慢性中風個案持續參與醫療院所之復健治療的動機探討

中文摘要長期參與復健治療的動機已被證實會影響中風預後，但是由於國內外復健模式不同，國外的慢性中風個案大部分為居家復健模式，而台灣慢性中風個案參與醫療院所門診復健的比例偏高；再者，中風個案參與復健治療的動機研究對象多為住院個案；另外，個案與臨床專業人員彼此對於動機的不一致觀點以及「持續」參與復健治療之動機的研究缺乏，故本研究的目的即是深入探討台灣慢性中風個案持續參與醫療院所之復健治療的動機，及影響動機的決定因子，以利臨床專業人員在介入過程中，利用溝通及教育來達成個案與臨床專業人員之間的共識，以幫助個案提升駕馭自我的恢復情況及健康的促進的能力。本研究納入的受訪者為20位發病超過6個月的慢性中風個案，年齡介於60~86歲，能聽懂訪談者所詢問的問題及能清楚表達與回答問題，另外，還需要持續在醫療院所接受6個月的復健治療且出席率達80%的個案。透過1~2次半結構及一對一的深入訪談，並且作錄音。最後將訪談、錄音及觀察等質性資料，以「紮根理論」的質性研究法加以編碼、分析、比較，而產生理論架構，作為理解中風個案持續到醫療院所執行復健活動的動機之依據。在資料分析的過程中並採取策略以確保資料的可靠性及降低可信度的威脅。研究結果顯示，有5個主要範疇：「積極的生命態度」、「與家人間良好的互動與協調」、「自覺復健的益處」、「良好的復健治療經驗」及「個案以復健活動為生活中主要的職能習慣」為影響持續參與復健治療的動機，而其中又以「積極的生命態度」、「與家人間良好的互動與協調」、「自覺復健的益處」為主要的動機，每一個都可以直接影響參與復健治療形成一種生活中的職能習慣，另外，有時會倆倆互相影響，或者是三個動機相互影響下，產生持續參與行為，形成一種職能習慣。而「以復健活動為生活中主要的職能習慣」是所有個案最後必定會形成的一種現象，在形成職能習慣的過程中，又會因為良好復健治療的經驗，而產生正向的影響。由此可知，形成持續參與行為的過程，動機不是單獨存在，而是一種多方向的動機模型。因此，從持續參與復健治療的這些個案身上，可以瞭解到他們擁有正向的生命態度，且除了重視參與復健對本身的益處外，家人的期待與互動在華人的社會文化中也是重要的影響因素，而對於女性個案而言，其較在意是否能維持家庭、性別角色的期待。因此以上這些結論可以提供臨床實務需要重視的部份，強調以家庭為中心的介入模式，結合個案整體生理、心理和社會功能，以提高個案之安適感及職能調適的能力。

關鍵字

紮根理論；動機；職能習慣

並列摘要

Abstract Previous studies have demonstrated that the motivation of stroke survivors’ long-term engagement in rehabilitation affects the outcome of their recovery. Due to different delivery systems of rehabilitation between Taiwan and other countries, the majority of chronic stroke survivors participate in home rehabilitation in other countries, while higher proportion of them engage in outpatient rehabilitation program at medical institutions in Taiwan. In addition, studies that focused on stroke survivors’ motivation of rehabilitation are mostly regarding inpatients and they often have inconsistent perspectives of rehabilitation motivation when compared to clinical professionals; furthermore, a lack of researches done on motivation of “continuing” engagement in rehabilitation is also observed. The purpose of this study, hence, is to investigate the motivation of chronic stroke survivors’ continuing engagement in rehabilitation at medical institutes and the determinants of motivation. Based on the results of this study, professionals not only are able to achieve clinical consensus among the stroke survivors and them in the interventional process, but also are able to help enhance stroke survivors’ perceived control on recovery and health promotion. The study recruited 20 chronic stroke survivors with onset of more than six months, aged 60 to 86 years old. The participants must be able to understand the interview questions and can articulate and answer questions accordingly. Additionally, they have already engaged in rehabilitation program at medical institutes for more than six months and had 80% attendance rate. Through 1 to 2 times semi-structured in-depth individual interviews and recordings, the researcher applied “grounded theory” to code, analyze, compare qualitative data and produce a theoretical framework for understanding the motivation of stroke survivors’ continuing engagement in rehabilitation at medical institutes. In the process of data analysis, the researcher adopts strategies to ensure the reliability of information and reduce the threat credibility. The results show that there are five major themes: the positive attitude toward life, good interaction between families, perceived rehabilitational benefits, good rehabilitation experiences and rehabilitation activities as the main occupational habit of daily living. While “the positive attitude toward life”, “good interaction between families”, “perceived rehabilitational benefits” are the three main types of motivation, each of which is able to directly influence the formation of engagement in rehabilitation as an occupational habit. However, sometimes the three types of motivation would interact with each other and then affect the formation. Another important finding is that “rehabilitation activities as the main occupational habit of daily living” is the theme that every participant experienced at last, and, “good experiences of rehabilitation” produce a positive impact on this. Thus, during the formation of continuing participation in rehabilitation, not one type of motivation exists alone; rather, it is a multi-dimensional model of motivation. Therefore, we could now understand that those who are willing to participate in rehabilitation continuously not only have a positive attitude toward life but also value perceived rehabilitational benefits. Additionally, the family expectations and interaction is also an important factor in Chinese culture, and, not surprisingly, our female participants care more about whether they can meet the traditional gender- role-expectations in order to maintain the family. In summary, these conclusions provide important insights for clinical practicing that it is necessary to utilize a family-centered interventional approach and to pay attention to stroke survivors’ overall physical, psychological and social function in order to enhance their capacity of occupational adaptation and well-being.