台灣精神障礙者社區化就業服務品質評估與成效關係探討

Abstract

目的：精神障礙者多擁有工作動機，但受精神症狀干擾及社會污名化等因素影響，造成精障者比正常人更難進入競爭性職場就業。支持性就業服務乃是讓個案快速進入競爭性職場為主要目標，屬 「先安置再訓練（Place-and-Train）模式」 ；透過快速找尋工作機會，讓個案進入符合個案能力及興趣之整合性工作職場，與一般人一起競爭及合作。而就服員則在安置個案之後提供以職場為主的支持與協助，針對個案職務的能力需求進行評估與訓練，扮演在雇主與個案之間的協調者的角色。支持性就業服務整合醫療及職業重建專業的服務，透過規律的開會討論，提供個案最即時且符合職務需求的持續協助，並被視為最具實證支持的精障者職業重建模式。國內對於精神障礙者之社區化就業服務乃是採納1980年代美國之支持性就業服務理念所發展出來。但，我國對精障者社區化就業服務是否符合支持性就業服務之標準？我國精障者社區化就業服務之成效為何？等很少有人探討。因此，本研究希望使用「支持性就業服務品質量表（Supported Employment Fidelity Scale, SEFS）」，探討國內提供精障者之就業服務情形，並且透過各機構所獲得之品質量表分數與就業成效之關係探討以了解各機構提供就業服務情形及對成效之影響，以協助提高台灣針對精障者之就業服務品質。 研究方法：本研究使用SEFS對於負責民國98年台灣各縣市之精障者社區化就業服務之20間機構進行訪視，透過與就服員之半結構式會談及基本資料表的填寫以取得各機構人員、組織、服務及成效資料，並使用SPSS 程式11.5版本進行描述性統計、曼-惠二氏U檢定、Spearman's rho分析。 研究結果：訪視機構之SEFS總分皆達到Fair Fidelity以上，甚至有四間機構有達到Good Fidelity，代表台灣之社區化就業服務模式的確屬於支持性就業模式的一種。由於在醫療整合度、延展性聯繫與服務、雇主經營等層面與國外精障者支持性就業服務標準有較大的差異，因此，台灣之精障者社區化就業服務無法達到Exemplary Fidelity等級。服務品質屬於Good Fidelity等級之機構在25題評分標準中，除O2（就業服務與醫療團隊溝通頻率）、S8（多元化職務型態）、S9（多元化雇主）三題外，其他各題之得分皆高於屬於Fair Fidelity等級之機構，且有五個題項（VS2：就業服務時間比例、O1：就業服務與精神醫療整合度、S4：快速找尋競爭性就業工作、S12：無時間限制之持續支持、S13：以社區為主之服務提供）達顯著之統計學上的差異。品質等級達Good Fidelity之機構在媒合成功率、穩定就業率、平均月薪、每週平均工時四項就業相關成效皆比服務品質等級達Fair Fidelity機構高，但皆未達顯著之統計學上的差異。醫療與非醫療機構僅在題項S13（以社區為主之服務提供）上，有顯著差異，醫療機構明顯花較高之時間比例於社區情境中提供就業相關服務；醫療機構在媒合成功率、穩定就業率、平均月薪、每週平均工時四項就業相關成效皆比非醫療機構來的高，但皆未達顯著差異。全職工作者比例與媒合成功率、每週平均工作時數達高度正相關。提供沒有時間限制之持續支持，並找尋較多全職工作機會，可獲得較高之平均月薪，且達中度相關。 結論與建議：本研究建議台灣應該在就業服務應與醫療團隊合作程度、延展性聯繫與服務、雇主經營等三方面未達國外實證支持性就業服務標準進行改善，以提高台灣針對精障者之支持性就業服務品質。

Introduction. Most people with severe mental illness want to get jobs, but they could not find or maintain competitive employments because of the repetitive interference of psychiatric symptoms and social stigma. Supported Employment (SE) is a place-and-train model that helps people with severe mental illness to achieve the employment goal by concerning their preferences, skills, and experiences, as well as providing individual place and support service. Till now, SE has become the most evidence-based approach in helping people with severe mental illness to return to and stay in competitive work. SE services in Taiwan follow the 1980’s American SE model. There was no study to discuss the quality and effectiveness of the SE services for people with severe mental illness in Taiwan. Therefore, the purposes of this study are (1) to explore the quality and vocational outcomes of the SE services for people with severe mental illness by using the Supported Employment Fidelity Scale (SEFS); and (2) to explore the relationships between service quality and vocational outcomes. Methods. Twenty agencies, which were responsible for government’s SE services for people with severe mental illness, were included in this study. Data collected through interviewing the agency’s employment specialists to get information about the personnel, organization, services, and vocational outcomes. The data was analyzed by using SPSS 11.5 for Windows by descriptive statistics, Mann-Whitney U, Spearman's rho. Results. By using SEFS, the fidelity scores were ranged from 74 to 103, which were greater than the criterion score of standardized SE. That means that all interviewed agencies meet the standards of the SE. Low integration of SE services with mental health treatment, not providing enough assertive engagement and outreach service, and poor relationship between employment specialists and employer were three major reasons that the interviewed agencies could not enter the Exemplary Fidelity level (score > 114). Compared to agencies reaching Fair Fidelity, agencies reaching Good Fidelity level got more scores in most SEFS items, and in which five items scores got statistically significant differences. Good Fidelity level agencies had better outcomes in every vocational outcome than Fair Fidelity level agencies; however, that did not make statistically significant difference. Most of the fidelity’s scores except item S13 (Community-based services) had statistically significant difference between medical and non-medical agencies. Medical agencies also had better outcomes in every vocational outcome than non-medical agencies, but there was no statistically significant difference. Results also showed that permanent employment rate had high correlation with competitive employment rate and every week’s work-hours in average.Providing time-unlimited follow-along supports & more permanent job had moderate correlation with average month’s payment. Conclusion. SE services in Taiwan should enhance the integration of SE services and medical health treatment, provide more assertive engagement and outreach, and put more emphasis on interaction between employment specialists and employers to make better fidelity in SE for people with severe mental illness.