居家復能近年來逐漸受到重視，是促進健康老化的長期照護新典範。個案參與目標設定，是使復能訓練具意義的關鍵性環節，然現有研究對此關鍵要素的了解有限。此外，復能提供者在執行復能時面臨許多挑戰，需有實務下的執行架構，以幫助執行者思考和執行，然未有研究詳探復能提供人員如何架構並執行復能介入。現有研究對復能過程的探討，多侷限在復能參與者於服務中的感受，缺乏對實務的深入觀察，和同時包含多元觀點經驗的研究。復能與照護的制度和文化有關，而台灣尚無相關類型的研究。因此，本研究目的為：(一)、了解復能目標設定的過程及參與者經驗；(二)探討專業人員如何架構復能訓練。
本研究應用個案延伸法，透過訪談復能服務的提供者和接受者、實地觀察服務，和蒐集專業人員提供之服務紀錄三種資料蒐集方式。共五名65歲以上服務使用個案參與，向外延伸服務關係人，共六位主要照顧者、八位服務提供者參與，並另招募四名未參與研究但具復能業務經驗者，擔任參與者檢核焦點團體成員。研究者進入場域後逐步將關注重點聚焦，並輔以文獻閱讀，進行文本-詮釋-文獻驗證等的循環性分析。
研究目的一的結果分為三主題，(1)目標磨合的方式：目標設定並非可切割的獨立步驟，而是貫串整個復能，並透過個案、照顧者和復能提供人員的彼此牽拉，以及檯面下的溝通而不斷改動的；(2)個人影響因素：個人對資訊的掌握度、及主觀意識的強烈度關係人對於復能目標設定的主導權；(3)環境影響因素：對目標的想望受照顧價值觀及制度的影響。
研究目的二的結果則發現，復能個案具個別差異，然復能訓練的架構仍具共通性。全面且貼近個別化生活的復能執行架構包含：①服務起始時「與個案接上線」、「從此時此刻開始」，②過程中「這個也讓他試試，那個也讓他試試」，③結尾時「總結並預告」及「結束在生活」，並○4透過個別化的調整，使復能訓練自然順暢的進行。
本研究的發現可以提升服務提供者和接受者對復能目標設定和訓練過程的覺察。此外，將專業人員的隱性知能知識具象化，有助其覺察到復能訓練的複雜性，有意識的規劃和界定復能訓練。本研究提出新的復能執行要素和復能過程的時間尺度，有助將復能實務具象化，作為未來計畫和執行，及修訂政策的參考，促進更有效率且在地化的復能服務。

SUMMARY
Home-based reablement is a new paradigm of long-term care that promotes healthy aging. Little is known about the implementing process. This study aim to (1)explore the process and participants’ experience of goal-setting, and to explore how professionals constructed the intervention in reablement. This was an extended case study. We recruited five reablement clients aged over 65, and stakeholders included six caregivers and eight service providers. Data were collected by interviews, observations, and service records collection. One focus group were held for member checking. For the first aim, results showed that goal-setting was an dynamic process re-adjusted or changed constantly, and influenced by personal factors and contextual factors. For the second aim, the results revealed a practice structure including” catching up on the current situation of the client”, “letting the client try and explore”,” guiding the client back to life” and “adjusting the reablement intervention individualized”. The findings indicate that reablement is a complexity intervention and therapists used tacit knowledge to construct reablement sessions.

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