專科護理師執業範圍與執業模式之研究－－以台、美之比較為中心

A Study of the Scope of Practice and Practice Pattern of Nurse Practitioners-Based on the Comparison of Taiwan and American Legal Systems

美國有些州之專科護理師（下稱專師），其執業範圍，接近醫師之執業範圍，具確立醫療診斷、開立藥物與檢驗檢查醫囑、轉介病人之權限，並於醫師處於一合作關係下提供照護予病人，即專師可獨立執業，僅於照顧病人有疑義時可向醫師諮詢或將病人轉介予醫師（此稱醫師專師合作模式）。反觀護理人員法第24條第3項規定我國專師僅得於醫師指示下與監督下執行醫療業務，其執業之獨立性與自主性遠不如美國專師。我國「專科護理師於醫師監督下執行醫療業務辦法」引進美國「預立醫療流程」概念，專師依預立醫療流程有開立藥物、治療處置、檢驗檢查醫囑之權限，預立醫療流程雖使我國專師執業之獨立性與自主性略為提升，惟仍與美國之「醫師專師合作模式」所賦予專師之獨立性與自性相去甚遠。又醫院是否施行預立醫療流程，乃由醫院自行決定，專師執業倘無預立醫療流程可資依據，並無上述醫囑權，以預立醫療流程之有無作為執業範圍有所差別之依據，似有不妥。本文欲比較我國和美國專師執業範圍與執業模式之差別，並評析「專科護理師於醫師監督下執行醫療業務辦法」之不足或缺失，並對此提出立法建議。

In the United States, the scope of practice of nurse practitioners (NPs) is similar to the scope of practice of physicians. U. S. NPs have privilege of making medical diagnosis, ordering drugs and tests, and referring patients. U. S. NPs collaborate with physicians to provide care to patients and it means that NPs could consult with physicians or refer patients to physician if they encounter difficulties in taking care of patients. However, according to the Paragraph 3 of the Article 24 of the Nurse Acts, Taiwan NPs could implement medical interventions only under the supervision of physicians. At this point, the autonomy of Taiwan NPs is less than that of U. S. NPs. Scope-of-Practice Regulation adopts the concept of protocol, and regulates that NPs have privileges of ordering drugs, tests, and treatment based on the protocol. Although the use of protocol increases the autonomy of NPs, the autonomy of NPs is far behind that of NPs. In addition, using protocol or not is determined by individual hospital. NPs who practice without protocol do not have the privileges of ordering drugs, tests, and treatments. However, the differences of the scope of practice are based on using protocol or not that is inappropriate. The purpose of this article is to compare the differences of the scope of practice and the practice pattern between U. S. NPs and Taiwan NPs, to analyze the shortcoming of the Scope-of-Practice Regulation, and finally to make suggestions from legal aspects for the Scope-of-Practice Regulation.