台灣癌症多專科團隊運作的衝突、氣氛、溝通、與凝聚力對專業分享與交互記憶之影響:全國性實證研究

Abstract

背景 癌症的照顧及治療有極快速的進步，以多專科治療求取病人最佳成效的觀念催化了多專科團隊（multidisciplinary team, MDT）的形成。期待MDT能提供病人品質的照顧、提升專業人員的滿意度、及有品質的團隊決議、或臨床高指引遵從率等。MDT的目標是以病人為中心，理想的癌症照護是依專業分工，避免單科主導病人全程治療。但各家對MDT的同意及投入程度皆不盡相同，照護存有歧見，作法也仍各異。團隊成員皆有高度自主性，在醫院這講究資歷及輩份的組織科層內工作，使得集合眾人的MDT必有其特徵及專屬於醫療面的組織問題。多數癌症MDT的研究集中在結構及成果面向，對內部運作的細節認知不多，其內容及影響也有待了解。因此本研究目的是探討台灣MDT運作中包括如下: (一) 衝突、氣氛、及溝通與凝聚力的關係。(二) 衝突、氣氛、溝通及凝聚力與專業分享 (包括: 知識分享、開放) 的關係。(三) 衝突、氣氛、溝通及凝聚力與與交互記憶 (包括 :專業度、信用、及工作協調) 的關係。(四) 衝突、氣氛、溝通及凝聚力與與交互記憶 (包括 :專業度、信用、及工作協調) 的關係。 研究方法 從文獻中尋找影響組織運作的重要影響構面形成假說，以氣氛、衝突、溝通為自變項，中介變項為凝聚力，依變項為專業分享行為及交互記憶。經專家深度訪談形成問卷後發送，以通過癌症品質認證的醫院中的四大癌症團隊為對象，使用團體及個人問卷詢問各成員。並同時舉辦焦點團體座談。 因研究概念架構與團隊及個人兩套問卷資料的多階層複雜性，使用R，LISREL，與Mplus等統計分析軟體，以兩階段進行多變項分析，包括使用廣義估計方程式（generalized estimating equations, GEE）方法進行多變項迴歸分析與兩階層路徑分析（two-level path analysis）。此外，從大量的質性資料中取得重要訊息，並以NVivo質性軟體分析訪談逐字稿，來了解各構面之間的關聯性。在分析量性資料驗證假說後，與質性結果行三角驗證，以檢驗其一致性或互補性的一種混和研究法。 結果 總共回收41家醫院計164個團隊問卷及1,800份個人問卷。經資料處理後，得到1,600份有效的個人問卷。來自私立醫院的團隊計96隊（58.5%），公立其次計56隊（34.1%）。會議頻率以每2週1次占多數（59.8%），地點大多固定（99.4%）。影響專業分工的原因，在中小醫院以個人薪資的影響、科部的業績要求、及病人不足為最常見（p < 0.001）。在大醫院以臨床試驗誘因、學術升等、病人太多是主要前三因素 （p < 0.001）。雖無統計差異，新診斷病例數多的醫院其團隊討論時間略長 （p = 0.128）。初診病例在1,000-1,999床的醫院有68.8%的團隊可全部提報（p < 0.001），而在大於2,000-3,999床的醫院，卻有78.6%的團隊須改採部分提報。首次復發病例是部份、全部或不提報，各醫院並無差異（p = 0.031）。全部實質方式，或條列式及實質討論兩者並存，也無統計差異。團隊的溝通、安全氣氛及衝突與凝聚力呈正相關，也可不經凝聚力的中介效應影響團隊開放程度。凝聚力可正向影響專業分享。溝通及安全氣氛也可不經凝聚力與團隊協調有正面相關。 結論 研究支持團隊的溝通、安全氣氛及衝突與凝聚力的正相關性，及凝聚力可正向影響專業分享。交互記憶中的團隊協調以外，專業及信用可能被認為是醫療從業的個人基本素養，因此在假說中欠缺與交互記憶整體有意義的關聯性，且交互記憶中三個次構面間的複雜關係也有待進一步的探討。多專科團隊目前尚無法也不宜與病人的存活連結，工作地盤的競奪是多科合作的最大障礙。建議型塑團隊的安全氣氛，誘導成員以開放的態度促進MDT運作，醫院及政府應以管理及政策排除團隊合作的障礙，並鼓勵未來更多MDT的研究。

Background The praradigm of cancer care evolved in accordance with the rapid advancement of techonology and medicine in recent years. This has fostered the practice of multi-disciplinary team (MDT) approach to maximize the benefits of cancer patients. MDT has been proved to provide quality care in many respects, such as consistency and continuity of care, coordination, team effectiveness, and satisfaction of the professionals, etc. However, there have been different interpertations and commitments to the MDT per se among providers. Many factors embedded that are unique and influencital in cancer care teams are largely unclear, especially in teams stacked with bureaucracy, seniority and professional hierarchy. The influence of intraprofessional interactions to the performance of oncology MDT is to be defined. The goal of this study is to explore the realationship between conflict, climate and communication between cohesion, knowledge sharing and transactive memory system within MDT teams. Materials and method In order to understand the professional interactions and team process in MDT, a number of influential factors were identified from the literature review. Among all these factors, climate, conflict, communication, and cohesion were chose as independ-ent variables. Cohesion is the intermediate variable。Dependent factors were knowledge sharing behavior and transactive memory. Both team and personal ques-tionnaires were distributed to 4 different cancer MDTs (breast, lung, colon, head and neck cancers) in every accreditated institute. Meanwhile, the audio records of focus groups and experts’ in-depth interviews were transcribed word-for-word. Due to the complexity of the framework and two-level questionnaires, statistical analysis was performed using the R, LISREL, and Mplus statistical software. The multivariate analysis proceeded in two steps: (1) multiple linear regression model with the generalized estimating equations (GEE) method and (2) two-level path analysis. Word-for-word recording transcription was analyzed by the NVivo qualitative analysis software. In the end, the hypotheses were examined by the results of the quantitative and qualitative analyses in the mixed-methods study. Results A total number of 164 teams and 1,600 personal questionnaires were analyzed. Among them, 96 (58.5%）teams are from public, and 56（34.1%）are from private hospitals. Most of the meetings ( 59.8%）were held every two weeks. Common causes undermining the teamwork in non-medical centers include personal salary concern, performance requirement and insufficient patients（p < 0.001）. However, in medical centers, causes are the incentives of joining or conducting clinical trials, academic achievement, and excessive numbers of patients （p < 0.001）. Average time spent on each case discussion was longer in hospitals of more new cases than are not (p = 0.128）. Exactly 68.8% of the teams has all new cases reported in hospitals with 1,000-1,999 beds（p < 0.001）, as opposed to 78.6% of the teams in hosptials with more than 4,000 beds op for cases selected for reporting. There is no distinction either be-tween ways of selecting cases for discussion in MDT or among all hospitals. Team communication, safety climate and conflict have an association with cohesion, and openness without the mediate effect through cohesion. Cohesion has positive associa-tion with knowledge sharing behavior. Communication and safety climate can both detour cohesion and have positive association with coordination. Conclusions Our model supports the positive assoication between communication, climate, and conflict with cohesion. Other than the coordination, the relationship of transactive memory system with other constructs can not be displayed in our framework as ex-pected. People may assume the professionalism and credibility are the fundamental disciplines that needless to mention in health care. Besides, the non-recursive relationships within all subconstructs in transactive memory system require future research. Currently, it’s insufficient to link the patients’ outcomes to the MDT. A professional turf war, incurred by different reasons is the main obstacle of teamwork. However, team building with safety climate and openness to facilitate the performance of MDT was highly recommended. Hospital management and government policy should ber implemented to reduce the barrier of teamwork, and to encourage more MDT research in the future.