自我管理促進方案在慢性阻塞性肺病病人之成效

The efficacy of a self-management program in patients with chronic obstructive pulmonary disease

張怡雅(Yi-Ya Chang)

指導教授 ： 戴玉慈

國立臺灣大學/醫學院/護理學研究所/博士(2017年)

https://doi.org/10.6342/NTU201700226

摘要

研究背景:因為吸菸、空氣汙染與人口老化等因素，慢性阻塞性肺病的發生率與死亡率都有增加的現象。根據世界衛生組織的預估，慢性阻塞性肺病將於2030年成為全球死亡原因的第三名。慢性阻塞性肺病對現代人的威脅逐漸加重，因此慢性阻塞性肺病病人對醫療照顧的需求與所造成的醫療負荷不容忽視，所以如何減少慢性阻塞性肺病病人發生急性惡化與提升其生活品質，將是照顧慢性阻塞性肺病病人的重要關鍵。而教導病人疾病的照顧技巧及生活管理是護理人員的角色功能之一，但有效提升病人自我管理之護理的方法需要研究證實，因此引發筆者研擬慢性阻塞性肺病病人自我管理促進方案並探究其成效。
研究目的:本研究之目的在探討慢性阻塞性肺病病人自我管理促進方案在疾病知識、自我效能、病人積極度、生活品質與因呼吸問題而發生非預期就醫之成效，並了解促成或阻礙慢性阻塞性肺病病人執行自我管理之因素。
研究方法:本研究為一個隨機分派的臨床試驗研究，樣本來自於北部某醫學中心胸腔內科門診的慢性阻塞性肺病病人，收案時間為2015年1月至2016年5月。運用動機式會談與成人學習理論設計，提供實驗組病人3個月之「意、學、思、達、行」的自我管理促進方案，內容包含:自我管理手冊的自我學習、施與個案1.5小時的強化動機及自我管理討論、設定個別性的行動計劃、定期的電話支持。而對照組病人則進行傳統的衛教。所有的研究對象於實驗介入前(前測、T0)、實驗介入後1個月(後測、T1)、實驗介入後3個月(後後測、T2)等三個時間點進行疾病知識(Chronic Obstructive Pulmonary Disease knowledge Questionnaire; COPD-Q)、自我效能(Pulmonary Rehabilitation Adapted Index of Self-Efficacy; PRAISE)、病人積極度(Patient Activation Measure；PAM)與生活品質(COPD Assessment Test; CAT)的成效指標之資料收集，並於實驗介入後6個月(T3)進行因呼吸問題而非預期就醫情形之資料收集。以SPSS 22.0進行資料分析，運用描述性統計呈現研究對象基本屬性與成效指標的狀況，並以推論性統計獨立t檢定(Independent-t test)、卡方檢定(X2-test)及廣義估計方程式(Generalized estimating equation ; GEE)分析自我管理促進方案介入之成效。
研究結果:本研究實驗組與對照組各有30人，共60人參與本研究。結果顯示(1)本研究對象的平均年齡為72.03歲、以男性居多(占91.7%)、教育程度以高中畢業居多(占30.0%)、大多數皆處於退休狀態(73.3%)、疾病階段多屬於輕度(GOLD I) (58.3%)與中度(GOLD II) (28.3%)；風險的高低與症狀之多寡以A群病人(58.3%)與B群病人(41.7%)占多數；(2)兩組病人的基本屬性皆無顯著差異性；(3)兩組病人在不同的時間點比較，實驗組在一個月的後測(T1)及三個月的後後測(T2)其疾病知識、自我效能、病人積極度皆優於對照組，且統計上有顯著差異性；(4)比較組別與時間的交互作用，實驗組病人於T1及T2其疾病知識、自我效能、病人積極度皆優於對照組，且統計上有顯著差異性；實驗組病人於T1之生活品質優於對照組，且統計上有顯著差異性；(5)因呼吸問題而引發非預期就醫的情形，兩組病人並無統計上顯著差異性；(6)影響病人進行自我管理的因素包含:環境、時間、身體不適及行動計劃之目標。
結論:本研究結果發現「意、學、思、達、行」的自我管理促進方案可以增進慢性阻塞性肺病病人的疾病知識、自我效能、病人積極度及生活品質，並幫助病人落實有益的行為於日常生活中。因此，護理人員可以運用不同於傳統的方式去誘發與引導病人自主學習疾病管理相關知識和技能並給予適度的支持，可幫助慢性阻塞性肺病病人於日常生活中更有效的執行自我管理。

關鍵字

慢性阻塞性肺病 ； 自我管理 ； 自我效能 ； 生活品質

並列摘要

Background: The incidence and mortality rate of chronic obstructive pulmonary disease appears to be increasing as a result of factors such as smoking, air pollution, and population aging. The World Health Organization has predicted that chronic obstructive pulmonary disease will be the third leading cause of death worldwide by 2030, demonstrating that chronic obstructive pulmonary disease is a growing threat to global health. The burden of medical expenditures and the needs of patients with chronic obstructive pulmonary disease should not be neglected. Therefore, determining how to reduce the occurrence of acute exacerbation in patients with chronic obstructive pulmonary disease and improve their quality of life is crucial. Nurses must teach patients to care for themselves and manage their disease. However, the most effective means of improving patients’ self-management skills requires confirmation through evidence from research. Therefore, the efficacy of a self-management program for patients with chronic obstructive pulmonary disease was explored in this study.
Purposes: To evaluate the efficacy of the motivating, self-learning, reflecting, action plan verbalizing, and action taking (MSRAA) self-management program delivered by a case manager on disease knowledge, self-efficacy, patient’s activation level, quality of life, and unexpected medical treatment in patients with chronic obstructive pulmonary disease, and to find out influence factors on self-management for patients with chronic obstructive pulmonary disease.
Methods: A randomized controlled trial was designed for intervention and evaluation in the MSRAA self-management program conducted at the outpatient thoracic clinic of a medical center in northern Taiwan from January 2015 to May 2016. The MSRAA self-management program, which was designed on the basis of motivational interviewing and theory of adult learning included patients’ self-learning from a booklet, a 1.5 hour discussion, that inspiring motivation for self-management, creating patient himself/ herself, and scheduling telephone calls in advance, was implemented in the experimental group for 3 months. The usual care plan was implemented in the control group. Questionnaires were used for the collection of data on disease knowledge (Chronic Obstructive Pulmonary Disease knowledge Questionnaire; COPD-Q), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy; PRAISE), patient’s activation level (Patient Activation Measure；PAM), and quality of life (COPD Assessment Test; CAT) at the baseline (T0), first month (T1), and third month (T2). In addition, data on unexpected medical treatment was collected at the sixth month. SPSS 22.0 was used for data analysis. Data analysis consisted of basic characteristics and outcome indicators presented in term of descriptive statistics; inferential statistics were by independent-t test, X2-test and generalized estimating equation (GEE).
Results: Of the 60 eligible participants, 30 were randomly assigned to the MSRAA self-management group and 30 to the conventional care group. The results of this study were as follows: (1) The participants were mostly male (91.7%), senior high school graduates (30.0%), retired (73.3%), GOLD I stage (58.3%), and group A (58.3%) with an average age of 72.03 (SD = 11.14). (2) The baseline characteristics of participants between the two groups showed no statistically significant differences. (3) The MSRAA self-management group had significant differences in disease knowledge (p < 0.001), self-efficacy (p < 0.001), and patient’s activation level (p < 0.001) compared to the control group at T1 and T2. (4) Statistically significant differences were found in disease knowledge (p < 0.05), self-efficacy (p < 0.01), and patient’s activation level (p < 0.01) in the interactions between groups and time (T1, and T2). A statistically significant difference was found in quality of life (p < 0.05) in the interactions between groups and time (T1). (5) No statistically significant difference was found in unexpected medical treatment between the two groups. (6) The factors that influence on self-management are environment, time, physical discomfort and the goals of action plans.
Conclusions: The results supported the assertion that the MSRAA self-management program improves patients’ disease knowledge, self-efficacy, patient’s activation level, and quality of life, and help patients to carry out beneficial behaviors in their daily life. A nurse can feasibly use the program to motivate and support patients with chronic obstructive pulmonary disease to learn self-management skills, realize their responsibility for self-management, and improve their quality of life.

並列關鍵字

chronic obstructive pulmonary disease ； self-management ； self-efficacy ； quality of life

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