職能治療參與度量表發展與應用─以中風病人為例

Development and Application of the Occupational Therapy Engagement Measure: A Patient with Stroke Perspective

呂文賢(Wen-Shian Lu)

指導教授 ： 謝清麟 ； 連雅慧

國立中正大學/管理學院/企業管理學系/博士(2016年)

摘要

背景：職能治療(Occupational Therapy, OT)參與度可定義為：「個案於OT單位、病房或家中，遵從並參與或投入職能治療師所規劃的治療性方案或活動的程度。」研究顯示個案之參與度影響治療方案能否順利推動，更影響OT品質與成效。然而尚無研究針對個案之OT參與度深入探究，國際上現有三份復健參與度問卷，其評量對象並非針對職能治療個案設計，且都各有其臨床使用上之限制，另其信效度未充分驗證。亦即目前尚欠缺完善之中風病人OT參與度評估工具，嚴重影響臨床與研究人員對個案參與度之掌握與OT品質之提升。
研究目的：一、發展職能治療參與度評估工具(Occupational Therapy Engagement Measure, OTEM)；二、驗證此工具之信度與效度；三、探討OTEM的臨床效用。
研究方法/程序：分為三個階段：一、評估工具之發展：透過焦點團體及文獻回顧發掘適當的題項做為量表發展之基礎。並邀請專家進行審核。 再進行認知訪談修改題目，以確認OTEM之題目與量尺。二、OTEM信效度驗證：徵召中風個案，由個案之治療師以OTEM進行評量，並進行探索性因素分析及驗證性因素分析，以驗證OTEM之內部一致性、建構效度、預測效度等心理計量特性。最後根據心理計量之結果，決定OTEM之最終內容。三、邀請使用過OTEM的職能治療師進行深度訪談，探討OTEM的臨床效用。
結果：共16名生理疾病臨床職能治療師參與焦點團體，第一階段發展OTEM題項共16題，4點頻率量尺。共201名住院中風個案參與探索性因素分析，結果得到單一向度（14題項）之OTEM。驗證性因素分析結果顯示，共217名住院中風個案參與，得到單一向度（5題項）之OTEM，且具有良好的建構效度。使用者亦表示，OTEM有助於治療師對個案參與度更多層面之了解，且此量表適用不同診斷的病人，精簡的5題項OTEM有潛力可以取代目前使用的參與度評量項目。
結論：經驗證5題項之OTEM具有良好建構效度，且題項精簡適合臨床上使用，本研究成果可以作為後續職能治療參與度相關因子研究或臨床效用研究之基礎；亦有助於職能治療人員對於病人OT參與度之掌握與追蹤，進而改善影響個案OT參與度之因素，有效提升治療品質與成效。另一方面，具有信效度之OTEM，有潛力可以取代目前臨床上使用的參與度評量項目。

關鍵字

參與 ； 職能治療 ； 中風

並列摘要

Background: Occupational therapy (OT) engagement of stroke patients can be defined as ‘the degree by which stroke patients follow and engage in the therapeutic programs designed by her/his occupational therapist at clinical setting or at home’. Previous studies have shown that the implementation and the effectiveness of therapeutic programs are highly affected by patients’ engagement. However, little research investigates OT engagement, limiting our understanding and promotion of engagement. There are three measures that assess patients’ rehabilitation engagements to date. However, these measures are not designed especially for stroke patients. In addition, these three measures have their limitations individually in clinical use, and the reliability and validity of these measures have not been fully verified. Notably, there is no reliable measure to assess the OT engagement of stroke patients yet; the shortcomings will hamper the master of clinicians and researchers in engagement, and impede the improvement of quality of OT treatment.
Purpose: to develop the Occupational Therapy Engagement Measure (OTEM), and further examine the reliability and validity of the OTEM.
Method: Three stages were planned. First, development of the instrument: We developed the OTEM through literature reviewing and interviewing experts and employing cognitive interview to further examine the items and rating scale of the OTEM, then we revised/finalized the OTEM. Second, validation of the psychometric properties of the OTEM: We recruited participants with stroke, who were assessed by their own therapists using the OTEM, and using exploratory factor analysis and confirmatory factor analysis to examine the internal consistency, construct validity and predictive validity of the OTEM. The final version of the OTEM will be decided on the basis of the results of the psychometric investigations. Third, to interview the OTs who have used the OTEM to investigate the clinical utility of the OTEM.
Results: A total of 16 OTs participated in the focus group. In the first stage, the OTEM with 16 items and 4-point-frequency scale has been developed. A total of 201 inpatients with stroke participated in the study of exploratory factor analysis of the OTEM. The results showed that the OTEM was uni-dimension with 6 items. A total of 217 inpatients with stroke participated in the study of confirmatory factor analysis of the OTEM. The results showed that the uni-dimension OTEM with 5 items had good construct validity. The users of the OTEM indicated that the multiple items of the OTEM improves the OT’s acknowledge of the multiple facets of the engagement, and the OTEM is suitable for patients with various diagnosis. In addition, the OTEM has potential to replace the item of engagement used in clinical setting at present.
Conclusion: The 5-item OTEM with good construct validity has been validated. The precise items of the OTEM are suitable used in clinical setting. The results of this study could be the basis of further studies to investigate the related factors and the clinical utility of the OTEM. In addition, the results of this study could be helpful to the OT to manage and monitor the level of engagement of the patients in therapeutic activities, and improve the factors those affect the engagement to promote the quality of therapy and therapeutic outcomes. Besides, the OTEM with sound reliability and validity has potential to replace the items related to the engagement which are used in clinical settings at present.

並列關鍵字

Engagement ； Occupational therapy ； Stroke

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