农村订单定向医学毕业生在乡镇卫生院工作现状、长期工作意愿及其影响因素的质性研究

Working Status,Willingness of Long-term Retention in Township Heath Centers and Associated Factors in Targeted Admission Medical Graduates:a Qualitative Study

背景2010年我国农村订单定向医学生免费培养工作启动,旨在为农村地区培养具备本科学历的全科医生,改善农村地区基层医师匮乏的状况。2018年首批农村订单定向医学生返回乡镇卫生院工作,开始履行为期3年的农村地区卫生服务合约。目的了解农村订单定向医学生在乡镇卫生院的工作现状,以及服务期满后继续留在农村乡镇卫生院工作的意愿及影响因素,探索促进农村地区长期保留医疗卫生人才的机制。方法于2019年1—8月,对64例广西医科大学2015届农村订单定向医学毕业生进行半结构式焦点小组访谈,访谈内容包括在农村乡镇卫生院的薪酬待遇、工作内容、工作氛围、工作条件、服务期满后继续留在乡镇卫生院工作的意愿及影响因素等。将访谈录音资料完整转录为书面文字,采用主题分析法编码、提炼主题。结果访谈共提取11个主题,分别为:农村订单定向医学毕业生在乡镇卫生院的薪酬水平达到预期,但呈现地域差异化;兑现入编、“五险一金”等待遇,基本解决住房问题;进修培训机会少;职务晋升空间大;工作内容以临床诊疗活动为主,部分涉及医技工作;工作氛围和谐,竞争感不强,院负责人重视;基本药物不足,所学难以致用;实验室检查设备落后,卫技人员匮乏,无法开展多种常用检查;服务期满后继续留在乡镇卫生院工作的意愿不明确;支持乡镇发展的国家政策、明晰的职业发展、友好的工作氛围、解决农村卫生问题的意愿、在农村地区工作获得的成就感等是促进其长期留任乡镇卫生院的因素;基本药物短缺、医疗设备落后、培训进修机会缺乏、工作繁重及收入水平偏低等是阻碍其长期留任乡镇卫生院的因素。结论多数农村订单定向医学毕业生暂未明确长期在农村乡镇卫生院工作的意愿,薪酬水平不是影响其服务期满后继续留在农村地区工作的主要因素,而乡镇卫生院基本药物不足、医疗设备落后及继续教育短缺是阻碍其长期留在农村地区工作的主要因素。

Background The rural-oriented tuition-free medical education(RTME)program has been launched in China since 2010,aiming to provide rural areas with general practitioners with medical undergraduate degrees and to address the shortage of rural physicians.The first graduates with RTME came back to the contracted township health center to work in 2018 and started fulfilling a 3-year obliged health services in rural areas.Objective To investigate the working status of graduates with RTME in rural primary health care institutions,their intentions towards long-term retention in rural areas and relevant associated factors.Methods A qualitative study was conducted from January to August 2019,using a semi-structured focus group discussion with 64 individuals with RTME who graduated from Guangxi Medical University in 2015 and started serving local rural areas in 2018.Guided by an outline,the discussion covered issues about salary,scope of work,work atmosphere,and working conditions in township health centers,intention of retaining in the township health center after fulfilling the contractual obligations,and factors associated with long-term retention in township health centers,and was recorded,transcribed,and organized into themes using thematic analysis.Results A total of 11 main themes emerged,including:salaries in the township health center met expectations of most graduates with RTME but showed geographical differences;the township health center has kept its promise of providing officially budgeted posts and purchasing the"five social insurances and one housing fund"as well as basically solving the housing problem;the opportunities for continuing medical education were reported to be insufficient;graduates with RTME would be easily considered for administrative posts of rural primary health care organizations;graduates with RTME mainly engaged in clinical diagnosis and treatment of disease,some of them also in auxiliary examinations;graduates with RTME worked in an atmosphere of harmony and less competition,and would be noticed significantly by the leaders;insufficient essential drugs crippled performances of graduates with RTME;both behindhand medical equipment and deficiency of health technicians made some common auxiliary examinations unavailable in township health centers;the attitudes towards retention in township health centers after fulfilling the contractual obligations were unclear;national policies in favor of towns and villages development,promising career development,friendly work atmosphere,willingness to address rural health issues,and sense of achievement derived from working in rural areas were factors encouraging long-term retention in township health centers;insufficient essential drugs,behindhand medical equipment,scarce opportunities for continuing medical education,heavy workload,and low salaries were factors impairing long-term retention in township health centers.Conclusion The graduates with RTME showed unclear intentions towards long-term retention in township health centers.The salary was not a leading factor to impair their retention in such organizations after fulfilling the contractual obligations.However,insufficient essential drugs,behindhand medical equipment,and scare opportunities for continuing medical education emerged as major barriers for rural areas to retain these graduates.