| 摘要: | 背景：醫病共享決策（Shared Decision Making, SDM）在全球被廣泛推崇為最佳醫療決策模式，能促進病人自主權，提高醫病信任，並有效利用醫療資源。臺灣自2016年起積極推動SDM，衛生福利部建立SDM平台，並將其納入醫院評鑑基準，強調病人及家屬的參與。然而，臺灣醫療環境忙碌，醫生常無足夠時間詳細討論，護理人員在SDM過程中扮演更重要角色。他們需確保病人和家屬獲得充分資訊並參與決策，但護理人力不足與工作壓力限制其參與度。文化因素也對SDM實施有重要影響，護理人員需尊重病人和家屬的文化價值觀，確保他們的意見和偏好得到表達和考慮。這些挑戰顯示護理人員在SDM過程中的核心地位。對此，臺灣尚缺對護理人員SDM的行為參與程度及影響因素的深入研究。
目的：為深入瞭解影響護理人員SDM參與程度的因素，本研究採用計畫行為理論（Theory of Planned Behavior, TPB）作為理論基礎，進行質量性混合研究，探討影響護理人員SDM的行為參與度因素，包括執行意圖、態度、主觀規範及行為控制等，並透過深度訪談瞭解實際運用SDM的阻力因素與促進因素，以提出改善方案，將SDM更廣泛應用於臨床照護中。
方法：本研究在臺灣北、中、南、東部選取有執行SDM經驗的醫院進行收案，採立意取樣方式以具臨床經驗的護理人員為研究對象，量性與質性研究對象不重疊。量性研究利用TPB理論評估護理人員執行SDM的意圖、態度、主觀規範和行為控制對SDM行為參與度的影響。質性研究採半結構式訪談，依主題分析法進行分析，歸納出影響護理人員參與SDM的阻力與助力因素。
結果：臺灣護理人員在實施SDM過程中面臨多重挑戰，包括資源不足、資訊交流不暢、醫療人員態度消極、病人決策能力不足、SDM團隊分工不明確及缺乏SDM技能。資源不足和溝通障礙降低了護理人員的行為控制，影響他們的SDM實踐意願和效果。醫療人員的態度和病人決策能力不足進一步削弱了SDM的推行，而角色定位模糊和技能缺乏也限制了護理人員的參與度。支持性的組織文化和政策是促進SDM實施的關鍵因素。促進因素還包括提供適切的SDM輔助工具，以及隨著年資和職業經驗的增長，護理人員在SDM相關領域的能力顯著提高。
結論：為提高護理人員在SDM的行為參與度，醫療機構應增加資源支持，提供充足的時間和工具幫助護理人員有效地進行SDM，並應制定有效策略以留住資深護理人員，因其專業技能和豐富經驗能提升SDM的參與度。還應加強對護理人員SDM的專業培訓，提升溝通技巧和SDM技能。同時要有更明確SDM團隊的職責分工，建立支持SDM的組織文化和政策，最終提升醫療照護品質。
Background: Shared Decision Making (SDM) is globally recognized as the optimal model for medical decision-making, promoting patient autonomy, enhancing patient-provider trust, and effectively utilizing healthcare resources. Since 2016, Taiwan has actively promoted SDM, with the Ministry of Health and Welfare establishing an SDM platform and incorporating it into hospital evaluation criteria, emphasizing the involvement of patients and their families. However, Taiwan's healthcare environment is busy, and doctors often lack sufficient time for detailed discussions, making the role of nurses in the SDM process more crucial. Nurses must ensure that patients and their families receive adequate information and participate in decision-making. However, the shortage of nursing staff and work pressure limit their participation in SDM. Cultural factors also significantly impact the implementation of SDM, as nurses need to respect the cultural values of patients and their families, ensuring their opinions and preferences are fully expressed and considered. These challenges highlight the central role of nurses in the SDM process. Currently, there is a lack of in-depth research on the level of participation in SDM by nurses in Taiwan and the factors influencing their involvement.
Objective: To comprehensively understand the factors influencing nurses' participation in SDM, this study employs the Theory of Planned Behavior (TPB) as its theoretical foundation. A mixed-methods approach is used to explore factors affecting nurses' involvement in SDM, including intention to perform the behavior, attitudes, subjective norms, and perceived behavioral control. In-depth interviews are conducted to identify barriers and facilitators in the practical application of SDM. The findings aim to propose improvement strategies for more extensive implementation of SDM in clinical care.
Methods: This study selected hospitals with experience in implementing SDM from northern, central, southern, and eastern Taiwan. Purposeful sampling was used to recruit nurses with clinical experience as research subjects, ensuring that participants in the quantitative and qualitative studies did not overlap. The quantitative study utilized the Theory of Planned Behavior (TPB) to assess the impact of nurses' intentions, attitudes, subjective norms, and perceived behavioral control on their participation in SDM. The qualitative study employed semi-structured interviews and thematic analysis to identify barriers and facilitators influencing nurses' participation in SDM.
Results: Nurses in Taiwan face multiple challenges in implementing SDM, including insufficient resources, poor information exchange, negative attitudes from medical personnel, inadequate patient decision-making abilities, unclear division of labor within SDM teams, and a lack of SDM skills. Insufficient resources and communication barriers reduce nurses' behavioral control, affecting their willingness and effectiveness in practicing SDM. The negative attitudes of medical personnel and patients' inadequate decision-making abilities further hinder the implementation of SDM, while unclear roles and lack of skills limit nurses' participation. Supportive organizational culture and policies are key factors in promoting SDM implementation. Facilitating factors also include providing appropriate SDM tools and the significant improvement of nurses' abilities in SDM-related fields with increasing seniority and professional experience.
Conclusion: To increase nurses' participation in SDM, healthcare institutions should enhance resource support by providing sufficient time and tools to help nurses effectively engage in SDM. Effective strategies should be formulated to retain experienced nurses, as their professional skills and extensive experience can enhance SDM participation. Additionally, professional training for nurses in SDM should be strengthened to improve communication and SDM skills. There should also be a clearer division of responsibilities within SDM teams, and a supportive organizational culture and policies should be established to ultimately improve the quality of healthcare. |
