隨著老年人口快速的增加，後續照護需求也跟著上升。出院準備服務是持續性照護的一部分，其流程又與護理人員日常的照護工作相符。護理人員在整個流程中扮演著相當關鍵的角色，他們對於此計劃的了解程度與態度，更是影響他們的執行程度與計劃成效的重要因素之一。因此為了提供醫院管理者可供參考的量化資料，本研究以問卷調查的方式，來探討護理人員對此計劃的了解及態度。研究的樣本是取自南部某醫學中心一般病房的護理人員，共有２３２位完整的回覆了這份問卷。問卷的內部信度為0.882，效度則採用專家效度，而所取得的資料是以SPSS來進行分析。
　　研究結果顯示曾經接受過出院準備服務教育訓練的人，對於出院準備服務流程的了解程度，比未曾接受過類似教育訓練的人明顯的高得多（p < 0.001）。另外，經常參與出院準備會議的護理人員，相對於其他護理人員，也是比較了解出院準備服務流程（p=0.009）。年資超過十年者，也比其他人，有較深的了解（p=0.015）。在態度部分，時常參與的護理人員，對於出院準備服務的態度，比其他的回覆者來得明顯的正向許多（p=0.015）。相對於沒受過出院準備服務教育訓練的人，曾經受過相關教育訓練的人，對於出院準備服務，抱持著較為正向的看法（p=0.014）。此外，在相關性部分，研究的結果顯示了了解程度與年資、出院準備服務教育訓練的有無以及參與程度是有顯著的相關。態度則與教育訓練的有無、參與程度、工作負擔以及了解程度有顯著的相關。
從此研究的結果中，我們可得知教育訓練的提供及高參與度不但對於了解程度有顯著的影響，對於所抱持的態度也是有相當顯著的影響。另外，在實施出院準備之後，由於人力的不足，護理人員的確也承受了更多的工作負擔。增加的工作負擔，也因此影響了他們對於此計劃的態度。然而，從研究的結果中，我們發現了加深了解程度，是有助於改變態度的。而增加了解程度的有效方法之一，變是提供給這些護理人員足夠的教育訓練，並且透過教育訓練來培植足夠的人力，以解決人力不足的問題。
後續照護的需求，在老年人口持續的攀高之下，還會繼續上升，為了使出院準備的服務能夠達到更好的成效，專業的人力培訓，是相當重要的。透過此研究，我們發現教育訓練並不足夠，但是教育訓練的提供，卻是有助於改善了解程度及態度的。因此，建議醫院的管理者，或是有關的主管機關，能夠提供更多的教育訓練給護理人員，另一方面，對於人力不足的問題，也該透過人力訓練的計劃來解決。

Background and purpose: The needs for the post-discharge care increases in tandem with the rapid growth of the ageing population. Discharge planning, as part of continuity of care, is parallel with nursing care. The nurses play the key role in the discharge planning process. Their understanding and attitudes towards discharge planning are likely to affect the practice and the effectiveness of discharge planning. Therefore, this study aimed to explore the nurses’ understanding of the discharge planning process and their attitudes towards it.
Methods: The self- administrated questionnaires were delivered to all the nurses working in a general care units in the medical center in southern Taiwan. 332 nurses were approached. The data were analyzed by SPSS 12.0 applying descriptive statistics, ANOVA, chi-square test and Pearson correlation analysis. The reliability of the questionnaire is 0.882.
Results: The net response rate is 69.9 percent. About 43 percent of the respondents are with the employment length over 10 years. 43 percent of the respondents had received discharge planning education. Only 10.7 percent of respondents got involved in the discharge planning meetings frequently. The mean value of the understanding between the respondents with the discharge planning training and those without were significantly different (p < 0.001). The significant difference was found in the understanding among the respondents with the different level of involvement in the discharge planning meetings (p< 0.001). There was a significant difference found in the mean value of attitudes among the respondents with different frequency of involvement in the discharge planning meetings. The mean scores of the whole attitudes were significantly higher in the respondents with training than in those without training (p=0.014). Understanding was associated with duration of employment, the discharge planning training or education, and level of involvement in the discharge planning meetings. Attitudes were associated with the level of involvement in the discharge planning meetings and workload. The strong correlation was found between the respondents’ understanding and attitudes.
Conclusion: Understanding of the discharge planning process and the attitudes towards discharge planning were influenced by the duration of employment, the involvement in the discharge planning meetings and the education or training regarding discharge planning. Therefore, to increase the understanding and to change the attitudes, the nurses should be provided with the more discharge planning education and opportunities to participate in the discharge planning meetings.

Index
Figure & Table index……………………………………………………………….III
Chinese abstract…………………………………………………………………….IV
Abstract……………………………………………………………………………...VI
CHAPTER 1 1
INTRODUCTION 1
OBJECTIVES 5
CHAPTER 2 6
LITERATURE REVIEW 6
CONCEPTUAL FRAMEWORK 17
CHAPTER 3 20
METHODS 20
3.1HYPOTHESES 20
3.2 Design 20
3.3 The Instrument 21
3.4 Reliability and validity 22
3.5 Subjects 23
3.6 Ethical issues 23
3.7 Data collection 24
3.8 Data analysis 24
CHAPTER 4 26
RESULTS 26
5.1 Demographic characteristics of the respondents 26
5.2 Nurses’ understanding of discharge planning process 29
5.3 Nurses’ attitudes towards discharge planning 34
5.4 Workload v.s. Demographic Characteristics 37
5.5 Correlations between the level of understanding and nurse characteristics 39
5.6 Correlations between attitudes and nurse characteristics 40
5.7 Correlation between attitudes and understanding 41
CHAPTER 5 43
DISCUSSION 43
CHAPTER 6 47
CONCLUSION 47
SUGGESTION 48
LIMITATION 48
CONTRIBUTION 49
REFERENCES 50
APPENDIX 1 57
APPENDIX 2 59
APPENDIX 3 63

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