing, new post-discharge life, in contrast to the inability to image post-discharge life and anxiety to any changes before leaving the chronic ward. The patients faced a number of challenges at multiple levels: i) inadequate personal care skills, the adverse effects of residual psychotic symptoms, the increased financial burden, and limited learning capacity at the individual level; ii) adaptation to family life and family’s monitoring, challenges to adapt to interpersonal interaction at the rehabilitation facilities and workplaces, and limited community participation at the interpersonal level; iii) limited support provided by the outpatient clinic follow-ups and the end of social support provided by the chronic ward after discharge at the hospital level; and iv) the challenges of dealing with various community resources to maximize their inter-connection and utilization at the community level. Factors that facilitate the process of returning to the community included: helpful rehabilitation experiences and discharge plans in the chronic ward; family’s supports on life management and finances; rehabilitation training, disease management, and activity coordination in the rehabilitation facilities; support received at the workplace; social welfare that provided basic financial supports; and religious beliefs and activities that facilitated social integration. Conclusion：Leaving hospitals and returning to the community is a process to re-organize life experiences and re-establish social network for patients with chronic mental illness, who face multiple challenges at the personal, interpersonal, hospital, and community levels. Important factors that facilitate the process include the discharge plan, adequate supports provided by the family, rehabilitation facilities, workplace, social welfare, and religion. Future policies aimed to assist the patients to return to the community should consider personalized supports that incorporate patients’ subjective experiences and needs, address challenges faced at multiple levels, and link the patients to various resources in the community.

並列關鍵字

Community ； qualitative study ； schizophrenia ； discharge ； psychiatric ； Taipei city ； chronic psychiatric ward

參考文獻

Ahmed, A. O., Murphy, C. F., Latoussakis, V., McGovern, K. E., English, J., Bloch, A., . . . Savitz, A. J. (2016). An examination of neurocognition and symptoms as predictors of post-hospital community tenure in treatment resistant schizophrenia. Psychiatry Res, 236, 47-52. doi:10.1016/j.psychres.2016.01.001

Google Scholar

Alptekin, K., Akvardar, Y., Kivircik Akdede, B. B., Dumlu, K., Isik, D., Pirincci, F., . . . Kitis, A. (2005). Is quality of life associated with cognitive impairment in schizophrenia? Prog Neuropsychopharmacol Biol Psychiatry, 29(2), 239-244. doi:10.1016/j.pnpbp.2004.11.006

Google Scholar

Anthony, W. A., Cohen, M. R., Farkas, M. D., & Bachrach, L. L. (1990). Psychiatric rehabilitation: Center for Psychiatric Rehabilitation, Boston University, Sargent College of Allied Health Professions Boston, MA.

Google Scholar

Australia Government Department of Health. (2006). The role of case management. Retrieved from https://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-p-mono-toc~mental-pubs-p-mono-bas~mental-pubs-p-mono-bas-acc~mental-pubs-p-mono-bas-acc-cas

Google Scholar

Barut, J. K., Dietrich, M. S., Zanoni, P. A., & Ridner, S. H. (2016). Sense of Belonging and Hope in the Lives of Persons with Schizophrenia. Arch Psychiatr Nurs, 30(2), 178-184. doi:10.1016/j.apnu.2015.08.009

Google Scholar

國際替代計量

「回歸社區」：臺北市一所醫院精神科慢性病房思覺失調症病人出院經驗之質性研究

未授權

主題瀏覽