「ACP模擬情境溝通訓練方案」對護理人員與慢性腎臟科病人討論ACP之成效

The Effects of an ACP Simulation-Based Communication Training Program for Nurses Discussing ACP with Patients with Chronic Kidney Disease

陳瑞娥(Jui-O Chen)

指導教授 ： 林秋菊

高雄醫學大學/護理學院/護理學系博士班/博士(2021年)

摘要

背景:善終是末期疾病照顧追求的目標，而預立醫療自主計畫(Advance Care Planning, ACP)是達此目標的最佳策略。ACP已是全球趨勢，然國人普遍缺乏此概念，未預先簽署預立醫療決定，往往當病危時才匆促決定，或失去決定能力時才由家屬代為決定。文獻指出護理人員缺乏ACP相關知識與溝通技巧訓練，以至於沒有自信與病人討論ACP。因此，有必要發展有效介入方案來解決此問題。
目的: 本研究旨在發展與測試「ACP模擬情境溝通訓練方案」(ACP Simulation-Based Communication Training Program, ACP-SCT program)對護理人員與腎臟科病人討論ACP之成效。
方法: 本研究採雙組重複測量類實驗設計，分二階段進行。第一階段為發展ACP-SCT program；第二階段為測試ACP-SCT program之成效，在此階段同步收集量性和質性資料。以方便取樣方式，招募北、中及南部醫院之腎臟科相關單位的護理人員為受試者，共收案96位。實驗組接受每週一次，每次4小時，為期三週的「ACP模擬情境溝通訓練方案」; 對照組則僅給予「ACP模擬情境溝通訓練方案」手冊。兩組分別在實驗組方案介入前(T0)、實驗組方案結束當天(T1)與實驗組方案結束後三個月(T2)進行成效評量。量性評量工具為結構性問卷，包括資本資料、ACP知識量表、ACP溝通自信量表。量性資料以卡方檢定、獨立t檢定及廣義估計方程式(generalized estimating equations, GEE)進行推論性統計分析。此外，為了解實驗組受試者對ACP-SCT program的學習經驗與成效機制，本研究以2題開放性問題來收集受試者自我評量的質性資料，並以內容分析法來分析資料。
結果: 兩組組內的時間效應分析顯示，實驗組的ACP知識和ACP溝通自信的平均分數在T1和T2皆顯著高於T0 (Wald χ2=47.43, p <.001; Wald χ2=41.09, p <.001)；對照組ACP知識平均分數僅在T1顯著高於T0 (Wald χ2=7.53, p=.023)，ACP溝通自信在T1和T2與T0相比較皆無顯著差異(Wald χ2=1.22, p=1.000; Wald χ2=1.50, p=.946)。在二次後測時兩組組間的效應分析顯示，在控制T0數值下，實驗組的ACP知識及ACP溝通自信在T1 (Wald χ2=14.82, p <.001; Wald χ2=53.81, p <.001)和T2 (Wald χ2=16.56, p <.05; Wald χ2=31.83, p <.05)的調整後平均數皆顯著高於對照組。實驗組受試者完成三週ACP-SCT program後，分析他們對方案成效自我評量的質性資料發現，他們認為在溝通技巧學習方面，最大的突破是學會如何應用同理心與病人會談，以及更有自信與病人討論死亡的議題。在課程活動設計的回饋，他們認為團隊導向學習法增加自己的ACP知識及溝通技巧；角色扮演讓自己了解溝通能力的不足；回饋讓自己修正溝通技巧缺點; 書寫反思週記讓自己透過省思，而將所學的溝通技巧內化於心。
結論與實務應用: ACP-SCT program係以理論為基礎所發展的方案，研究顯示此方案可有效提升護理人員ACP知識、ACP溝通自信。在臨床上此方案可作為培訓ACP人員溝通訓練教材的參考，以培育更多具備討論ACP能力的護理人員。基此，我們建議將本研究所設計的ACP-SCT program推行於臨床實務，期使病人善終的照護理念能落實。

關鍵字

預立醫療照護計畫 ； 模擬情境 ； 溝通訓練方案 ； 慢性腎臟疾病

並列摘要

Background: A good death is a goal pursued by end-stage illness care. However, advance care planning (ACP) is the best strategy to achieve this goal. ACP is a global trend, but, Chinese people generally lack this concept and do not sign advance care decision in advance. The decision is often made in a hurry when it is critically ill, or when the decision-making ability is lost, the decision is made by their family members. The literature points out that nursing staff lack ACP-related knowledge and communication skills training, so that they are unconfident and afraid to discuss with patients. Therefore, it is necessary to develop an effective intervention program to solve this problem.
Purpose: This study was to develop and test the effects of the” ACP Simulation-Based Communication Training Program” (ACP-SCT program) for nurses discussing ACP with patients with chronic kidney disease.
Methods: This study conducted a quasi-experimental design with repeated measures, which was carried out in two stages. The first stage was to develop the ACP-SCT program; the second stage was to
test the effectiveness of the ACP-SCT program, and at this stage, both quantitative and qualitative research data were collected simultaneously. Convenience sampling was used to recruit ninety-six nurses from the department of the hospitals located in northern, central and southern Taiwan. The intervention group received “ACP-SCT program” once a week, 4 hours eachtime for 3 weeks. The control group was only given the ACP-SCT program manual. All of the participants underwent the assessments of the outcome variables three times as follows: pre-intervention (T0), immediate post-intervention (T1), and 3-months follow-up (T2). Quantitative outcome measures included demographic, the ACP knowledge scale, ACP communication confidence scale. Data were analyzed by chi-square test, independent t-test, and generalized estimating equations (GEEs). In addition, in order to understand the participants’ learning experience and effective mechanism of the ACP-SCT program, this study used 2 open-ended questions to collect qualitative data, and analyze the data with content analysis.
Results: The analysis of within-group effects of two group showed that the intervention group had a greater improvement over time of average scores of ACP knowledge and ACP communication confidence at T1and T2 were significant higher than those than T0 ( Wald χ2=47.43, p <.001); the average score of the ACP knowledge in the control group was only significantly higher at T1 than at T0 (Wald χ2=7.53, p=.023), and there was no significant difference in ACP communication confidence between T1 and T2 and T0 (Wald χ2= 1.22, p=1.000; Wald χ2=1.50, p=.946). The analysis of between-group effects of time showed that the average scores of ACP knowledge and ACP communication confidence of the experimental group at T1 (Wald χ2=14.82, p <.001; Wald χ2=53.81, p <.001) and T2 (Wald χ2 =16.56, p <.05; Wald χ2=31.83, p <.05) were significant higher as compared with the control group. After the participants in the intervention group completed the three-week ACP-SCT program, the qualitative data of their self-evaluation on the effectiveness of the program were analysed. They thought the greatest breakthrough in communication skills was to learn how to apply empathy and become more confident when they discuss the issue of death with the patients. In the feedback of program activity design, they believed that the team-based learning method increased their own ACP knowledge and communication skills; role-play allowed them to understand the insufficiency of communication skills; feedback allowed them to correct the shortcomings of communication skill; writing weekly reflection journals to make themselves think again, and internalize communication skills.
Conclusion and Implications for practice: The ACP-SCT program was developed based on a theoretical framework. This study showed that this program could effectively improve nurses’ ACP knowledge, ACP communication confidence. It is recommended that it can be a teaching material for the communication training of ACP facilitators, and cultivate more nurses with the ability to discuss ACP in the future. Based on this, we strongly recommended that the ACP-SCT program should be implemented in clinical practice, also hoping to apply to the care of the patient at end-of-life.

並列關鍵字

advance care planning ； simulation ； communication training program ； chronic kidney disease

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中文文獻