【作者】 何敏静；

【导师】 蔡文智；

【作者基本信息】 南方医科大学 ， 护理学， 2011， 硕士

【摘要】 国内外对医务人员(hospital staff)的职业伤害都给予了积极的重视,大量研究表明,处在医疗环境下的各种职业伤害,除了与医务人员的个人因素有关外,还与组织环境管理因素、社会因素等密切相关。医务人员在医院这样一个特殊的环境工作,经常受到物理性、化学性、生物性、心理性等职业危害性因素威胁,并且日常工作处于高度紧张的应激状态,满意度降低,职业倦怠感增加,职业伤害发生率升高,致使离职人员增多。而医院的组织环境对保护医务人员的职业健康发挥了重要的作用,对促进医务人员安全操作和减少职业损伤起到了较好的预测作用。医院的组织环境是指所有潜在影响组织运行和组织绩效的因素或力量,对组织的生存和发展起着决定性作用。我国的职业防护措施在逐步完善中,但有关职业伤害发生的个人因素研究较多,而对组织环境管理因素的研究较少,国内尚未有针对组织环境管理对职业伤害影响的调查量表,制约了对组织环境管理现状的调查,无法系统地提出促进职业安全,保护职业健康的意见。有鉴于此,本研究对组织环境管理现状进行了深入的调查和研究,并获得了一些有利、有益的信息,为制定针对性的改进措施提供了客观依据。目的基于上述的研究需要和现状,本研究拟在大样本采集影响医务人员职业伤害的组织环境管理因素和人口社会学一般资料的基础上,运用流行病学调查方法和统计学分析理论,综合分析不同特征人群对组织环境管理的满意度,结合组织环境管理各因素,筛选出导致医务人员职业伤害发生的高危因素,以及职业伤害低上报意愿的影响因素,分析组织环境管理的不足,提出针对性的改进意见,为提高医院的组织环境管理水平,完善职业伤害上报追踪制度,保障医务人员的职业安全提供依据。本研究所获得的各种信息和资料将有助于下一步建立医务人员职业伤害调查量表,评估职业伤害的各种危险因素,开展合理有效的干预管理工作。方法查阅国内外大量文献,参照德克萨斯大学公共卫生学院研制的医院组织环境管理调查量表和邓凌师姐的医务人员职业伤害调查表,经过专家咨询,小组讨论,自制组织环境管理对职业伤害影响调查问卷,内容包括被调查者的一般情况,组织环境管理情况以及职业损伤情况3个项目。其中一般情况包括调查对象的人口社会学资料,如医院等级、性质、科室、性别、年龄、工龄、职称、岗位、学历等。组织环境管理情况包括6个维度33个条目,分别为人力资源配置(4个条目)、工作环境(3个条目)、安全设施配备(4个条目)、组织文化(9个条目)、安全行为(5个条目)以及组织关怀(8个条目)。职业损伤包括对过去6个月中,意外锐器伤、皮肤黏膜暴露、跌伤、皮疹、烫伤/烧伤和腰背伤的发生次数、上报次数的调查,以及对过去6个月中,因相关职业损伤而损失的工时统计。组织环境管理因素各个条目采用Likert5级评分法进行满意度的评估。采用多阶段分层整群抽样的方法,按照不同地区,不同医院等级、不同科室进行分层抽样,于2010年5月-7月对广东省4个市共18家医院1233名医务人员进行问卷调查。人员比例按照PPS抽样法(按规模大小成比例的概率抽样法)抽取调查对象。回收的调查数据经Excel 2003双人双机录入,核查后导入SPSS13.0统计软件进行统计学处理,对调查表的信效度进行Cronbach’s a系数信度分析、Spearman相关性分析和因子分析。将5级评分归类为3级评分(即选择“不满意、很不满意”或“极少、从来无”者确定为“不满意”或“无”,赋值为3分,选择“一般”或“有时”者赋值为2,选择“非常满意、满意”或“总是、经常”者确定为“满意”或“有”,赋值为1分),不同率之间的比较采用χ2分析,不同人口社会学特征人群组织环境管理总分差异比较采用方差分析,组织环境管理各因素对职业伤害发生和上报情况的影响用Logistic回归分析。结果1.共发放调查表1400份,回收1286份,回收率91.9%,有效问卷1233份,有效率为95.9%。本研究调查了18家医院,包括三级医院5家,二级医院7家,一级医院6家,其中男性248人,女性985人,年龄17-62岁(平均29.4±6.8岁),工龄0.5-44年(平均7.9±7.0年),98.0%医务人员为汉族,其余为少数民族。岗位：护理人员875人(71.6%),医疗人员313人(25.6%),技术人员20人(1.6%),行政管理人员5人(0.4%),后勤人员9人(0.7%)；职称：初级808人(66.0%),中级221人(18.1%),高级(含正副高)75人(6.1%),其它120人(9.8%)。2.调查表经过信效度检验分析,总的Cronbach’s a系数为0.931,各维度的Cronbach’s a系数为0.700～0.903,各条目均分与总均分之间具有相关性,因子分析结果表明调查表具有良好的结构效度。3.对不同社会人口学特征人群的组织环境管理满意度分析发现,不同人群医院等级、性别、工龄、职称和婚姻状况之间的差异有统计学意义(F=20.276、5.168、22.983、6.061、4.682,P<0.05),而科室、年龄组、岗位和学历之间的差异没有显著的统计学意义(F=0.686、0.313、1.452、1.322,P>0.05)。4.皮肤黏膜暴露的发生率为44.3%,而上报率只有27.7%。与皮肤黏膜暴露发生有关的因素有：科室、学历、科室成员年龄构成比情况、科室人数合理配置情况、工作场所不安全状况、工作场所的温度控制情况、管理者是否注重为员工创造健康安全工作环境以及接触血液/体液或其它污染物时是否戴手套等(χ2=8.834、10.407、24.350、33.446、21.920、26.859、34.432、14.586,P<0.05)。影响皮肤黏膜暴露上报的组织环境管理因素有：科室人数的配置情况、有无对严格执行防护措施的员工表扬、奖励以及制定决策时,是否把保护工作人员的安全放在首位等(χ2=17.787、22.297、26.918,P<O.05)。5.锐器伤的发生率为43.6%,而上报率只有34.8%。与锐器伤发生有关的因素有：医院等级、科室、学历、岗位、工作环境是否过度拥挤、高年资工作人员有无主动积极参与职业安全管理工作、接触血液/体液或其它污染物时是否都戴手套、每次发生伤害后,有无及时分析原因并制定改进措施等(χ2=9.341、7.033、16.630、35.686、11.096、27.983、14.097、26.296,P<0.05)。影响锐器伤上报的组织环境管理因素有：科室人数的配置情况、有无对严格执行防护措施的员工表扬、奖励,接触污染物时均戴手套以及洗手后是否在工作服上擦干等(χ2=18.386、30.515、7.824、6.814,P<O.05)。6.腰背伤的发生率为29.8%,而上报率只有17.2%。与腰背伤发生有关的因素有：科室、工龄、科室成员年龄构成比情况是否满意、科室人数的配置情况、工作场所不安全的情况和领导层有无听取有关促进职业安全的意见等(χ2=16.371、33.326、40.096、40.468、60.541、46.666,P<0.05)。影响腰背伤上报的组织环境管理因素是科室成员是否共同制订职业防护相关决策(χ2=11.913,P<0.05)。结论1.各级医院组织环境管理水平存在差异,医务人员对组织环境管理的各个方面满意度不一,要全面提升组织环境的管理水平,提高医务人员的满意度,减少职业伤害的发生,提高职业伤害的上报。2.组织环境的管理从多方面影响着职业伤害的发生和上报。影响职业伤害发生的因素具体有科室成员年龄构成比情况、科室人数合理配置情况、工作环境拥挤状况、温度控制情况和不安全隐患、高年资工作人员参与职业安全管理状况、领导层有无听取促进职业安全的意见、管理者是否注重创造健康安全的工作环境、接触血液/体液或其它污染物时戴手套情况、发生职业伤害后,有无制定改进措施等。影响职业伤害上报的因素具体有科室人数合理配置情况、科室成员有无共同制定职业防护相关决策、对严格执行各种防护措施的员工有无给予表扬、奖励、接触血液/体液或其它污染物时有无戴手套、洗手后是否在工作服上擦干等。提示了组织环境的管理对职业伤害的发生具有非常大的影响,必须改善组织环境的管理,包括重新分配医务人员的工作职责,精简工作程序,提高工作效率,建立安全的工作环境,加强职业防护培训,提高管理者的素质,营造积极的组织文化氛围,体现组织的人文关怀等。3.在降低职业伤害发生的同时,还必须提高医务人员职业伤害的上报意识,使组织掌握职业伤害的最新数据,对职业伤害情况制定针对性的应对措施,不断提高组织环境的管理水平,提升竞争力,留住并吸纳贤才,为医院的持续健康发展积蓄力量。医疗队伍的壮大才能使整个医疗体系高速、有效、安全地运转。4.职业伤害受个人因素、职业因素、社会因素、管理因素等多因素共同作用,组织环境管理的改善作用于医务人员,使其更新防护知识,增强防护意识,提高标准预防的依从性和对潜在危险的判断力。希望在营造积极的组织文化氛围和提供贴心的组织关怀的影响下,实现1+1大于2的影响力,保护医务人员的职业安全。更多还原

【Abstract】 Positive attention was given to occupational injury with hospital staff by both domestic and abroad. A lot of researchs have confirmed, that all kinds of occupational injury happenned in hospitals, in addition to relate with the individual characteristics of hospital staff,but intimate correlative with the factors of organizational environment administration and society.Hospital staff work in a special place, were always theated by occupational harm factors,such as physical,chemical,biological,psychological factors, et al.They always in highly nervous and over-emergency status,the satisfaction of job was reduce,the feeling of job burnout was increase,the incidence of occupational injury was raise,result to the employee turnover.The organizational environment of hospital play remarkable role in maintenancing health of hospital staff.lt prompted hospital staff work according to the operation procedures and played a part in predicting the occupational injury.The organizational environment of hospital was the factors or power,which influenced the operation and performance of organization potentially. Organizational environment played a decisive function in a tissue’s living and developping.Even though the occupational preventive measures were improving in China,but a large number of related researchs were limited to the individual characteristics on the impact of occupational injuries of hospital staff, organizational environment administration factor has reported rarely.There was not questionnaire about the influence of organizational environment administration,restricted the investigation about the situation of organizational environment administration.It resulted that cannot systematically procure useful opinions,which could promote occupational safe and protect occupational health.Because of this,we conducted to penetrating study and research in the situation of oganizational environment administration,and procuring some beneficial and useful information,which provided objective basis for offer targeted improvement measures.Objective:Based on the above research needs,we will be plan to collect the imformation on organizational environment administration which inflect the occupational injuries of hospital staff,and the sociology of population characteristics.We will use of epidemiological survey methods and statistical analysis,and comprehensive analysis different features medical staff the satisfaction of organizational environment administration,connect with the factors about organizational environment administration,screen the risk factors which led to occupational injury,and the influential factors on the low reporting rate of occupational injury. We will analysis the shortage of organizational environment administration,provide tergeted improvement measures.It will provide basis for improve the level of the organizational environment administration,improve the reporting and tracking system of occupational injury,provide security of occupational health.This study acquired information and data will help us to establish the measuring scale of occupational injury of medical staff,make assessment of all kinds of risk factors,and to conduct reasonable and effectable intervention management work.Method:We used the multi-stage stratified cluster sampling method,and sccording to different cities,hospital grades,jobs in hospitals,wards to atratify sampling.We have adopted a self-designed questionnaire based on previous studies,reference the safety climate questionnaire and the occupational injuries questionnaire of hospital staff,that made by my feacher elder sister Deng Ling,by expert consultation,group discussion and pre-survey to determine.The questionnaire have 3 parts,that is including the respondents in general,the status of organizational environment administration and the situation of occupational injury.Part 1:general state of health consist of the sociological characteristics of respondents,such as the level of hospital、the properties、the kind of department、gender、age、work experience、title、position、education and so on.Part 2:organizational environment administration factors include 6 layers 32 items,there are allocation of human resource(4 items)、workplace environment(3 items)、security facilities provided (4 items)、organizational culture(9 items)、safe operation(4 items) and organizational care(8 items).Part 3:the situation of occupational injury include in the past 6 months,the happenning and reporting of accidental sharp injury、mucocutaneous exposure、falling、rash、burn and low back pain,and because of the injuries,how much time did they lose.Using Likert 5 class score method of assessment of the degree of satisfaction.A survey was conducted from 1 May to 31 July,2010.There were 4 city 18 hospitals 1233 hospital staff participated in this study.The research data were entried in Excel 2003 by two people and two computers,and checked there was not wrong data,then send to the SPSS 13.0 statistics software.The questionnaire’s reliability analysis was through Cronbach’s a coefficient,spearman releted analysis and factor analysis.The comparision of different rate was byχ2.The comparision of satisfaction of organizational environment administration between different sociological characteristics of respondents was by variance analysis. The analysis of the influence about organizational environment administration on the happenning and reporting of occupational injury by Logistic regression.Results:1.The subjects were 1400 hospital staff members from 18 hospitals.Our respondents were drawn from 5 Level 3 hospitals, Level 2 hospitals and 6 Level 1 hospital in 4 cities.The response rate was 91.9%(1286 respondents).Among them,1233 questionnaires were used for analysis because of missing data for some of the studied variables.Hospital staff are:248 male,985 female,age include 17-62(29.4±6.8). Work experience 0.5-44 years(7.9±7.0).Career:nurse 875(71.6%),doctor 313 (25.6%),technologist 20(1.6%),administrative personnel 5(0.4%),logistics staff 9(0.7%);Professional title:Primary level 808(66.0%),middle level 221(18.1%),high level 75(6.1%),others 120(9.8%).2.The reliability and validity tests showed that the general Cronbach’a coefficient of the questionnaire is 0.933,the Cronbach’a coefficient of every dimension was 0.702-0.903,the average of various items were correlation with the total average.Factor analysis showed the questionnaire has good structure validity.3.Analysis the satisfaction of organizational environment administration between different sociological characteristics of respondents found that,the difference among the level of hospital、gender, work experience、title and marital status had statistics significance (F=20.276、5.168、22.983、6.061、4.682, P<0.05),and the difference among ward、age、job and education did not have statistics significance(F=0.686、0.313、1.452、1.322, P>0.05).4.The incidence of mucocutaneous exposure was 44.3%,and reporting rate was 27.7%.The factors which relating to the occurrence were:ward、education、the age constitution of members in the ward、appropriate allocation of ward members、the hidden danger in workplace、the temperture control in workplace、the satisfaction of management that if it created a health and safe workplace for the staff and the execution of staff wore gloves when contacted the blood/body fluid or another contaminations and so on (χ2=8.834、10.407、24.350、33.446、21.920、26.859、34.432、14.586, P<0.05).The organizational environment administration factors which affected the reporting of mucocutaneous exposure were:the number of people configuration in the ward、the frequency of praise or award when the member executed standard precautions strictly and when making decision, whether put the safty of the workers on the primacy,and so on(χ2=17.787、22.297、26.918, P<0.05).5. The incidence of sharp injury was 43.6%,and reporting rate was 34.8%.The factors which relating to the occurrence were:the level of hospital、ward、education、job、crowded situation of the workplace、whether the elder qualification staff participated in the management of occupational safety initiatively、the execution of staff wore gloves when contacted the blood/body fluid or another contaminations and after occupational injury occurred,whether the corrective measures are formulated timely after the happening of the employment injuries,ect (χ2=9.341、7.033、16.630、35.686、11.096、27.983、14.097、26.296, P<0.05). The organizational environment administration factors which affected the reporting of sharp injury were:appropriate allocation of ward members、the frequency of praise or award when the member executed standard precautions strictly、the execution of staff wore gloves when contacted the contaminations and dry the hands on the overalls after washing hands and so on (χ2=18.386、30.515、7.824、6.814, P<0.05)6. The incidence of low back pain was 29.8%,and reporting rate was 17.2%.The factors which relating to the occurrence were:ward、work experience、the age constitution of members in the ward、appropriate allocation of ward members、the hidden danger in workplace and whether the administration hearing the poinions to promote occupational safety ect (χ2=16.371、33.326、40.096、40.468、60.541、46.666, P<0.05). The organizational environment administration factors which affected the reporting of low back pain were if the members made the occupational protection decisions together (χ2=11.913, P<0.05)Conclution:1. The administration level towards to the organizational environment existent differences at all level hospitals. The degree of satisfaction from different hospital staff is differences too. In that case, the above-mentioned aspects should be raised to reduce the occupational injuries and increase the reporting action.2. The happenning and reporting of the occupational injuries can be influenced by many aspects of organizational environment administration. Such as:age structure and appropriate allocation of ward members; crowded situation of the workplace; temperature control; hidden danger, whether the elder qualification staff participated in the management of occupational safety initiatively; whether the administration hearing the poinions to promote occupational safety, the satisfaction of management that if it created a health and safe workplace for the staff、the execution of staff wore gloves when contacted the blood/body fluid or another contaminations、whether the corrective measures are formulated timely after the happening of the employment injuries, ect, will influence the happence of the occupational injuries. And the report data will be inflenced by the reasons such as appropriate allocation of ward members; if the members made the occupational protection decisions together; the frequency of getting praise or award when the member executed standard precautions strictly; the execution of staff wore gloves when contacted the blood/body fluid or another contaminations; whether dry the hands on the overalls after washing hands and so on. It can be seen that the happening of the employment injuries can be much influenced by the management level towards to the organizational environment, so which should be improved, including:operating duty of medical staff should be reapportion;working routine should be simplified; work efficiency should be raised;a safe working environment should be builded; occupational protection training should be strengthennde;managers quality should be increased,positive organizational culture atmosphere should be created and organizational care should be reflected.3. We should reduce the employment injuries, at the same time, we should strengthen the reporting awareness of the medical staff, which can make the staff know the latest data, then the counter-measure can be drawn up.Increase the level of organizational environment administration,pomoted competitiveness,absored talented person,saved power.In that case, madical system can run high-speed, effctively and safely.4. To sum up, occupational injuries can be influenced by many aspects such as individual factor, society factor, occupational factor, management factor and so on. The existence of management level towards to the organizational environment can renew defend and preserve aknowledge and consciousness, increase the compliance of standard prevention and the judgement of potential dangerous.By the influence of positive organizational culture atmosphere and close organizational care, to ensure the occupational safety of our medical staff.更多还原