探討高熟齡族住民觀點下的機構照顧服務品質

為因應高齡社會與少子化，設立普及和永續的長照服務體系實足關鍵。惟現今家庭結構以核心家庭為主，家庭之老人照顧功能逐漸消退，因此機構式長照系統仍有其重要性。在提升其量能之際，兼顧品質亦是推動完整長照體系的一環。本研究特別聚焦在長照機構內高熟齡族的住民，探討他們認為好的服務品質為何？主要的原因是這些住民雖然目前仍可言語，接受訪談，但其可能在短期內就無法言語，因此在未來就無法對服務品質的不佳來抱怨，機構也就無法得知其服務品質的好壞，而僅能從觀察或其家人的回饋中得知，這樣對於這些高熟齡老人在機構內的生活品質是沒有助益的。故本文針對這些尚能言語，但快要無法言語的老人進行研究，希望能更深入了解這些高熟齡族的真實經驗與感受，這不僅能幫助機構了解他們的需求，也助於這些老人未來在機構內長期的生活品質；且亦能對於目前長照機構的評鑑制度或服務品質評估指標提供一些額外的資訊，希望能更多考量這些齡族的需求。另外，本文也會訪談照顧服務員及護理師，來了解他們的觀點，以比較這些人群之間觀點的異同之處，並探求可以滿足住民真實需求的可行方法。詳細來說，是針對東部2間長照機構的12位住民，和照顧服務員與護理師各6位進行深度訪談，以及實地觀察，最後得出以下研究結果：首先，住民觀點的照顧服務品質可分為6大面向：環境（即機構環境的表徵）、基本權利（指作為人應享有的自由、自主權利，應受到他人尊重）、服務者的態度（指護理師與照顧服務員在提供照顧服務過程中，讓住民所感受到的行為表現）、人際與社會互動（機構內的住民與院內外之人、事、物保持一定的互動關係是必要的）、需求滿足（機構應盡可能讓住民反應的需求能夠被滿足，以利於住民的身心健康）、品質管理（為維持甚至提升機構提供的照顧品質，因而需要品質管理），共計32個正負向指標。機構、服務提供者若能維持正向指標、改進負向指標，將有助縮小住民期望與服務提供的落差，以提升機構照顧服務品質。只是照顧人員之觀點，整體上與住民看似相近，但又有些差異；藉由比較二者異同，便能暸解到雙方在服務品質上認知不同處為何，進而分析可能原因、調和雙方視角差異等。其次，再就本研究之住民觀點的照顧品質指標，與相關照顧服務品質理論如PZB的服務品質模型等，加以深入對話與討論，以提出差異所在與發現；接著，再將本研究結果與現行機構評鑑指標進行檢視對照，而能夠暸解住民觀點的照顧服務品質被關注的程度，並敦促將住民之真實心聲納入。這當中，已「高度符合」住民對照顧品質的想望之項目有：空間整潔、活動空間大小、隱私保障、避免肢體約束、尊重自主性、機構活動、與外界團體互動；而「大致符合」者有：飲食需求、身體清潔需求；「僅部分符合」者有：服務者態度、住民間互動、服務改進；「並未符合」者有：復健設施的重要、床位分配/室友分類問題、與外籍照服員的語言溝通障礙、照顧人員的流動率、行動受限的困擾、與照顧人員的互動、情感需求、維持身體機能的期望、重視服務即時性。考量到如何將住民之想望轉換為具體可行的評鑑指標，並不容易，尚須經多方商討，故在此僅提出幾個可能現階段較能相對簡單去調整的項目，包含復健設備、態度、身體清潔需求及服務改進。最後，依據研究結果與相關討論對話，綜合提出理念、政策與實務的相關建議，盼望能對機構長照服務的品質提升有所貢獻。

關鍵字

長期照顧；機構式服務；照顧服務品質；服務使用者

並列摘要

In order to cope with the aged society and the low-birth rate, it is crucial to establish a universal and sustainable long-term care service system. However, the majority of current family structure is the nuclear family, and the function of family's elderly-caring is gradually fading. Therefore, the institutional care is still essential for the long-term care system. At the same time as improving in quantity of long-term care, quality is also a part of promoting a integrated long-term system. This study focuses on the residents of high-aged people in the institutions to discuss what they think is good quality of care service. The main reason is that although these residents are still able to speak and accept interviews, they may not be able to speak in the short time, so they may not be able to complain about the poor quality of service in the future. The caregivers and managers will be incapable of knowing the quality of their services, but only from observations of residents or feedback from their families, this is not helpful for the quality of life of these high-aged elderly people in the institutions. Therefore, this article is aimed at these aged people who now are still able to speak but probably soon are unable to speak. I hope to have a deeper understanding of the real experiences and feelings of these high-aged people. This will not only help the institutional staff understands their needs, but also help the elderly to have a better care quality within the institutions; and can provide some additional information for the current evaluation system or assessment indicators of service quality of the long-term institutions, hoping to have more considerations of these aged people’ needs. In addition, this article will also interview caregivers and nurses to understand their views about the care quality, to compare the similarities and differences between these three groups, and to explore possible ways to meet the real needs of the residents. In detail, in-depth interviews and field observations are conducted, with 12 residents, 6 caregivers and 6 nurses of 2 long-term institutions in the eastern Taiwan. The following findings have been concluded: First of all, the quality of care services from the residents' perceptions can be divided into six major perspectives: 1) the environment (i.e., the representation of the environment in the institutions), 2) the basic rights (referring to the right of freedom and autonomy as a person should have, and also should be respected by others), 3) the attitude of the service provider (referring to the nurses and caregivers’ behaviors in the process of providing care services, felt by the residents), 4) interpersonal and social interactions (the residents maintain a certain interaction and relationship with the people inside and outside the institutions is necessary), 5) demands satisfaction (staff should be able to meet the residents' needs as much as possible, since it is beneficial for the residents' physical and mental health), 6) quality management (to maintain or even improve the quality of care provided by the institutions, and therefore require quality management), and total of 32 positive and negative indicators. If staff and service providers can maintain positive indicators and improve negative indicators, it will help narrow the gap between residents' expectations and actual service delivery, and further improve the quality of institutional care services. However, the perceptions of the caregivers and nurses seems similar to the residents in the whole, but still there are some differences. By comparing the similarities and differences between these people, we can understand the difference between the providers and the users in terms of service quality, and then analyze the possible causes and reconcile the differences between the two sides. Secondly, by getting into a conversation and discussion with the indicators of care quality of the residents' perceptions in this study and related theories of care service quality such as PZB model, we can bring forward the differences and findings; then, the results of this study and the current governmental evaluation indicators of long-term care institutions are used to view and compare, thus we can understand the extent to which the quality of care services from the residents' perceptions is concerned, and urge for the recognition of the true voice of the residents. Among them, the items that have been "highly consistent" with the residents' desire for quality of care are: cleanliness of space, size of activity space, privacy protection, avoidance of physical restraint, respect for autonomy, hosting activities, interaction with outsider; "substantially consistent" are: dietary needs, physical cleaning needs; "only partially met" are: attitude of service provider, interaction within the residents, service improvement; "not met" are: the importance of rehabilitation facilities, bed allocation / roommate classification problem, and the language communication barriers with foreign caregivers, the turnover rate of caregivers, the limitations of mobility, the interaction with caregivers and nurses, the emotional needs, the expectation of maintaining physical function, and the importance of service immediacy. Considering it is not easy to convert the residents' desires into the concrete and feasible evaluation indicators, and still needs further discussion through experts, scholars, and so on. Therefore, I only bring up a few items that may be relatively simple to adjust at this stage, including rehabilitation equipment, attitude, physical cleaning needs and service improvement. Lastly, based on the research results and relevant discussions, I comprehensively propose some recommendations on ideas, policies and practices, and hope to contribute to the quality improvement of the institutional long-term care services.