医疗服务中的信任违背与修复研究

In recent years, the patient-provider relationship in China is increasingly intense and a series of terrible assaults by patients and their parties against healthcare workers have been reported, which has attracted increasing public concern. Trust crisis between patients and healthcare providers, especially the violation of patients' trust, is widely regarded as one of the cruxes of this alarming phenomenon. Repairing violated patients' trust then becomes the key to rebuild harmony between patients and doctors and stop violence involving medical staff. Unfortunately, regulators and operators of healthcare are ignorant and lack of tools on trust management during medical care. Although there is urgent demand on theories and tools on patients’ trust management, few researchers’ attention has been focused on trust repair in health field. So, this study will use contextualized research strategy combining qualitative and quantitative methods to study trust violation and repair in medical care. Firstly, by critical incident technique and multi dimensional scaling method, this study will explore manifestation and type of trust violation under the medical context in China; Secondly, through scenario-simulation method, we will investigate patients' atrribution of violation and their demands on trust repair and common repair tactics violators commonly adopt according different type of trust violation; Thirdly, a scenario experiment will be used to verify the effect of provider’s repair tactics; Fourthly, this study will try to grasp the mechanisms of trust violation and repair in real-life situation by embedded multiple-case study research, and develop an integrated model of patients' trust violation and repair in the China context; Finally, we will put forward management suggestions on repair of trust violation according to the findings above. The expected findings of this study would contribute to the local understanding of patient's trust violation and repair, and have important practical implications for health system to improve trust management and rebuild patients’ trust.

近年来，中国医患关系日趋紧张、暴力伤医事件时有发生，医患信任危机尤其是患者对医方的不信任，被公认为症结之一，修复患者信任因此成为构建和谐医患关系、预防涉医暴力的关键。目前医疗服务管理者和提供者的信任管理能力不足、有效工具缺乏，亟需研究者提供理论依据和管理工具，以指导患者信任的有效修复。本课题将运用定性与定量相结合的研究策略，对医疗服务中的信任违背与修复进行系统研究。一，通过关键事件法和多维尺度法，探索信任违背在中国医疗服务情境下的表现及分型；二，通过问卷调查，总结患方对信任违背的归因、修复诉求及医方常用修复策略；三，通过情景模拟调查，验证医方修复策略的效果；四，通过嵌入式多案例研究，挖掘医疗服务情境中的信任违背发生与修复机制，构建理论模型；最后，基于研究发现，提出医疗信任管理建议。本研究预期成果有利于增加对医患信任的本土化理解，对卫生领域提升信任管理水平、重建医患信任具有重要意义。

近年来，中国医患关系紧张、暴力伤医事件时有发生，患者对医方不信任被公认为症结之一，修复患者信任成为构建和谐医患关系、预防涉医暴力的关键，亟需研究者提供理论依据和管理工具，以指导患者信任修复。本课题运用定性与定量相结合策略，对医疗服务信任违背与修复进行了系统研究。.一，确定了5维度医务人员信任违背类型，即正直型、责任型、角色型、善意型和能力型违背，和4维度医疗机构信任违背类型，即医疗外服务支持、诚信型、效率型和服务质量型违背。二，在能力型信任违背中，医方三种常用修复策略为：否认+沟通解释、经济赔偿+沟通解释以及第三方调解+经济赔偿+沟通解释，分别占36.8%、13.4%和22.2%；感知医方努力程度对修复效果产生最大正向影响（β=0.838、0.819和0.873，P＜0.05）；患者信任倾向对修复效果产生重要正向影响（β=0.115、0.174和0.160，P＜0.05）。三、患者内部性归因以及负面情绪反应会对信任意愿产生直接负向影响（β=-0.160，-0.192，P＜0.05）；修复措施满意度会对患者信任意愿产生直接的正向影响（β=0.500，P＜0.05）。四，通过多案例研究，构建了医疗纠纷情境中的信任违背与修复模型：患者信任前期交往基础，在患者感知到破坏行为后会进入归因过程，进入到信任崩溃阶段后会对负面消息进行扩散，医方通常难以对其进行及时修复，患者认知水平和情绪反应均加大了修复难度。“心理—偏好”、“资源—获取”和“制度—环境”均对信任修复产生影响，显示出患者信任内驱力不足，与医方交往基础不平衡，政策环境不完善等问题。最后，基于研究发现，提出了建议：政府应该强化预防理念，完善法治监督，正确引导舆论。医方需优化服务体验以获取患者初始信任，提升沟通有效性、信任修复及时性和针对性，应提高医生技术能力，完善纠纷处理机制，建立多组合修复策略，响应患者诉求，消除患者不良情绪；医务人员应提升沟通能力，增强医患互动。研究成果对增加对医患信任的本土化理解，提升卫生领域信任管理水平、重建医患信任具有重要意义。