【作者】 周倩；

【导师】 张新平；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2022， 博士

【摘要】 【目的】医院感染已成为全球健康的重要威胁,医护人员的感染预防和控制(infection prevention and control,IPC)行为是降低此类风险的重要保证。医护人员IPC行为不理想,亟需系统机制研究分析,本研究发现患者安全系统工程(Systems Engineering Initiative to Patient Safety,SEIPS)模型可以为系统提升医护人员IPC行为提供理论依据,且适用于IPC领域。基于此,本研究的目的为:(1)构建基于SEIPS模型的医护人员IPC行为影响机制的理论模型并验证,(2)设计基于医护人员偏好的IPC行为提升干预策略。【方法】理论构建方面,基于Walker和Avant的理论分析、文献研究和医护人员访谈的主题分析对SEIPS模型进行分析,析取医护人员IPC行为及影响因素的内涵,对关键构念进行界定,归纳出各构念之间的关系假设并阐释内在作用机理,构建基于SEIPS模型的医护人员IPC行为影响机制理论模型。基于Hinkin的问卷发展和验证步骤进行问卷开发。实证研究获得833份医护人员有效样本,采用结构方程模型对构建的理论模型进行检验。使用偏差校正的非参数百分位Bootstrap方法,反复抽样5000次,进行中介效应检验和置信区间估计。基于构建的模型和离散选择实验,使用调节Logit、混合Logit和潜类别Logit模型建模,选择最优模型并量化医护人员的偏好。【结果】(1)本研究构建的理论模型的核心构念主要包括IPC医护人员认知、IPC组织管理、IPC工具与技术、IPC任务、IPC内部环境、IPC外部环境、IPC系统复杂性和IPC行为。各构念之间基本关系包括各构念对IPC行为的直接作用和通过IPC系统复杂性的中介作用。(2)测量:形成了8个维度如IPC医护人员认知和IPC系统复杂性,共38个条目的调查问卷。实证研究中各维度Cronbach’sα均在0.8以上,信度较好;累积解释方差为80.087%,几乎所有条目载荷均大于0.6,验证性因子分析结果适配度良好(RMSEA=0.065,CFI=0.925,TLI=0.917,IFI=0.926),组合信度较好(CR均>0.8),收敛效度较好(AVE均>0.5),且区分效度较好。(3)机制验证:IPC医护人员认知(β=0.110,P=0.003)、IPC内部环境(β=0.417,P<0.001)和IPC外部环境(β=0.350,P<0.001)对IPC系统复杂有正向影响。IPC任务(β=0.172,P=0.003)和IPC内部环境(β=0.221,P<0.001)对IPC行为有正向影响。IPC系统复杂性(β=0.106,P=0.048)对IPC行为有正向影响。中介效应检验结果显示医护人员IPC认知(95%CI:0.001-0.033,P=0.015)、IPC内部环境(95%CI:0.009-0.088,P=0.015)和IPC外部环境(95%CI:0.007-0.075,P=0.018)通过IPC系统复杂性影响IPC行为的中介效应显著。(4)基于医护人员偏好的干预设计:通过比较各模型拟合优度发现潜类别Logit模型为最优模型。占比最多的分组(43.9%)中,采取开展培训,加强领导重视和安全氛围,提升防护用品可用性,优化IPC工作流程,减少工作量,改善物理环境和改变外部环境的系数均显著,且在0.367到1.033之间变化。占比36.4%的分组中,除开展培训以及加强领导重视和安全氛围的系数不显著外,其他均显著,系数在0.237到0.970之间变化。占比最少的分组(19.7%)中,仅采取培训方式的系数显著(β=3.767,P<0.001)。【结论】本研究构建了基于SEIPS模型的医护人员IPC行为模型,其核心构念为IPC医护人员认知、IPC组织管理、IPC工具与技术、IPC任务、IPC内部环境、IPC外部环境、IPC系统复杂性和IPC行为;核心关系是以上构念对医护人员IPC行为的直接作用,以及IPC系统复杂性在其中发挥的中介作用。本研究针对关键构念构建了信效度良好的测量工具。医护人员针对IPC行为提升干预存在偏好差异,大部分医护人员倾向于采取开展培训,加强领导重视和安全氛围,提升防护用品可用性,优化IPC工作流程,减少工作量,改善物理环境和改变外部环境的措施来设计干预方案。【创新和不足】创新点:(1)构建了基于SEIPS模型的医护人员IPC行为影响机制的模型:本研究基于医院管理学、管理科学、人因工程学和心理学等学科的交叉,从人因工程的角度和系统复杂性的角度出发,结合医护人员的实地定性分析和定量数据验证,构建了基于SEIPS模型的医护人员IPC行为理论模型,拓宽了SEIPS模型的应用范围和IPC领域的研究视角,弥补了复杂性理论在概念和操作方面的局限,丰富管理科学等学科的理论。(2)构建了针对医护人员IPC行为影响机制模型构念的测量:本研究进行了科学的问卷开发过程,构建了信效度较好的测量问卷,弥补了医院感染管理学针对IPC工具和技术、IPC任务、IPC内部环境、IPC外部环境和IPC复杂性测量基础薄弱的不足;基于任务分析法形成的IPC行为调查问卷可用于IPC行为依从性和正确性的测量,拓展了测量IPC行为的视角和方法。(3)基于离散选择实验分析了医护人员IPC行为提升干预策略的偏好:通过离散选择实验设计得到的提升医院IPC行为干预的分析结果,拓宽了医护人员IPC干预设计的思路,丰富了我国医护人员IPC行为的提升设计策略。不足:本研究采用医护人员的自我报告行为,未来可尝试使用医护人员真实行为开展深入研究。调研对象为三甲医院的医护人员,构建的IPC行为影响机制模型对于其他等级医院医护人员的适用性和推广性仍有待研究。更多还原

【Abstract】 [Objective] Healthcare-associated infections have become a threat to global health.Infection prevention and control(IPC)behaviors in medical staff are important to control such risks.However,the compliance of medical staff’s IPC behaviors is not ideal.Research aimed at exploring systematic mechanism is urgently needed.SEIPS(Systems Engineering Initiative to Patient Safety)model can provide a theoretical basis for improving the IPC behaviors of medical staff systematically.Nevertheless,there are limitations in the application of theoretical framework and practice.Based on this,the purpose of this study is to:(1)construct and verify the theoretical model of the influencing mechanism of infection prevention and control behaviors in medical staff based on SEIPS model,(2)design an intervention strategy for IPC behavior improvement based on medical staff preference.[Methods] With respect to theoretical construction,firstly,the SEIPS model was analyzed based on the Walker and Avant analysis,literature research and qualitative research of medical staff interviews.The construct of IPC behaviors and influencing factors in medical staff were extracted.The relationship hypotheses between the variables in this study were summarized to explain the internal mechanism.Together a theoretical model of influencing factors of the IPC behavior mechanism of medical staff based on the SEIPS model was built.The formation of measurement of variables in the model included the process of questionnaire construction and examination.Using the developed measurement,the survey obtained 833 valid samples of medical staff.The constructed theoretical model was tested using structural equation modeling.A bias-corrected nonparametric percentile Bootstrap method was used to test the mediation effect and estimate the confidence interval,with 5000 repeated sampling.Based on the above,the survey data were modeled using adjusted Logit,mixed Logit and latent class analysis models to quantify the preferences of medical staff via discrete choice experiment.The optimal model was selected by comparing the results of the three models.[Results](1)The core constructs of the theoretical model mainly included IPC medical staff cognition,IPC organizational management,IPC tools and techniques,IPC tasks,IPC internal environment,IPC external environment,IPC system complexity and IPC behaviors.The basic relationships between the constructs in this study included the direct effect of each construct on IPC behaviors and the mediation effect through IPC system complexity.(2)Measurement of variables: A questionnaire with a total of 38 items was developed,including 8 dimensions such as IPC medical staff cognition and IPC system complexity.The Cronbach’s α of each dimension was above 0.8,and the reliability was good;the cumulative explained variance was 80.087%,and almost all item loadings were greater than0.6.The results of confirmatory factor analysis had a good degree of fit(RMSEA=0.065,CFI=0.925,TLI =0.917,IFI=0.926),the combined reliability was good(CR>0.8),the convergent validity was good(AVE>0.5),and the discriminant validity was good.(3)Verification of the mechanism: IPC medical staff cognition(β=0.110,P=0.003),IPC internal environment(β=0.417,P<0.001)and IPC external environment(β=0.350,P<0.001)had significant positive effects on the IPC system complexity.The IPC task(β=0.172,P=0.003)and the IPC internal environment(β=0.221,P<0.001)had significant positive effects on IPC behaviors.IPC system complexity(β=0.106,P=0.048)had a significant positive effect on IPC behaviors.The results of the mediation effect test showed that medical staff IPC cognition(95%CI: 0.001-0.033,P=0.015),IPC internal environment(95%CI:0.009-0.088,P=0.015)and IPC external environment(95%CI: 0.007-0.075,P=0.018)had the indirect effect significantly on IPC behaviors through IPC system complexity.(4)Intervention design based on medical staff preference: The latent class analysis model was found to be the optimal model among the three models by comparing the goodness of fit of the models.In the group with the largest proportion(43.9%),the medical staff tended to take all types of interventions to improve IPC behaviors,with the coefficient varying from 0.367 to 1.033.In the 36.4% subgroup,only the coefficients of medical staff taking training,strengthening leadership attention and safety atmosphere were not significant,with the coefficients varying from 0.237 to 0.970.Among the 19.7% group,there is a very strong preference for training to improve IPC behaviors(β=3.767,P<0.001).[Conclusion] This study innovatively constructs an IPC behavior mechanism model based on the SEIPS model targeting medical staff.The core elements of the SEIPS model are IPC medical staff cognition,IPC organization management,IPC tools and techniques,IPC tasks,IPC internal environment,IPC external Environment,IPC system complexity;the core relationship is the direct influence of the above elements on the IPC behaviors of medical staff,and the mediation influence of IPC system complexity between them.This study constructs a measurement tool of the IPC behaviors model of medical staff based on the SEIPS model,including 8 dimensions and 38 items,with good reliability and validity.Intervention design studies found differences in preference for IPC intervention among medical staff.The intervention design study identified priority IPC measures,including training for the majority of healthcare workers,strengthening leadership and safety climate,improving PPE availability,optimizing IPC workflow,reducing workload,improving the physical environment,and changing the external environment measures to design intervention programs.[Innovation and deficiencies]Innovation points:(1)Innovation of theoretical model: This research is based on the intersection of hospital infection management,management science,human factors engineering and psychology.From the perspective of human factors engineering and system complexity,combined with on-site qualitative analysis and verification of quantitative data among medical staff,a theoretical model of medical staff IPC behaviors based on SEIPS model is constructed.The model broadens the application scope of SEIPS model and the perspective of IPC field research;fills the gap in the limitations of concepts and operations in complex theory;and enriches management science and theories of psychology and other disciplines.(2)Innovation of measurement tools: This study carried out a scientific questionnaire development process,constructed a measurement questionnaire with good reliability and validity,and formed the tool to measure IPC tools and techniques,IPC tasks,IPC internal environment,IPC external environment and IPC complexity.The questionnaire formed by IPC behaviors based on hierarchical task analysis method can be used to measure the compliance and correctness of IPC behaviors,which expands the perspective and method of measuring IPC behaviors.(3)Innovation of the design idea of intervention plan:The analysis results of improving hospital IPC behavior intervention obtained through discrete choice experimental design broaden the idea of medical staff IPC intervention design and enrich the design strategy for improving IPC behaviors of medical staff.Weaknesses: The self-reported behaviors of medical staff are measured in this research,and future research can try to use the real behaviors of medical staff to conduct more indepth research.The research objects of this study are medical staff in tertiary hospitals,so the generalization of this model to medical staff in other grades of hospitals still needs to be studied.更多还原