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研究生:蔡依倫
研究生(外文):YI-Lun Tsai
論文名稱:臺灣醫院醫師的醫療糾紛恐懼之本質、工作環境相關因素與其影響
論文名稱(外文):The nature, work-related factors and consequences of fear of medical malpractice disputes among hospital physicians in Taiwan
指導教授:鄭雅文鄭雅文引用關係
指導教授(外文):Yawen Cheng
口試委員:楊秀儀姚開屏董鈺琪邱文聰
口試委員(外文):Hsiu-I YangKaiping YaoYu-Chi TungWen-Tsong Chiou
口試日期:2020-01-06
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:健康政策與管理研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2020
畢業學年度:108
語文別:中文
論文頁數:135
中文關鍵詞:醫療糾紛恐懼醫師工作環境醫師疲勞防禦醫療離職意願
外文關鍵詞:fear of medical malpractice disputesphysicians’ work environmentphysician burnoutdefensive medicineturnover intention
DOI:10.6342/NTU202000511
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目的
本研究之研究目的有四:(1)以深入訪談探討醫療糾紛恐懼的本質,包括其內容與影響;(2)發展問卷量表工具以測量醫師的醫療糾紛恐懼,並檢視其信效度;(3)以實證研究檢驗醫師個人特質、工作環境因素對於醫師的醫療糾紛恐懼之預測性;(4)並檢驗醫療糾紛恐懼對於醫師疲勞、防禦醫療與離職意願的影響。
方法
針對目的一,採用立意取樣方式,深入訪談來自不同地區、年齡層、科別、性別共30位醫師,以紮根理論方式探討醫師的醫療糾紛恐懼之本質與其影響。針對目的二,利用開放編碼與軸心編碼分析,發展醫療糾紛恐懼量表,並召開專家會議以獲得問卷的表面效度,最後再以全國的急診醫師為調查對象,檢驗此量表的建構效度。針對目的三及目的四,以同一調查樣本,檢驗醫療糾紛恐懼以及各變項之相關性,總共回收1,045份有效問卷。
結果
訪談結果顯示,醫療糾紛恐懼本質為:(1)「訴訟的恐懼」,包括「過程」和「結果」;(2)「聲譽受損的恐懼」,包括「一般聲譽」和「專業聲譽」;(3)「暴力的恐懼」,包括「言語暴力」和「肢體暴力」;(4) 「對媒體的恐懼」,包括「大眾媒體」和「自媒體」。
針對研究目的二,因素分析萃取出兩個因素:其一為「感知的負面後果」,其內容包含「聲譽受損的恐懼」、「暴力的恐懼」和「對媒體的恐懼」;其二為「感知的風險」,其內容包含「訴訟的恐懼」和「感知的醫療糾紛威脅」,兩個分量表的信度良好,Cronbach’s α分別為0.946與0.838。迴歸分析結果顯示,「醫療糾紛經驗」、「工作量」、「醫院究責」皆為醫療糾紛恐懼兩個分量表的預測因子;而醫療糾紛恐懼兩個分量表均可預測醫師的工作疲勞、服務對象疲勞、防禦醫療和離職意願。
結論
本研究指出,臺灣醫師對於醫療糾紛的恐懼不僅來自訴訟,也來自其他不同來源。本研究並指出,過去的醫療糾紛經驗、過多的工作量和醫院究責會加重醫師的醫療糾紛恐懼,進而增加醫師疲勞、防禦醫療和離職意願。醫院管理階層應定期舉辦醫療糾紛的教育活動,以降低醫師對於醫療糾紛之恐懼,一旦出現醫療糾紛爭議,應在過程中對醫師當事人提供足夠的保護措施,並減少對醫療糾紛的究責文化。衛生主管機關則應制定相關政策,關注醫師工作量,並對媒體與訴訟程序進行規範,才能減少醫師的醫療糾紛恐懼、疲勞、防禦醫療與離職意願。
Objective
Medical malpractice and the problem associated with it remain an important issue, yet relatively little is known regarding the nature of the fear of medical malpractice disputes of physicians. This study aims to (1) explore the nature of “fear of medical malpractice disputes”, including its contents and consequences (2) to validate the scale of “medical malpractice fear score” (3) to investigate how work environment factors may affect medical malpractice fear and (4) to examine how medical malpractice fear may affect physicians’ burnout, defensive medicine and turnover intention.
Methods
To address the first study objective, a qualitative study using in-depth interviews focused on personal experiences and observations of medical malpractice disputes from the physicians’ perspective. Thirty hospital-employed physicians varying in subspecialties, gender, institution, length of time in practice, affiliation, and location of practice participated in this study, including individuals who had experienced medical malpractice disputes and those who had not.
To address the second study objective, we developed a scale to measure “medical malpractice fear” according to results of in-depth interviews and other scales that have been developed to measure physicians’ fear of malpractice or litigation. We also invited experts in the field of law and clinical medicine, public health, hospital management and psychometrics to examine the questionnaire and also had physicians to read these questions to make sure all items were understandable.
In the third and fourth parts, a cross-sectional survey was conducted among emergency physicians in Taiwan. A structuralized questionnaire was used to collect information with regard to their workloads, experiences of medical malpractice disputes, level of fear and burnout, defensive medicine, turnover intention, and knowledge and attitude toward the hospital policies of medical malpractice disputes.
Results
Physicians’ fear of medical malpractice disputes consisted of four major categories, that were (1) fear of litigation, included process and outcome (2) fear of reputation damage, included general reputation and professional reputation (3) fear of violence, including verbal violence and physical violence (4) fear of media, including mass media and self-media. After exploratory factor analysis, two factors were extracted. The first one contained fear of reputation damage, fear of violence and fear of media, naming “perceived negative consequences”, while the second one contained the fear of litigation and perceived threats, naming “perceived risks”. The two scales demonstrated good internal consistency (Cronbach’s α 0.946 and 0.838, respectively) and construct validity. Physicians with experiences of medical malpractice disputes, more workloads and liability culture of hospital had higher levels of both perceived negative consequences and perceived risks, which then predicted physicians’ burnout, defensive medicine and turnover intention.
Conclusions
Physicians’ fear of medical malpractice disputes was not confined to that of litigation, but also included negative consequences from different sources. Work overload and liability culture of hospital might increase physicians’ fear of medical malpractice disputes, which subsequently aggravate physicians’ burnout, practice of defensive medicine and premature attrition. Hospitals should provide early assistance to resolve any potential medical malpractice disputes, sufficient protection for involved physicians and regular educational activities to improve medical staff’s knowledge and attitudes of medical malpractice disputes. Governmental authorities concerning health affairs should formulate policies to attend to physicians’ workload, in order to decrease physicians’ fear of medical malpractice disputes, burnout, defensive medicine and turnover intention.
目錄
口試委員會審定書...........................................................................................i
致謝.............................................................................................................. ii
中文摘要.........................................................................................................iii
英文摘要.........................................................................................................v
目錄.............................................................................................................viii
第一章 緒論..................................................................................................1
第一節 研究動機...........................................................................................2
第二節 研究背景............................................................................................2
第三節 研究目的.........................................................................................4
第四節 研究的重要性.................................................................................4
第二章 文獻探討...................................................................................................5
第一節 醫療糾紛現況.................................................................................5
第二節 醫療糾紛訴訟................................................................................11
第三節 醫療糾紛恐懼................................................................................14
第三章 研究方法................................................................................................19
第ㄧ節 研究架構........................................................................................19
第二節 研究設計........................................................................................20
第三節 質性訪談........................................................................................21
第四節 發展量表........................................................................................24
第五節 問卷調查........................................................................................28
第四章 質性訪談研究結果................................................................................31
第一節 研究樣本特性................................................................................31
第二節 訪談研究編碼:總論....................................................................32
第三節 訪談研究編碼(一):訴訟的恐懼..............................................39
第四節 訪談研究編碼(二):聲譽受損的恐懼......................................45
第五節 訪談研究編碼(三):暴力的恐懼..............................................46
第六節 訪談研究編碼(四):對媒體的恐懼..........................................48
第七節 訪談研究編碼(五):醫院文化與工作環境................................50
第八節 訪談研究編碼(六):醫療糾紛恐懼的影響................................54
第五章 量性調查研究結果..................................................................................57
第一節 研究樣本特性..................................................................................57
第二節 信效度分析......................................................................................62
第三節 變項的計算與分組..........................................................................67
第四節 卡方檢定..........................................................................................72
第五節 羅吉斯迴歸分析..............................................................................80
第六章 討論與建議..............................................................................................85
第一節 醫療糾紛恐懼的本質......................................................................86
第二節 醫療糾紛恐懼的測量..................................................................... 95
第三節 醫療糾紛恐懼的相關因素..............................................................97
第四節 醫療糾紛恐懼的影響......................................................................109
第五節 政策意涵...........................................................................................113
第六節 研究限制..........................................................................................114
第七節 結論與建議......................................................................................115
第八節 預期貢獻..........................................................................................116
第九節 未來研究方向..................................................................................117
參考文獻....................................................................................................................118
附錄一 訪談大綱..................................................................................................130
附錄二 問卷全文..................................................................................................131
附錄三 各變項次數分佈圖..................................................................................133

圖目錄
圖一 醫療糾紛的形成與處置管道...............................................................6
圖二 本研究之研究架構...............................................................................19


表目錄

表一 受理委託醫事鑑定案件數統計表.....................................................8
表二 全國各縣市醫療糾紛調處案件量統計.............................................9
表三 全國各縣市醫療糾紛調處成立率統計表........................................10
表四 鑑定結果統計表................................................................................13
表五 醫療糾紛恐懼之測量構面與問卷題項..............................................25
表六 自覺工作量、醫院文化與醫師行為之測量構面與問卷題項..........27
表七 工作疲勞與服務對象疲勞之測量構面與問卷題項........................27
表八 本研究受訪者一覽表........................................................................34
表九 醫療糾紛恐懼訪談研究結果編碼表................................................37
表十 2019年度急診專科醫師執業登記狀況調查結果...........................58
表十一 回收問卷醫師特質分析................................................................59
表十二 醫療糾紛恐懼量表的信度分析....................................................66
表十三 醫院支持的信度分析....................................................................66
表十四 本研究工作量之計算方法與分組................................................70
表十五 各變項分數分佈狀況與所佔百分比............................................73
表十六 各變項高低分組方式與組別所佔百分比....................................73
表十七 「感知的負面後果」之卡方檢定(人口學變項)....................74
表十八 「感知的負面後果」之卡方檢定(醫師特質變項)................75
表十九 「感知的負面後果」之卡方檢定(醫院變項)........................76
表二十 「感知的風險」之卡方檢定(人口學變項)............................77
表二十一 「感知的風險」之卡方檢定(醫師特質變項)....................78
表二十二 「感知的風險」之卡方檢定(醫院變項)............................79
表二十三 「感知的負面後果」與「感知的風險」之迴歸分析.............80
表二十四 「工作疲勞」與「服務對象疲勞」之迴歸分析.....................83
表二十五 「防禦醫療」與「離職意願」之迴歸分析.............................84
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