【作者】 马效恩；

【导师】 李士雪；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2013， 博士

【摘要】 研究背景编制外人员是我国党政机关和企事业单位人事管理的一个产物,随着经济社会的发展,编制外人员发生着深刻的变化,在各部门、单位中,他们起的作用越来突出,但其边缘化角色仍然没有得到明显改善。公立医院作为保障人民群众生命健康的事业单位,编制外人员普遍存在已成为客观现实,他们既发挥着不容忽视的作用,也存在一定的管理难点和风险,需要深入研究和认真探索。目前包括公立医院在内的事业单位人事管理明显滞后于时代发展,已经不能适应社会主义市场经济体制的要求和社会事业发展的需要。严格的编制管理限制了公立医院的发展,医院把聘用编制外人员作为解决人员限制和事业发展矛盾的一种途径,不断得到应用,成为一种普遍现象出现在公立医院人事管理中。政府加强了公立医院的岗位管理,但大部分公立医院仍然停留在传统人事管理阶段,僵化的机制体制在某种程度上促进编制外人员的发展；医药卫生行业在社会服务发展中形成的刺激因素,成为公立医院编制外人员不断增长的内在驱动；编制外人员在医院建设发展中的作用越来越大,但其地位、待遇等仍没有较大改善,仍缺乏正确的对待和应有的重视；编制外人员规模的增大,虽然较好地缓解了医院人力资源上困难,但又给医院管理带来了新的问题和挑战。随着经济社会的发展,医疗需求的快速增长,政治经济体制和医疗改革的深入进行,编制外人员管理的问题也会越来越多,各种难以预测的问题会对未来医院管理带来新的难题,需要公立医院及时应对、有效解决。研究的目的和意义编制外人员是公立医院人力资源的重要组成部分和有益补充,强化编制外人员管理,对于公立医院适应市场经济发展,推动医院全面科学发展具有积极的现实意义。进行编制外人员管理研究,是公立医院提高服务水平、保证服务质量的客观要求,是公立医院提升人力资源管理科学化水平、促进医院可持续发展的必然选择,是公立医院维护保障医院和编制外人员合法权益的有效途径。本研究对于公立医院人力资源管理研究具有一定的推进,对于公立医院编制外人员管理具有一定的指导意义,对于推进公立医院改革有一定作用,不仅对编制外人员管理理论问题的研究具有一定的学术价值,且对于市场经济条件下公立医院人力资源管理提供了很好的思路和建议。资料来源与研究方法本研究的资料主要来源于文献资料和现场调查。通过文献检索查阅、整理归纳、全面分析,廓清编制外人员相关概念及分类,分析比较各类编制外人员管理的异同,在人力资源管理理论、激励理论、和谐理论、公平理论等基础上,提出了公立医院编制外人员管理理论框架。本研究的现场调查根据济南市医院的实际情况,本研究调查采用全面调查的方法,于2012年9月选取济南市卫生局市直所属14家公立医院的编制外工作人员作为研究对象,进行自填式问卷调查。14家公立医院其中按照医院等级分为：三级医院6家,二级医院7家,一级医院1家；以医院类型分为：综合医院7家,专科医院6家,中医医院1家。本次调查共发放调查问卷2524份,回收问卷2118份,回收率为83.91%,其中有效问卷2114份,总有效回收率为83.76%。资料分析方法主要包括描述性统计分析、单因素统计推断分析、多因素统计推断分析,统计分析软件为SPSS15.0。主要研究结果1.济南市公立医院编制外人员情况分析缺编是济南市公立医院的普遍现象,而且有的医院非常严重。济南市公立医院编制外人员用工数量庞大,编制外人员数量在医院占的比重呈不断扩大趋势,编制外人员在医院的不同岗位发挥着不容忽视的作用,为医院的建设发展做出较大贡献。编制外人员缺乏科学、公正的聘用管理和考核制度；编制外人员用工广泛,突破了传统的辅助性岗位范围；编制外人员用工方式以院内直接聘用为主,劳务派遣和人事代理为辅；编制外人员存在法律保障不得力导致维权难现象；医院对编制外人员多采用“重使用、轻培养”的方式；大部分公立医院里较为普遍地存在同工不同酬现象,编制外人员总体收入偏低,并存在着严重的“平均主义”,其薪酬模式简单单一,缺少非经济性薪酬,不能充分体现编制外人员岗位、业务水平、工作绩效等因素。2.济南市公立医院编制外人员满意度水平分析公立医院的编制外人员对待遇持“不确定”者最多,说明他们对待遇满意程度总体不高,需要提高待遇的意愿较为普遍,并对自身在医院发展中缺乏明晰的定位和清醒的认识。通过对编制外人员的待遇满意度水平和工作满意度水平进行方差分析,不同职业岗位、不同层次医院、不同类型医院、不同学历、不同职称、不同收入、有无奖金、同工同酬与不同工同酬等组间差异有统计学意义,说明不同因素的编制外人员在待遇和工作的满意度水平上存在差异。另外,不同性别、不同年龄、不同工作年限的编制外人员在待遇满意度水平上也存在差异。通过对编制外人员总体满意度进行多元线性回归分析,编制外人员工作总体满意度的影响因素为：工作成就感、收入与工作量比、工作的稳定性、单位政策的实施方式、判断的自由、工作条件、独立工作的机会、保持忙碌状态、自主的工作、判断的自由、领导对待下属的方式等。3.济南市公立医院编制外人员离职意愿分析近三年编制外人员离职呈一个不断上升趋势,且编制外人员普遍存在离职意愿,统计分析结果显示,不同医院性别、年龄、学历、工作年限的编制外人人员离职意愿水平无差异(p>0.05)；不同医院等级、类型、职业、职称、个人收入、有无奖金、是否同工同酬、是否签订合同、五险一金缴纳情况的编制外人员离职意愿水平具有显著性差异(p<0.05)。离职意愿得分随着医院等级的升高而显著增加,医技人员的离职意愿得分最高,工勤人员的离职意愿得分最低,离职意愿得分随着个人收入的逐步增加而明显降低,有奖金的编制外人员离职意愿得分明显低于无奖金者。编制外人员工作满意度的降低将会更多的导致他们辞去现有工作,而如果当获得外部工作的可能性升高时,他们对工作的满意度却未必呈降低趋势。福利待遇低、家庭原因、学习机会是编制外人员离职的三大原因；工资待遇、发展空间、技术水平是编制外人员重新就职的主要原因。4.济南市公立医院编制外人员工作倦怠分析本研究从情绪耗竭、消极怠慢和专业效能感三个维度对编制外人员工作倦怠进行分析,统计结果提示编制外人员的工作倦怠三个维度均随人口学特征的不同而呈现差异(p<0.05)的因素有：医院类型、职业、工作年限、个人收入和奖金是否同工同酬；工作倦怠三个维度均未随人口学特征的不同呈现差异(p>0.05)的因素有：年龄、职称。情绪耗竭和消极怠慢方面,随着医院等级的升高编制外人员的倦怠水平显著增加(P<0.01)；在专业低效能感方面无医院等级差异(P>0.05)；在情绪耗竭和消极怠慢方面,护理和其他卫技人员的倦怠水平最高,管理人员最低(P<0.01)；在专业低效能感方面放射人员的倦怠水平最高,工勤人员最低(P<0.01)：女性在情绪耗竭和专业低效能方面的倦怠水平明显高于男性(P<0.05),但在消极怠慢方面两者无显著差异(P>0.05)；职称在情绪耗竭和消极怠慢方面未呈现差异,但在专业低效能感方面,随着职称的升高,倦怠水平逐渐降低(P<0.01)；三个维度的工作倦怠水平均随着个人收入的逐步增加而明显降低(P<0.01)；编制外人员工作满意度的降低将会导致他们对现有工作产生倦怠心理,尤其将会在工作中表现出消极怠慢的工作态度,其次将产生情感和情绪方面的疲劳状态。编制外人员的情绪和工作态度将更多的相关与外在的组织条件因素,例如工作条件、政策、待遇等等。5.济南市公立医院编制外人员工作不安全感分析编制外人员总体上具有工作安全感,统计结果提示医务人员的工作不安全感随人口学特征的不同而呈现差异的因素有：医院等级、类型、职业、学历、工作年限、个人收入、奖金、同工同酬、签订合同、五险一金缴纳等；年龄因素在工作不安全感及其两个维度均未呈现差异。编制外人员的不安全感水平随着医院等级的升高显著增加；护理和其他卫技人员的不安全感水平最高,管理人员最低；女性在质量性不安全感水平明显高于男；编制外人员不安全感水平随着工作年限的增加显著升高；工作不安全感水平均随着个人收入的逐步增加而明显降低；无奖金的编制外人员不安全感水平明显高于有奖金者；编制外人员对现有工作产生的不安全感心理将会导致他们对工作满意度的降低；编制外人员对现有工作产生的不安全感心理将会导致他们离职意愿的增加；编制外人员对现有工作产生的疲劳情绪、工作态度的冷漠消极、能力效率低下等均与其工作中的质量性不安全感密切相关。结论与政策建议本研究基于济南市公立医院编制外人员具体情况和存在的问题,提出了如下应对措施和建议：建立完善科学合理的编制外人员管理制度,引导编制外人员发挥积极作用；依法保护编制外人员的合法权益,努力构建和谐的劳动关系；构建科学的系统的公立医院编制外人员激励机制,有效降低工作不满意度和工作倦怠感；发挥医院文化的凝聚作用和激励作用,吸引和鼓舞编制外人员；建立适应编制外人员实际情况、相对公平合理的薪酬体系；做好编制外人员的职业生涯规划和教育培训,为其创造良好的发展空间；做好编制外人员思想和心理工作,解决编制外人员不良情绪倾向。通过本研究启示医院管理者要树立以人为本的人力资源管理理念,建立主动适应市场需求的人力资源应变机制,营造一视同仁、内外无别的人力资源管理氛围。更多还原

【Abstract】 Research backgroundPersonnel outside the establishment are the product of personnel management of China’s party and government organizations and enterprise and public institution. With the development of economy and society, personnel outside the establishment changed greatly. Their roles in the departments and the units are more and more important, but their marginalized roles still remain to be improved. As a public institution of safeguarding people’s life and health, public hospitals have personnel outside establishment, which is an objective reality. Personnel outside establishment play significant roles while there exist some management difficulties and risks, which require further study and careful exploration.The personnel management of public institutions (public hospital included) lacks obviously behind the development of our times, which could not meet the requirements of socialist market economic system and of the development of social undertakings. Strict establishment management limits the development of public hospital. To solve the restriction and the development, the way hospitals adopted is to hire personnel outside establishment, which is used continuously and becomes a common phenomenon in the personnel management of public hospital. The government has strengthened post management of public hospitals; however, most public hospitals still stay at the stage of traditional personnel management. Such rigid institution mechanism to some certain has promoted the development of personnel outside establishment. The stimulating factors formed in the development of medical and health industry in social service becomes the innate driving force of the growth of personnel outside establishment. The roles personnel outside establishment playing in the development of hospital construction are more and more important, but their status and salaries still remain to be improved, lacking correct treatment and attention it should be given. Though the size of personnel outside establishment keep increasing, which relieves the problems of human resource of hospitals, it also brings new problems and challenges to hospital management. With the development of the society and the economy, the fast increase of medical requirement, as well as further implement of political and economic systems and medical reforms, there are more and more problems in management of personnel outside establishment. Various unpredictable problems may bring new troubles to hospital management, which asks public hospitals take efficient and timely measures.Research objectives and significancePersonnel outside establishment are an important part and beneficial supplement of human resources of public hospitals. To strengthen the management of personnel outside establishment has active significance for public hospitals to adapt the development of market economy and in promoting comprehensive and scientific development of the hospital. Management study of personnel outside establishment is the objective requirement of enhancing service level and guaranteeing service quality of the hospital. It is the natural selection of public hospitals to improving the scientific level of human resource management and promoting hospitals’ sustainable development. It is an efficient way for public hospitals to maintain the legal rights of the hospital and personnel outside establishment. This research may promote the study of human resource management of public hospitals, with guiding significance to management of personnel outside establishment. It could promote the development of public hospitals. It has certain academic value in theoretic study of management of personnel outside establishment and offers good thoughts and suggestions to human resource management in market economy.Data sources and research methodsThe data of this research are mainly from documents and on-field investigation. Through searching documents and references, arranging, classifying and analyzing, relevant concepts and categories of personnel outside establishment are clarified, and the differences and similarities of each category are analyzed and compared. On basis of human resource management theory, incentive theory, harmony theory and equity theory, the theory framework of management of personnel outside establishment is put forward. The on-field investigation is based on the actual conditions of Jinan hospitals. This research adopts the method of complete investigation. In September,2012, personnel outside establishment of14public hospitals affiliated to Jinan Health Bureau were selected as the research objects, who were asked to fill in questionnaire survey. Based on their levels these14public hospitals include6tertiary hospitals,7second-class hospitals and1first-class hospital; based on their types, these14hospitals include7general hospitals,6specialized hospitals and1TCM hospital.2524questionnaires were released and2118were retrieved, which was83.91%. The valid questionnaires were2114, with the total recovery rate of83.76%. The analyzing methods of the data mainly include descriptive statistical analysis, single factor analysis of statistical reference and multi-factor analysis of statistical reference. The statistical analysis software is SPSS15.0. Major results1. Analysis of personnel outside establishment of Jinan public hospitalsVacancy is a common phenomenon of Jinan public hospitals. Personnel outside establishment of Jinan public hospitals are a large number, which keeps increasing in the proportion of the staff of the hospital. They play an important role in various posts of hospitals and contribute greatly to the development of hospitals. Scientific and justice employment and assessment systems are lacked for personnel outside establishment; wide use of personnel outside establishment breaks the range of traditional auxiliary posts. The employment methods are with direct employment as the major method and labor dispatch and human agency as the auxiliary. Personnel outside establishment have difficulties in safeguarding their rights for lack of legal protection. Hospitals mainly adopt the manner of "laying emphasis on working while neglecting training". In most public hospitals, the inequalities in the workplace exist generally. The pays of personnel outside establishment are generally lower, with serious "equalitatarianism". Their salary pattern is simple, lacking economic salary, which could not reflect their posts, professional skills and working performances.2. Analysis of satisfaction of personnel outside establishment of Jinan public hospitalsMost personnel outside establishment are not sure about their salaries, which shows that they are generally not satisfied with their salaries, that they have the hope to have their salaries increased, and that they have no clear definition and understanding of their roles in the development of the hospital. Through analysis of variance of their satisfaction about their salary and their work, the differences between different posts, hospitals of different levels and types, personnel with different education backgrounds, professional titles, incomes, with or without bonus, equal pay for equal work and unequal pay for equal work have statistical significance, which shows that personnel of different factors are different in attitudes towards their salaries and work. Besides, personnel of different sexes, ages and working time also have different attitudes in their satisfaction with their salaries. Through multi-variable linear return analysis of the general satisfaction of personnel outside establishment, the influencing factors are mainly sense of achievements, ratio between income and workload, stability of the work, implement of unit’s policy, freedom of judgment, working conditions, opportunities of working independently, being busy, working independently, free judgment and the manner of the leaders to their subordinates.3. Analysis of turnover intention of personnel outside establishment of Jinan public hospitalsIn the past three years, turnover of the personnel outside establishment has kept increasing and the turnover intention exists universally. The results of statistical analysis shows that there is no difference of the turnover intention of the personnel of different hospitals, sexes, ages, education backgrounds and working time (p>0.05); there is significant difference of the turnover intention of the personnel of different hospitals levels and types, careers, professional titles, incomes, bonus, inequality in workplace and signing contracts and five-insurance payment (p<0.05). The scores of turnover intention increase greatly with the upgrading of the hospital levels. The turnover intention of technicians scores the highest, while that of the working peoples the lowest. The score of turnover intention reduces obviously with their increase of incomes. The scores of turnover intention of personnel outside establishment with bonus are obviously lower than those without bonus. The lower of their satisfaction about their work may lead to quit of the job; however, if the possibility of obtaining exterior work increases, their satisfaction about the work may not be lowered. Low salary, family and chance of study are the three major reasons for the personnel’s turnover; salary, development space and technical skills are the main reasons of their back in office.4. Analysis of job burnout of personnel outside establishment of Jinan public hospitalsThis research analyzes job burnout from three dimensions, i.e. emotional exhaustion, cymcism and professional efficacy. The statistical results shows that these three dimensions has differences (p<0.05) with the differences of demographic characteristics, the factors of which are hospital types, career, working time, whether income and bonus equal for equal work. The three dimensions of cymcism shows no difference (p>0.05) with the difference of demographic characteristics, the factors of which are age and professional title. In terms of emotional exhaustion and cymcism, the lassitude level increases obviously with the increase of the hospital levels (P<0.01); there is no hospital difference in professional efficacy (P>0.05). In terms of emotional exhaustion and cymcism, the lassitude level of nurses and other medical workers is the highest, while that of the managers is the lowest (P<0.01); in terms of professional efficacy, the lassitude level of radiological workers is the highest, while that of the logistics worker is the lowest (P<0.01). The lassitude level of female in emotional exhaustion and professional efficacy is obviously higher than that of male(P<0.05), but there is no obvious difference in cymcism(P>0.05). Professional title has no difference in emotional exhaustion and cymcism, but in professional efficacy, the lassitude level increases gradually with the rise of professional titles (P<0.01). The lassitude level of all three dimensions lowers obviously with the income increasing gradually (P<0.01). The lower of satisfaction of their work may lead to their lassitude in their work, especially such lassitude will be expressed in their work, and then emotional tiredness may come up. The emotions and working attitudes of personnel outside establishment will related to more exterior factors, such as working conditions, policies and salaries.5. Insecurity analysis of personnel outside establishment of Jinan public hospitalsGenerally personnel outside establishment feel insecure with their work. The statistic results suggest that factors that affect physician’s insecurity are levels and types of hospitals, careers, education background, working time, income, bonus, equal pay for equal work, signing contract and five-insurance payment; the factor of age has no difference in insecurity and its two dimensions. The insecurity of personnel outside establishment increases significantly with the increase of the hospital levels; the insecurities of nursing and other medical workers are the highest, while those of the managers are the lowest; the quality insecurity of female is obviously higher than that of male; the insecurity of personnel outside establishment increases with the increase of their working time; the insecurity level reduces obviously with the increase of their incomes; the insecurity of personnel without bonus is obviously higher than that of those with bonus; the insecurity of their work may lead to the reduce of their work satisfaction, which may also lead to their turnover intention. The tiredness, coldness and indifference, as well as low efficiency of their work are closely related with their quality insecurity of their work.Conclusion and policy suggestionBased on the specific conditions and existing problems of personnel outside establishment of Jinan public hospital, this research puts forward the following measures and suggestions:build perfect reasonable scientific management system of personnel outside establishment, guiding them to exert positive effects; protect their legal rights, constructing harmonious labor relations; construct systematic scientific incentive mechanism, reducing effectively dissatisfaction and tiredness of their work; exert the role of coherence and incentive of hospital culture, attracting and encouraging personnel outside establishment; establish reasonable and fair salary system based on their actual conditions; do well career planning and training, providing good development chances; do well ideological work and psychological work, easing the tendency of bad mood. This research demonstrates that hospital managers shall build the people-oriented ideology of human resources, establish the changing mechanism of human resource adapted to market requirements, building a management atmosphere of treating personnel equally without discrimination.更多还原