臺北地區護理人員之重症病人疼痛評估與處置施行現況

Nurses’Pain Assessment and Management Practices: A Survey in Taipei

陳穎珊(Ying-Shan Chen)

指導教授 ： 廖媛美

臺北醫學大學/護理學院/護理學研究所/碩士(2014年)

摘要

疼痛是加護單位重症病人的常見問題，護理人員於重症病人的疼痛評估與處置扮演重要角色。由於現存知識對於重症單位護理人員執行疼痛評估與處置之瞭解有限，因而進行本研究。本研究之目的為：(1)調查臺北地區重症護理人員之疼痛評估與處置執行狀況、(2)瞭解重症護理人員執行疼痛評估與處置的促進因素與障礙因素、(3)探討重症護理人員於無法自我表達之重症病人族群頻繁使用疼痛評估工具之相關因素。
本研究為橫斷式的描述性、相關性研究，共收案381位任職於加護單位之全職護理人員。以一份結構式問卷進行資料收集，收集資料包含：重症護理人員之個人特性、執業環境特性及其針對重症病人執行疼痛評估與處置之狀況，用於調查疼痛評估與處置執行狀況之中文量表包含二十九個題項。資料分析採用SPSS 19.0版統計軟體，以p值小於0.05界定為具有顯著意義。本研究以描述性統計呈現護理人員之個人特性與執業環境特性，以及針對重症病人執行疼痛評估與處置之狀況與促進/障礙因素，並以邏輯斯迴歸(Logistic regression)分析護理人員於無法自我表達之重症病人頻繁使用疼痛評估工具之相關因素，依據邏輯斯迴歸分析之最終模式結果，呈現各個相關因素的勝算比及95%信賴區間。
本研究重症護理人員的平均工作年資為4.5年± 4.8年，性別以女性佔多數(n = 366, 96.1%)，教育程度以大學居多(n = 276, 72.4%)，約八成護理人員(n = 310, 81.4%)已接受過加護訓練。針對可使用口語或其他方式溝通之重症病人，多數護理人員會使用疼痛評估量表(n = 370, 97.1%)，並認為病人可提供最準確的疼痛評估(n = 297, 78%)；對於無法使用口語或其他方式溝通之重症病人，多數護理人員表示會使用疼痛評估量表(n = 328, 86.1%)，並認為護理人員可提供最準確的疼痛評估(n = 252, 66.1%)。
本研究之護理人員認為可促進其執行疼痛評估與處置的因素為單位需使用標準化的評估工具(n = 262, 68.7%)、醫師開立足夠劑量的止痛藥物(n = 252, 66.1%)以及單位使用疼痛相關的作業流程/指引(n = 251, 65.8%)（表五）。會阻礙護理人員執行疼痛評估與處置的因素為：病人無法溝通(n = 203, 53.2%)、病人病況不穩，例如：血液動力學不穩定(n = 196, 51.4%)以及臨床護理業務工作量(n = 195, 51.1%)。於無法使用口語或其他方式溝通之重症病人，護理人員頻繁使用疼痛評估量表之相關因素為：任職於已獲Joint Commission International (JCI)評鑑認證之醫院5.51 (OR=5.51, 95% CI 2.93-10.34, p < .001)、工作單位有入住接受外科治療之病人(OR=2.49, 95% CI 1.52-4.06, p < .001))或任職機構備有適用此類病人之疼痛評估量表(OR=3.35, 95% CI 1.55-7.24 , p < .01)的護理人員，較任職於未獲JCI評鑑認證之醫院、工作單位無入住接受外科治療病人或任職機構未備有適用此類病人疼痛評估量表之護理人員較傾向於會頻繁使用疼痛評估量表。
疼痛是重症病人的主要壓力源之ㄧ，本研究之結果可應用於以下領域：教育、研究、臨床實務。於醫療機構、教育機構提供重症病人疼痛評估與處置的相關教育課程，可提昇醫療照護提供者執行重症病人疼痛評估與處置的能力。於本研究用於調查疼痛評估與處置執行狀況的中文量表，可持續應用於教育機構或未來進行的相關研究，以檢驗醫療照護提供者執行重症病人疼痛評估與處置之狀況與相關教育介入措施的成效。

關鍵字

重症病人 ； 重症護理人員 ； 疼痛評估 ； 疼痛處置

並列摘要

Pain is a common problem among critically ill patients in intensive care units. Nurses employed at intensive care units play an important role .However, current knowledge about nurses’ practices of pain assessment and management at intensive care units is limited. This study aimed to (1) investigate critical care nurses’ practices of pain assessment and management for critically ill patients, (2) understand enablers and barriers related to critical care nurses’ practices of pain assessment and management, and (3) explore associated factors of critical care nurses’ frequent utilization of pain assessment tools among non-communicative critcallly ill patients.
This study was a cross-sectional, descriptive, correlational design. In total, 381 Taiwanese nurses who were full-time employed at intensive care units were recruited. Information related to critical care nurses’ individual characteristics, working environment characteristics, and practices of pain assessment/management for critically ill patients was collected by a structured questionnaire. The Chinese scale developed to assess nurses’ practices of pain assessment/management comprises 29 items. SPSS 19.0 software was used to analyze collected information. Statistical significance was established at p < .05. Descriptive statistics was used to demonstrate critical care nurses’ individual characteristics, working environment characteristics, practices of pain assessment/management for critically ill patients, and enablers/barriers related to nurse’ practice of pain assessment/management. Logistic regression was used to examine associated factors of frequent utilization of pain assessment tools for non-communicative patients. For the final model of logistic regression, estimated odds ratios and associated 95% confidence intervals of frequent utilization of pain assessment tools for each independent variable were obtained.

Mean working experience of the 381 critical care nurses was 4.5± 4.8 years. The majority of nurses were female (n = 366, 96.1%), had bachelor degrees (n = 276, 72.4%), and had received training of intensive care (n = 310, 81.4%). For communicative critically ill patients, the majority of nurses (n = 370, 97.1%) reported that they would use pain assessment tools, and considered patients themselves could provide the most accurate pain assessment (n = 297, 78.0%). The majority of nurses (n = 328, 86.1%) reported that they would use pain assessment tools for non-communicative critically ill patients, and considered nurses as the persons who could provide the most accurate pain assessment (n = 252, 66.1%).
The nurses reported that availability of standardized pain assessment tools (n = 262, 68.7%) and at working settings, and prescriptions of sufficient analgesic dosage (n = 252, 66.1%) and pain management guidelines (n = 251, 65.8%) were the enhablers of their practices of pain assessment/management. The barriers of their practices of pain assessment/management were taking care of non-communicable patients (n = 203, 53.2%) and patients with unstable conditions (n = 196, 51.4%) (e.g., hemodynamic instability).and or working loading (n = 195, 51.1 %). Factors associated with nurses’ frequent utilization of pain assessment tool amomg non-communicative critically ill patients were hospital type, working unit, and availability of pain assessment tool. Nurses employed at the Joint Commission International (JCI) accredited hospitals (OR=5.51, 95% CI 2.93-10.34, p < .001)the units with patients receiving surgical treatment (OR=2.49, 95% CI 1.52-4.06, p < .001), or the institutions implementing pain assessment tool for non-communicative patients (OR=3.35, 95% CI 1.55-7.24 , p < .01) were more likely to frequently utilize pain assessment tool than those employed at the hospitals without JCI accreditation approvals, the units without patients receiving surgical treatments, or the institutions without implementing pain assessment tool for non-communicative patients.
Pain is a major stressor for critically ill patients. Our study findings could be applied to the following areas: education, research, and clinical practices. The Chinese scale developed to assess healthcare providers’ practices of pain assessment and management for critically ill patients could be used in education settings or future research to examine healthcare providers’ practices of pain assessment and management and effects of related education interventions.

並列關鍵字

critically ill patients ； pain assessment ； pain management

參考文獻

方慧芬、蔡麗雲、洪敏瑛、吳名珠、陳麗娟、陳淑卿（2004）．比較安

寧病房與一般內科病房護理人員對癌症疼痛處理知識之差異．新臺

北護理期刊，6（2），49-62。[Fang, H. F., Tsai, L. Y., Hong, M. Y., Wu. M. J., Chen, L. C., & Chen, S. C(2004). Knowledge about cancer pain management-the comparison between nurses working in hospice and internal medicine inpatient wards. New Taipei Journal of Nursing, 6(2), 49-62.]

李秀枝、吳聖良（2010）．病人主訴術後疼痛強度與護理人員評估結果

差異之比較．護理雜誌，57（3），60-68。[Li, S. Z., & Wu, S. L (2010). Postoperative pain: comparative differences between that reported by patients and nurses. The Journal of Nursing , 57(3), 60-68.]