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研究生：	楊月頴 Yang, Yueh-Ying
論文名稱：	發展與評值以人之需求為核心的望得失智症行為與精神症狀管理模式的適用性 The Development and Feasibility Evaluation of the Person need-centered WANT care management model for behavioral and psychological symptoms of dementia
指導教授：	王靜枝 Wang, Jing-Jy
學位類別：	博士 Doctor
系所名稱：	醫學院 - 護理學系 Department of Nursing
論文出版年：	2020
畢業學年度：	108
語文別：	英文
論文頁數：	106
中文關鍵詞：	失智症、行為精神症狀、WANT管理模式
外文關鍵詞：	dementia, behavioral and psychological symptoms, WANT management model
相關次數：	點閱：81 下載：2
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中文摘要
研究背景：在台灣居住於長期照護機構中的老年住民患有失智症之比率相當高，而大多數的照護人員普遍未接受足夠的失智症照護教育訓練，尤其對失智者特有的行為與精神症狀不甚了解，故無法同理或適切提供符合其需求的照顧，大多只能依據醫囑給予鎮靜藥物，或進行保護性約束，甚而加劇住民的照護問題與增加照護負荷。過去有許多研究顯示，一套精心策畫的非藥物治療策略，可以有效管理失智症BPSD，降低醫療成本，還可增加照護品質，而在台灣目前仍缺乏失智症行為精神症狀的照護管理模式。
研究目的：本研究旨在架構於本土過去探索失智症行為與精神症狀之需求實證，發展以人之需求為核心的「失智症行為與精神症狀管理模式」（稱之為望得模式，WANT Model），並測試以此模式發展的教育訓練計畫之臨床適用性。
研究設計：本研究採混合設計，分兩階段進行，第一階段發展WANT模式內容，第二階段測試望得模式教育訓練計畫之臨床的適用性。
研究方法：收案地點為南部某長期照護機構，採配對方式納入照顧者20人與其所對應照顧的失智症長者20人；介入措施為新發展的望得模式教育訓練計畫，為期3個月。資料收集時間為開始進行介入照護模式前1週、介入後4週及12週。測量工具含中文版焦躁量表、失智症憂鬱量表、失智症照顧態度量表、失智症混亂行為自我效能量表；以及質性訪談含接受望得模式教育訓練的助益及負荷狀況與困難為何。量性資料統計方式為重複測量、質性資料採內容分析法。
研究結果：量性研究成果發現，此模式可幫助照服員有效處理失智症住民的焦躁F(1.40,26.61) =6.01, p=.01與憂鬱F(2,38)=6.52，p=.00，且可以提升照服員對失智症的照顧態度F(2,38) = 5.74,p=.01，但在照服員自我效能部分F(1.24,23.58)=2.49，p=.11則無顯著性改善；質性成果發現，照服員的自覺成效包括：1.對失智者的問題行為注意力與處置能力提升2.較能以人為中心看問題 3.改變對失智的態度且影響自身行為表現4.照顧負荷與壓力減輕。而照服員在接受與執行望得模式教育訓練計畫期間所面臨的問題包括：缺乏邏輯性反思能力、缺乏學習動機，以及望得手冊使用率低。
結論：本研究結果呈現以望得模式所設計的教育訓練計畫，整體上對照服員處置失智症者行為精神症狀之初步成效良好。其有助於減輕失智症住民的焦躁與憂鬱，並改善照服員對失智症住民的照顧態度。此外，照服員也自覺這樣的介入訓練讓他們較能關注失智症者之問題行為，較能體認失智症者是需要被尊重與理解的，也會從問題的背後去思考問題的原因與代表意義。另一方面，更能針對個案需求，擬定符合個別性的照顧措施，幫助滿足需求，緩解失智症問題行為。介入期間，照服員與失智症住民的互動增加且彼此的相處變得融洽。然而，照服員在執行望得模式教育訓練計畫期間，也因自身學識限制與工作負荷等問題，而較無法作邏輯性反思與缺乏學習動機。未來應可針對本適用性研究之發現，去做該模式之教育訓練計畫的介入時程、時間長短以及照服員的教育程度等修正的研究與實務。

Background: The prevalence of dementia among residents living in long-term care facilities (LTC) is high in Taiwan, yet most of the care-providers in LTC received little dementia related education, are lack of knowledge in dealing with behavioral and psychological symptoms of dementia (BPSD) and thus unable to emphasis residents’ needs and provide appropriate care. They rely mostly on sedative medicine and protective restrain, leading to worsen care problems and increase care burden of the care-providers. Previous studies showed that a well-designed non-pharmacological care and management strategy for dealing with BPSD could reduce caregiver burden, improve care quality, and reduce care cost while no care model to manage BPSD has been developed in Taiwan.
Purpose: Based on previous local studies, the purpose of this study was to develop a person need-centered management model (named WANT model) for BPSD and evaluate the feasibility of the WANT model education and training program.
Design: This study adopted a mix-method design and was divided into two phases. In the first phase, the content of WANT model education and training program was developed, and the second phase was to exam the clinical feasibility of the program.
Methods: Participants adopted matched-pairs in which 20 care-providers and their care receivers (residents with dementia, RwD) from one LTC in southern Taiwan was recruited. The duration of the WANT model education and training program lasted 3 months. Data were collected on the fisrt week prior to the intervention, 4th week and 12th week after the intervention. Measurement tools include: Demographic sheet for RwD, demographic sheet for care-providers, Cohen-mansfield agitation inventory, Cornell scale for depression in dementia, Attitudes toward dementia care scale, Dementia behavior disturbance self-efficacy scale. The interview approach was used to collect qualitative data including effectiveness and implementation problems of WANT model education training program and dementia care burden. GLM repeated measure was conducted for quantative data analysis while content analysis was performed for qualitative data analysis.
Results: In quantitative outcomes, findings indicated that the program relieved agitation F(1.40, 26.61)=6.01, p=.01 and depression of residents with dementia F(2,38)=6.52,p=.00 and enhanced attitude of care-providers F(2,38)=5.74,p=.01. However, no significant improvement was found in self-efficacy F(1.24,23.58)=2.49, p=.11. In qualitative outcomes, care-providers perceived that their ability to note and manage BPSD improved, they can see problems from more person-centered perspective, and their attitude changed towards dementia and alter behavior and care burden and stress decreased. Problems encountered during the WANT model education and training process including lack of logical reflexive thinking competence, lack of learning motivation and low usage rate of WANT manual.
Conclusions: Results of this study present an overall benefit of the WANT model education and training program. It helps to reduce the agitated behavior and depression of RwD and to improve the care-providers' attitude towards the RwD. In addition, care-providers self-reported that they are able to pay more attention on BPSD and to notify needs of RwD, and their needs be respected and understood, and also could think about the cause and underlying meaning of the problem after received the training program. Furthermore, they became more capable of responding to individual needs and formulate individualized care interventions to meet the needs of RwD and to relieve their BPSD. During this period, the interaction between care-providers and RwD increased and they got along well with each other. However, during the implementation of the WANT model education and training program, the care-providers were unable to make logical reflections and lack of learning motivation due to their own knowledge limited and workload. Based on the feasibility evaluation of this research, it is suggested that future research and clinical implementation can modify the intervention time and duration and take care-providers’ education level into consideration.

List of contents
中文摘要...................................................  I
致謝.......................................................................... II
Abstract………………………………………………………………………….....III  
List of contents…………………………………………………………………........  V
List of tables…………………………………………………………………………  VII
Appendix……………………………………………………………………VIII 
Chapter 1.Introduction……………………………………………………………   1
1.1  Study Background………………………………………………………....   2
1.2  Research purposes………………………………………………………..    4
1.3  Research Hypothesis………………………………………………………    5
1.4  Definition of Terms………………………………………………………    6
       1.4.1  Behavioral and Psychological Symptoms of Dementia…………    6
       1.4.2  Self-efficacy of care-provider…………………………………….   7
       1.4.3  Caring Attitude of care-provider………………………………….   8
       1.4.4  Care Burden of care-provider……………………………………    9
Chapter 2. Literature Review……………………………………………………...  10
  2.1  Behavioral and Psychological Symptoms of Dementia……………………   11
  2.2  Need-oriented and person-centered care model……………………………   14
  2.3  Effects of Dementia Education and Training Programs……………………   17
Chapter 3. Methodology………………………………………………………….....  19
3.1  Study design……………………………………………………………….....  20
3.2  Participants and settings………………………………………………….....   22 
  3.3  Data collection procedure………………………………………………….....  23
  3.4  WANT Model Education and Training Program…………………………......  25
3.5  Ethical considerations…………………………………………………….......  27
3.6  Study Instruments………………………………………………………........   28
   3.6.1  Demographic sheet for resident with dementia……………………...   28
   3.6.2  Demographic sheet for care-provider…………………………….......  29
   3.6.3  Chinese versions of Cohen-Mansfield Agitation Inventory;CCMAI....  30 
   3.6.4  The Cornell scale for Depression in Dementia, CSDD…………….....  31
   3.6.5  Attitudes toward Dementia Care Scale, ADCs………………….........  32
   3.6.6  Dementia Behavior Disturbance Self-efficacy Scale, DBDSS)…........  33
3.6.7  Observation diary, Focus Group Interview Record Analysis Report 
      and Semi- structure questionnaire….....………………………...........   34
3.7  Statistical analysis……………………………………………………........…   35
Chapter 4 Results……………………………………………………………............   36
4.1  WANT model……………………………………………………………..........  37
     4.1.1  Expert panel process of WANT model.................................................   37
     4.1.2  Cotent of WANT model………………………………………….........  38
     4.1.3  Conceputal basis of WANT Model……………………………….......   39
     4.1.4  Thinking pathway and simulation example..........................................   40
4.2   Demographic characteristics…………………………………………….......   42
4.3   Quantitative Measurement Effects of WANT model education and training  
      Program……………………………………………………………….….......  46
4.4   Qualitative Self-reported effectiveness of WANT model education and
 training program…….………………………………………….………….....   49
4.4.1  The ability to note and manage BPSD improved..................................   49
4.4.2.  To see problems from more person-centered perspective………   50
4.4.3.  Changed attitude toward dementia and alter behavior………….   51
4.4.4.  Reduce care burden and relieve stress……………………….…   53
4.5   Problems encountered during the WANT model education and training 
process………………………………………………………………….    54
4.5.1  Lack of logical reflexive thinking competence……………….     54
4.5.2  Lack of learning motivation……………………………………    56
4.5.3  Low usage rate of WANT manual………………………………    57
Chapter 5. Discussion……………………………………………………………    58
5.1   Quantitative effects of WANT model education and training program…    59
5.1.1  Agitated behavior………………………………………………    59
5.1.2  Depression………………………………………………………   60
5.1.3  Self-efficacy……………………………………………………    61
5.1.4  Attitude…………………………………………………………    62
5.2   Qualitative self-reported effectiveness of WANT model education and 
training Program………………………………………………….....…     63
5.2.1  The ability to note and manage BPSD improved.......................     63
5.2.2  To see problems from more person-centered perspective……..     64
5.2.3  Changed attitude toward dementia and alter behavior…………     65
5.2.4  Reduce care burden and relieve stress…………………………     66
5.3   Problems encountered during the WANT model education and     
training process.........................................................................................    67
5.3.1  Lack of logical reflexive thinking competence…………………    67
5.3.2  Lack of learning motivation……………………………………     68
5.3.3  Low usage rate of WANT manual………………………………     70
5.4   Future Recommendation…………………………………………………    71
5.5   Limitations and future research………………………………………….    72
5.6   Implications for practice………………………………………………….    73
5.7   Conclusion…………………………………………………………………   74
References…………………………………………………………………………...   75

List of tables
Table 1  Demographic sheet for care-provider (N=20)……………………………..44
Table 2  Demographic sheet for dementia resident (N=20)…………………………45
Table 3  Comparison of outcome variables within three time measures(N=20)……48


Appendix
Appendix 1.   WANT model education and training program manual…………….   82
Appendix 2.   Approval of the Human Research Ethics Committee of National 
Cheng Kung University…………………………...........………..…   88
Appendix 3.   Consent for care-provider approved by the REC of National Cheng 
             Kung University…..........................………………………………    89
Appendix 4.   Consent for PwD (or proxy) approved by the REC of National Cheng
Kung University.………………………….……………………     91
Appendix 5.   Consent for Delphi expert approved by the REC of National Cheng 
             Kung University………………………………….............................   93
Appendix 6.   Demographic data sheet for RwD……………………………………  95
Appendix 7.   Demographic data sheet for care- provider…………………………   96
Appendix 8.   Approval of the Attitudes toward Dementia Care Scale……………   97
Appendix 9.   Instrument of the Attitudes toward Dementia Care Scale……..….….   98
Appendix 10.  Approval of the DBD Self-efficacy Scale………………………….   99
Appendix 11.  Instrument of the DBD Self-efficacy Scale…………………………   100
Appendix 12.  Approval of the Chinese version of the Cohen-Mansfield Agitation Inventory Scale……………………………………………..........….   101
Appendix 13.  Instrument of the Chinese version of the Cohen-Mansfield Agitation 
Inventory Scale………………………………………………..…     102
Appendix 14.  Approval of the Chinese version of the Cornell Scale for Depression
             in Dementia……................................................................…………   104
Appendix 15.  Instrument of the Cornell Scale for Depression in Dementia………   105



                                    

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