變遷環境中主體性的重構：臺灣醫務社會工作之建制民族誌研究

醫務社工在醫院佔有重要位置，被認為是最貼近服務對象的專業。但不像其他社會工作領域，醫務社工在醫院被認為像客人的位置、什麼都會，但樣樣都不精、說不清楚自己的主體性，甚至追求績效、文書工作比重視個案信任關係更普遍，離服務對象好像越來越遠。是什麼樣的原因和因素導致對醫務社工專業的不了解和造成專業主體性的變化？本研究目的為：1.以醫務社會工作者經驗為立足點，希望揭露醫務社工主體是透過哪些國家政治經濟、政策制度、醫院組織發展和社工專業化運作形成；2.檢視醫務社工的醫院日常實作，解析此工作世界背後所鑲嵌的結構關係，透視當中潛藏的意識形態與支配關係；3.期望研究結果對當代醫務社會工作主體，提出政策、實作和專業論述策略之建議，作為未來醫務社工在醫療體系中確認其專業主體性，建立專業認同和增進專業地位之參考。研究方法採取建制民族誌（Institutional Ethnography, IE），以交織性觀點（Intersectionality）切入，透過深度訪談法和文本／檔案資料分析法進行資料收集，共訪談25位醫務社工，收集醫務社工相關歷史檔案資料和日常工作文本。發現變遷環境中，醫務社工主體性的演變和其日常工作世界，並進一步揭露背後的交織性因素與支配關係。資料收集與分析從2017年3月起，一直到完成正式論文。本研究結果有三：1.發現醫務社會工作的主體演變，包括：（1）慈善與美式醫務社工主體：我是醫務社工；（2）醫院財團化下的醫務社工主體：我是醫務社工，更是醫院員工；（3）國家定義的醫務社工主體：我們是醫務社工師，也曾是社工；以及（4）健保與醫院營利化交織下的醫務社工主體：我們還是醫務社工！等主體性變化。2.醫務社工的主體是在多重交織面向下的演變結果。焦點聚集在健保與醫院營利化交織性因素上，是造成對醫務社工專業主體不了解或產生工作斷裂經驗的重要原因。包括：（1）健保與醫院營利化交織下重組的出院準備「工作」；（2）健保與醫院營利化交織下質變的團體與社區工作；以及（3）健保與醫院營利化交織下共謀的醫院評鑑。3.本研究進一步提出反抗支配關係，醫務社工另一種主體的可能，包括：（1）扁平的健保VS立體的日常；（2）醫務社會工作VS健康照顧社會工作；和（3）專科社工師VS生活大師。研究結論部分，本研究提出：1.醫務社工的交織性位置：主體性的演變與重構；2.醫務社工的斷裂經驗與專業韌性：有變動的挑戰，但有不變的承諾；與3.醫務社工專業化再思考：專業主體性的正常性混亂。最後，提出：1.國家政策：回歸非營利本質的醫療服務；2.醫療院所：別忘了醫師誓言核心價值；以及3.醫務社工：專業論述策略的第三條路等研究建議。

關鍵字

醫務社會工作；醫務社工；交織性；建制民族誌

並列摘要

Medical social workers are notable for being the professionals that work extremely closely with clients in hospitals. However, unlike social workers in other fields, medical social workers are seen as guests in hospitals who are versatile but lack specialisation and subjectivity and have become increasingly distant from clients. The reasons and factors behind the misunderstanding of the medical social work profession and changes in professional subjectivity were the main topics of this study. The research objectives of this study were as follows: 1. reveal relevant factors to the establishment of the subjectivity of medical social workers, such as the politics and economics of the country, policies, regulations, hospital development, and the professionalisation of social workers, from the standpoint of medical social workers and their experiences; 2. examine daily practices of medical social workers to analyse the structural relationships in the field of work and review the hidden ideology and dominance within; 3. propose suggestions of professional discursive strategy that serve as references for medical social workers to confirm a professional subjectivity, establishing professional identity, and promoting professional status in hospitals in the future. This study employed Institutional Ethnography, performing in-depth interviews and text and archival analysis from the perspective of intersectionality for data collection. A total of 25 medical social workers were interviewed, and historical archives relevant to medical social workers and texts containing their daily works were collected. The research period began in March 2017 and lasted until the thesis was completed. The research results were as follows. 1. The subjectivity of medical social workers changed between the followings: (1) The subjectivity of charitable and American-style medical social workers was ‘I am a medical social worker.’ (2) The subjectivity of medical social workers under the corporatisation of hospitals was ‘I am a medical social worker and an employee of the hospital.’ (3) The subjectivity of medical social workers by the national definition was ‘We are medical social workers who were once social workers.’ and (4) The subjectivity of medical social workers affected by the intertwining relationship between national health insurance and hospital profitisation was ‘We are still medical social workers.’ 2. The subjectivity of medical social workers was a result of multiple aspects of the intertwining relationship. Focusing solely on the intertwining relationship between national health insurance and hospital profitisation was a crucial reason for the misunderstanding of the professional subjectivity of medical social workers and their disconnected work experiences. Such factors included (1) discharge planning ‘works’ under the intertwining relationship between national health insurance and hospital profitisation; (2) altered group and community work under the intertwining relationship between national health insurance and hospital profitisation; and (3) the conspiratorial hospital evaluation under the intertwining relationship between national health insurance and hospital profitisation. 3. Other possible subjectivity definitions proposed in this study included (1) flat national health insurance versus three-dimensional daily practice; (2) medical social work versus healthcare social work; and (3) specialised social workers versus life masters. The research conclusions were as follows. 1. The intertwined position of medical social workers: the evolution and reconstruction of their subjectivity. 2. The disconnected experiences and professional resilience of medical social workers: dynamic challenges and unchanged promises. 3. Rethinking the professionalism of medical social workers: the normal chaos of professional subjectivity. Finally, several suggestions are made for national policies, hospital organisation, and discourse on the subjectivity of medical social workers.