職業壓力源對護理師生理、心理健康之影響

Abstract

研究背景：目前研究顯示護理工作量與工作壓力有關，並進而影響護理人員的心理健康狀態與離職意圖。而護理工作以病人為中心，每位護理人員照護的病人數（護病比）可能與護理工作壓力源相關，因此護理執業環境中，有關護病比、護理職業壓力源等因素對於護理人員的影響值得深入討論。 研究目的：本研究共包含三大主題：（1）護病比對護理人員離職意圖之影響；（2）護病比與護理工作壓力源之相關性；（3）工作壓力源與護理人員生心理健康之探討。 研究方法：（1）以全國醫院評鑑合格醫院為母群體，以橫斷性問卷調查及中介效應模型分析全日平均護病比是否因個人疲勞、對服務對象疲勞及工作滿意度差等中介變項間接影響護理人員的離職意圖；（2）以全國醫院評鑑合格醫院為母群體，透過橫斷性問卷調查分析全日平均護病比與護理工作壓力源量表之相關性；（3）以臺北市及新北市醫院內外科病房護理人員為研究對象，自最後一天休假日起至第二工作日共72小時，透過貼片型心率感測器收集心律變異性參數作為生理健康指標、以問卷調查簡式健康量表及疲勞量表得分作為心理健康指標，並使用護理工作壓力源量表評估護理工作壓力，檢視護理職業壓力源與生理、心理健康指標之相關性。 研究結果：（1）共分析1,409份有效問卷，標準化全日平均護病比可因護理人員自覺之個人疲勞、對服務對象疲勞及工作滿意度差間接影響離職意圖；（2）經分析698份有效問卷後，發現護病比與護理工作壓力源量表之所有分量表均呈正相關，且當標準化全日平均護病比增加時，「未能滿足基本生理需求」、「告假困難」及「工作家庭衝突」等壓力源感受度較高；（3）護理職業壓力源與護理人員自覺之個人疲勞、對服務對象疲勞及心理困擾呈正相關，與工作後睡眠期間之心律變異性增加較少有關；而心律變異性減少則與疲勞及心理困擾的增加有關。 結論與建議：綜合以上發現，建議醫療機構除了遵循法規安排足夠的護理人力，應定期評估護理職業壓力源，依結果針對不同單位擬定優先改善目標；建議衛生福利部所公告之各醫院全日平均護病比資訊，可進一步增列符合法定護病比標準的病房百分比，並再評估護病比標準的適切性；建議未來研究可同時比較法定護病比計算公式與本研究所提出之計算方法，兩者與護理職業壓力源、生心理健康指標與離職傾向之相關性為何，依評估結果檢視與擬定執業環境改善措施，以降低護理人力之流失。

Background: Nursing workload has been reported as associated with occupational stress, and might further influence nurses’ mental health and their intention to leave the job. Nursing highlights patient-centered care and consequently the total number of patients taken care of by each nurse in each shift, patient–nurse ratio (PNR), may be related to nurses’ occupational stressors. Therefore, the effects of PNR and nurses’ occupational stressors on nurses is worthwhile to explore. Objectives: This study included three themes: (1) the effects of the PNR on nurses’ intention to leave and considering the mediating roles of burnout and job dissatisfaction; (2) to identify the association between the PNR and nurses’ occupational stressors; (3) to analyze the relationship among nurses’ occupational stressors, mental health status and heart rate variability (HRV). Method: (1) The study analyzed the data of two pooled cross-sectional surveys collected in 2013 and 2014. The average daily PNR (ADPNR), nurses’ personal burnout, client-related burnout, job dissatisfaction, intention to leave, and other demographics were collected using a structured questionnaire. The ADPNR were standardized according to the level of hospitals. Multiple regression models were used to examine mediation hypotheses. (2) Data was obtained by a self-administered questionnaire, which queried the ADPNR, the subscales of the Nurses’ Occupational Stressor Scale (NOSS), and other demographic data. Multivariate linear regression models were used to estimate the adjusted standardized ADPNR for the incremental trend of nursing stressors. (3) Nurses were recruited from medical and surgical wards of hospitals in Taipei City and New Taipei City. Data collection started from the last off day and the following two work days. The NOSS was regarded as the independent variable, parameters of HRV were mediators, and the Brief Symptom Rating Scale (BSRS-5), personal burnout scale and client-related burnout scale were the dependent variables for the mental health indictors. Results: (1) A total of 1,409 valid questionnaires were analyzed. The association between the ADPNR and intention to leave their job was significantly mediated by personal burnout, client-related burnout, and job dissatisfaction. Higher standardized ADPNRs predicted higher levels of personal burnout, client-related burnout, and job dissatisfaction, each of which resulted in higher levels of intention to leave the current job. (2) Among the 698 nurses who participated, higher standardized ADPNR was significantly positively associated with the subscales of the NOSS. “Difficulty taking leave,” “unmet basic physiological needs,” and “work-family conflict” increased more than the other subscales when the ADPNR increased. (3) There was a positive relationship between the NOSS and nurses’ personal burnout, client-related burnout and BSRS-5, and a positive relationship between less increased HRV during the recovery phase after work. Besides, decreased HRV was associated with higher personal burnout, client-related burnout and BSRS-5. Conclusions and suggestions: According to the above findings, it is suggested that medical institutions should arrange sufficient PNRs in compliance with the standard, as well as regularly assess the nursing occupational stressors and then set improvement targets for different units based on the results. In addition, the information of the ADPNR of each hospital announced by the Ministry of Health and Welfare should further add the percentage of wards that meet the standard of PNR, and reassess the suitability of the standard. Last, future studies can collect more information, such as bed occupancy rate, to compare the formula of the ADPNR by the Standards for Setting up Medical Institutions with the formula proposed in this study, and explore whether these two kinds of ADPNR are associated with occupational stressors, physical and mental health indicators, and nurses’ intention to leave. Then the assessment can be used to improve the nursing practice environment and nursing staff retention.