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題名 精神科護士在護病關係中的組織認同與權力現象
Identity and power of nurse- patient relationship in psychiatric nurse
作者 廖珮君
Liao, Pei-Chun
貢獻者 鄭同僚
Cheng, Tung-Liao
廖珮君
Liao, Pei-Chun
關鍵詞 護病關係
權力關係
精神科
nurse patient relationship
power
psychiatry
日期 2011
上傳時間 30-Oct-2012 14:28:11 (UTC+8)
摘要 護理專業對護病關係義涵的建構承襲南丁格爾時代的護理典範，以及Hildegard E. Peplau 的<護理的人際關係>，將護理的功能位置定義在理解與協助病患的需求，因此護病關係實屬<療癒性>的人際關係。
護士在不容質疑的護理價值中形構自己的護士角色，那是不自覺與缺乏自我省察的護病關係。事實上，護病關係是不對等關係，專業化的助人功能與角色本身蘊含權力關係的互動。本研究參照傅柯的觀點，對權力的體認其實大部分是正面或構成面；傅柯本身並不斥責權力的社會關係，權力的正面效應是構成與塑造人類生活的運作機制，而真理也是人類建構與塑造而成為實際人類生活的「真理」。護士身為照顧者必須提供助人的角色，但是自己也是醫療技術宰制的受困者，面對病患的需求召喚，護士如何承擔被他者喚起的主體，而自我情緒察覺是啟動自身照顧倫理的動能。
人的知識建構與變化受到體制一連串新的權力技術的演變所控制，病房常態的護理活動是受到醫療制度與社會文化的歷史因素的影響。台灣醫療生態在經濟與效用的實務趨向中，護病關係的事實內涵產生形變與爭議。而護士在照護決策中的權力運作展現，同時也承受臨床機構影響護士照護工作的權力因素。
本研究以批判民俗誌的知識論與方法學進行臨床護病關係現象的田野觀察，揭露臨床結構所習以為常且不自覺的權力關係中，以及護士的面對這權力現象的認同政治。研究場域為精神專科療養院的急性病房，進行近半年時期間斷的護理現場觀察，並訪談15位病房護士，透過敘述訪談對話歷程，協助護士自我察覺在護病關係中的權力互動與消長。發現從醫療專業、醫療空間與病房管理等架構脈絡，理解護士被賦予理所當然的權力地位；闡述醫療生態受到健保制度、機構評鑑與精神衛生法等脈絡影響，護病關係也走向經濟成本與價值效率的考驗；從對病患主體的關懷，轉向為配合醫療體制的經濟價值互動，因此病患主體的照護已經被現有體制邊緣化。
本研究的結果企圖啟動護士反思護病關係的質變化與工具化，護士的自覺可以實踐與再構以人文關懷為主的護病關係，並提供給學校護理教育在實務訓練的參照教材。
Nurse-patient relationship in nursing takes on Florence Nightingale age , as well as Hildegard E. Peplau’s therapeutic relationship, defines the function of care in understanding and contributing to the patient`s needs.
Nurses in the nursing care of unquestionable value formulation in their nursing role; it is not self-consciousness and lack of self-examination of nurse-patient relations. In fact, the nurse-patient relationship is unequal relationship, as professional help functionality roles and power relations embedded interaction
This study based on Foucault`s power and knowledge view, recognition of power largely positive composition; Foucault does not rebuke the social relations of power, power is the positive effect of composition and operation mechanism of shaping human lives, and truth is the construction and shaping of mankind became the actual human life "truth". Nurse role as helper must be provided need for patient, but medical institute dominate self of nurse, then face to patients’ needs calling, nurses how to assume he associated with herself subject, and emotions awareness is self-care for nurse.
Construction and changes of human knowledge are controlled by the institutional evolution of a series of new power technologies, Ward nursing routine and activity are under the influence of medical systems and factors of socio-cultural history. Taiwan medical ecology trends of eco-economy and effectiveness, nurse-patient relations is deformation and disputes. Power of nurses is in care decisions making, but also is coercion under the factors of clinical institutions.
This research with epistemology and methodology of critical ethnography, observed nurse-patient relations of nursing field, discovered habit and unconsciously power of NPR, and identified politics for power relationship. Research field of mental acute ward of Psychiatry, observation and collection on the half-year, and interviewed 15-Ward nurse, through narrative interviews with dialogue process to help nurse self-awareness flowing power of nurse-patient relations. The outcomes are to be owned power of NPR from the medical profession, medical space and ward management routines.；and elaborated that medical ecology was challenged by health insurance system, the evaluation of medical and mental health law , nurse-patient relationship to economic cost and value efficiency tests; From the subjects care of patient turn to tie in with the economic value of health care system interactions, the subject of patient care has been marginalization of existing institutions.
The results of the research attempts to start reflection on nursing quality for variation and tools of nurse-patient relations, the consciousness of power in NPR and active humanistic concern nurse-patient relations, and made available to schools of nursing education in the practical training of reference materials.
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描述 博士
國立政治大學
教育研究所
92152515
100
資料來源 http://thesis.lib.nccu.edu.tw/record/#G0921525151
資料類型 thesis
dc.contributor.advisor 鄭同僚zh_TW
dc.contributor.advisor Cheng, Tung-Liaoen_US
dc.contributor.author (Authors) 廖珮君zh_TW
dc.contributor.author (Authors) Liao, Pei-Chunen_US
dc.creator (作者) 廖珮君zh_TW
dc.creator (作者) Liao, Pei-Chunen_US
dc.date (日期) 2011en_US
dc.date.accessioned 30-Oct-2012 14:28:11 (UTC+8)-
dc.date.available 30-Oct-2012 14:28:11 (UTC+8)-
dc.date.issued (上傳時間) 30-Oct-2012 14:28:11 (UTC+8)-
dc.identifier (Other Identifiers) G0921525151en_US
dc.identifier.uri (URI) http://nccur.lib.nccu.edu.tw/handle/140.119/54968-
dc.description (描述) 博士zh_TW
dc.description (描述) 國立政治大學zh_TW
dc.description (描述) 教育研究所zh_TW
dc.description (描述) 92152515zh_TW
dc.description (描述) 100zh_TW
dc.description.abstract (摘要) 護理專業對護病關係義涵的建構承襲南丁格爾時代的護理典範，以及Hildegard E. Peplau 的<護理的人際關係>，將護理的功能位置定義在理解與協助病患的需求，因此護病關係實屬<療癒性>的人際關係。
護士在不容質疑的護理價值中形構自己的護士角色，那是不自覺與缺乏自我省察的護病關係。事實上，護病關係是不對等關係，專業化的助人功能與角色本身蘊含權力關係的互動。本研究參照傅柯的觀點，對權力的體認其實大部分是正面或構成面；傅柯本身並不斥責權力的社會關係，權力的正面效應是構成與塑造人類生活的運作機制，而真理也是人類建構與塑造而成為實際人類生活的「真理」。護士身為照顧者必須提供助人的角色，但是自己也是醫療技術宰制的受困者，面對病患的需求召喚，護士如何承擔被他者喚起的主體，而自我情緒察覺是啟動自身照顧倫理的動能。
人的知識建構與變化受到體制一連串新的權力技術的演變所控制，病房常態的護理活動是受到醫療制度與社會文化的歷史因素的影響。台灣醫療生態在經濟與效用的實務趨向中，護病關係的事實內涵產生形變與爭議。而護士在照護決策中的權力運作展現，同時也承受臨床機構影響護士照護工作的權力因素。
本研究以批判民俗誌的知識論與方法學進行臨床護病關係現象的田野觀察，揭露臨床結構所習以為常且不自覺的權力關係中，以及護士的面對這權力現象的認同政治。研究場域為精神專科療養院的急性病房，進行近半年時期間斷的護理現場觀察，並訪談15位病房護士，透過敘述訪談對話歷程，協助護士自我察覺在護病關係中的權力互動與消長。發現從醫療專業、醫療空間與病房管理等架構脈絡，理解護士被賦予理所當然的權力地位；闡述醫療生態受到健保制度、機構評鑑與精神衛生法等脈絡影響，護病關係也走向經濟成本與價值效率的考驗；從對病患主體的關懷，轉向為配合醫療體制的經濟價值互動，因此病患主體的照護已經被現有體制邊緣化。
本研究的結果企圖啟動護士反思護病關係的質變化與工具化，護士的自覺可以實踐與再構以人文關懷為主的護病關係，並提供給學校護理教育在實務訓練的參照教材。		zh_TW
dc.description.abstract (摘要) Nurse-patient relationship in nursing takes on Florence Nightingale age , as well as Hildegard E. Peplau’s therapeutic relationship, defines the function of care in understanding and contributing to the patient`s needs.
Nurses in the nursing care of unquestionable value formulation in their nursing role; it is not self-consciousness and lack of self-examination of nurse-patient relations. In fact, the nurse-patient relationship is unequal relationship, as professional help functionality roles and power relations embedded interaction
This study based on Foucault`s power and knowledge view, recognition of power largely positive composition; Foucault does not rebuke the social relations of power, power is the positive effect of composition and operation mechanism of shaping human lives, and truth is the construction and shaping of mankind became the actual human life "truth". Nurse role as helper must be provided need for patient, but medical institute dominate self of nurse, then face to patients’ needs calling, nurses how to assume he associated with herself subject, and emotions awareness is self-care for nurse.
Construction and changes of human knowledge are controlled by the institutional evolution of a series of new power technologies, Ward nursing routine and activity are under the influence of medical systems and factors of socio-cultural history. Taiwan medical ecology trends of eco-economy and effectiveness, nurse-patient relations is deformation and disputes. Power of nurses is in care decisions making, but also is coercion under the factors of clinical institutions.
This research with epistemology and methodology of critical ethnography, observed nurse-patient relations of nursing field, discovered habit and unconsciously power of NPR, and identified politics for power relationship. Research field of mental acute ward of Psychiatry, observation and collection on the half-year, and interviewed 15-Ward nurse, through narrative interviews with dialogue process to help nurse self-awareness flowing power of nurse-patient relations. The outcomes are to be owned power of NPR from the medical profession, medical space and ward management routines.；and elaborated that medical ecology was challenged by health insurance system, the evaluation of medical and mental health law , nurse-patient relationship to economic cost and value efficiency tests; From the subjects care of patient turn to tie in with the economic value of health care system interactions, the subject of patient care has been marginalization of existing institutions.
The results of the research attempts to start reflection on nursing quality for variation and tools of nurse-patient relations, the consciousness of power in NPR and active humanistic concern nurse-patient relations, and made available to schools of nursing education in the practical training of reference materials.		en_US
dc.description.tableofcontents 目 錄
第一章 緒論
(一) 從自己的經驗說起 1
(二) 台灣精神醫療體系的變遷 2
(三) 研究輪廓 2
第一節 研究背景與動機 3
(一)研究背景 3
一、精神醫療轉型下的護理生態 3
二、精神醫療中護病倫理的田野觀察 7
(二) 研究動機 9
一、研究關注的面向一:精神醫療體制與政令運作下的組織認同現象 9
二、研究關注的面向二:護病關係是人文關懷的取徑還是權力關係的面具 9
第二節 研究目的與問題 11
第三節 重要性與預期貢獻 12
第四節 名詞解釋 13

第二章 文獻探討
第一節 治療性人際關係/護病關係 15
(一) 治療性人際關係/護病關係理論 15
(二) 護病關係的倫理與技藝 17
(三) 護病關係的相關研究 20
(四) 護病關係相關文獻評述與研究相關性 22
第二節 組織信任與認同政治 23
(一) 組織信任與認定 23
(二) 認同與認同政治 24
(三) 組織/政治認同的文獻評述與研究相關性 27
第三節 醫護階級與權力關係 28
(一) 傅柯的精神瘋狂史與權力論述 29
(二) 當代精神醫療體系的壓迫與服從 32
(三) 權力概念評述與研究相關性 36
第三章 研究方法
第一節 批判民俗誌的相關理論 38
(一)批判民俗誌的理論基礎 39
(二)使用批判民俗誌研究的價值 41
一、關懷並轉化精神醫療體系中不平等的權力關係 41
二、啟動精神醫療生態與護病關係意識型態的公開評論 41
(三)Carspecken的批判民俗誌的理論與實務應用 42
(四)批判民俗誌相關的教育/護理研究 44
一、批判俗民誌應用在台灣教育/護理相關研究 44
1.教育相關研究 45
2.護理相關研究 47
二、西方批判俗民誌應用在教育/護理相關研究 48
1.教育相關研究 48
2.護理相關研究 49
三、相關研究評述 51
(五) 使用批判民俗誌方法的理由 52
(六)本研究設計的整體概念 54
第二節 資料的收集 54
(一)資料收集 55
一、精神科病房的田野觀察與記錄 56
1.田野的場域介紹 56
2.進入田野觀察與紀錄 56
3.病房的地理環境 60
二、個別的訪談 60
1.問題的發展與設計 62
2.訪談對象的準備與邀請 64
(二)批判民俗誌研究的信賴度與真實性 65
一、批判民俗誌研究的信度立場 66
二、批判民俗誌的效度問題 68
(三)綜觀評述 71
第三節 資料的分析 72
(一)資料的理解與詮釋 73
(二)批判的反省 74
(三)社會實踐性 75
第四節 研究倫理 76
第四章 大眾療養院的歷史背景與大眾病房轉型紀事目錄
第一節 大眾療養院的歷史 80
一、外來政權變遷的脈絡 80
二、臺大醫院領軍的時代 84
三、醫院評鑑、精神衛生法與健保給付的時代 86
四、大眾療養院目前精神醫療的發展 91
第二節 大眾病房的轉型紀事 92
一、大眾病房誕生 92
二、亞急性病房 93
三、急性病房 95
四、轉型後的困境 96
五、約束隔離過多的現象 100
六、性別互動剝削的大病房 101
七、以護理站為中心的家庭化環境 103
第三節 大眾療養院與大眾病房的歷史與社會脈絡架構 105
第五章 精神科護士的工作日誌 106
第一節 白班的護理工作 107
一、準備上班 107
二、團隊會議交班 108
三、精神科的團隊會議 110
四、醫護的討論互動 113
五、準備護理活動 116
六、護士與病患最密集的互動 118
七、護理治療是唯一活動 122
八、找你的護士 123
九、護士給藥的策略 126
十、安全與寢務檢查活動 129
十一、護士的工作空間 130
十二、病患上職能治療 133
十三、特殊個案的處理 134
十四、午餐時間 138
十五、午餐以後的護理活動 142
十六、下午的活動 146
第二節 小夜班的護理工作 147
一、功能性的護理 148
二、夜間的活動治療 149
三、電話的心理支持 153
四、九點鐘熄燈 154
第三節 精神科護士工作架構分析 155
第六章 護病關係中的權力真相與認同政治
第一節 精神醫療空間的權力現象 156
一、護理活動的規訓化 156
二、醫療空間家庭化的分配 160
三、護士使用隔離室的權力 162
四、護理站為界的不同權力國度 166
第二節 醫療政策的權力延展與認同政治 170
一、評鑑制度與健保給付制度建構下的護病關係 170
二、體制建構護病關係中的認同政治 175
第三節 護士權力與認同政治的概念架構與論述 177
第四節 解構護病關係中權力互動的教育論述 179
一、云云眾護 何來權力 181
二、批判教育學在護士身為受迫者的解構論述 182
三、典型在夙昔--精神護理生涯圖像的重構與反動 184
四、自我敘述的啟動 --- 教師介入職場輔導的行動規劃 186
五、自我察覺與賦權的開創 189		zh_TW
dc.language.iso en_US-
dc.source.uri (資料來源) http://thesis.lib.nccu.edu.tw/record/#G0921525151en_US
dc.subject (關鍵詞) 護病關係zh_TW
dc.subject (關鍵詞) 權力關係zh_TW
dc.subject (關鍵詞) 精神科zh_TW
dc.subject (關鍵詞) nurse patient relationshipen_US
dc.subject (關鍵詞) poweren_US
dc.subject (關鍵詞) psychiatryen_US
dc.title (題名) 精神科護士在護病關係中的組織認同與權力現象zh_TW
dc.title (題名) Identity and power of nurse- patient relationship in psychiatric nurseen_US
dc.type (資料類型) thesisen
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