急診護理師護理能力、單位在職教育機會與學習成效：現況與影響因子

Abstract

背景：根據2020年資料，台灣急診的年就診人數為 382 萬人、就診率為每十萬人口 16,221 人，急診護理人員如何在緊急且大量的照護活動中維持專業品質，至為重要。急重症照護本為護理專業中之特殊領域，包含急診及加護病房，進階教育畫分上也常一概而論，尤其著重加護訓練；然而急診與加護病房之疾病種類、病人屬性與工作模式其實大相逕庭，實際教育需求與現況之教育方針恐有落差。事實上，國內外研究已顯示：急診之在職教育無法反映實際需求，導致急診護理師之護理能力甚至有較其他單位低的趨勢。 研究目的：（一）調查並比較急診及病房之人口學特性（性別、年齡、婚姻、子女、薪水）、臨床經驗（年資、其他單位經驗、護理階級、臨床教師、在職培訓認證）、知識背景（學歷）、護理能力、教育機會與學習成效；（二）分別探討急診及病房各自的「人口學特性、臨床經驗、知識背景」與「護理能力」之關聯性；（三）分別探討急診及病房各自的「護理能力、教育機會與學習成效」之間的相關性，以及「學習成效」介於教育機會、學習成效之間的中介關係。 研究方法：本研究為橫斷式、因果比較研究，採方便取樣設計，對國內北、南部醫學中心之急診、內外科病房護理師進行電子問卷調查。收案條件為：（1）現任成人科之急診或內外科病房護理師；（2）現任單位工作年資大於等於2年；（3）工作醫院為醫學中心等級。排除條件為：（1）非臨床之急診或內外科病房護理師（亦即擔任主管、行政職）；（2）婦（產）科、精神科、手術後送病房之護理師。研究參與者需填寫基本資料，並運用下列量表自評：採「護理人員臨床護理能力評量表」、「單位在職教育學習成效量表」，及自擬之「單位在職教育機會量表」。統計分析採Spearman correlation探討相關性，以及無母數Mann-Whitney、Kruskal-Wallis Test進行獨立樣本檢定，最後以線性迴歸瞭解各變項對護理能力之解釋力，並建立中介模型。 研究結果：（一）本研究最終收案急診及病房護理人員分別為89、87人。無論急診或病房樣本，護理能力高低排序皆為：照護、計畫評值、教學輔導、研究能力；而急診之「護理能力、教育機會、學習成效」皆低於病房，尤其教育機會，急診顯著低於病房。（二）急診族群中，年齡、護理階級與「教學輔導能力」具正相關性；薪水與「照護能力」具有正相關性；執照數、加護病房認證與「總護理能力、照護能力、教學輔導能力、計畫評值能力」具正相關性；非急重症單位經驗與「研究能力」具正相關性；子女數、臨床教師認證、總年資與「總護理能力、教學輔導能力」具正相關性。經迴歸分析驗證，僅「非急重症單位經驗」可顯著預測急診樣本之研究能力42%變異量，病房則未有此現象。（三）在急診族群中，「學習成效、教育機會、護理能力」三者之間存在相關性，且學習成效為教育機會、護理能力之間的完全中介因子，病房則無法成立中介關係。 結論：影響護理能力的因素會因為探討的護理能力次面向或族群不同而有所差異，例如：非急重症經驗能預測急診人員的研究能力，但病房則無此現象。值得注意的是，加護病房認證雖能提升急診專業，但以迴歸分析進一步分析，卻未能顯著預測護理能力，似有其他潛在因素須考量，例如：加護病房認證之培訓內容可能不完全符合急診的學習需求；另一方面，加護病房認證反而使病房人員之護理能力呈現下降趨勢。整體來說，培訓內容與實際能力與需求間可能仍有斷層，甚至若過度學習不符合需求的臨床技能，可能會對能力有反效果。 此外，急診在護理能力、教育機會、學習成效三方面均有低於病房之趨勢，特別是「教育機會」，急診顯著低於病房，更顯現急診的專業教育仍有改善空間。根據研究結果支持之「教育機會─學習成效─護理能力」中介模型，若能提供符合急診專業需求之教育機會，應能有效提升護理能力。總而言之，除持續加強護理能力之外，增進急診專科之教育機會與學習成效，亦為未來重要之努力方向，盼此研究結果有助於急診專業之發展。

Background: In 2020, reported emergency department (ED) visits rose to 3.82 million per year in Taiwan with a visit rate of 16,221 per 10 thousand people. While handling such an emergent situation with increased patient volume, it is particularly important to monitor and maintain the quality of nursing care. Acute and critical care both belong to a special field in nursing that covers nursing activities occurring in ED and intensive units. While current acute and critical training in Taiwan focused on intensive care training more than ED, the scope of acute care can be very different than intensive care. That is, nurses working in ED may not receive needed on-the-job training in Taiwan. In fact, several studies have shown that ED nurses’ nursing competency is lower than nurses of surgical and medical ward. Aims: This study aimed to explore and compare ED nurses’ training experience and nursing competencies with nurses from surgical and medical wards. The specific aims were to: (1) explore and compare ED and ward nurses’ demographic characteristics, clinical experience, knowledge background, nursing competency, opportunities of on-the-job training, and learning effectiveness, (2) examine the association between “demographic characteristics, clinical experience, and knowledge background ” and nursing competency of ED and ward nurses, respectively, and (3) examine the mediating influence of learning effectiveness in the relationship between “opportunities of on-the-job training” and “nursing competency.” Methods: This was a cross-sectional, causal-comparative study recruiting nurses working in EDs and adult medical/surgical wards at medical centers in Taiwan. The inclusion criteria were nurses who: (1) currently worked in an ED or adult medical/surgical ward of a medical center in Taiwan, and (2) had equal to or more than two years of working experience in the current setting. The exclusion criteria were nurses who (1) were non-clinical staff, such as administrative supervisors, and (2) worked in obstetrics and gynecological, psychiatric, and postoperative recovery ward. The study participants were required to provide demographic data and self-rate online questionnaires of “Nursing Clinical Competency Scale”, “ Learning Effectiveness of On-the-job Training Scale”, and a research-developed “Opportunities of On-the-job Training Scale.” Spearman Correlation and non-parametric test, such as Mann-Whitney and Kruskal-Wallis Test, and linear regression were used to examine the differences and relationships between variables. Results: (1) A total of 89 and 87 nurses of ED and medical/surgical wards completed the study, respectively. Sorting the subcategories of nursing competency based on the self-rated scores in descending order and found that the highest rating was “clinical nursing care competence”, followed by “planning and evaluation competence”, “teaching and consulting competence”, and “nursing research competence.” These results were similar in both groups of nurses. Moreover, ED nurses’ nursing competency, opportunities of on-the-job training, and learning effectiveness were lower than ward nurses’, especially ED nurses’ opportunities of on-the-job training reached statistically significant meaning. (2) In the ED group, age and nurse level positively correlated with teaching and consulting competence; salary positively correlated with clinical nursing care competence; the number of certification and ICU certification positively correlated with “total nursing competency, clinical nursing care competence, teaching and consulting competence, and planning and evaluation competence”; non-critical-unit experience positively correlated with nursing research competence; and finally, “the number of children, clinical mentor certification, and years of total working experience” positively correlated with “total nursing competency, and teaching and consulting competence.” However, in the linear regression analysis, only non-critical-unit experience can explain 42% variances of nursing research competence. (3) In the ED group, learning effectiveness had a complete mediator effect on the relationship between opportunities of on-the-job training and nursing competency. Conclusions: Nursing competencies of ED and medical/surgical ward nurses are affected by a variety of variables. For example, non-critical-unit experience can predict ED nurses’ nursing research competence, but not ward nurses’. It is noteworthy that while ICU certification significantly correlated with ED nurses’ competency, we failed to find a prediction relationship between them. It suggests that there may be other underlying factors that affect ED nurses’ nursing competency; on the other hand, ICU certification can significantly decrease ward nurses’ nursing competency. Overall, inappropriate training may sometimes do more harm than good. “ED nurses’ nursing competency, opportunities of on-the-job training, and learning effectiveness” are lower than ward nurses’, specifically, the differences in opportunities of on-the-job training between the two groups reach statistically significant differences. It suggests the urgent need to improve ED’s professional training. According to the mediator model of “opportunities of on-the-job learning - effectiveness - nursing competency”, the more professional education or training meet ED nurse’ needs, the better the nursing competency. In conclusion, the outcomes of the study suggest not only the need to enhance ED nurses’ nursing competency, but also provide factors worth intervening.