急性醫療機構護理人員臨床倫理困境之探討

Exploring the Clinical Ethical Dilemma for Nursing Staff in Acute Health Care Institutions

本研究旨在了解護理人員發生臨床倫理困境情形，並比較各層級急性醫療機構之差異。以文獻探究法、案例分析法和問卷調查法進行，參考護理人員的倫理困境案例，及文獻查證研擬出「護理人員倫理困境量表」，採LikertScale5點計分。研究對象為私立醫療院所護理協會會員醫院的護理人員，採隨機抽樣方式，抽出醫學中心1家、區域醫院4家、地區教學醫院4家，共發出問卷824份，有效回收問卷738份，有效回收率88%。研究結果發現：護理人員臨床倫理困境的發生機會，乃介於有時和偶而之間，發生機率最高的前五名依序為：「隱瞞病情」、「病人無恢復可能，但家屬要求積極救治，讓病人倍受折磨」、「有自主決定能力的病人，醫療團隊為避免醫療糾紛，會優先參考家屬的意見」、「生活品質與延長生命間的抉擇」、「病情解釋只對家屬做說明，病人心存疑問，該不該告知」，與其工作職稱、工作年資及工作單位有關，尤其是加護單位、急診，在統計學上具有顯著差異。其中以「家屬要求醫療人員對病人隱瞞病情」發生機會最多。不同等級的醫院中，醫學中心的發生機會最高，其次為區域醫院，地區醫院最低。未來醫療機構能針對較常發生的臨床倫理困境，制定處理標準和流程，並列為在職教育的重點，以提升護理人員解決倫理困境的能力。The purposes of this study are to understand how nurses cope with ethical dilemmas and compare the differences between different accreditation levels of acute health care institutions. The research methods include literature review, case analyses, and questionnaires. Based on the case reports from nurses and literature review, the nursing ethical dilemma questionnaire was drafted with a 5 point Likert scale. Research subjects came from nursing staff members of the Nursing Association of Private Health Care Institutions. Through random sampling, one medical center, four regional hospitals, and four district hospitals were included in this study. Questionnaires were distributed to all day shift nurses, 824 in total, of the participating hospitals. 738 copies were collected with a valid response rate of 88%. The result of this study indicated that the chances of nurses encountering ethical dilemma are between sometimes and occasionally. The top five dilemmas in terms of frequency in descending order are: withholding information; there is no hope of recovery, but the family request not to give up and the patient suffers; the health care team consults with the family members to avoid potential malpractice law suites even when the patient is able to make the decision; the choice between quality of life and prolonging life; only the family are informed of the progress and cannot decide whether to inform the patient when he or she has questions regarding his or her condition. The most frequent situation is that families request withholding information from patients. The differences in distribution are related to job title, seniority, and work unit. There are statistically significant differences in the intensive care units and emergency departments. In terms of hospital accreditation levels, the frequency is the highest in the medical center, followed by the regional hospital with the district hospital lowest. Health care institutions should promulgate guidelines and standard operation procedures for the frequently encountered ethical dilemmas. Continuing education should also focus on these aspects to increase the ability of nurses in solving ethical dilemmas.