【作者】 周志新；

【导师】 陈晓阳；

【作者基本信息】 山东大学 ， 人文医学， 2014， 博士

【摘要】 研究背景近年来,世界范围内医疗服务提供体系的变化极大地威胁到医学的本质与价值观念。医学专业受到来自政府、市场以及行业自身越来越强大的影响,由于医疗导向失策、医学的物化、医患利益冲突等问题的出现,导致医务人员义利观有所改变,拜金主义、功利主义、实用主义、个人主义有所滋长,使医师职业精神的弘扬和发展面临着新的挑战。国内关于医师职业精神的研究起步较晚,多年以来,国内学者对医师职业精神的理解几乎限定在医师职业道德这一层面,医师职业精神的形成主要依靠医师自律和行业自治。然而,医师职业精神作为医师群体共有的核心价值观,其不仅仅停留于道德和观念层面,还同时受制于物质和制度等因素。在医师职业精神的建构过程中,不能仅仅强调个体内在德性的塑造,还应注重其物质和制度等外在环境建设,其中包括医院薪酬管理制度。薪酬不仅是劳动力再生产的必要条件,也是实现个人价值目标的物质基础与保障,个体对于薪酬的态度和反应会严重影响他们对组织的感情和行为。相关研究显示,薪酬满意度是研究薪酬与个体行为之间的纽带,其对个体与组织的直接作用效果引起了学术界的广泛关注。目前科学合理地制定医疗机构薪酬制度,提高医师薪酬满意度,最大限度地发挥薪酬激励作用,促进医师职业精神建设,提升医疗机构的整体效能和核心竞争力,已成为新医改关注和研究的焦点。研究目的本研究的总体目标是：探讨薪酬满意度与医师职业精神的关系,为医师职业精神建设提供理论依据。(1)探讨薪酬满意度与医师职业精神的理论关系；(2)利用相关问卷量表测量国内临床医师的薪酬满意度与职业精神水平；(3)从相关实证数据研究薪酬满意度与医师职业精神的关系；(4)提出提高临床医师薪酬满意度及医师职业精神的相关建议。研究方法本研究首先从儒家伦理、制度伦理以及德性伦理等角度探讨医师职业精神构建的相关理论,同时研究薪酬满意度与医师职业精神的理论关系。其次,对美国学者赫尼曼(Heneman)和希沃布(Schwab)1985年编制的员工薪酬满意度量表(PSQ量表)进行适当修正,并用来测量国内临床医师的薪酬满意度。在相关问卷基础上,编制中国文化背景下医师职业精神测量问卷,对国内临床医师的职业精神进行测量。选择有代表性的样本医院的临床医师进行问卷调查。在对样本数据进行质量分析的基础上,根据理论假设,建立结构方程模型,使用统计分析软件进行变量间关系检验。最后,在理论研究与实证研究的基础上,提出提高国内临床医师薪酬满意度及职业精神的建议与策略。研究结果本研究理论部分研究表明：在儒家伦理视域下建构医师职业精神具有一定的实践价值和理论意义,儒家义利思想为处理市场经济条件下医师薪酬与职业精神关系问题提供了重要洞见,医师职业精神的建构应重新置于一个既重视对医师德性培养而又兼顾医师的合理利益追求的道德视野之中,这样才能建立和谐的市场经济条件下的医师职业精神；当前国内医师职业精神制度化建设及薪酬制度均存在一定的问题,在制度伦理视域下建构医师职业精神具有一定的现实意义,薪酬制度是医疗机构管理制度的重要组成部分,只有建立合理的薪酬制度才能提高临床医师的薪酬满意度,较高的薪酬满意度反映了制度的合理性,可以促进医师职业精神建设。德性伦理与制度伦理相互作用,相辅相成,在医师职业精神建构过程中,应实现制度伦理与德性伦理的相互转化与相互契合,合理的薪酬制度可以提高薪酬满意度,同时也可以促进内在德性水平的提高,促进医师职业精神的建构。本研究实证研究结果显示：在不同人口特征的临床医师薪酬满意度差异方面,不同性别的临床医师在薪酬水平、加薪、福利、薪酬管理满意度与总体薪酬满意水平上均有显著差异,女性均高于男性。不同年龄的临床医师在薪酬水平、福利、薪酬管理满意度和总体薪酬满意水平间均无显著差异存在,但在加薪满意度上具有显著差异,30岁以下组、41岁以上组加薪满意度均显著高于30-40岁组,差异均有显著性(P=0.010、0.015),而30岁以下组与41岁以上组间差异无显著性(P=0.863)。不同工作年限、不同科室的临床医师在薪酬水平、加薪、福利、薪酬管理满意度与总体薪酬满意水平间均无显著差异存在。除加薪满意度外,不同学历的临床医师在薪酬水平、福利、薪酬管理满意度与总体薪酬满意水平间均有显著差异,在薪酬水平满意度上,中专及以下组显著低于本科组、研究生组,差异均有显著性(P=0.012、0.008),大专组显著低于本科组、研究生组(P=0.035、0.020)；在福利满意度上,中专及以下组显著低于大专组、本科组、研究生组,差异均有显著性(P=0.029、0.000、0.000),而其他三组间两两比较,差异均无显著性；在薪酬管理满意度上,中专及以下组显著低于大专组、本科组、研究生组,差异均有显著性(P=0.021、0.000、0.000),而其他三组间两两比较,差异均无显著性；在总体薪酬满意水平上,中专及以下组显著低于本科组、研究生组,差异均有显著性(P=0.001、0.000),大专组显著低于研究生组(P=0.028)。不同职称的临床医师在福利、加薪和薪酬管理满意度上均无显著差异,而在薪酬水平、总体薪酬满意水平上均有显著差异,在薪酬水平满意度上,住院医师组、主治医师组显著低于主任医师组,差异均有显著性(P=0.003、0.001)；在总体薪酬满意水平上,住院医师组、主治医师组也显著低于主任医师组,差异均有显著性(P=0.005、0.026)。除福利满意度外,不同级别医院的临床医师在薪酬水平、加薪、薪酬管理满意度与总体薪酬满意水平上均有显著差异,在薪酬水平、加薪满意度和总体薪酬满意水平上,一级医院组均显著低于三级医院组,差异均有显著性(P=0.005、0.011、0.005)；在薪酬管理满意度上,一级医院组均显著低于二级医院组、三级医院组,差异均有显著性(P=0.005、0.030)。在不同人口特征的临床医师职业精神差异方面,不同性别、不同年龄、不同学历、不同科室、不同级别医院的临床医师在职业态度、职业行为、职业技能、职业自律与总体职业精神水平上均无显著差异。不同工作年限的临床医师在职业态度、职业技能、职业自律与总体职业精神水平上均无显著差异,但在职业行为水平上有显著差异,5年及以下组职业行为水平显著低于11-15年组、16年以上组,差异均有显著性(P=0.040、0.020),而与6-10年组差异无显著性(P=0.080)；6-10年组与11-15年组、16年以上组差异均无显著性(P=0.930、0.780),11-15年组与16年以上组差异无显著性(P=0.950)。不同职称的临床医师在职业态度、职业技能、职业自律与总体职业精神水平上均无显著差异,但在职业行为水平上差异显著,住院医师组职业行为水平显著低于副主任医师组,差异有显著性(P=0.040),其他各组间两两比较差异均无显著性。在薪酬满意度与医师职业精神关系方面,薪酬水平满意度与职业态度、职业技能、职业自律及总体职业精神水平均呈显著正相关(r=0.107、0.113、0.137、0.129,P=0.013、0.045、0.046、0.045),福利满意度与职业态度、职业行为、职业技能、职业自律及总体职业精神水平均呈显著正相关(r=0.272、0.201、0.106、0.100、0.210,P=0.016、0.039、0.040、0.044、0.035),加薪满意度与职业技能水平呈显著正相关(r=0.108,P=0.031),薪酬管理满意度与职业态度、职业行为、职业技能、职业自律及总体职业精神水平均呈显著正相关(r=0.108、0.112、0.139、0.150、0.188,P=0.035、0.029、0.045、0.032、0.048)。在薪酬满意度各维度对医师职业精神的预测力方面,薪酬水平、福利和薪酬管理满意度对职业态度水平具有预测能力,其中薪酬管理满意度的预测能力最好；福利和薪酬管理满意度对职业行为水平具有预测能力,其中薪酬管理满意度的预测能力最好；薪酬满意度的四个维度对职业技能水平均具有预测能力,其中福利满意度的预测能力最好；薪酬水平、福利和薪酬管理满意度对职业自律具有预测能力,其中薪酬水平满意度的预测能力最好。研究结论临床医师薪酬满意度由薪酬水平满意度、福利满意度、加薪满意度及薪酬管理满意度四个维度构成。临床医师职业精神由职业态度、职业行为、职业技能和职业自律四个维度构成。不同人口特征的临床医师薪酬满意度及其职业精神存在部分差异。薪酬满意度各维度与医师职业精神呈部分正相关,且薪酬满意度对医师职业精神各维度具有一定的预测力。更多还原

【Abstract】 BackgroundIn recent years, the nature and values of medicine are threatened greatly by the health care delivery system changes in the worldwide. The medical profession is influenced more and more by the government, market and self-profession. Due to medical guide missteps, medical materialization, doctor-patient interest conflicts, the righteousness and profits viewpoints of clinicians have changed, the money worship, utilitarianism, pragmatism, individualism are increased, so promoting and developing the medical professionalism has been faced new challenges. Over the years, the apprehensions on medical professionalism of Chinese scholars are almost limited to the level of professional ethics, and the formation of medical professionalism mainly emphasize on self-regulation of physician and profession. As the shared core value of physician groups, medical professionalisms not only stay at the level of ethics and attitudes, but also subject to the material factors and systems at the same time. Pay not only is a necessary condition for the reproduction of labor, but also is the material basis to achieve the personal value goals, the attitudes and reactions of individuals on pay would seriously affect their feelings and behavior on organization. Research shows that pay satisfaction is the ligament between salary and individual behavior research, and its direct effects on the individual and organization attract widespread attention. Currently, scientific and reasonable formulating the pay institution of medical agency, improving the pay satisfaction of clinicians, playing the incentive effects of pay mostly, promoting the construction of medical professionalism, improving the overall performance and core competitiveness of hospital, have been become the focus of the new health care reforms.ObjectiveThe total objectives of this study were investigating the relationship between pay satisfaction and medical professionalism to prefer the theoretical basis for medical professionalism construction. (1) Discussing the theoretical relationship between pay satisfaction and medical professionalism.(2) Measuring the levels of pay satisfaction and medical professionalism by certain scales or questionnaire(3) Investigating the correlations between pay satisfaction and medical professionalism from the empirical study(4) Providing some suggestions to improve the pay satisfaction and medical professionalism of cliniciansMethodsFirstly, the related theories of medical professionalism construction were discussed from Confucian ethics, institutional ethics and virtue ethics, while the theoretical relationship between pay satisfaction and medical professionalism was studied. Secondly, the pay satisfaction questionnaire (PSQ) compiled by American scholar Heneman and Schwab at1985was properly corrected to measure the Chinese physician pay satisfaction. Based on related questionnaire in some researchs, the questionnaire for medical professionalism under Chinese cultural background was complied to measure the medical professionalism of clinicians in some representative hospitals. Based on the data analysis and theoretical assumptions, the structural-equation model was established, the relationships between variables were tested by statistical analysis software. Finally, on the basis of theoretical and empirical researches, some recommendations and strategies were proposed to increase the pay satisfaction and medical professionalism of clinicians.ResultsTheoretical part of this study showed that, the medical professionalism construction had some practical value and theoretical significance in sight of Confucian ethics, the righteousness and profits viewpoints of Confucian provided some ideas for dealing with relation between salary and medical professionalism under the market economy, the medical professionalism construction should be re-placed in the moral visual fields, which not only focus on physician moral training but on the legitimate interests pursued by the physician being, so as to build a harmonious medical professionalism under market economic conditions. Currently, the domestic institutionalization of salary and medical professionalism had some problems, the medical professionalism construction in sight of institutional ethics had some practical significances, the pay system was an important part of the medical system, establishing a reasonable pay system could raise the pay satisfaction of medical staff, and the high pay satisfaction reflected the rationality of system, which could promote the construction of medical professionalism. Virtue ethics and institutional ethics were interacted and complemented each other, in the construction process of medical professionalism the conjunction of institutional ethics and virtue ethics should be achieved, the reasonable pay system could increase the pay satisfaction and inherent virtue at the same time, which could promote the construction of medical professionalism.In this study, the empirical results showed that, on the difference in pay, satisfaction between clinicians with different demographic characteristics, the differences in pay levels, pay raise, welfare, compensation management satisfaction and overall satisfaction levels between male and female were significant, the latter were higher than the former. The differences in pay levels, welfare, compensation management satisfaction and overall satisfaction levels between different ages were not significant, but the difference in pay raise was significant, the clinicians aged less than30years and more than40years were higher than those aged from30-40years (P=0.010,0.015). The differences in the four dimensions of pay satisfaction and overall satisfaction levels between clinicians with different working life and departments were not significant. Except for pay raise satisfaction, the differences in pay levels, welfare, compensation management and overall satisfaction levels between clinicians with different educational background were significant. In pay level satisfaction, the moderate vocational training education or less group were lower than the undergraduate group and graduate group (P=0.012,0.008), the high vocational training education group was significantly lower than the undergraduate group and graduate group (P=0.035,0.020); In welfare satisfaction, the moderate vocational training education or less group were lower than the high vocational training education group, undergraduate group and graduate group (P=0.029,0.000,0.000), while, the difference was not statistically significant among other three groups (all P>0.05); In compensation management satisfaction, the moderate vocational training education or less group were lower than the high vocational training education group, undergraduate group and graduate group (P=0.021,0.000,0.000), while the difference was not statistically significant among other three groups (both P>0.05); In the overall satisfaction levels, the moderate vocational training education or less group were significantly lower than the undergraduate group and graduate group (P=0.001,0.000), the high vocational training education group was significantly lower than graduate group (P=0.028). The differences in welfare, pay raise and compensation management satisfaction levels between different professional titles were not significant, and the differences in pay levels and overall level satisfaction were significant, in the pay level satisfaction, the resident physician group and attending physician group were significantly lower than the chief physician group (P=0.003,0.001); In the overall pay satisfaction, the resident physician group and attending physician group were also significantly lower than the chief physician group (P=0.005,0.026). Except for welfare satisfaction, the differences in pay levels, pay raise, compensation management and overall level satisfaction between physicians at different levels of hospital, in the pay levels, pay raise and overall level satisfaction, the grade-I hospital group were significantly lower than the grade-Ⅲ hospital group (P=0.005,0.011,0.005); In satisfaction on compensation management, grade-1hospital group were significantly lower than the grade-Ⅱ hospital group and grade-Ⅲ hospital group (P=0.005,0.030).On the difference in medical professionalism between clinicians with different demographic characteristics, the differences in professional attitudes, professional behaviors, professional skills, professional discipline and overall professionalism levels between different sexes, ages, educational backgrounds, departments, levels of hospital were not significant. The differences in professional attitudes, professional skills, professional discipline and overall professionalism levels between clinicians with different working life were not significant, but the difference in professional behaviors was significant, the five years or less group were significantly lower than11-15year group and more than16year group (P=0.040,0.020), but no difference was found when compared with6-10year group(P=0.080); The differences between6-10year group and11-15year group, more than16year group were not significant (P=0.930,0.780), and the difference between11-15year group and more than16year group was also not significant (P=0.950). The differences in professional attitudes, professional skills, professional discipline and overall professionalism level between clinicians with different professional titles were not significant, but the difference in professional behaviors was significant, the resident physician group was significantly lower than associate chief physician group (P=0.040), and the differences between other groups were not significant.In the relations between pay satisfaction and medical professionalism, pay level satisfaction were positive correlated with professional attitudes, professional skills, professional discipline, and the overall level of professionalism (r=0.107,0.113,0.137,0.129, P=0.013,0.045,0.046,0.045), the welfare satisfaction were positive correlated with professional attitudes, professional behaviors, professional skills, professional discipline and the overall level of professionalism (r=0.272,0.201,0.106,0.100,0.210, P=0.016,0.039,-0.040,0.044,0.035), the pay raise satisfaction.was positive correlated with professional skills (r=0.108, P=0.031), the compensation management satisfaction were positive correlated with professional attitudes, professional behaviors, professional skills, professional disciplines and overall professionalism level (r=0.108,0.112,0.139,0.150,0.188, P=0.035,0.029,0.045,0.032,0.048).In the predictive ability of pay satisfaction dimensions for medical professionalism, the pay levels, welfare and compensation management satisfaction had the predictive ability for professional attitudes, while the compensation management satisfaction was the best; The welfare and compensation management satisfaction had the predictive ability for professional behaviors, while the compensation management satisfaction was the best; The four dimensions of pay satisfaction all had the predictive ability for professional skills, while the welfare satisfaction was the best; The pay levels, welfare and compensation management satisfaction had the predictive ability for professional discipline, while the pay level satisfaction was the best.ConclusionsThe dimensions of pay satisfaction of clinicians include pay levels, pay raise, welfare, compensation management satisfaction, and the dimensions of medical professionalism include professional attitudes, professional behaviors, professional skills, professional discipline. The differences in pay satisfaction and medical professionalism among different demographic characteristics of clinicians are statistically significant partly. Some dimensionas of pay satisfaction of clinicians are positive related with the medical professionalism, and the pay satisfaction have some the predictive ability for some dimensions of medical professionalism.更多还原