運用PZB服務品質模式衡量專科護理師之醫療服務品質

Application of PZB Service Quality Model in Evaluating the Medical Service Quality of Nurse Practitioner Care

林家弘(Chia-Hong Lin)

指導教授 ： 孫秀卿

國立臺灣大學/醫學院/護理學研究所/碩士(2017年)

https://doi.org/10.6342/NTU201700365

摘要

背景與目的：台灣專科護理師照護模式為專科護理師協同輔助主治醫師共同提供病人連續性及整合性之醫療照護方式，此照護模式逐漸成為台灣許多醫院替代住院醫師人力的經營政策。然而，專科護理師的醫療服務品質是否符合病人的期待，病人對此照護模式的感受評價如何，目前國內仍未有相關研究探討。有鑑於此，本研究之目的為：一、瞭解專科護理師照護模式下病人之基本屬性與疾病相關因素。二、探討病人對專科護理師醫療服務品質之期望程度、感受評價與兩者間之差距。三、探索影響病人對專科護理師醫療服務品質之相關因素。
研究方法：本研究採橫斷式、描述相關性研究設計，以立意取樣方式針對北部某醫學中心之專科護理師照護模式病房進行資料收集。運用PZB服務品質模式建構之問卷進行資料收集，本問卷內容包含病人基本屬性資料表、自擬之服務品質量表(SERVQUAL量表)與疾病相關因素資料表，收案期間為2016年6月1日至2016年11月30日，期間內有效問卷共200份。資料以探索式因素分析方法確認發展量表之效度、並以描述性統計、獨立樣本t 檢定、相依樣本t 檢定、單因子變異數分析、皮爾森積差相關、廣義估計方程式進行資料分析。
研究結果：本研究SERVQUAL量表在建構效度檢驗上，結果萃取出五項因素的累積解釋變異量達66.76%，而整體量表也具高度的內部一致性(Cronbach's Alpha = 0.969)。收案病人以男性居多(56.5%)，平均年齡為57歲，對專科護理師角色認知多處於模糊地帶，病情症狀進展呈穩定狀態。研究分析結果顯示：病人對專科護理師照護模式之醫療服務品質有很高的期望(M = 6.46)；在感受評價的分數(M = 5.77)也達量表中間值以上，顯示病人對專科護理師的醫療服務品質有一定程度的肯定。然而，在五大醫療服務品質構面中，病人在「可靠性」構面的期望程度最高；於「回應性」構面的感受評價最低，對醫療服務品質的期待與感受間大多呈現顯著的差異(p < 0.001)，尤其以「可靠性」構面(M = 1.998)的表現落差最大，其次為「回應性」構面(M = 0.828)，對「有形性」構面(M = 0.088)差距最小。影響病人對專科護理師之醫療服務品質的相關因素中發現，若病人對專科護理師角色定位的認知程度越高，或是由急診入院的病人群，其對醫療服務品質的差距會越大，但若病人有感受到專科護理師執行臨床照護的確實性，無論探視的頻次多寡，則病人對整體專科護理師醫療服務品質的差距會變小。
結論與建議：病人感受到的專科護理師的醫療服務品質仍有落差，特別是可靠性層面。本研究認為專科護理師照護模式應優先改善可靠性、回應性及保證性三大醫療服務品質構面產生之差距，可以藉由1. 強化專科護理師對病人主要疾病症狀困擾之整合性的專業評估與處置指引，尤其在疲倦照護、疼痛控制、發燒評估處置及共病症管理的教育訓練。2. 在病人執行檢查及處置前，專科護理師應向病人或家屬詳細說明處置過程細節、治療後續進展並告知應注意的事項，以降低病人對疾病所產生的恐懼與不安。3. 培養以病人為中心的實證照護能力，讓病人對專科護理師的照護產生信心與依靠感，提高護病間的信任度。如此便可縮小專科護理師主要醫療服務品質構面缺口之落差，進而增進專科護理師連續性及整合性的醫療照護品質。

關鍵字

專科護理師 ； 醫療服務品質 ； 服務品質模式

並列摘要

Background and Objective: Taiwan Nurse Practitioner Care Model (NPCM) is the nurse practitioners in collaboration with the auxiliary physician-in-charge to provide continuity and integration of the patient's medical care. Many hospitals apply this care model to replace the shortage of resident physician. However, at present, there is no related research in Taiwan about whether the quality of medical service of the nurse practitioners meets the expectation of the patients and how the patients feel about the care model. Therefore, the purposes of this study were to: (1) explore the demographic and disease-related characteristics of patients under the NPCM, (2) investigate the patients’expectations of the quality in the NPCM, the perceptions of the actual care provided and measure the gap between patients’expectations and perceptions, and (3) identify the important factors affecting the quality of the NPCM.
Methods: This study adopted a cross-sectional, descriptive correlational design with purposive sampling to collect the data from a medical center in Northern Taiwan. The PZB service quality model was used to develop the modified Service Quality (SERVQUAL) scale. The structured questionnaire included patients’ demographic and disease-related characterisitcs of patients. The survey was conducted from 1st June to 30th November 2016. Finally, 200 patients inculded in this study.The construct validity was examined by exploratory factor analysis, and the data were analyzed by descriptive analysis, independent t-test, paired t-test, one-way ANOVA, Pearson’s correlation, and generalized estimating equations(GEE).
Results: The modified SERVQUAL scale had a good construct validity with 5 factors which could explain 66.76% variances. The scale had the good reliability of internal consistency with Cronbach's Alpha value 0.969. Major patients were those with stable disease, were male (56.5%) with mean age of 57 years old. Most of them did not understand about the role and position of nurse practitioners. The results of the study showed that patients had overall high expectation (M=6.46) on the quality of medical service in the NPCM, and the average scores of the patients’perceptions (M=5.77) were above the middle level of the scale, which showed that the patients recognized the care by nurse practitioners. Comparing the five medical service quality dimensions, patients had the highest expectation of "Reliability", and the lowest perception in " Responsiveness." Differences between expectations and perceptions among the most of the dimensions were significant (p < 0.001). The largest gap between expectations and perceptions was “Reliability" (M=1.998), following by " Responsiveness "(M=0.828). The smallest gap was "Tangible" (M=0.088). The results revealed that the patients with a higher level of cognition of the role and position of nurse practitioners or admitted from the emergency department had greater gaps in quality of medical care. However, the patients felt the authenticity of the medical care performed by nurse practitioners, the gap in quality of medical care would be smaller regardless of the frequency of the nurse practitioners’ visitings.
Conclusion and recommendation: There is still gap in quality of medical care perceived by the patients, especially in the dimension of reliability. Overall, the results of the study suggest the service quality dimensions of “Reliability”, “Responsiveness” and “Assurance in the nurse practitioners care model should be firstly improved by performing following suggestions: (1) Nurse practitioners should enhance the abilities in assessment and management for major diseases’ sign and symptoms, particularly in fatigue, pain, fever and comorbidities. (2) Nurse practitioners need to explain the details of the disease progression, medical procedure and precautions to the patient or his families before the examination or treatment to reduce the patient's fear and anxiety. (3). Nurse practitioners should cultivate the patient-centered with evidence-based health care so that the patients will be more trust on nurse practitioners. Then, that will help nurse practitioners to build trust and credibility with patients and improve the continuity and integrated quality of medical care.

並列關鍵字

Nurse Practitioner ； Medical Service Quality ； Service Quality Model

參考文獻

Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987). A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases, 40(5), 373-383. doi: 10.1016/0021-9681(87)90171-8

中文部分

王元昭（2009）．醫療服務品質認知差異之研究．台灣大學，台北市。

王潤清、林靜蘭、柯舜娟、張艾玲、陳月枝、李雅文（2014）．某醫學中心專科護理師對工作範疇的看法[The Views of Nurse Practitioners toward the Scope of their Work in a Medical Center]．長庚護理，25（2），137-148。doi: 10.3966/102673012014062502002

台灣專科護理師學會(2011，02月07日)．建議專科護理師的專業能力．取自http://www.tnpa.org.tw/papers/papers_detail2.asp?id=50