護理人員工作負荷與工作壓力對其承諾影響之探討

研究目的在全民健保「低成本，高品質」的理念下，各家醫院考量成本效益，為達到病床高使用率，多採用縮短住院日數及病床流通政策；而病人快速出/入院及同時照護多科病人，對原本即人力匱乏之護理單位，無疑是雪上加霜；故本研究目的為探討護理人員工作負荷、工作壓力與承諾之相關性，並找出影響工作負荷及工作壓力對承諾之預測因子。研究方法本研究為前瞻性、橫斷式研究設計，研究對象為南部某醫學中心35個一般病房之正職護理人員，主要以結構式問卷調查收集資料﹔問卷量表以李克特氏(Likert)加總量尺法的五點尺度及九點尺度計分設計，內容包含個人屬性、護理工作負荷、工作壓力、承諾等四大部份，量表之信度為Cronbach’s α0.73-0.93。收案時間為103年1月至103年2月，共發放600份問卷，回收568份，扣除無效問卷14份，有效樣本為554份(有效回收率92.3%)；整理調查資料並運用統計軟體SPSS for window 20.0電腦套裝軟體進行統計分析，以次數分配、百分比、平均數、標準差作描述性統計分析，再以t檢定、單因子變異數分析、薛費事後檢定、皮爾森積差相關及層級迴歸分析進行推論性統計。研究結果未婚、無子女者較已婚、有子女者有明顯較高的工作壓力，尤其是在｢個人反應」、｢工作關注」、｢勝任」構面顯著較高，但對專業承諾及組織承諾相對顯著較低。進階層級N者工作壓力明顯較高，N3以上者專業承諾高於N2，但N及N3以上者組織承諾高於N2。照護科別三科(含)以上之護理人員較照顧兩科(含)以下者，明顯處於較高工作負荷、｢個人反應」、｢工作關注」構面之較高工作壓力、及較高組織承諾，但對專業承諾的差異並不顯著。延遲下班及家人不支持其護理工作者，工作負荷及工作壓力都顯著較高，而有延遲下班者與無延遲者對承諾的差異性不顯著，但家人支持者其承諾較家人不支持者高。個人屬性與護理工作負荷、工作壓力對專業承諾及組織承諾皆有顯著性影響力(p<0.001)，家人支持從事護理工作者對承諾有正向顯著影響力、工作壓力對承諾有負向顯著影響力，而工作負荷需藉由工作壓力的中介而對專業承諾產生負向影響力。結論本研究發現，護理人員工作負荷藉由工作壓力產生對承諾之負向影響，即工作壓力為工作負荷與承諾間之中介變項；家人支持對於工作負荷、工作壓力及承諾皆有顯著之影響力；而研究對象之延遲下班情形較國內外類似研究結果要為嚴重，故建議醫療機構及護理主管，積極深入了解不同屬性護理人員之工作負荷因素，採取適當改善政策，減少延遲下班情形及提升家人對護理工作之支持度，減少工作壓力，增加承諾感，以提升護理留任率。

關鍵字

工作負荷；工作壓力；專業承諾；組織承諾

並列摘要

Purpose Under a "low-cost, high-quality" concept pushed by the National Health Insurance, and in order to achieve high utilization of hospital beds, shorter length of stay and higher turnover of beds are implemented to accomplish cost-effectiveness of hospitals, while early discharge, immediate refilling and demanding multidisciplinary nursing are overwhelming to the existing shortage of nursing manpower. The purpose of this study aims to explore the impact of nursing workload and job stress on commitment, and identify significant predictors for commitment. Methods This study was a prospective, cross-sectional one, involving 554 nurses, who were enrolled from 35 general wards of a medical center in southern Taiwan. Data collection were made through survey by structured questionnaire; Scoring for questionnaire is based on Likert scale, either in five-point scale or in nine-point scale. Four dimensions of questionnaires comprise personal attributes, nursing workload, job stress, and commitments, where Cronbach's αis 0.73-0.93. Time interval for data collection spanned from January to February in 2013.With a total of 600 subjects surveyed, we obtained 568 responses, of which 554 questionnaires were valid, the effective rate being 92.5%. SPSS for window 20.0 was employed for statistical analysis, covering frequency distribution, percentage, mean, and standard deviation for descriptive statistics, and then, independent t-test, one-way ANOVA with post hoc Scheffe’s test, Pearson product-moment correlation and hierarchical multiple regression analysis for inferential statistics. Result Compared with those who are unmarried and childless, those who are married with children have significantly higher job stress and significantly higher scoring, especially, in the questions about "personal response", "work concerns", "competency", but significantly lower scoring for professional commitment and organizational commitment. For nurses, seniority is positively associated with job stress. Level Three Nurse (N3) has significantly higher professional commitment than Level Two Nurse(N2), and N3 and Level One Nurse( N1) have significantly higher organizational commitment than N2. Working in wards where services of three or more disciplines are offered, nurses have significantly higher workload, "personal response", and "work concern" in dimension of job stress, and higher organizational commitment than those working in wards where services of two or less disciplines are needed. For professional commitments, there is no difference between them of different seniority. There are significant higher workload and job stress for those who have overtime work and lack of family support for their nursing work. There is no association between commitment with overtime work, but commitment is positively associated with family support. Personal attributes, nursing workload and job stress have significant impact on professional commitment and organizational commitment as well (p <0.001). Family support has significant positive impact on commitment, but job stress has significant negative impact on commitment. Through job stress as a moderator, workload has significantly negative impact on commitment. Conclusion The study found that through job stress as a moderator, workload has significantly negative impact on commitment. Family support has significantly negative impact on workload and job stress but significantly positive impact on commitment. Overtime work is worse in this study, compared to reports previously made, in Taiwan and abroad as well. Therefore, it is suggested that supervisors of medical institutions and nursing department actively investigate nurses' workload of different disciplines in the organization, take appropriate steps to reduce overtime work and boost family support for nurses, reduce job stress, and encourage commitment in order to help nurses keep moving on.