探討兒科護理師面對病童使用體外維生系統加護護理的壓力源

Abstract

近年來醫療資訊的發達及媒體的渲染，讓病人和家屬對於體外維生系統（Extracorporeal Life Support, ECLS）存有過度的期望，在兒科加護病房中體外維生系統的使用也越來越普遍，常會面對什麼樣的病人才適合使用、由誰來決定、病人的預後和未來的生活品質、使用後的合併症，誰來撤除或永無止盡地使用，從中衍生了許多的倫理議題，讓加護病房的護理人員除了面對高張力的醫療環境，因為每個人的價值觀的不同在照護病人的理念上也會産生衝突，而出現了許多的挫折、適應不良的問題。因此想要去探討兒科加護病房護理師在照顧使用體外維生系統病童時，遭遇的工作壓力，及決策過程中該如何去處理及應對。 本研究為描述性調查研究，於2014年01月27日至2014年3月26日止，採焦點團體方式會談15位兒科加護病房護理師，會談時間約60-100分鐘。利用半結構式的會談大綱進行資料收集，藉由護理人員主觀感受的敍說與描述照顧體外維生系統維生系統病童及家屬的護理經驗。資料分析將會談記錄所得的資料加以歸納、分析及整理，將其隱含的意義完整呈現，以找出兒童加護病房護理人員在照顧此類病童時所面對的壓力源。 依據Colaizzi（1978）所提出的現象學研究步驟進行資料分析，研究結果歸納出四個範疇：病童及家屬照護的挑戰、護理人員照護能力的自我準備度、跨團隊的協調溝通及合作、臨床決策的倫理困境。 一、病童及家屬照護的挑戰，此範疇包含兩個主題：（1）病童屬性複雜多變，其次主題為：疾病種類複雜，無法專精及病況多變，生命驟然喪失；（2）家屬面對病童病情的不確定感，其次主題為：決定治療前的掙扎、等待體外維生系統手術過程中的焦慮、不捨與不確定感的未來、不符實際的期待與現實的落差及面對生命末期不輕言放棄。 二、護理人員照護能力的自我準備度，此範疇包含三個主題：（1）體外維生系統照護，其次主題為：手術用物及儀器操作不熟悉、手術用物準備流程過於急迫、害怕操作機器及警告聲、害怕體外維生系統管路的操作；（2）新手上路摸索學習，其次主題為：初次照顧的莫名壓力、自我摸索忐忑不安、懵懵懂懂手足無措；（3）緊急狀況變化判斷及應變，其次主題為：照護經驗少致判斷評估能力不足、照護標準不一難以判斷突發狀況、異常狀況之緊急處置、合併症發生後的心靈創傷。 三、跨團隊的協調溝通及合作，此範疇包含二個主題：（1）團隊合作默契的磨合，其次主題為：放置維生系統時的急迫氛圍、緊急狀況處置的立即支援、跨團隊成員的照護能力；（2）不同醫療處置時的抉擇，其次主題為：醫療處置意見的多面向、醫療處置的整合。 四、臨床決策的倫理困境，此範疇包含三個主題：（1）維生系統放置的抉擇，其次主題為：客觀中立說明、尊重家屬選擇及讓家屬有時間撫平心理的衝擊；（2）維生系統與病童照護的考量，其次主題為：科學證據與人性照護的掙扎、置放原則標準化與醫療公平性的平衡；（3）維生系統撤除的選擇，其次主題為：生命延長與生活品質的考量、疾病合併症的自然過程。 本研究結果發現兒科加護病房護理師在照護體外維生系統病童的過程中，所要面對的壓力包含許多，尤其是在病童家屬方面、照護團隊的合作及溝通、臨床實境的抉擇，以及自我專業能力的學習成長，藉此提供醫療人員在照護類似個案時的方向以及自我壓力的調適，並協助護理師在學習新的高科技醫療的照護方式時，能夠有適當的訓練，跨團隊的協調及合作，並能增加急重症的安寧照護以提供更人性化的照護品質。

Background and purposes: In recent years, owing to the medical development and media spreading, patients and families are over expectations to the Extracorporeal Life Support (ECLS). The use of ECLS also becomes prevalent in Pediatric Intensive Care Unit (PICU). The problems which the medical staff faces are as follows: what kinds of patients are suitable for use, who is able make the decision, the influences of the prognoses and the complications of the patients, the future life quality of the patient, who will be in charge of removing the ECLS or keeping it without unknown ending. It is wonder that this is to extend the patient’s life or death. For this, the ethical issue makes the nursing staff has to face not only high tension but also frustration and maladaptation of the medical environment. The purpose of this research was to explore the stressors that nurses of PICU may encounter when tending children using ECLS, and it also discusses the decision making process. Methods: It is a qualitative descriptive study. From January 1st to March 26th 2014, focus groups are being held with 15 nurses from Pediatrics ICU as participants, each meeting lasts 60 - 100 minutes. Semi-structured interviews are adopted to collect data, making the participants subjectively narrating and describing their experiences in taking care of children using ECLS, and their interactions with patients’ families. The interviews are recorded, processed and analyzed in hope to unveil its thorough picture beneath the data and to find nurses’ possible pressure sources when tending children with ECLS. Result: The data was analyzed according to the phenomenology methods suggested by Cloaizzi(1978) and categorized in four domains: the challenges of caring patient and his family, the medical care of ECLS, the self-preparedness of nurse competence, the ethical dilemma of clinical decision making. First, the challenges of caring patient and his family includes two themes: 1. The complexity of patient’s condition, the subthemes is includes the complexity and variety of the disease course, and the sudden loss of patient’s life. 2. The family’s uncertainty in illness among patients, the subthemes includes the struggle before they decide to receive treatment, the reluctance and anxiety when they wait for the operation of setting ECLS, the uncertain of future, the unrealistic expectation and the discrepancy in reality and perseverance during the end of life. Second, the self-preparedness of nursing competence, includes three themes: 1. Medical care of ECLS, the subthemes includes the unfamiliarity with the medical supply and equipment, the rush of preparation, the fear to operate the medical devices and their alarms, the fear to operate the circuit of ECLS. 2. The learning curve of the newbie, the subthemes includes the pressure when they firstly face the patients with ECLS, the upset and helpless feeling of self-learning. 3. The judgment and reaction during emergency, the subthemes includes lack of experience of caring ECLS patients, the inconsistence of the standard of medical care, the emergent management in abnormal situation, the psychological trauma after compilation occurs in patients. Third, the communication and co-operation between medical teams, includes two themes: 1. The adjustment of team work, the subthemes includes the urgent atmosphere during the placement of ECLS, the immediate support of emergent medical management, the capacity of cross-team members. 2. The decision making between different medical management, the subthemes includes multiple perspectives of medical management, the integration of medical management. Fourth, the ethical dilemma of clinical decision making, includes three themes: 1. The decision to place ECLS, the subthemes includes objective explanation, the respect for the choice of the family and the rest period of family for their psychological shock. 2. The consideration of ECLS and medical care of patients, the subthemes includes the struggle between scientific evidence and humanity, the balance between the standardization of the criteria of ECLS placement and the equality of medical care. 3. The decision making of the withdrawal of ECLS, the subthemes includes the consideration of life prolongation and life quality, the nature course of disease complications. Conclusion: This research suggests that the nurses are under several kinds of pressure in treating children with ECLS, among which the most dominant ones come from the families of the patients, the collaboration and communication required in inter-professional practice, the decision-making needed in clinical context, as well as their demand in ameliorating proficiency of nursing. This research hopes to provide a direction and guidance to medical staff who works in similar background to their better adaptation to the pressure, and to assist them in getting proper training in terms of learning new nursing skills with cutting-edge technology, and the ability to collaborate with others in inter-professional practice, as well as to increase hospice care for better nursing quality.