工作特征模型视角下基层卫生人员内在激励机制研究

Job Characteristics Model-based Study of the Intrinsic Incentive Mechanism for Primary Health Workers

背景对基层卫生人员的激励关乎新医改“强基层”和分级诊疗目标的实现,研究者大都关注外部激励措施及其对基层卫生人员工作结果的影响,忽视了工作本身所具备的内在激励作用。目的以工作特征模型为研究框架,分析当前基层卫生人员工作特征现状,探究其对基层卫生人员工作结果的内在激励作用,并比较工作特征五维度与收入等外部激励因素对工作结果的作用大小,为提高基层卫生人员的工作动机与绩效提出政策建议。方法采用多阶段抽样法,以山东省三市18家社区卫生服务中心和20家乡镇卫生院为样本来源地,2021年2—6月选取各样本来源地调查当日在岗的基层卫生人员为研究对象,采用自设问卷对其进行调查。采用方便抽样法,从完成调查者中抽取167例基层卫生人员作为访谈对象,对其进行半结构化访谈,了解基层卫生人员对工作特征的认知情况。采用Pearson相关分析工作特征五维度及外部激励因素与基层卫生人员自主动机、工作绩效、职业倦怠、离职意愿之间的相关性,采用多元分层线性回归分析工作特征五维度及外部激励因素对基层卫生人员工作结果的影响及其程度。采用主题框架法对访谈资料进行分析。结果共回收有效问卷870份。工作特征五维度中,基层卫生人员在技能多样性维度上的平均得分最高,为(4.09±0.71)分;在任务完整性维度上的平均得分最低,为(3.18±1.04)分;在任务重要性、工作反馈性、工作自主性3个维度上的平均得分分别为(3.91±0.76)、(3.46±0.83)、(3.43±0.79)分。Pearson相关分析结果显示,基层卫生人员自主动机、工作绩效与工作特征各维度呈正相关(P<0.05),职业倦怠和离职意愿与工作特征各维度呈负相关(P<0.05)。多元分层线性回归结果表明,工作特征五维度对自主动机、工作绩效、职业倦怠、离职意愿4个工作结果变量的贡献率(R2)分别为18.8%、11.3%、16.5%和21.9%,其对4个工作结果变量的解释力强于收入等5项外部激励因素[5项外部激励因素对4个工作结果变量的贡献率(R2)分别为1.7%、3.4%、5.8%和11.8%]。通过访谈发现,基层卫生工作在工作特征的5个维度上存在任务碎片化、自主性受限、反馈机制不足等问题。结论对于基层卫生人员而言,工作特征的内在激励作用对工作结果的解释力强于外部激励因素的外在激励作用,但基层卫生人员的现实工作特征与理论上的工作特征之间存在差距。应重视工作本身的内在激励作用,通过增加培训机会和提高培训质量、为基层卫生人员减负赋能、加大资源投入和减少政策束缚、完善绩效管理制度等重塑基层卫生人员对工作的认知,从而提升基层卫生人员的工作动机与绩效。

Background The incentivation for primary health workers is vital for the realization of two goals of the new healthcare reform in China,namely strengthening primary healthcare and achieving hierarchical diagnosis and treatment.Most previous studies put more emphasis on extrinsic incentive measures and their effect on job outcomes,ignoring the intrinsic motivation effect of job itself.Objective To perform an analysis of the job characteristics of primary health workers using the framework of Job Characteristics Model,assess their intrinsic motivation effect on job outcomes of these workers,and compare the strength of impact of the five dimensions of job characteristics and income and other extrinsic motivators on job outcomes,and put forward policy recommendations for improving work motivation and performance of primary health workers.Methods A survey using a self-developed questionnaire was conducted with primary health workers who were on duty on the day of the survey selected from a multistage sample of healthcare settings(including 18 community health centers and 20 township health centers)in three cities of Shandong Province from February to June 2021.Then,from those who effectively completed the survey,167 cases were selected using convenience sampling to attend semi-structured interviews to understand their views of the characteristics of job as a primary health worker.Pearson correlation was used to analyze the correlations of the five dimensions of job characteristics and extrinsic motivators with autonomous motivation,performance,burnout,and turnover intention.Hierarchical multiple linear regression was used to analyze the strength of impact of the five dimensions of job characteristics and extrinsic motivators on job outcomes.Thematic analysis was used to analyze the interview data.Results A total of 870 cases who handed in effective questionnaires were included for analysis.Among the five dimensions of job characteristics,respondents scored highest and lowest on skill variety(4.09±0.71)and task identity(3.18±1.04),respectively,and their scores on task significance,feedback from job and autonomy were(3.91±0.76)(3.46±0.83)and(3.43±0.79),respectively.Pearson correlation analysis showed that the level of each of the five dimensions of job characteristics had a positive correlation with autonomous motivation and performance(P<0.05),and had a significant negative correlation with burnout and turnover intention(P<0.05).Hierarchical multiple linear regression revealed that the five dimensions of job characteristics had significant impacts on job outcomes,specifically,autonomous motivation(R2=18.8%),performance(R2=11.3%),job burnout(R2=16.5%)and turnover intention(R2=21.9%),whose explanatory power was stronger than that of five extrinsic motivators(The R2 values of the five extrinsic motivators' contributions to the four job outcomes were 1.7%,3.4%,5.8%,and 11.8%,respectively).The interview results reflected the problems of task fragmentation,limited autonomy and insufficient feedback from job.Conclusion In primary health workers,the intrinsic motivation effect of job characteristics outweighs the extrinsic motivation effect in terms of explanatory power for job outcomes.And there is a gap between actual and theoretical job characteristics.Attention should be paid to the intrinsic motivation effect of job itself.Some measures should be taken,such as increasing training opportunities and quality,reducing work-related burden of these workers and empowering them,increasing resource investment and reducing policy constraints,improving the performance management system,to reshape job perceptions to improve work motivation and performance of primary health workers.