【作者】 张华；

【导师】 徐凌忠； 尹文强；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2011， 博士

【摘要】 研究背景：卫生人力资源是卫生资源的重要组成部分,同时也是最活跃的部分。近年来,随着我国社会主义市场经济体制的逐步建立和完善,国内医疗市场竞争日趋激烈,卫生人才流动呈现活跃态势。我国政府对人才流动的问题早有关注。自1983年以来,国家颁布了一系列有关人才流动的政策文件,为引导卫生人才合理流动,优化卫生资源配置提供了政策依据。人才流动,有狭义和广义之分,狭义的人才流动指组织间的流动,即通常所说的“跳槽”；广义的人才流动是指人才从一种工作状态到另一种工作状态的变化,工作状态可以根据工作岗位、工作地点、职业性质、服务对象及其性质等因素来确定。工作变动即指狭义的人才流动。目前,国内外对医疗卫生行业人员流动的研究主要集中在：(1)人员流动现状的研究；(2)人员流动原因或影响因素的研究；(3)人员流动效果(或影响)评价；(4)人员流动的政策建议。其中,人员流动的效果在这三个方面中是最核心的问题,因为它体现的是流动的成与败。目前国内外主要从社会、单位和个人三个层面对人员流动的效果进行评价,既有积极的一面,又有消极的一面。从目前关于人员流动效果的研究来看,具有以下特点：(1)主要集中在社会和单位层面,针对流动者个体流动效果的研究很少；(2)理论方面的研究较多,而实证研究较少；(3)多从广义的人员流动入手,未对工作变动(狭义的人员流动)进行深入研究,而在人员流动的各种方式中,工作变动是影响个体流动效果最重要的方式；(4)针对个体流动效果的研究多采用询问流动者自身总体感受的方法,没有形成相关的评价指标体系和评价方法。人作为流动的主体,流动效果的好坏对其有直接的影响,关系到卫生人员工作的质量、效果和他们的身心健康,同时也关系到人民群众的健康,因此,应作为重点进行关注从个体角度研究卫生人员流动的效果具有以下重要意义：(1)帮助卫生人员客观分析和认识流动的效果；(2)及时发现流动效果差的人员或某些方面,并给予必要的干预；(3)可以作为指导卫生人员合理流动的重要依据。研究目的：通过对山东省不同经济状况地区县级公立医院发生过工作变动的卫生技术人员的工作状况进行调查,比较卫生技术人员工作变动前和后、发生过工作变动者与未变动者、工作变动者与国家县级医院医务人员、以及不同特点工作变动人员之间工作状况的差别,综合评价卫生技术人员的工作变动效果,为进一步改善卫生技术人员的工作状况、提高医疗服务质量、引导卫生技术人员合理流动提出相关政策建议。具体目的如下：(1)了解县级公立医院卫生技术人员曾经工作变动情况；(2)分析县级公立医院发生过工作变动的卫生技术人员的基本情况；(3)比较卫生技术人员工作变动前和后、发生过工作变动者与未变动者、以及工作变动者与国家县级医院医务人员之间工作状况的差别；(4)比较不同特点工作变动人员工作状况之间的差别；(5)综合评价卫生技术人员的工作变动效果；(6)提出进一步改善卫生技术人员的工作状况、提高医疗服务质量和引导卫生技术人员合理流动的相关政策建议。研究方法：本次调查采用多阶段分层整群随机抽样方法,对山东省威海、东营和菏泽的9个县(市区)全部公立医院的卫生技术人员进行了问卷调查,包括发生过工作变动的人员和无工作变动人员,以无工作变动人员作为对照组。采用描述性分析方法对卫生技术人员基本构成情况、工作变动情况以及发生过工作变动的卫生技术人员基本情况等进行分析；采用单因素分析方法比较卫生技术人员工作变动前和后、发生过工作变动者与未变动者、工作变动者与国家县级医院医务人员、以及不同特点工作变动人员之间工作状况的差别；选用基于2种权重(CRITIC权重和熵权重)的3种综合评价方法(TOPSIS法、相对差距和法和秩和比法)对卫生技术人员的整体工作状况进行综合评价,并对组合标准分进行描述性分析、单因素和多因素分析；采用单因素和多元线性回归分析方法分析卫生技术人员的离职意向。主要结果：(1)工作变动的特点。各县级公立医院工作变动人员在卫生技术人员中所占的比例差别较大。多数人选择在自己年纪轻、刚工作不久,学历、职称和职务较低时变动工作,经验丰富的高素质人才变动工作者较少。工作变动的原因仍以个人和家庭原因为主。工作变动类型以上调居多。(2)工作变动的效果既有利又有弊。有利的方面体现在：工作技能多样性提高、工作意义增加、工作自主性提高、工作反馈程度加大、工作对个人能力提高的程度加大、工作满意度提高、离职意向降低、工作投入增加、职业倦怠程度下降、平均月收入增加。不利的方面有：工作负荷加重、消极情绪增多、工作控制感下降、工作压力感上升、工作影响家庭的程度提高、工作强度较大、患者信任程度降低、医疗纠纷增加、执业环境变差。(3)工作变动的整体效果较好。工作变动人员在本单位的工作状况最好,其次是本单位无工作变动人员,最差的是工作变动人员在原单位时。工作状况好的工作变动者的特点是：下调工作单位、女性、年龄大、儿科、中医科或其他科室、中专及以下学历；工作状况较差的工作变动者的特点是：上调工作单位、男性、年龄小、所在科室为外科、妇科或内科、本科及以上学历。综合评价总分升高者主要表现为：收入有所改善、工作强度降低、工作态度和工作情绪积极、工作特征良好；综合评价总分降低者主要体现在：工作强度变大、工作情绪变差、工作影响家庭程度变大、工作感受和工作态度变差。(4)无工作变动人员的整体工作状况比工作变动人员差。工作自主性低；工作满意度评价中对直接上级的满意度和总体满意度低；离职意向中“经常想离开”和“一年内准备离职”程度高；中度职业倦怠者的比例高,特别是成就感低落程度较高；工作影响家庭的程度小,主要表现在压力冲突小；上周最长连续工作时间和每月值夜班次数均高；平均月收入低；希望个人收入、个人工作能力和工作条件得到改善的比例高；自感病人和居民尊重程度低；自感患者信任程度低；执业环境评价不如工作变动人员。(5)离职意向程度越高者,工作状况综合评分越低。离职意向的高危因素有内科、执业环境评价差者、工作技能多样性程度低、工作对个人能力提高的程度小、工作满意度低、工作自主性程度高、工作对个体控制情绪表达的要求高、工作压力感大、职业倦怠程度高。工作变动者和无工作变动者的离职意向没有区别。政策建议：(1)从宏观层面引导卫生技术人员合理变动工作。从社会层面上,第一,健全各项法律法规、政策和制度。第二,大力营造与社会主义市场经济相匹配的引进人才、选拔人才、奖励人才、评价人才的政策环境。第三,落实目前鼓励卫生技术人员到基层机构和经济欠发达地区工作的各项政策。第四,形成具有良好职业道德规范的社会氛围。从用人单位层面上,第一,使有用之人“进得来”：实行聘用制,公开招聘、择优聘用,专职与兼职相结合,积极推行柔性引才政策。第二,要“留得住”人才：提供良好的薪酬待遇和生活条件；实行人性化管理；注重单位现有人才和引进后对人才的管理,为人才创造良好的工作环境；转变单位用人机制,将以往靠行政约束人的办法转变成按需求约束人和按价值约束人的管理办法；制定行之有效的激励机制；重视卫生技术人员职业生涯规划。第三,合理流出：建立解聘、辞聘制度,畅通人员出口,增加用人制度的灵活性。(2)发现易发生工作变动的重点人群,及时干预和指导。针对试用期前后的新人危机、在职两年后的升迁危机和在职五年后的工作厌倦危机采取不同的措施对员工进行干预和指导。(3)为充分发挥工作变动者的良好工作状态提供条件：帮助工作变动者尽快适应工作特征的变化；了解工作变动者的工作情绪和工作感受；关心和帮助工作变动者解决家庭问题；关注工作变动者的工作态度；解决其他可能影响工作变动者的相关问题。(4)重视无工作变动人员的工作状况。研究的意义及创新性：目前从国内外的各种相关研究来看,从个人层面、实证角度对卫生技术人员进行全面的流动效果评价的文献很少,多数是从社会、单位水平进行研究,而忽视了流动对卫生技术人员个体的影响,因此,本研究可以弥补这一空白,具有(?)定的创新性和现实意义。本研究得出的结论对于进一步改善卫生技术人员的工作状况、提高医疗服务质量、引导卫生技术人员合理流动等方面具有十分重要的作用和积极的现实意义。更多还原

【Abstract】 Background:Health human resources are the most important and active component of health resources. For the past few years, along with the development of socialism market-economic system, the competition in health market has been much stronger and the flow of health human resources has been more active. Chinese government has paid attention to the flow of health human resources and published a series of policies to guide the rational flow of health human rescources and optimize health recources allocation sincel983.Flow of personnel has a narrow meaning and a broad meaning. The narrow meaning is the flow between different organizations. That is job hopping. The broad meaning is the change from a work state to another. The work state can mean work post, work place, occupational nature, service objects and their characters, and so on. So turnover is the narrow meaning.At present, the researches at home and abroad on the flow of health staff focused on the following aspects:(1) Research on the state of personnel flow. (2) Research on the reason or factors of personnel flow. (3) Evaluation on the effects or impact of personnel flow. (4) Policy proposals for the flow of personnel. The effects of personnel flow are the key problems among three aspects because they can reflect success or failure of the flow. Now the researches on the flow effects of personnel focus on three levels at home and abroad:society, organization and individual. The effects were both positive and negative.The researches on the flow of personnel have three characteristics:(1) The researches focused on the society level or the organization level. And the few ones studied the flow effects of personnel on individual. (2) Theoretical researches were more than empirical ones. (3) The most researches focused on the flow of a broad meaning, but not turnover (a narrow meaning). However, turnover is the most important type of all types of flow, which influences the effects of individual flow mostly. (4) The methods of the researches on the individual flow effects of personnel were to inquire them about the overall feel of flow. Assessment indicator system and evaluation methodology about the flow effects of personnel were not formed. The flow effects of personnel can impact themselves directly, such as their performance quality, work effectiveness, their health of mind and body, and people’s health. So we must pay more attention to the flow effects of personnel.The evaluation on the flow effects of the health staff by individual has some significance. (1) The evaluation can help health staff to analyze and recognize their flow effects. (2) If the flow effects of the health staff were bad, the evaluation can help to find the inferior staff or their weakness, and intervene them in time. (3) The evaluation is an important basis to guide the flow of the health staff reasonably. Objectives:The work states of the health staff, who flowed into county-level public hospitals because of turnover in the areas with different economic situations of Shandong province, were investigated to synthetically evaluate the flow effects of the health staff, to compare the work states among different turn-overs, and to compare the work states of the turn-overs with those of three control groups. The first control group was the turn-overs when they worked in original unit. The second control group was the health staff who hadn’t change their jobs. The third control group was the medical personnel of the county hospitals in the Forth National Health Services Survey. Some policy recommendations were suggested to further improve the work states of the health staff, improve the quality of medical services, and guide the rational flow of the health staff. The specific objectives are as follows:(1) To understand the turnover situations of the health staff before they flowed into county-level public hospitals.(2) To analyze the demographic data of the turn-overs.(3) To compare the work states of the turn-overs when they worked in original unit with those when in current unit, to compare the difference between those who had changed their jobs and not, and to compare the work states of the turn-overs with the medical personnel of the county hospitals in the Forth National Health Services Survey.(4) To compare the work states among different turn-overs.(5) To synthetical evaluate the flow effects of the health staff.(6) To propose the relevant policy recommendations of improving the work states of the health staff, improving the quality of medical services, and guiding the rational flow of the health staff. Methods:Multistage stratified cluster random sampling method was adopted to survey the health staff of all the public hospitals in the nine counties of Weihai, Heze and Dongying in Shandong Province. Health staff were divided into two groups. One was turn-overs. The other was non turn-overs. The latter one was a control group. We described the basic composition of the health staff, turnover situation and the demographic characters of the turn-overs. Univariate analysis methods were adopted to compare the work states of the turn-overs when they worked in original unit with those when in current unit, to compare work states between those who had changed their jobs and not, to compare the work states of the turn-overs with the medical personnel of the county hospitals in the Forth National Health Services Survey, and to compare the work states among different turn-overs. With three evaluation methods (TOPSIS, the Sum of Relative Distance, and RSR) based on two weights (CRITIC weight and entropy weight),we synthetically evaluated the work states of the health staff and analyzed the results by described analysis, univariate analysis and multifactorial analysis. We analyzed the turnover intention of the health staff by univariate analysis and multivariate linear regression analysis. Main results:(1) The characters of turnover. The percent of the turn-overs among health staff were different in county-level public hospitals in different areas. Most of the people changed their work when they were young, just started their work, or their education, professional qualification and administrative duties were low, while the highly qualified and experienced personnel seldom changed their work. The main reasons of the turnover were still for individuals and their families. Promotion was the main type of the turnover.(2) The effects of the turnover had both advantages and disadvantages. The advantages mainly reflected in the following aspects:The diversity of job skills were increased; The work significance was increased; The job autonomy was improved; The degree of the work feedback was increased; The individual capacity was improved by the work; The work satisfaction was increased; The intension of dimission was reduced; The job involvement was increased; The job burnout was dropped; The average monthly income was increased. The disadvantages mainly reflected in the following aspects: The workload was increased; The negative emotions were increased; The job control was decreased; The work stress was increased; The extent of the work affecting the family was increased; The work intensity was greater; The patients trust was reduced; The medical tangle was increased; The working environment deteriorated.(3) The overall effect of the turnover was better. The work states of the turn-overs when they worked in current units were best, those who had not changed their work were better, and the worst were the turn-overs when thet worked in their original units. The feature of the good work states of the turn-overs were as following:downward turn-overs, female, older, department of pediatrics, traditional Chinese medicine or others, with at or below special secondary academic credentials. The feature of the bad work states of the turn-overs were as following:upward turn-overs, male, younger, surgical department, gynae department, or medical department, academic credentials at or above undergraduate. The turn-overs whose scores of synthetical evaluation in current units were higher than in original units had the following characteristics:their income improved, their work intensity reducing, owning more active work attitude and morale, the better job characteristics. The turn-overs whose scores were lower than before shows the following feature:larger work intensity, worse work emotion, work greatly affecting family and worse work feeling and attitude.(4) The overall work states of those who had not changed their work were worse than turn-overs. It was demonstrated as follows:The job autonomy was low; The satisfaction with the direct supervisor and the overall satisfaction was low; The turnover intention was high, especially "I always want to leave the hospital" and "Next year I will likely find a new job". The percentage of the moderate degree of the job burnout was high. In particular, the extent of reduced personal accomplishment was high; The extent of the family affected by the work was small, mainly because the pressure conflict was small; The longest continuous working time last week and the number of night shifts per month were both high. The average monthly income was low; The wish to improve individual income, work ability, and work conditions was more than turn-overs; The esteem degree of the patients and residents was low; The confidence degree of the patients was low; The evaluation on the practice environment of non turn-overs was worse than that of turn-overs.(5) The higher turnover intentions were, the lower synthetical evaluation scores of the work states were. The risk factors of the turnover intention were as following:medical department, bad assessments of the practice environment, low degree of the diversity of job skills, small level of improving the individual’s capacity, low degree of job satisfaction, high degree of job autonomy, high requirement for the expression of individual emotions, high working pressure, high job burnout. There were no differences of the turnover intension between turn-overs and non turn-overs. Suggestions:(1) It ought to guide the rational flow of the health staff from macro level. From social level, first, it should improve the laws, regulations, policies and systems. Second, it should create a policy environment of attracting talents, selecting talents, rewarding talents, and evaluating talents that matches with the socialist market economy. Third, it needs to implement all polices to encourage the health professionals to grass-roots organizations and work in the underdeveloped areas. Fourth, a good social atmosphere of professional ethics should be established.From the employer level, first, in order to make the useful talents "get in", it need promote the flexible policy actively such as:implementing system of employment under contract, opening recruitment, employing on the basis of competitive selection, and the combination of full-time and part-time. Second, in order to "retain" the talents, it should do as following:to provide a good remuneration package and living conditions; to implement human-based management; to focus on the management of the existing talents and introducing talents; to create a good working environment; to change the previous employment mechanism that constrained by administration into constrained by demand and values; to draw up the effective incentive mechanism; to emphasis on career planning of the health staff. Third, for the rational flow of health staff, it should establish the dismissal and resignation system, unclog personnel’ export and make the personnel system more flexible. (2) It ought to find the key personnel who are prone to change their work, and then the measures of intervention and guidance could be taken timely. Different measures and guidance should be taken to cope with the crises such as:the crisis of probationary period, the promotion crisis in active service for two years and the job burnout crisis in active service for five years.(3) It should provide the conditions for the turn-overs to play good working conditions. To help the turn-overs to adapt to the changes of the job characteristics as soon as possible; to acquaint the turn-overs with their work emotions and feeling; to help the turn-overs to solve family problems; to concern about the attitude of the turn-overs; to resolve the relative problems that may affect the turn-overs.(4) It ought to pay more attention to the work states of the health staff who had not changed their work. Significance and innovation:At present, a variety of domestic and international literatures show that the empirical researches on the turnover effects of the health staff at personal level are very few, and most researches referred to the level of society and units. So they ignored the influence of turnover on the health staff themselves. Therefore, this study can make up the gap and has some innovative and practical significance. The conclusions of this study has an important role and the positive and practical significance for further improving the work states of health staff, improving the quality of medical services, and guiding the rational flow of health staff.更多还原