護理人員倫理情緒困擾之現象研究

本研究的研究目的在於運用解釋性互動論分析護理人員面對發生倫理困擾情緒的臨床困境時，所呈現的認知衝突、價值觀思辨與行動。採用立意取樣法邀請三所教學醫院之急重症、成人腫瘤、兒童血液腫瘤、安寧、手術房、精神科等工作單位的在職護理人員，共有32位研究參與者，每位進行一次約2-3小時之訪談，其中僅有一位研究參與者訪談二次。訪談過程符合研究倫理研究參與者的知情同意，訪談內容全程錄音後轉為逐字文本，運用解釋性互動論進行研究分析。研究結果以四大範疇呈現。範疇一在告知疾病真相時，受華人文化影響而產生以家屬為主要告知對象的困擾：家屬對治療的決定可能與病人利益衝突，護理人員傾向於病人有知的權利，採取鼓勵病人詢問與提供訊息的行動；範疇二在治療方法選擇時，因規範倫理原則衝突而產生之決策困擾：當病人自主與行善或不傷害之倫理原則衝突，護理人員傾向考量病人最大利益，採取給予病人訊息或尊重病人決定的行動；範疇三在面對疼痛問題時，因執著嗎啡藥物使用而產生之處理困擾：當醫師與護理師對嗎啡類藥物的認知衝突，護理人員著重病人止痛與舒適的價值，採取同理關懷病人疼痛問題，以及教病人如何向醫師提出請求之行動；範疇四在面對末期照護時，因善終認知不同而產生之急救選擇困擾：當家屬違反病人意願堅持急救時，護理人員傾向協助病人善終的考量，採取提供家屬訊息與關懷病人之行動。直接行動與情感應用在本論文中稱之為臨床實踐智慧，能協助護理人員降低倫理情緒困擾的感受。依據研究結果提出在護理實務中降低倫理情緒困擾之五大步驟：步驟一以敘事方式書寫個人照護經驗；步驟二依循情境倫理分析敘事文本案例中認知衝突的癥結點；步驟三運用醫學實證與效益論分析病人在醫療決策上的不同後果；步驟四以解釋性互動論分析情境脈絡尋找阻礙護理師行動的可能因素；步驟五反思可以採取的行動或形成新的照護態度。研究結果將可用於護理倫理教育，改善護理人員倫理情緒困擾之現象。

關鍵字

情緒困擾；倫理困境；決策；解釋性互動論；衝突

並列摘要

The purpose of the dissertation was to use the interpretive interactionism in explanation and analysis of ethical distress in ethical dilemma presented by the cognitive conflict, value speculation and actions. In terms of the research process, the researcher invited nurses from three teaching hospitals, including ICU, adult oncology, pediatric hematology and oncology, hospice, OR, psychiatric different work units to participate by purposive sampling method. A total of 32 participants were joined in the study, every participant 2-3 hours of interview, of which only one participant interviewed twice. Data collection process in line with the informed consent of research participants ethical considerations, the interview contexts were recorded and changed to word-by-word texts to analyze by interpretive interactionism. The results were presented in four categories. The first category, when informed the truth, by the influence of Chinese culture, the distress was produced because the family was the main object to informed: the family decision might conflict with the interest of the patient, nurses tended to patients have the right to know in the value and encouraged patients to ask and gave them information in actions. The second category, in the choice of treatment, the decision-making problem was produced in the conflict of ethical principles: when the ethical principles of autonomy and benefit or no harm conflicted with, nurses tended to consider the best interests of the patient, to give the patient information or to respect the patient’s decision in actions. The third category, in the face of pain problems, the persistence of the use of morphine produced selection problems: the conflict of the use of morphine between the perception of physician and nurse, nurses tended to value the patient comfort, to care the pain problem of the patient and to teach the patient how to request the drugs to doctors in actions. The fourth category, in the face of the end of care, the distress of resuscitation was produced in the different cognition of good death: when the family assisted to resuscitate and violate the patient’s will, the nurses tended to assist patients in their good death considerations, to provide information for families and to take care of the patients in action. The application of action and affection referred to the clinical wisdom in the dissertation, can help nurses to reduce the feelings of ethical distress. Based on the results of the dissertation, the researcher puts forward five steps to reduce ethical distress in nursing practice: the first step is to write down the real patient story by narrative style, the second step is to analyze the narrative story by using situation ethics and find out the conflict points in the story, the third step is an medical empirical analysis and the use of utilitarianism on the best consequence of the patient, the fourth step is the analysis of the barriers in nurse actions by the interpretive interactionism, and the fifth step is the thinking in actions nurses can take or the generation of the new care attitudes. The results of the dissertation can be used in nursing ethics education to improve the phenomenon of nurses’ ethical distress.