Knowledge, Attitudes, Experiences, and Confidence of Nurses in Completing Advance Directives: A Systematic Synthesis of Three Studies

護理人員對「預立醫療指示」的知識、態度、經驗和信心：三項研究之系統性綜合文獻回顧

10.1097/JNR.0b013e318256095f

Diane Ryan；Mary Ann Jezewski

預立醫療指示 ； 臨終 ； 護理人員 ； 系統性綜合 ； advance directives ； end of life ； nurses ； systematic synthesis

The Journal of Nursing Research

20卷2期（2012 / 06 / 01）

131 - 141

英文

背景 「預立醫療指示」是病人在臨終前表達想要的治療方式之一；然而，目前在提升預立醫療指示的完成率方面，尚無有效且一致的解決方法。文獻查證發現，美國有三項研究以完全相同的研究方法但針對不同護理人員探討此議題。這些研究探討的概念包括護理人員對預立醫療指示的知識、態度、經驗及信心。目的 此系統性文獻回顧歸納此三項分別針對腫瘤科、重症單位及急診室護理人員之研究調查結果。方法 本文探討兩大研究問題：（1）護理人員在預立醫療指示之知識、態度、經驗和信心為何？（2）變項間的關係為何？此三項研究皆以預立醫療指示之知識、態度及經驗之問卷調查來收集資料。結果 調查結果顯示，護理人員的知識水準有60%正確，對預立醫療指示有中度信心，且對預立醫療指示的討論都很有經驗並予以支持。「倡護」是這些研究中所呈現的一個重要概念，且多數護理人員同意身為護理人員應維護病人的意願。時間是完成預立醫療指示的障礙，重症單位護理人員對預立醫療指示的認識優於腫瘤科或急診室護理人員，但造成此差異的原因尚不清楚。這些研究建議，討論病人的預後，在護理人員及醫師的預立醫療指示進階教育和培訓相當重要，以便護理人員對病患提供預立醫療指示的衛教，並介紹各種臨終照護方式。結論／限制 態度量表信度偏低，限制了所收集資料之統計分析，且本研究乃根據已發表之研究結果作二次分析，故亦限制了研究結果之統整與分析。護理人員需加以改善並提昇與病患討論預立醫療指示中所扮演的角色，臨終討論應是護理人員與各醫療團隊相互合作的過程。

Background: Advance directives (ADs) are one of the few means for patients to indicate their end-of-life (EOL) treatment option preference. An effective and consistent solution for increasing the AD completion rate remains elusive. A literature search revealed three studies completed in the United States that employed an identical methodology and focused on registered nurses (RNs). These studies examined a variety of concepts, including nurses’ knowledge, attitudes, experience, and confidence with regard to ADs. Purpose: This review completed a systematic synthesis of reported results from three survey studies that focused, respectively, on oncology, critical care, and emergency RNs who were members of various professional nursing organizations. Methods: Our investigation addressed the following research questions: What are the knowledge, attitudes, experience, and confidence of RNs with regard to ADs, and what is the relationship among these study variables? Each study used the Knowledge, Attitudes, and Experiential Survey on Advance Directives Instrument to obtain findings. Results: Findings indicated that level of knowledge of nurses was about 60% correct and that nurses reported a moderate level of confidence related to ADs. Nurses stated they were experienced in AD discussions and agreed with attitude statements indicating support of ADs. Advocacy was a theme in the findings of these studies, as most nurses agreed with the statement that nurses should uphold patients' wishes. Time was identified as an impediment to AD completion. Critical care nurses had higher levels of awareness of ADs, as compared with oncology and emergency room nurses, although the cause of this difference is unclear. Although RNs provided AD education and explanations and described the various types of EOL care, these study subjects suggested that discussions of patients’ prognoses may be an intervention more appropriate for nurses or other clinicians with advanced education and training. Conclusion/Limitations: The low Cronbach's alpha values in the attitude scales within the survey instrument posed limitations in the original research on the use of attitude scale scores in statistical analysis. The data examined in this study was obtained from published reports, which limited the synthesis and analysis of study findings. Nurses need to refine their role in AD discussions with patients. End-of-life discussions should be an interwoven process between RNs and the multidisciplinary team.

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