護理人員素質與病人觀點照護品質之相關性探討

Abstract

醫療品質是健康照護體系的重要議題之一，目前評估醫療品質的測量指標大部分採用專家的判斷，較少是以病人觀點來評估接受到的服務品質好壞，但隨著醫療體系的發展與全民健保的開放，醫院間的競爭加劇，以病人為中心(patient-centered)的服務模式勢必將成主流。由於國內外文獻大多探討病人對醫院整體、門診病人或某個疾病處置的醫療照護品質滿意度，或探討護理人員素質與住院病患死亡率間的關係，缺乏直接探討護理人員素質與病人照護品質滿意度的文獻。護理人員在醫療環境中為人數最多的第一線人員，過去研究指出護理人力與素質的提升，不僅可減少病人生命的損失，亦可減少醫療健保的支出。因此，本研究主要目的在於了解台灣病人觀點的照護品質，以及醫院病房護理人員素質，並探討彼此之相關性，期能引起政府及醫療產業對護理人員的重視，並了解目前台灣的護理人員素質。 本研究利用臺大鄭守夏老師2004年「全民健保出院病人調查」的問卷資料，問卷中的「病房護士服務情形」，分別對病房護士的專業能力、對病人的關心程度及態度、呼叫的回應速度、注意程度及溝通能力等五題，可以計算病人對護理照護品質得分(5-25分範圍)做為依變項；再利用財團法人醫院評鑑暨醫療品質策進會(以下簡稱醫策會)提供「醫院評鑑」中護理組的資料，取得醫院護理人員數量與素質資料做為自變項，內容分別有基層護理人員的護理師比例、大學學歷以上比例、平均臨床工作年資及急性病房護理時數(而非護理人員病床比)等四項。為使資料相對應，將醫策會醫院評鑑的護理組資料，依醫院填報時序選取2004及2005年受評醫院，對應出院病人調查有效問卷，共計得到95家地區教學以上層級醫院，以及5923份有效受訪者問卷，做為本研究的材料來源。 本研究發現，樣本醫院的護理人員素質，護理師比例為77.0%，具有大學以上學歷的佔19.5%，平均臨床工作年資為5.4年，急性病房護理時數平均值為2.5小時。病人對所測量五項護理照護表現的平均分數為20.1±2.8分。在雙變項分析中，護理師比例與大學學歷以上比例具高度相關，為了避免「共線性」的問題，最後選擇大學學歷以上比例納入多變項分析；最後以病人評分高低為依變項進行邏輯斯迴歸，在控制醫院評鑑等級、病人疾病診斷別、以及病人教育程度後，結果顯示護理人員大學學歷以上比例、平均臨床工作年資及急性病房護理時數，對病人觀點照護品質評分均呈現顯著正向影響。 整體而言，我們發現護理人員的數量與素質與病人對護理人員表現的評分有顯著相關，本研究發現與前人研究類似。醫院若要提高病人觀點的照護品質進而提升以病人為中心的照護理念，則應首重提升護理人員素質；而政府部門及整個醫療產業應共同努力，鼓勵護理畢業生投入臨床工作、增加臨床護理人力並鼓勵現職人員在職進修，在提升護理人員素質的同時，也將提高整體的醫療品質。

Quality of care is one of the important issues in the healthcare system. Nowadays, the professional judgment of quality is prevailing in measuring quality of healthcare; quality from patients’ perspectives is less concerned. However, along with the development of healthcare system and the National Health Insurance in Taiwan, patient-centered care gradually becomes the main-stream. Previous studies focused on the quality of nursing care using data from a small sample or only for specific diseases. Others reported the association between nursing staffing and hospital mortality rates. Nursing staff is the majority of work force in a hospital to take care patients directly. Literature indicated that sufficient and/or better trained nursing staff is associated with fewer deaths of patients as well as less healthcare cost. Therefore, the purpose of this study is to understand the quality of nursing staff in hospital, the quality of nursing care from patient’s perspectives, and the association between these two variables. This study employed data from a national discharged patient survey in 2004. There were five items concerning patient’s ratings of nurse performances such as clinical competence, attitude, response to calls and communication skills. A summary score (from 10 to 25) can be calculated. The questionnaire data was then linked with hospital nursing staff information from the Taiwan Joint Commission on Hospital Accreditation and Quality Improvement in 2004 and 2005. Four variables concerning the quality of nursing staff included the proportion of registered nurse, the percentage of nurses with bachelor degree or higher, years of experience, and total nursing hours per patient-day. This study included 95 hospitals and 5923 patients with completed questionnaires. Results from our sample hospitals indicated that 77.0% of the nurses are registered nurse, 19.5% of the nurses with a bacelor degree of higher, the average years of clinical experience was 5.4 years, and the average nursing hours was 2.5 hours per patient-day. The average patient’s rating on nursing performance was 20.1 (with SD of 2.8). The patient’s rating was then dichotomized and fitted in a multiple logistic regression. After controlling for the hospital accreditation levels, patient’s diagnosis, and patient’s education level in the regression model, we found that the percentage of nurses with bachelor degree, years of clinical experience, and total nursing hours were significantly and positively associated with patient’s ratings. Generally speaking, we found that more sufficient and better qualified nursing staff may increase patient’s perception of nursing performance. Our finding is similar to those previously reported. Hospitals intend to raise patient’s perception of healthcare quality to achieve the patient-centered care should increase the qualification of nursing staff first. Government and healthcare industry should encourage the enrollment of nurse graduates, increase nursing staff in hospitals, and encourage on-job training of nurses in order to promote the quality of nursing staff and the quality of care as a whole.