背景：急診室是病情告知最為頻繁的臨床場域，急診的迫切性、面對許多無法預期之疾病變化的情境中，被告知病情的病患及家屬往往無法得到周全的回覆，病情告知的不完整性可能會導致治療的延遲、病患照護不佳以及臨床工作上的低效率，不完整的溝通也會導致臨床糾紛及衝突事件。
研究目的：探討急診室病患家屬和急診護理師對醫師進行病情告知情境之感受差異。
研究方法：本研究採描述性研究設計，研究對象採定額抽樣及方便取樣，於南部某醫學中心急診室進行，病患家屬和急診護理師採結構式問卷收集，研究工具以Park等人發展的SPIKES短版量表共14題的量表為基礎而擬出共10題之病情告知自擬量表，資料以描述性統計、kappa一致性檢測及相關性統計進行分析。
研究結果：本研究共納入140名對象，分別為急診病患家屬及急診護理師共70組配對。有81.4%的急診病患家屬及60%的急診護理師認為進行告知的醫師有逹成告知的十個步驟，其中急診病患家屬與護理師皆認為醫師於開場白的自我介紹達成率最低(病患家屬88.57%、護理師82.66%)。急診病患家屬及急診護理師對於醫師進行病情告知的步驟於開場白、認知感受及結論三個面向呈現顯著一致性，兩組間的整體滿意度呈中度一致性(k = 0.4117)；另於各組滿意度及感受程度間呈現正相關，護理師組為0.445，病患家屬為0.594，而於急診病患家屬與護理師間滿意度呈正相關，為0.460。
結論：超過五成的急診病患家屬及護理師認為醫師完全達成病情告知的十個步驟，其中，病患家屬與護理師一致認為醫師於病情告知中自我介紹及結論對策部分達成率最低。而病患家屬及急診護理師對於告知過程整體感受的相關性高。研究結果顯示護理師應可以在病情告知及擔任協調者或為病人代言的角色功能，提供改善急診病情告知過程之參考，期能補足對於病情告知過程可能的溝通不良、降低不良事件，並提高患者及家屬對於就診的滿意程度。

SUMMARY
Breaking the bad news is an extremely common occurrence in the emergency department (ED) due to the sudden or unexpected diagnoses happen frequently. However, there is limited study to explore the experiences of bad news breaking in the ED. This study aims to determine the ED visitor’s family and the nurses' perception toward the bad news breaking in the emergency department, and further explore the differences between their perceptions. The descriptive study was conducted at the ED of a tertiary teaching hospital in southern Taiwan. The quota and convenience sampling were used to recruit 70 family and 70 nurses in this study. The 10-items questionnaire based on the six attributes derived from the SPIKES protocol was developed and validated by the experts. The kappa analysis was used to determine the agreement between the visitor’s family and nurses. There were 81.4% of family and 60% of nurses agree that the physician who broke the bad news had reached the total 10-items of the questionnaire. There are significant agreements in the scope of "setting", "perception", and "summary and strategy” between the family’s and nurses' perceptions. The satisfaction level of the family was significantly associated with those of the nurses, and showed the moderate agreement between them. The results of the study highlight the role of the nurses in the process of breaking the bad news in the emergency department, and also provided the references for improving the process of breaking the bad news in the emergency department.
Key words: Breaking the bad news, perception difference, emergency department
INTRODUCTION
Breaking the bad news is an extremely common occurrence in the emergency department (ED) due to the sudden or unexpected diagnoses happen frequently. The work flow and work tern in the ED always put a priority for stabilizing critical illness rather than building a communication relationship, which made the challenges for the ED physicians to deliver the bad news comprehensively. The incomprehensive breaking process might result in delay treatment of patients, poor care quality, inefficiencies in clinical work, and even medical dispute or conflict. However, there is limited study to explore the experiences of breaking the bad news in the emergency department. This study aims to determine the ED visitor’s family’s and the nurses' perception toward the bad news breaking in the ED, and further explore the differences between their perceptions.
MATERIALS AND METHODS
This is a cross-sectional, descriptive study carried out at the ED of a tertiary teaching hospital in southern Taiwan. The visitor’s family and the nurses who aged 20 years or older and are able to read Chinese were selected by convenient and quota sampling methods during 2018/03/012018/04/30. All participants were asked to complete the statured questionnaires, which included the socio-demographic information and the short-form assessment questionnaire of breaking bad news. The 10-items questionnaire based on the six attributes derived from the SPIKES protocol was developed and validated by the experts. The kappa analysis was used to determine the agreement between the relatives and nurses, and p<0.05 was considered as significant. BM SPSS Statistics 22 software was used for the analyses in this study.
RESULTS AND DISCUSSION
There are 140 cases, including 70 nurses and 70 visitor’s family in the emergency department. The majority of the family were 41-50 years old (n=21，30%), 61.4% were female and 31.4% were university graduates. While the majority of nurses were 21-30 years old (n=28，40%), mostly are female (n=57，81.4%)and 100% were university graduates. There were 81.4% of family and 60.0% of nurses agree that the physician who broke the bad news had reached the total 10-items of the questionnaire. There are significant agreements in the scope of "setting", "perception", and "summary and strategy” between the family’s and nurses' perceptions. In general, there is a low level of agreement between nurses’ and visitors’ family’s perceptions of the process of breaking bad news. There was positive correlation toward perceptions and satisfaction of the nurse group (r=0.445) and the emergency department visitor’s family (r=0.594). The satisfaction level of the relatives was significantly associated with those of the nurses (r=0.460), and showed the moderate agreement between them (k = 0.4117).
CONCLUSION
More than 50% of the ED visitors’ family and nurses agreed that the doctor had reached all the 10-items of process in breaking bad news. The items of S-Setting and S-Summary were the lowest achieving proportions of the physicians during the process of breaking bad news among the family and the nurses, and showed the obvious agreement, which means the two aspects need to be improved. . In addition, the satisfaction level of the family was significantly associated with those of the nurses. The results of the study highlight the role of the nurses in the process of breaking the bad news in the ED, and provided the references for improving the process of breaking the bad news in the ED.

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