医闹行为的归因模型构建及干预路径选择——基于扎根理论的多案例研究
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摘要
医闹事件在全国范围内频发,成为构建和谐医疗秩序的重要制约因素,受到学术界的广泛关注。当前关于医闹行为的诱致性因素仍缺乏系统性的整合研究。论文以G省2013—2017年影响较大的医闹事件为研究对象,运用扎根理论及多案例研究方法,对医闹行为的归因模型进行构建。研究发现:(1)医患双方及政府医疗纠纷处理机构的偏好是诱致医闹行为的内在驱动力。(2)制度性障碍尚未破除是诱发医闹问题的外在推力。正式纠纷解决制度运转不良以及当前医疗供给侧行政型市场化所引致的供方激励扭曲,加剧了医方行为的失当、患方过激维权手段的应用和政府纠纷处理机构非制度化处理方式的普遍化。(3)医患双方资源拥有类型及数量的多寡决定了其在医闹事件中的工具选择。患方既有源于自身的势能资源,也有来自亲缘、媒体等辅助资源,在对抗手段的选择上有较大空间,而医方受自身条件限制,在应对医闹事件的工具选择上较为狭窄和被动。(4)医院领导人的领导风格在医疗纠纷处理中扮演着重要角色,刚性领导风格更易于诱发患方的强力反弹,而柔性风格的领导者在弱化矛盾、舒缓危机中更具优势。最后,论文从构建"医-患-政"三方互信机制、革除制度梗阻、强化辅助型政策工具运用层面提出治理策略。
Medical disputes haveoccurred frequentlyacross the country, which is a major constraint on the construction of harmonious medical order. At present,there has been no systematic,integratedstudy ofthe inductivecause of severe medical disputes.This study took the disruptive incidents in G province involving medical disputes that occurred form 2013 to 2017 as its research objects and constructedan attribution model of the medical disputes through the application of grounded theory and the multiple case study method. The findings are as follows:( 1) The psychological preferences of both doctors and patients and the coordinating institutions of governmentregarding medical disputes were the internal driving force to increase medical disputes;( 2) The institutional obstacles,which are the external thrust to induce medical trouble,have not been eliminated. The alienation of the formal dispute resolution system and the distorted incentives of the medical services supplier caused by the current administrative marketization have aggravated the improper behaviors of doctors,the application of the excessive patient' s rights safeguards,and the universalization of the non-institutionalized treatment of the government dispute settlement agencies.( 3) The types and quality of resources owned by doctors and patients determine their choices of tools in medical incidents. The patientowns not only their individual potential energy resources,but also those potential energy resources from relatives,geography,media,and others,so they have more choices for confrontation. While being passive,doctors have little choice due to the limitations of their positions compared with patients.( 4) The style of hospital leadership plays an important role in the solution of medical disputes. Rigid leadership makes it easier for the patients to respond forcefully,whileflexible leadership has more advantages of weakening conflictsand crises. Finally,this paper puts forward solutions,such as building a "doctor-patient-government " tripartite trust mechanism,eliminating institutional obstructions,and strengthening the use of auxiliary policy tools.
Medical disputes haveoccurred frequentlyacross the country, which is a major constraint on the construction of harmonious medical order. At present,there has been no systematic,integratedstudy ofthe inductivecause of severe medical disputes.This study took the disruptive incidents in G province involving medical disputes that occurred form 2013 to 2017 as its research objects and constructedan attribution model of the medical disputes through the application of grounded theory and the multiple case study method. The findings are as follows:( 1) The psychological preferences of both doctors and patients and the coordinating institutions of governmentregarding medical disputes were the internal driving force to increase medical disputes;( 2) The institutional obstacles,which are the external thrust to induce medical trouble,have not been eliminated. The alienation of the formal dispute resolution system and the distorted incentives of the medical services supplier caused by the current administrative marketization have aggravated the improper behaviors of doctors,the application of the excessive patient' s rights safeguards,and the universalization of the non-institutionalized treatment of the government dispute settlement agencies.( 3) The types and quality of resources owned by doctors and patients determine their choices of tools in medical incidents. The patientowns not only their individual potential energy resources,but also those potential energy resources from relatives,geography,media,and others,so they have more choices for confrontation. While being passive,doctors have little choice due to the limitations of their positions compared with patients.( 4) The style of hospital leadership plays an important role in the solution of medical disputes. Rigid leadership makes it easier for the patients to respond forcefully,whileflexible leadership has more advantages of weakening conflictsand crises. Finally,this paper puts forward solutions,such as building a "doctor-patient-government " tripartite trust mechanism,eliminating institutional obstructions,and strengthening the use of auxiliary policy tools.
引文
安东尼·吉登斯(1998).社会的构成:结构化理论大纲.李康、李猛译.北京:生活·读书·新知三联书店.
常亮(2017).消费者参与共享经济的行为归因和干预路径---基于扎根理论的分析框架.贵州社会科学,8:89-95.
陈振明(1996).工具理性批判---从韦伯、卢卡奇到法兰克福学派.求是学刊,4:4-9.
丁鹏飞、迟考勋、孙大超(2012).管理创新研究中经典探索性研究方法的操作思路:案例研究与扎根理论研究.科技管理研究,17:229-232.
杜创(2017).动态激励与最优医保支付方式.经济研究,52(11):88-103.
费小冬(2008).扎根理论研究方法论:要素、研究程序和评判标准.公共行政评论,3:23-43.
高华、王晓洁(2017).基于扎根理论的BT债务风险因素识别研究.财会通讯,17:96-99.
顾昕(2018).新时代新医改公共治理的范式转型---从政府与市场的二元对立到政府-市场-社会的互动协同.武汉科技大学学报(社会科学版),6:589-600.
郭鹏飞、周英男(2018).基于扎根理论的中国城市绿色转型政策评价指标提取及建构研究.管理评论,8:257-267.
郭科、顾昕(2017).过度医疗的解决之道:管制价格、强化竞争还是改革付费?.广东社会科学,5:176-185.
黄振辉(2010).多案例与单案例研究的差异与进路安排---理论探讨与实例分析.管理案例研究与评论,2:183-188.
黄振辉(2011).表演式抗争:景观、挑战与发生机理---基于珠江三角洲典型案例研究.开放时代,2:71-84.
郇建立(2009).慢性病与人生进程的破坏---评迈克尔·伯里的一个核心概念.社会学研究,5:229-241.
景怀斌(2017).扎根理论编码的“理论鸿沟”及“类故理”跨越.武汉大学学报(哲学社会科学版),6:109-119.
贾旭东(2011).中国城市基层政府公共服务职能的不完全外包及其动因---基于扎根理论的研究发现.管理学报,12:1762-1771.
卡拉威利格(2013).心理学质性研究导论.郭本禹、王申连、赵玉晶译.北京:人民邮电出版社.
李理(2018).基于扎根理论的网络事件信任传递机制研究:以罗尔事件为例.全球传媒学刊,1:39-52.
任其亮、赵子玉(2018).基于扎根理论的网络约车服务质量影响因素研究.重庆交通大学学报(自然科学版),11:1-8.
盛娅农(2017).社会治理创新视角下我国医疗纠纷处理的问题与对策.社会科学研究,6:68-73.
田国强、陈旭东(2018).制度的本质、变迁与选择---赫维茨制度经济思想诠释及其现实意义.学术月刊,50(1):63-77.
汪波、段琪(2014).基于扎根理论的基层医疗卫生机构补偿机制及要素探析.大连理工大学学报(社会科学版),2:20-26.
王志鑫(2017).我国医患关系紧张的法律成因及其对策.卫生经济研究,3:15-18.
吴新叶、袁铭健(2017).医患冲突治理:法治的缺席及其矫治---一个基于身份冲突的解释框架.社会科学,12:13-20.
徐喆玥、谢莹(2016).医患信任现状及影响因素分析.中国卫生质量管理,2:49-52.
徐昕、卢荣荣(2008).暴力与不信任---转型中国的医疗暴力研究:2000~2006.法制与社会发展,1:82-101.
袁树卓、殷仲义、高宏伟、刘沐洋(2018).精准扶贫中贫困的瞄准偏离研究---基于扎根理论的内蒙古Z县建档立卡案例.公共管理学报,4:1-18.
杨绘荣(2013).外生性与预见性:艾伦·维尔达夫斯基论政治偏好.理论月刊,11:53-57.
詹姆斯·斯科特(2007).弱者的武器.郑广怀、张敏、何江穗译.南京:译林出版社.
张鑫、王丹(2018).基于扎根理论的个体医疗健康信息源选择行为影响因素研究.图书情报工作,14:5-13.
张晶(2017).正式纠纷解决制度失效、牟利激励与情感触发---多重面相中的“医闹”事件及其治理.公共管理学报,1:61-74.
朱恒鹏、昝馨、向辉(2014).财政补偿体制演变与公立医院去行政化改革.经济学动态,12:61-71.
郑庆杰(2015).解释的断桥:从编码到理论.社会发展研究,1:149-164.
Corbin,J.&Strauss,A.(2015).Basics of Qualitative Research:Grounded Theory Procedures and Techniques.CA:Sage.
North,D.C.(1990).Institutional Change and Economic Performance.Cambridge:Cambridge University Press.
Glaser,B.&Strauss,A.(1967).Discovery of Grounded Theory:Strategies for Qualitative Research.Chicago:Aldine Publishing Company.
Glaser,B.(1978).Theoretical Sensitivity.Mill Valley.CA:The Sociology Press.
Glaser,B.(2001).The Grounded Theory Perspective:Conceptualization Contrasted with Description.Mill Valley.CA:The Sociology Press.
Hernndez,D.(2016).Understanding“Energy Insecurity”and Why It Matters to Health.Social Science&Medicine,167:1-10.
Mom,T.J.M.,van den Bosch,F.A.J.&Volberda,H.W.(2009).Understanding Variation in Managers Ambidexterity:Investigating Direct and Interaction Effects of Formal Structural and Personal Coordination Mechanisms.Organization Science,20(4):812-828.
Strauss,A.&Glaser,B.(1965).Awarenessof Dying.Chicago:Aldine Publishing Company.
Smith,M.R.,Grealish,L.&Henderson,S.(2018).Shaping a Valued Learning Journey:Student Satisfaction with Learning in Undergraduate Nursing Programs,a Grounded Theory Study.Nurse Education Today,64:175-179.
Walker,C.,Baxter,J.&Ouellette,D.(2015).Adding Insult to Injury:The Development of Psychosocial Stress in Ontario Wind Turbine Communities.Social Science&Medicine,133:358-365.
Xu,P.,Xu,X.&Su,J.(2017).The Legitimacy Acquisition Mechanism of First-Moving Enterprise under the Background of Industrial Change-A Case Study of State Grid Corporation of China based on Grounded Theory.Economic Management,11:1-9.
Yao,Z.(2012).Practicing Clinical Medicine in a Post-Socialist State:An Empirical Study on Professional Autonomy of Chinese Urban Doctors.Hong Kong:Hong Kong University Dissertation.
常亮(2017).消费者参与共享经济的行为归因和干预路径---基于扎根理论的分析框架.贵州社会科学,8:89-95.
陈振明(1996).工具理性批判---从韦伯、卢卡奇到法兰克福学派.求是学刊,4:4-9.
丁鹏飞、迟考勋、孙大超(2012).管理创新研究中经典探索性研究方法的操作思路:案例研究与扎根理论研究.科技管理研究,17:229-232.
杜创(2017).动态激励与最优医保支付方式.经济研究,52(11):88-103.
费小冬(2008).扎根理论研究方法论:要素、研究程序和评判标准.公共行政评论,3:23-43.
高华、王晓洁(2017).基于扎根理论的BT债务风险因素识别研究.财会通讯,17:96-99.
顾昕(2018).新时代新医改公共治理的范式转型---从政府与市场的二元对立到政府-市场-社会的互动协同.武汉科技大学学报(社会科学版),6:589-600.
郭鹏飞、周英男(2018).基于扎根理论的中国城市绿色转型政策评价指标提取及建构研究.管理评论,8:257-267.
郭科、顾昕(2017).过度医疗的解决之道:管制价格、强化竞争还是改革付费?.广东社会科学,5:176-185.
黄振辉(2010).多案例与单案例研究的差异与进路安排---理论探讨与实例分析.管理案例研究与评论,2:183-188.
黄振辉(2011).表演式抗争:景观、挑战与发生机理---基于珠江三角洲典型案例研究.开放时代,2:71-84.
郇建立(2009).慢性病与人生进程的破坏---评迈克尔·伯里的一个核心概念.社会学研究,5:229-241.
景怀斌(2017).扎根理论编码的“理论鸿沟”及“类故理”跨越.武汉大学学报(哲学社会科学版),6:109-119.
贾旭东(2011).中国城市基层政府公共服务职能的不完全外包及其动因---基于扎根理论的研究发现.管理学报,12:1762-1771.
卡拉威利格(2013).心理学质性研究导论.郭本禹、王申连、赵玉晶译.北京:人民邮电出版社.
李理(2018).基于扎根理论的网络事件信任传递机制研究:以罗尔事件为例.全球传媒学刊,1:39-52.
任其亮、赵子玉(2018).基于扎根理论的网络约车服务质量影响因素研究.重庆交通大学学报(自然科学版),11:1-8.
盛娅农(2017).社会治理创新视角下我国医疗纠纷处理的问题与对策.社会科学研究,6:68-73.
田国强、陈旭东(2018).制度的本质、变迁与选择---赫维茨制度经济思想诠释及其现实意义.学术月刊,50(1):63-77.
汪波、段琪(2014).基于扎根理论的基层医疗卫生机构补偿机制及要素探析.大连理工大学学报(社会科学版),2:20-26.
王志鑫(2017).我国医患关系紧张的法律成因及其对策.卫生经济研究,3:15-18.
吴新叶、袁铭健(2017).医患冲突治理:法治的缺席及其矫治---一个基于身份冲突的解释框架.社会科学,12:13-20.
徐喆玥、谢莹(2016).医患信任现状及影响因素分析.中国卫生质量管理,2:49-52.
徐昕、卢荣荣(2008).暴力与不信任---转型中国的医疗暴力研究:2000~2006.法制与社会发展,1:82-101.
袁树卓、殷仲义、高宏伟、刘沐洋(2018).精准扶贫中贫困的瞄准偏离研究---基于扎根理论的内蒙古Z县建档立卡案例.公共管理学报,4:1-18.
杨绘荣(2013).外生性与预见性:艾伦·维尔达夫斯基论政治偏好.理论月刊,11:53-57.
詹姆斯·斯科特(2007).弱者的武器.郑广怀、张敏、何江穗译.南京:译林出版社.
张鑫、王丹(2018).基于扎根理论的个体医疗健康信息源选择行为影响因素研究.图书情报工作,14:5-13.
张晶(2017).正式纠纷解决制度失效、牟利激励与情感触发---多重面相中的“医闹”事件及其治理.公共管理学报,1:61-74.
朱恒鹏、昝馨、向辉(2014).财政补偿体制演变与公立医院去行政化改革.经济学动态,12:61-71.
郑庆杰(2015).解释的断桥:从编码到理论.社会发展研究,1:149-164.
Corbin,J.&Strauss,A.(2015).Basics of Qualitative Research:Grounded Theory Procedures and Techniques.CA:Sage.
North,D.C.(1990).Institutional Change and Economic Performance.Cambridge:Cambridge University Press.
Glaser,B.&Strauss,A.(1967).Discovery of Grounded Theory:Strategies for Qualitative Research.Chicago:Aldine Publishing Company.
Glaser,B.(1978).Theoretical Sensitivity.Mill Valley.CA:The Sociology Press.
Glaser,B.(2001).The Grounded Theory Perspective:Conceptualization Contrasted with Description.Mill Valley.CA:The Sociology Press.
Hernndez,D.(2016).Understanding“Energy Insecurity”and Why It Matters to Health.Social Science&Medicine,167:1-10.
Mom,T.J.M.,van den Bosch,F.A.J.&Volberda,H.W.(2009).Understanding Variation in Managers Ambidexterity:Investigating Direct and Interaction Effects of Formal Structural and Personal Coordination Mechanisms.Organization Science,20(4):812-828.
Strauss,A.&Glaser,B.(1965).Awarenessof Dying.Chicago:Aldine Publishing Company.
Smith,M.R.,Grealish,L.&Henderson,S.(2018).Shaping a Valued Learning Journey:Student Satisfaction with Learning in Undergraduate Nursing Programs,a Grounded Theory Study.Nurse Education Today,64:175-179.
Walker,C.,Baxter,J.&Ouellette,D.(2015).Adding Insult to Injury:The Development of Psychosocial Stress in Ontario Wind Turbine Communities.Social Science&Medicine,133:358-365.
Xu,P.,Xu,X.&Su,J.(2017).The Legitimacy Acquisition Mechanism of First-Moving Enterprise under the Background of Industrial Change-A Case Study of State Grid Corporation of China based on Grounded Theory.Economic Management,11:1-9.
Yao,Z.(2012).Practicing Clinical Medicine in a Post-Socialist State:An Empirical Study on Professional Autonomy of Chinese Urban Doctors.Hong Kong:Hong Kong University Dissertation.