臺灣博碩士論文加值系統

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 Validity）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 ANOVA、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。

With the constant changes in the National Health Insurance coverages, the emergency departments (EDs) at various hospitals have to readjust personnel 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 understand what coping strategies related to staffing arrangement have been used, and 4) to understand the perceptions of head nurses on current hospital 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 nurses 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 viewpoints on EDs . For the reliability, Cronbach’s α value was used to assess the internal consistency. Data were analyzed by descriptive statistics, one-way ANOVA, independent T-test and Pearson’s correlation analysis. In phase two, the qualitative approach was used to conduct in-depth face-to-face interview 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 higher 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 clinical 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 perceptions 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 than 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 who had above N3 level had positive perceptions than those of below N2 levels. However, no significant difference was found among age, level of education, 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 including untaken vacation, training, unfilled nurse vacancy, and overtime work.. There are reasons contributing to overtime work, such as unexpected high patient volume, administrative work, inadequate triage personnel, and ambiguous care areas and processes. In the survey, a variety of strategies are currently 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 for 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 for hospitals to improve nursing staffing and to improve the quality of nursing care in the EDs.

致謝.......Ⅰ
中文摘要....Ⅱ
英文摘要............Ⅳ
目錄.............. Ⅵ
圖表目次.............IX
第一章 緒論............1
第一節 研究動機與重要性..1
第二節 研究目的..........4
第三節 操作型定義.........5
第二章 文獻查証...........7
第一節 急診部（科）之特性..............7
第二節 人力配置對護理工作之影響因素....10
第三節 急診部（科）護理人力之相關研究..13
第四節 急診護理人力與醫院評鑑之關係....16
第五節 研究架構........................18
第三章 研究方法........................20
第一節 研究設計........................20
第二節 研究對象........................21
第三節 研究工具........................23
第四節　資料收集過程....................28
第五節 資料處理與分析..................30
第四章 研究結果........................34
第一節 護理人員之基本屬性..............34
第二節 護理人員基本屬性對工作看法之差異分析...37
第三節 急診護理人力調度結果與護理人員工作看法之相關分析......43
第四節 護理長對人力調度結果看法及其因應策略之質性分析.......................................... 48
第五節 護理長對評鑑之護理人力標準的看法及建議之質性分析...........................................60
第五章 討論.................................64
第一節 急診部（科）護理人員工作看法之差異...........................................64
第二節 護理人員人力調度結果與工作看法之相關性探討性...........................................66
第三節 護理長對護理人力調度結果及因應策略之看法...........................................68
第四節 護理長對人力標準之看法及建議.......................................... 72
第六章 結論與建議............................74
第一節 結論..................................74
第二節 建議..................................77
第三節 未來貢獻..............................79
第四節 研究限制............................................80
參考資料......................................81
中文部份......................................81
英文部份.................................... 84
附錄........................................ 88
附錄一 急診護理人員工作看法問卷調查表........88
附錄二　急診護理人力調度結果及因應策略訪談指引.93
附錄三 急診護理人員工作看法問卷調查表內容效度專家.95
附錄四 專家內容效度評分表............................................97
附錄五 急診護理人員工作看法問卷表之因素分析....100
附錄六 同意書.................................102

參考資料
中文文獻
于乃玲、胡瑞桃、周碧琴、賴瑞月（1999）•某醫院護理人員工作滿意度與留任意願相關性之探討•長庚護理，10（3），28-38。
王俊文、葉德豐、曾坤儀（2003）•台灣醫院評鑑趨勢之探討•中山醫學雜誌，14，513-522。
內政部（2005）．中華民國94年戶籍人口統計年報．摘自12月20日，2007，http://www.moi.org.tw/stat/index。
白玉珠、徐南麗、汪蘋（1999）•某醫學中心護理人員自評之護理能力及個人特質相關性研究•護理研究，7（3），209-220。
行政院衛生署（2005）．中華民國94年公務統計年報．摘自12月20日，2007，http://www.doh.gov.tw/statistic/人口統計概況/。
行政院衛生署（2005）．中華民國94年全民健康保險醫療統計年報．摘自12月20日，2007，http://www.doh.gov.tw/statistic/醫療統計年報/。
李葆瑋、劉長安 （2001） •探討內外科病房護理人員每日工作時間分配•榮總護理，18（2），193-203。
杜金錠、盧美秀、陳品玲、鄭綺、徐南麗 （2002）•護理長管理自我效能與管理成效間之相關研究•新臺北護理期刊，4（1），65-76。
林四海（2001）•我國醫院評鑑之探討•醫務管理雜誌，2（1），1-20。
周志中 （2003）•台灣急診醫學發展的過去、現在與未來•台灣醫界，46（3），25-30。
周志中 （2001）•急診醫療對未來醫院經營之衝擊•台灣醫界，44（8），35-36。
胡勝川（2004）•急診:快槍手又不失品質•台灣醫界，47（8），41-45。
胡蓮珍、曾淑梅、袁素娟（2003）•中部醫學中心護理工作滿意度及其相關因素之探討•中山醫學雜誌，14，315-325。
徐南麗（2001） •護理行政與管理•台北：華杏。
張媚、余玉眉、陳月枝、田聖芳 （2005）•台灣護理人力規劃之研究．台灣醫學，9，149-156。
陳永珄（2004）淺談人力資源規劃．品質月刊．10，34-37。
陳明晃、黃英傑（2003）．民眾對急診檢傷分類與等候時間的認知．台灣急診醫學會醫誌，5（3），128-131。
陳維恭、劉文斌、林克潢、林光隆（2004）．台灣急診主治醫師急診工作規劃的規劃．台灣急診醫學會醫誌，6（3），349-356。
張黎露（2005，11月）•護理人力及病人安全•於行政院衛生署主辦，護理政策系列論壇•台北：榮民總醫院。
蔡素玲（2005）•護理人力及醫院評鑑•於行政院衛生署主辦，護理政策系列論壇•台北：榮民總醫院。
蔡慧珠、鍾蘭香、胡瑞桃（2003）•急診病患需求滿意度及相關因素探討•醫院，36（5），27-40。
簡立建（2003） •如何設計一個理想先進的急診室－美國急診創傷醫學中心設計之最新觀念•台灣醫界，46（12），25-29。
嚴玉華、陳金鐘、王石甫（2004） 急診顧客滿意度調查結果及相關因素之探討．醫護科技學刊．6（4），285-396。
龔嘉德、趙善如、江玉娟、柳居豐、鍾昆融 （2003）•落實急診病患權益之探討•台灣醫學雜誌，5（4），207-214。


















英文文獻
Adams, J. G., & Biros, M. H. (2001). The endangered safety net: establishing a measure of control. Academic Emergency Medicine, 8(11), 1013-1015.
Basis, F., Pollack, S., Utits, L., & Michaelson, M. (2005). Improving the pattern of work towards emergency medicine at the Emergency Department in Rambam Medical Center. European Journal of Emergency Medicine, 12(2), 57-62.
Brown, R. B., & Adebayo, S. A. (2004). Perceptions of work-time and leisure-time among managers and field staff in a UK primary health care trust. Journal of Nursing Management, 12, 368–374.
Campball, W. B. (2001). Relationship of physician Volume to Mortality After Acute Myocardial Infraction. The Journal of the American Medical Association, 286(13), 1574-1575.
Charnley, E. (1999). Occupational stress in the newly qualified staff nurse. Nursing Standard, 13(29), 33-66.
Cone, K. J., & Murray, R. (2002). Characteristics, insights, decision making, and preparation of ED triage nurses. Journal of Emergency Nursing, 28 (5), 401-406.
Currie, V., Harvey, G., West, E., McKenna, H., & Keeney, S.(2005). Relationship between quality of care, staffing levels, skill mix and nurse autonomy: literature review. Journal of advanced nursing, 51(1), 73-82.
Derlet, R. W., Richards, J. R., & Kravitz, R. L.(2001). Frequency overcrowding in U.S. emergency departments, Academic Emergency Medicine, 8 (3), 151-155.

Donabedian, A.(1988).The quality of care: how can it be assessed? The Journal of the American Medical Association, 260, 1743-1748.
Fleming, K.C., Evans, J. M., & Chutka, D. S. (2003). Caregiver and Clinician Shortages in an Aging Nation. Mayo Clinic Proceedings, 78(8), 1026-1040.
Fridkin,S. K., Pear, S. M., & Willamson, T. H. (1996). The Rote of Understaffing in Central Venous Catheter-Associated Blood stream Infections. Infection Control and Hospital Epidemiology, 17 (3), 150-158.
Gardulf, A., Soderstrom, I. L., Orton, M. L., Eriksson, L. E., Arnetz, B., & Nordstrom, G. (2005). Why do nurses at a university hospital want to quit their jobs? Journal of Nursing Management, 13(4), 329-337.
Gay, L. R. (1992). Educationl research competencies for analysis and application. New York: Macmillan.
Hackenschmide, A.(2004). Living with Nurse Staff Ratios: Early Experiences. Journal of Emergency Nursing, 30(4), 377-379.
Harris, J., ＆ Hendricks, J. (1996). The lifeline of triage. Accident and Emergency Nursing, 4, 82-87.
Hauswald, M. (2005). Triage: better tools but the wrong problem. Academic Emergency Medicine, 12(6), 533-535.
Healy, C. M., & McKay, M. F. (2000). Nursing stress: the effects of coping strategies and job satisfaction in a sample of Australian nurses. Jouranl of Advanced Nursing, 31(3), 681-688.
Hobgood,C., Villani, J., & Quattlebaum, R. (2005). Impact of emergency department volume on registered nurse time at the bedside. Annals Emergency Medicine, 46(6), 481-489.
Laschinger, H. K., Wong, C. A., & Greco, P. (2006). The impact of staff nurse empowerment on person-job fit and work engagement/burnout. Nursing Administration Quarterly, 30(4), 358-367.
Curtin, L. (2003). An Integrated Analysis of Nurse Staffung and Related Variables: Effects on Patient Outcomes. Online Journal of Issues in Nursing, (8)3, 5-6.
Maura, M. (2000). Hospital Networking-Comparing the Work of Nurse with Flexible and Traditional Schedules. Journal of Nursing Administration, 30(4), 190-197.
McCaig, L. F., ＆ Ly, N. (2002). National hospital ambulatory medical care survey: 2000 emergency department summary. Advance Data from Vital and Health Statistics, 326, 1-31.
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., ＆ Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospital. New England Journal of Medical, 346(22), 1715-1722.
Nelson, H., & Sargent, D.J. (2001).Why do hospital death rates vary? The New England Journal of Medicine, 345(9), 692-694
Robertson, R. H., ＆ Hassan, M. (2001). Staffing Intensity, Skill Mix, and Mortality Outcomes: The Case of Chronic Obstructive Lung Disease. Health Service management Research, 12, 258-268.
Rothberg,M.B., Abraham,I.A., Lindenauer, P. K., ＆ Rose, D. N. (2005). Improving Nurse-to-patient Staffing Rations as a Cost-Effective Safety intervention. Medical Care, 43 (8), 785-792.
Schenkel, S. M., Khare, R.K., & Rosenthal, M. M. (2003). Resident perceptions of medical errors in the emergency department. Academic Emergency Medicine, 10, 1318-1324.
Schull, M. J., Ferris, L. E., Tu, J. V., Hux, J. E., & Redelmeier, D. A.(2001). Problems for clinical judgement: 3 Thinking clearly in an emergency. Canadian Medical Association journal, 164(8), 1170-1175.
Sheward, L., Hunt, J., Hagen, S., Macleod, M., ＆Ball, J.(2005). The Relationship between UK Hospital Nurse Staffing and Emotional Exhaustion and Job Dissatisfaction. Journal of Nursing Management, 13(1), 51-60.
Spetz, J. (2001). What should expect from California''s minimum nurse staffing legislation? The Journal Nursing Administration, 31(3), 132-140.
Steinbrook, R. (2002). Nursing in the crossfire. The New England Journal of Medicine, 364(22), 1757-1766.
Vieth, T. L., & Rhodes, K. V. (2006). The effect of crowding on access and quality in an academic ED. The American Journal of Emergency Medicine, 24(7), 787-794.
Yang, K. P. (2003). Relationships Between Nurse Staffing and Patient Outcomes. Journal of Nursing Research, 11(3), 149-158.