[[alternative]]A study of Perceived Nursing Work Environment among Nurses: An Example of Regional Teaching Hospitals in Taipei County

[[abstract]]本研究旨在探討護理人員對護理工作環境的認知。本研究採橫斷式問卷調查法，研究對象爲台北縣區域教學醫院服務滿三個月以上之護理人員，共回收1,461份（回收率89.5%）。研究工具爲Aiken及Patrician之護理工作環境指標量表。研究結果：(1)以因素分析萃取出：專業實務、專業發展、專業標準、人力與資源、醫護合作、行政主管支持、護理人員能力之七個構面，共解釋護理工作環境45.2%的變異量。(2)七個構面平均得分依序爲專業標準、行政主管支持、護理人員能力、醫護合作、專業發展、專業實務、人力與資源。運用護理工作環境指標量表評值台灣護理工作環境是很好的開端，建議未來針對不同層級醫院的護理人員進行工具信效度的測試，以了解護理工作環境的狀態，進而提供有效的環境改善措施以留任護理人員。[[abstract]]Objective: To examine the perceived nursing work environment among nurses of regional teaching hospitals in Taipei County. Methods: A cross-sectional survey was conducted for collecting data from 1,632 nurses who were met the criteria of selection. The respondents were 1,461 with a response rate of 89.5%. Measurements adapting from Aiken and Patrician's Revised Nursing Work Index (NWI-R) was used. Results: Seven factors were extracted and accounted for 45.2% variance of nursing work environment by factor analysis with an orthogonal rotation, such as professional practice, professional development, professional standard, staffing and resource adequacy, nurse-physician collaboration, supportive nurse manager, and nursing competence. The mean scores of the perceived nursing work environment arranged in order among nurses were professional standard, supportive nurse manager, nursing competence, nurse-physician collaboration, professional development, professional practice, staffing and resource adequacy. It is a good start to initiate investigation of perception of nursing work environment through the NWI-R in Taiwan. Future research is needed to evaluate the validity and reliability of the NWI-R among other nurses from different ownership hospitals and to understand the nursing work environment

空氣汙染與乳癌發生率之相關性研究

[[abstract]]根據衛生福利部之統計，台灣在過去20 年間乳癌的發生率快速的上升，女性乳癌的發生率從1995 年的28.46 (每十萬人)增加到2013 年的63.2 (每十萬人)，而乳癌標準化死亡率在近幾年則約為11.6 (每十萬人)。過去數十年間許多研究紛紛探討乳癌的危險因子，有研究指出乳癌的發生率在都市區域比在鄉村地區來得高，在台灣地區也有相同的發現，其中造成都市化程度與乳癌發生率差異可能與環境因子有關。近幾年國外的研究開始探討空氣污染對於乳癌的影響，且有研究指出與暴露於較低的空氣污染濃度的婦女做比較，女性暴露於較高的空氣污染濃度中，其乳癌的發生率較高，而造成乳癌的發生可能與許多空氣污染物為脂溶性，且可能在乳房組織中慢慢累積，此累積量若達到一定的濃度則可能導致乳癌的發生。在台灣尚未有研究針對空氣汙染與乳癌的議題進行系統性的探討，為此，本研究利用我國全民健康保險研究資料庫與貝氏最大熵法(Bayesian maximum entropy)的空氣汙染暴露評估方法來探討我國地區長期空氣汙染暴露與乳癌發生率的相關情形。利用多變量迴歸分析(logistic regression model)計算CO、NOX、O3、PM10、PM2.5、SO2 的平均汙染濃度(1998 到index date)與乳癌發生率之相對危險性估計值，在控制潛在干擾因子(年齡、共病情形、慢性阻塞性肺病、平均投保薪資等級、與投保所在鄉鎮市區之都市化程度)，本研究僅發現PM2.5 濃度每增加四分位差的單位，則有1.13(95%CI=1.03-1.25)的風險可能罹患乳癌。本研究利用群體資料探討空氣汙染與乳癌發生率之相關性，研究結果發現懸浮微粒子空氣汙染可能與乳癌的發生有相關，未來研究針對較長期的汙染暴露濃度評估來探討此議題是有必要性的

醫院品管圈的團隊結構與衝突處理行為

[[abstract]]目標：探討大台北地區區域級以上醫院之品管圈團隊結構(團隊合作規範、團隊任務凝聚力)與團隊衝突處理行為之相關性。方法：採橫斷式問卷調查法，有效樣本為大台北地區16家醫院263個品管圈團隊1914成員，回收率達86.80%。研究工具包括Chatman及Flynn之團隊合作規範量表、Van de Van及Ferry之團隊任務凝聚力量表和Rahim之衝突處理行為量表，量表Cronbach’s alpha值範圍為0.70~0.92，顯示各量表具良好內在一致性。以團體為分析單位，每個團隊內個人層級之資料聚合來代表該團隊分數，以單因子變異數分析(one-way analysis of variance)、內部相關係數(Intraclass correlation coefficients)及eta square檢定個人資料聚合為團體資料之適切性，再以迴歸模式分析團隊合作規範、任務凝聚力與團隊衝突處理行為之關係。結果：控制團隊規模與品管圈組圈次數後，團隊合作規範(b＝0.49，p＜0.01)、團隊任務凝聚力(b＝0.10，p＜0.05)兩者共解釋整合型衝突處理行為58%變異量；團隊合作規範(b＝-0.17，p＜0.05)能解釋支配型衝突處理行為15%變異量；逃避型與順應型團隊衝突處理行為模式皆未達顯著意義。結論：團隊合作規範與團隊任務凝聚力較能預測品管圈整合型與支配型衝突處理行為，研究結果將有助於未來醫療相關機構在教育訓練及實務上應用之參考並作為未來相關研究的依據。 Objectives: This study investigated the relationship between group structures (i.e., cooperation norms and task cohesion) and styles of handling conflict within the quality control circles (QCCs) of Taipei-area hospitals. Method: Utilizing a cross-sectional design with the distribution of questionnaires, a valid sample was collected which included 263 groups comprised of 1914 individuals from 16 hospitals. The instruments with acceptable Cronbach's alpha values, ranging from 0.70~0.92, were included in this study. Because of unit for group level analysis, the aggregated individual level data in a single group were used as representative values of the group. The results of intra-class correlation coefficients, eta-square, and one-way analysis of variance indicated that the aggregated individual level data satisfactorily represented group level data. Four hypotheses were tested by regression analysis. Results: The response rate was 86.8%. After controlling for the variables of group size and times of QCC formation, cooperation norms (b=0.49, p＜0.01) and task cohesion (b=0.10, p＜0.05) together accounted for 58% of the variance in the ”integrating” style of handling conflict, while cooperation norms (b=-0.17, p＜0.05) alone accounted for 15% of the variance in the ”dominating” style of handling conflict. ”Avoiding” and ”obliging” styles of handling conflict were not predicted by cooperation norms and task cohesion. Conclusions: The findings of the current study suggest that cooperation norms and task cohesion are good predictors of the ”integrating” and ”dominating” styles of handling conflict for the QCCs of hospitals. The results may thus be helpful for health care institutions seeking to improve the quality of in-service education, practice, and research

Group Perspective: Group Structure and Effectiveness of Quality Control Circles in Hospitals

[[abstract]]目標：探討台北地區區域級以上醫院之品管圈團體結構（團體規模、團體合作規範、團體任務規範及團體任務凝聚力）與團體效能之相關性。方法：採橫斷式問卷調查法，台北地區已推行品管圈之醫院共19家，有16家醫院品管圈圈員同意接受調查，共收集263個有效品管圈樣本，包括1,914位品管圈圈員，團體回收率達86.80%。以團體為分析單位，每個團體內的個人層級之資料將聚合代表該團體的分數，以內部相關係數(Intraclass correlation coefficients, ICCs), eta squared (η^2)，及單因子變異數分析(one-way analysis of variance)檢定，確定個人層級資料可聚合後代表團體層級之資料，再以迴歸模式進行四個與團體相關之研究假說檢定。結果：團體合作規範、團體任務規範、團體任務凝聚力與團體效能呈正相關之三個假說獲得支持，共解釋51%團體效能的變異量，但團體規模與團體效能則無顯著的正相關，該假說未獲支持。結論：品管圈具有較高的團體合作規範、團體任務規範及團體任務凝聚力的特質時，會有較好的績效表現，因此建議未來可積極建立團體合作規範、團體任務規範及團體任務凝聚力來促進良好的團體互動，以提昇團體效能。 Objectives: This study aimed to investigate the relationship between group structures (group size, cooperation norms, task norms, and task cohesion) and group effectiveness of the quality circles of hospitals in Taipei area. Methods: A cross-sectional research design was adopted for data collection. Two hundred and sixty-three quality circle groups with 1,914 individuals from the 16 of the 19 hospitals in the Taipei area were enrolled for analysis. The groups' response rate was 86.8%. Because the unit for analysis was the quality circle group, the aggregated individual-level data in a single group were used as the representative values for the group. Results of intraclass correlation coefficients (ICCs), Eta-squared (η^2), and one-way analysis of variance showed that aggregated individual-level data were capable of representing the group level data. Multiple regression analysis was adopted to test four hypotheses. Results: Groups with higher levels of cooperation norms, task norms, and task cohesion had greater feeling of group effectiveness as perceived by the members. In spite of this group size was not considerably associated with group effectiveness. The cooperation norms, task norms, and task cohesion accounted for 51% of the variance in group effectiveness. Conclusions: It was concluded that the group members having better feeling of cooperation norms, task norms, and task cohesion demonstrated highe

The Relationship between Leadership Style and Group Effectiveness: An Example of Quality Control Circles of Hospitals in Taipei Area

[[abstract]]Objectives: The aim of the study was to examine the association between the leadership styles and group effectiveness of quality control circles (QCCs) of hospitals accredited at the level beyond regional teaching in the Taipei area. Methods: Based on the predictive corelational design, data were collected from target members of QCCs by using structured questionnaires modified from Stogdill's LBDQ-Ⅱ and Hwang's group effectiveness questionnaires from May 2002 to June 2002. At a group response rate of 86.8%, 263 QCC groups including 1994 cases from 16 hospitals in the Taipei area were enrolled for analysis using individual circle members as the study targets. Results: The result of logistic regression analysis revealed significantly positive association between combined task and consideration-oriented leadership and group effectiveness (OR=1.47, p＜.001). Multiple regression analysis also showed considerably positive association between combined task and consideration-oriented leadership and group effectiveness (β=.052, p＜.001). The results were consistent with the leadership of combined product center and people center as the best one to promote the group effectiveness reported by O'Donnell & O'Donnell and the characteristics of democratic leadership style in the managing grid theory proposed by Blake and Mouton. Conclusions: This study discovers the leadership style of combined task and consideration-orientation is a basic aspect in the training course of enhancing hospital QCC effectiveness, can promote human relations and group interactions, and, moreover, achieves persistently high group effectiveness

The Truth about Quality: An Introduction of Quality Function Deployment

[[abstract]]由於財務限制，醫療健康產業面臨競爭壓力，藉由改善健康照護品質以提升組織面臨之挑戰，但若無法對品質的內涵理解透徹，即無法有效改善健康照護品質。本文旨在幫助醫療成員了解品質機能展開法的技能，以便了解顧客的聲音及有效改善品質。 Health care industries have faced competitive pressure due to cost constraint. Improving health care quality is an approach to increasing the competitive challenges an organization faces. However, the effort of improvement would be ineffectual without clearly understanding the meaning of quality. This paper assists health care providers in understanding quality function deployment (QFD) techniques which can find out the voice of the customer and enhances the quality effectively

加速失敗時間模式分析新發乳癌病患併發血栓栓塞對其存活的影響

[[abstract]]目標：血栓栓塞併發症（TEEs）為乳癌併發症主要之一且增加死亡風險，本研究擬探討台灣新發乳癌病患併發血栓栓塞之相關因素及對其兩年存活的影響。方法：本回溯性世代研究使用1997至2010年全民健康保險研究資料庫。以Poisson分佈探討2000到2008年新發乳癌世代觀察兩年其併發TEEs的發生情形。透過propensity socre匹配後再以Accelerated Failure Time Model檢視有無併發症病患對其兩年存活之影響。結果：2000-2008年新發乳癌世代共80,598人，罹癌確診後兩年內併發TEEs之累積發生率1.78%（95% CI = 1.74-1.82），且第一個半年併發症發生密度為1.38發生事件數／每100個人年。併發TEEs危險因子有年齡（≧65歲比＜45歲adjusted incidence rate ratio [adj. IRR] = 3.87，95% CI = 3.80-3.93），共病指數（≧3分比0分adj. IRR = 1.96，95% CI = 1.93-2.00），有高血壓病史（adj. IRR = 1.43，95% CI = 1.41-1.45），有乳房手術者（adj. IRR = 1.47，95% CI = 1.45-1.49），接受放射線治療者（adj. IRR = 1.29，95% CI = 1.28-1.31），接受化學藥物治療者（adj. IRR = 1.40，95% CI = 1.38-1.42），醫院層級（地區醫院比醫學中心adj. IRR = 1.13，95% CI = 1.11-1.15）。AFT model分析顯示在控制其他變項後，有併發TEEs者比無者有較高比例的兩年死亡風險（adjusted Rate Ratio = 2.55, 95% CI = 2.24-2.91），且風險隨時間增加而增加。結論：新發乳癌病患併發TEEs會增加其死亡風險。醫療專業人員者可針對易併發TEE之危險群（如年長、共病指數高、有高血壓、接受乳癌手術、接受化療放療），即早警覺並提供適當的預防措施以利降低併發症的發生及提升癌症照護品質

The Relationship between Facility Characteristics and the Quality of Care in Nursing Homes

[[abstract]]本研究目的在探討護理之家機構性性(經營型態、規模、佔床率、護理人員護理時數、病患服務員照護時後)與照護品質(壓瘡率、跌倒率、轉／住至急性照護機構率、感染率、使用身體的束率)的相關性。參考Donabedian品質管理理論模式，採描述相關性設計，以隨機分層抽樣方式，自全台123家立案護理之家抽取39家，以郵寄結構式問卷方式共進行3個月的資料收集，計32家護理之家全程參與。以組織層級分析單位，採描述性統計及邏輯迴歸進行資料分析。結果顯示經控制民特性後，獨立型態護理之家比醫院附設型態護理之家傾向有低跌倒率與低感染率，且機構床位數大於45床者傾向有較高跌倒率。本研究結論是護理之家機構的經營型態及機構規模與機構所提供的照護品質(跌倒率及感染率)有關。討論與建議在文內有詳細描述。 The purpose of this study was to examine the relationship between the facility characteristics (ownership, size, occupancy rate, registered-nurse hours per patient day, nursingassistant hours per patient day) and the quality of care (pressure ulcer rate, falls rate, rate of transfer/discharge to inpatient acute care, infection rate, rate of use of physical restraint) in nursing homes. Based on Donabedian's quality management framework, a descriptive correlational design was used. Stratified random sampling was adopted to select 39 homes from 123 licensed nursing homes. Thirty-two nursing homes returned the structured questionnaires by mail over a three-month period. Data were analyzed using descriptive statistics and logistic regression at the organizational level. The results of this study revealed that after controlling for characteristics of residents, independent nursing homes had lower falls and infection rates than hospital-affiliated homes. Facilities with over 45 beds had higher falls rates. The study concludes that the ownership and size were associated with the quality of care (falls and infection rates) in nursing homes. Discussion and suggestions are described

The Effectiveness of Case Management for Burn Patients in a Medical Center

[[abstract]]本研究旨在探討個案管理模式於燒燙傷病患照護之成效，包括病患知識、居家自我照護行為、對醫護人員服務之滿意度、平均住院天數、及平均住院醫療費用。 在北台灣某醫學中心進行一個為期16個月針對燒傷病患提供個案管理照護模式的類實驗性研究。以立意取樣的方式將病患分為對照組（n=30人）接收傳統的照護，實驗組（n=40）接受額外的個案管理照護，包括接受自我照護教育及符合治療指引的照護服務。 個案管理介入16個月後實施前後比較均達統計上顯著差異，病患知識在實驗組有明顯地增加由5.95分進步到9.63分，對照組的進步較些微由5.07分增加到7.20分。居家自我照護行為執行正確率實驗組比對照組有明顯地進步（85.50%比70.28%），對醫護人員滿意度亦有明顯高出（108.78分比86.83分）。平均住院天數實驗組比對照組有明顯縮短（16.23天比23.17天），平均住院醫療費用亦有明顯降低（138,467.58元比219,582.23元）。 經個案管理模式實施，提供燒燙傷病患較完整的照護方針，促進多專科團隊合作，建議推展至其他高成本高數量疾病之個案。 This study investigated how nursing case management impacts patient knowledge, self-care behavior at home, satisfaction with healthcare, average length of stay and costs. A sixteen-month quasi-experimental design was conducted in the burn unit of a Taipei medical center. A purposive sampling method was used to collect data. Burn patients were assigned to a control group (CG)(n=30) who received standard care from their primary care nurse or an intervention group (IG)(n=40) who received additional management, including education in self-management and implementation of burn guidelines for treating burn victims. After 16 months, patient knowledge scores significantly increased from 5.95 to 9.63 in IG as compared to a slight increase from 5.07 to 7.20 in CG. Primary outcome scores also improved significantly in IG: self-care behavior at home scores improved from 70.28% to 85.50%, and satisfaction with healthcare improved from 86.83% to 108.78%. Secondary outcomes improved significantly in IG compared to CG: average length of stay improved from 23.17 to 16.23 days, and cost improved from 219, 582.23 to 138,467.58 NT dollars. Results of this study have major implications for health care management models. First, more comprehensive guidelines for burn patient care can be structured. Still, the findings demonstrate great progress in cooperation between multidisciplinary team members in burn center. Finally, this case management model can be implemented in other high-cost and high-volume patients groups

Factors Associated with Nurse Aides Who Willingness to Retention: Example of Long-Term Care Facilities in Taipei

[[abstract]]Taiwan has an aging population, which means the need for long-term care is increasing. Long-term care is a human-oriented service industry whose main manpower is provided by health care workers; therefore, the purpose of this research was to focus on the factors associated with nursing aides who are willing to stay on the job in order to improve the quality of patient care. Data were collected between March and April 2003 using cross-sectional study design and based on a questionnaire. Research samples were taken from 196 nurse aides from 15 long-term care facilities located in districts of Taipei city. The results showed that (1) there was a statistically significant negative correlation between nursing aides' level of education and willingness to stay on the job(r =-.24, p＜.01); (2 )there was a statistically significant positive correlation between nursing aides' work experience (r=.16, p＜.05), health condition (r =.18, p＜.05) , and willingness to stay on the job; (3) there was a statistically significant positive correlation between bed occupancy rates and nursing aides' willingness to stay on the job (r=.31, p＜.01); (4) there was a statistically significant positive correlation between nursing aides' job satisfaction and willingness to stay on the job (r =.63, p＜.01). According to the results of regression analysis, the predictors of willingness to stay on in long-term care are level of education, bed occupancy rates, and job satisfaction (40% of total variance). It is hoped that this information will be applied to future policy development of retention strategies in long-term care in Taiwan