探討住院醫師工時與工作疲勞及病人安全之相關性研究

The Exploratory study of the Association between Residents’ working hour, Burnout, and Patient Safety

鄭佳慧(Chia-Hui Cheng)

指導教授 ： 邱瓊萱

臺北醫學大學/公共衛生暨營養學院/醫務管理學研究所/碩士(2015年)

摘要

背景及目的：近年來我國住院醫師過勞死之新聞事件頻傳，醫師與家屬走上街頭抗議，敘說著白袍下的辛酸血淚，引起世界各國對於住院醫師工時立法的聲浪逐漸高漲，也成為官方關注的議題。歐洲先進國家早在1993年通過「歐洲工作時間指令」(Working Time Directive; EWTD)，來規範住院醫師的工時，以保護醫師免於因過勞而犯下錯誤傷害病人，而這些規範都有越來越嚴格的趨勢。在2003年，美國畢業後醫學教育評鑑委員會( Accreditation Council for Graduate Medical Education, ACGME)亦完成對全國教學醫院住院醫師的工時規範。在2011年，美國ACGME針對住院醫師每週工作時間、連續工作時間、連續休息時間等工作項目更進一步訂定明確的規範。然而，在台灣對於住院醫師工時的相關研究較少，對於醫師的工時也沒有明確的規範，因受限於醫師對病人的責任，勞基法亦不適用於醫師。故本研究透過問卷調查方式，以瞭解台灣於2013年所頒佈之住院醫師勞動權益保障參考指引對住院醫師的影響，並且盼能為後續學者採用決策分析模型上，於探討及制定住院醫師工作時數能提供重要參考模型參數，進而為醫師工時政策制定者帶來重要的依據，使得住院醫師在臨床工作中獲得該有的教育與訓練，進而增進工作品質及保障病人安全。
研究方法：透過自填式問卷調查的方式，以台北地區某二家醫學中心及三家區域醫院之(總)住院醫師以及PGY醫師為研究對象。問卷量表引用台大健康政策與管理研究所鄭雅文老師所研發之中文版「職場疲勞量表」以及我國WHOQOL台灣版問卷展小組發展之「台灣簡明版世界衛生組織生活品質問卷(WHOQOL-BREF台灣版)為研究工具，測量住院醫師之工作負荷，並建立操作型定義，並以描述性統計、雙變項分析、迴歸分析等統計方法，探討住院醫師工時與其健康狀態、工作負荷以及病人安全變項間之關聯性。
結論：
(1)經由本研究樣本分析結果發現，住院醫師之每週平均總工時(含值班)為72.24小時，此結果與過去文獻略有差距，顯示醫療院所對於住院醫師之工時及排班方式，有明顯之調整與改善。
(2)對於醫師自覺工作負荷狀況與其健康狀況，經由多變項分析結果顯示，醫師工作負荷與健康狀況之生理健康構面，有統計上顯著負向相關；而進一步探討不同工時(依據樣本數四分分布狀況分組)影響醫師自覺工作疲勞與健康狀況之趨勢分析結果顯示，工時小於56小時及56-73小時之受訪醫師其健康狀況與工作疲勞相關程度為最高。
(3)階層性迴歸分析結果顯示，醫師所屬職業科別是重要控制變項，對於整體研究架構的解釋力有24.7%。於控制醫師個人特質，如：婚姻狀況、科別、職級及總工作年資條件後，醫師「每週總工時」不論與工作負荷或病人安全構面間皆未達統計上顯著相關，其與雙變項分析結果一致；然於醫師因「工作負荷」所造成之「生理健康」對於病人安全的影響達統計上顯著相關。進一步探討不同職業科別之醫師，其工作疲勞與病人安全相關構面，發現各科別之醫師工作疲勞與醫療疏失有統計上顯著關係，其中又以外科、兒科及其他科別之醫師工作疲勞與醫療疏失線性關係最為顯著。

關鍵字

醫師工時 ； 健康狀態 ； 工作疲勞 ； 病人安全

並列摘要

Background: For the past years, increasing number of incidences were reported, the sudden deaths of young residents after their long duty hour. In order to assure residents’ well-being, fatigue, and patient safety, Taiwan government launched a policy to set ceiling up to 88 hours per weeks to regulate duty hours of residents. Therefore, we sought to conduct the research whether the policy could efficiently improve resident well-being, fatigue, and patient safety.
Method: This study was conducted in 5 major teaching hospital in Taipei. 150 residents were invited and all of them compeleted the self-reported questionnaire which included Occupational Burnout Scale, World Health Organization Quality of Life (WHOQOL-BREF) and duty hour. Data was issued and collected by research group members, and also supervised by IRB. Statistical analysis methods included descriptive statistics, t-test, ANOVA, and hierarchical multiple regression analysis.
Results:
(1)The average total working hour was 72.24 (s.d = 16.83), the result was different from the past statistics. The possible reason of the result is that after Taiwan government launched a policy to set ceiling up to 88 hours per weeks to regulate duty hours of residents in 2003, the hospitals began to improved the resident working hour.
(2)According to the Multivariate Statistical Analysis, the study demonstrated that the resident workload was related to health status (p<0.01).
(3)By Hierarchical regression analysis to check the assumptions of the research model. The Hierarchical regression showed that benefit finding significantly increased medical error response in the presence of high workload. These results suggest that benefit finding may have a patient safety effect. In order to check the specific association between physician fatigue and patient safety, we divided the sample into seven groups based on different specialities – general medicine, internal medicine, surgery, pediatric, emergency, Ob/Gyn, and others. The resident fatigue was related to patient safety (p<0.01) for all specialities, and it was especially apparent for the tendency in general medicine.

並列關鍵字

Resident working hour ； Burnout ； Health status ； Patient safety

參考文獻

Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annu Rev Psychol, 52, 397-422. doi: 10.1146/annurev.psych.52.1.397

一、英文文獻

Anupam B. Jena & Vinay Prasad. (2013). Duty hour reform in a shifting medical landscape. J Gen Intern Med.

Arnedt, J. T., J. Owens, M. Crouch, J. Stahl & M. A. Carskadon (2005). Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. Jama, 294(9): 1025-1033.

ACGME-approved: September 26, 2010 Effective: July 1, 2011http://www.acgme.org/acgmeweb/tabid/285/GraduateMedicalEducation/DutyHours/Archive/ApprovedStandards.aspx