急診護理人員及護理長對急診工作之看法探討
中文摘要
由於健保給付政策不斷地改變，使得各醫院急診為滿足病人就醫的需求及符合評鑑標準，不得不在人力的配置上做調 整以提升服務品質，故本研究目的旨在（一）了解與比較護理人員之基本屬性不同，其對急診工作看法之差異；（二）了解護理人員之護理人力調度結果與急診工作看法之相關性；（三）了解急診部（科）護理長對護理人力調度 結果之看法及所採行之因應策略；（四）了解急診部（科）護理長對目前評鑑人力標準的看法及未來建議。
本研究採混合式設計，資料收集共分為兩個階段，第一階段採量性研究法，以方便取樣方式選取新竹以北 30% 之醫 院急診護理人員為本研究對象。本研究工具以自擬之結構性問卷進行調查。問卷效度採內容效度（ Content Validit y ）檢定。另以因素分析將問卷內容歸納為排班方式、工作環境、工作負荷及整體感受四個構面，而以 Cronbach’s α 值檢定各構面之內在一致性，各構面結果依序為 .71 、 .69 、 .73 及 .87 。資料收集後以描述性統計、 one-way ANOV A 、 independent T-test 及 Pearson’s correlation analysis 進行分析。第二階段則採質性研究法，針對受訪醫院之急診部（科）護理長做面對面深入訪談，資料則以內容分析法分析。
本研究問卷共發出 431 份，回收 355 份問卷，回收率為 82.3% ，有效樣本數共 346 護理人員。結果在護理人員對排班 方式之看法而言，區域醫院之護理人員較地區教學醫院為正向（ p<.05 ），且進階分級 N3 （含）以上之護理人員較 N3 以下者為正向（ p<.05 ）。就工作環境之看法而言，年齡小於 30 歲之護理人員比 30 歲以上者為正向（ p<.01 ）；年資滿 1 年至未滿 5 年之護理人員較不滿一年者為正向 （ p<.01 ）。就工作負荷而言，高級心臟救命術（ ACLS ） 合格者較未合格者正向（ p<.05 ），但年齡、教育程度、年資及進階級數則未達統計上之差異。就整體工作感受而言
，進階級數 N3 （含）以上之護理人員比 N2 （含）以下者及未參加進階者正向（ p<.01 ），但年齡、教育程度、年 資則未達統計上之差異。另本研究發現排班方式與積欠休、逾時下班及臨時召回上班呈負相關 （ p<.05 ）。工作環 境與發生異常事件亦呈負相關（ p<.05 ）。而工作負荷與逾時下班也呈負相關（ p<.01 ）。護理人員之整體感受與 發生異常事件數呈負相關（ p<.01 ）。
在質性資料分析後發現，急診部（科）目前護理人力皆為積休狀態，造成原因為補充非例行休假人力、遞補人員受訓 之人力、新進人員召募困難及支援急診外業務過多。而逾時下班原因為病人過多、交班時間病人突增、護理長利用交 班宣導時間過長、擔任小組長處理行政業務、檢傷人員能力不足、擔任教學工作及文書工作做不完等。臨時召回上班 原因為機動調度，為補足人員非預期性之休假及因應大量傷患湧入等。而護理長曾採行之因應策略包括改善照護流程、補充合理之人力、減少人員離職率等。然護理長對護理界及急重症委員會之建議包括不同層級醫院不應使用相同的 人力標準，應依照疾病嚴重度、檢傷分類級數及留觀床護理時數做規劃，也期待護理界前輩及急重症委員會注重急診 護理人力之相關議題，以維護急重症護理人員權益等。
本研究結果除提供醫院評鑑機構制定急診護理人力標準之參考依據外，亦能提供未來醫院改善護理人力配置之參考，以提升急診護理品質。
A Study of Work Perceptions Ａ mong Nurses in the Emergency Department
英文摘要
With the constant changes in the National Health Insurance coverages, the emergency departments (EDs) at various hospitals have to readjust personn el staffing in order to improve the quality of patient care. Therefore, the aims of this study were 1) to compare and understand the differences between nurses’ demographics and their work perceptions, 2) to understand the relationship between staffing arrangement and nurses’ work perceptions, 3) to u nderstand what coping strategies related to staffing arrangement have been used, and 4) to understand the perceptions of head nurses on current hospit al accreditation personnel standards and their suggestions.
This study was a mixed-method design. Two phases were used to collect data. In first phase, the quantitative approach was used to survey 30% of nurs es from hospitals in northern of Taiwan. A self-developed work perception questionnaire was used to survey nurses in the EDs .The questionnaire was assessed by content validity and factor analysis. Four themes were emerged, including work schedule, work environment, workloads, and overall view points on EDs . For the reliability, Cronbach’s α value was used to assess the internal consistency. Data were analyzed by descriptive statistics, one-wa y ANOVA, independent T-test and Pearson’s correlation analysis. In phase two, the qualitative approach was used to conduct in-depth face-to-face int erview with head nurses in the e EDs . Data were analyzed by content analysis.
A total of 431 questionnaires were administrated and 355 questionnaires were returned(82.3% return rate). The results were as follows. There are high er perceptions of work schedule for nurses in district hospitals than those in regional hospitals (p<.05) and for nurses with N3 level or above in the clin ical ladder system than those with the levels lower than N3 (p<.05). For the work environment, nurses whose age was less than 30 years had positive p erceptions than those of above 30 years (p<.01). Nurses who had one to five years of working experience had positive perceptions than those of less th an one year (p<.01). For the workload, nurses who had ACLS certificates had positive perceptions than those without(p<.05). However, no significant difference was found on age, level of education, years of working experience, and level of clinical ladder. For the overall viewpoint on EDs, nurses wh o had above N3 level had positive perceptions than those of below N2 levels. However, no significant difference was found among age, level of educat ion, and years of working experience. Nevertheless, a negative relationship was found between work schedule and vacation accumulation or vacation debt, overtime, and calling back to work (p<.05). A negative relationship was also found between work environment and number of incidences (p<.05) . A negative relationship was found between workload and overtime (p<.01) and between overall viewpoints and number of incidences (p<.01).
The qualitative analysis of the data show that the majority of EDs nurses have vacation accumulation or debt, which is attributed to the reasons includi ng untaken vacation, training, unfilled nurse vacancy, and overtime work.. There are reasons contributing to overtime work, such as unexpected high p atient volume, administrative work, inadequate triage personnel, and ambiguous care areas and processes. In the survey, a variety of strategies are curr ently used by head nurses to deal with nurses’ vacation accumulation or debt, such as improving care processes, increasing staffing level, and reducing turnover rate. Suggestions from head nurses include that hospital accreditation personal standard should be adjusted based on severity category, triage level, and nursing care hours. In addition, Emergency Nurse Association should pay more attention to nursing staffing-related issues and raise a voice f or ED nurses’ rights.
The findings not only serve as a reference for hospital accreditation committees to set a policy for nursing staffing standards, but also provide a basis f or hospitals to improve nursing staffing and to improve the quality of nursing care in the EDs.
