加護病房護理人員執行發燒處置決策過程之文化脈絡

The Cultural Context of the ICU Nurses Decision-Making Process in Fever Management

施瓊芬(Chiung-Fen Shih) ； 蘇淑芬(Shu-Fen Su) ； 王守玉(Cindy Shou-Yu Wang)

《護理暨健康照護研究》 8卷2期 (2012/06) Pp. 128-137

https://doi.org/10.6225/JNHR.08.2.128

摘要

背景：加護病房重症患者常出現發燒症狀，易造成病人不舒適且增加代謝率及耗氧量；護理人員需能有效地執行發燒處置，因此了解護理人員在決策發燒處置時之情境脈絡是極為重要的議題。目的：探討加護病房護理人員執行發燒處置決策過程之文化脈絡。方法：採茁根理論研究法，以半結構式訪談指引對11位來自三家醫院、七個不同成人加護病房之護理人員進行一對一深入訪談。質性資料之分析過程以持續性比較、理論性抽樣、文獻查證、同儕檢視和專家審閱，來維持研究分析之正確性和嚴謹度。結果：「 加護病房發燒處置之單位文化」為本研究發現之主要範疇，是由「固著於傳統發燒處置」及「病房未制定發燒處置指引」兩個次類別所形成，它會深深影響加護病房護理人員執行重症病人發燒處置決策過程。本研究發現，護理人員會因為單位未制定發燒處置之臨床照護指引，就根據病房傳統的方式來處理重症病人的發燒症狀； 護理人員往往因為缺乏實證依據來執行發燒處置，內心容易產生不確定感，可能降低病人發燒照護品質。結論／實務應用：本研究發現加護病房發燒處置之單位文化是影響重症護理人員執行發燒處理之重要因素，因此我們建議，護理教育和醫療機構在制定發燒處置臨床指引時，應考量實證證據及單位現存之發燒處置文化，以促進護理人員執行臨床決策。

關鍵字

發燒處置 ； 決策過程 ； 加護病房 ； 茁根理論 ； 單位文化

並列摘要

Background: Fever is a common symptom in critically ill patients and may induce complications and increase mortality in intensive care unit (ICU) patients. Therefore, explorations of effective fever management and related cultural factors of influence are important.Purpose: This study explores the cultural context of the ICU-nurse fever management decision-making process.Methods: This qualitative study was undertaken using a grounded theory approach. We developed a semi-structured questionnaire for in-depth interviews conducted with 11 participants from 7 ICUs in 3 hospitals. Constant comparison, theoretical sampling, literature review, member checking and an expert panel were used to ensure research trustworthiness.Results: The ”ICU's unit culture of fever management” category that emerged from study data comprised the two subcategories of ”stubbornly persist in traditional fever management” and ”ICUs have no standardized fever management guidelines.” Unit culture was found to affect the fever management process of ICU nurses significantly. This study discovered that a prevalent lack of a standardized fever protocol led participants to manage patient fever symptoms using traditional ICU practices that were not based on published evidence. Participants thus expressed feeling uncertain about their treatments, which could negatively impact upon the quality of care given to critically ill patients.Conclusions / Implications for practice: Findings indicate ICU cultural mores are an important factor influencing the fever management process for nurses. Thus, we suggest that nursing education and medical institutions consider empirical evidence and unit culture when developing fever management guidelines in order to facilitate effective nurse decision-making.

並列關鍵字

fever management ； decision-making process ； intensive care unit ； grounded theory ； unit culture

參考文獻

Hoffman, K. A., Aitken, L. M., & Duffield, C. (2009). A comparison of novice and expert nurses' cue collection during clinical decision-making: Verbal protocol analysis. International Journal of Nursing Studies, 46(10), 1335－1344. doi:10.1016/j.ijnurstu.2009.04.001

Kiekkas, P., Brokalaki, H., Manolis, E., Askotiri, P., Karga, M., & Baltopoulos, G. I. (2007). Fever and standard monitoring parameters of ICU patients: A descriptive study. Intensive and Critical Care Nursing, 23(5), 281－288. doi:10.1016/j.iccn.2007.04.001

Kramer, L. W. (2010). Evidence-based practice: Fever evaluation and early recognition of systemic inflammatory response syndrome in critical care patients. Dimensions of Critical Care Nursing, 29(1), 20－28. doi:10.1097/DCC.0b013e3181be4a74

Laupland, K. B. (2009). Fever in the critically ill medical patient. Critical Care Medicine, 37(Suppl. 7), S273－S278. doi:10.1097/CCM.0b013e3181aa6117

Mackowiak, P. A. (2000). Physiological rationale for suppression of fever. Clinical Infectious Diseases, 31(Suppl. 5), S185－S189. doi:10.1086/317511