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Article(id=1321170520670851958, tenantId=1146029695717560320, journalId=1319373219989389464, issueId=1321170520196895605, articleNumber=null, orderNo=null, doi=10.11847/zgggws1143377, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1697990400000, receivedDateStr=2023-10-23, revisedDate=1726588800000, revisedDateStr=2024-09-18, acceptedDate=1732118400000, acceptedDateStr=2024-11-21, onlineDate=1792921198289, onlineDateStr=2026-10-25, pubDate=1741536000000, pubDateStr=2025-03-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1792921198289, onlineIssueDateStr=2026-10-25, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1792921198289, creator=13701087609, updateTime=1792921198289, updator=13701087609, issue=Issue{id=1321170520196895605, tenantId=1146029695717560320, journalId=1319373219989389464, year='2025', volume='41', issue='3', pageStart='257', pageEnd='384', issueExtLink='null', onlineDate='null', pubDate='1741536000000', pubDateStr='2025-03-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1792921198175, creator='13701087609', updateTime=1792921198175, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=303, endPage=310, ext={EN=ArticleExt(id=1321170520977036151, articleId=1321170520670851958, tenantId=1146029695717560320, journalId=1319373219989389464, language=EN, title=A structural equation model analysis of the influence of learning organization construction for primary care physicians, columnId=1320427696342020970, journalTitle=Chinese Journal of Public Health, columnName=Epidemiological Research, runingTitle=null, highlight=null, articleAbstract=
Objective

To analyze the influence of primary care physicians′ professional identity and job resilience on the construction of learning organizations, and to provide a reference for the reform of primary healthcare supply-side capacity.

Methods

From August to October 2022, 400 primary care physicians were selected from Yichang in Hubei province, Zhongmu in Henan province, Neijiang in Sichuan province, and Jinan in Shandong province using purposive sampling. Structural equation modeling was constructed using AMOS 28 software to analyze the influencing factors of learning organization construction among primary care physicians.

Results

A total of 387 valid questionnaires were collected from primary care physicians, of which 27.65% (107 individuals) were classified as high-learning primary care physicians. Primary care physicians with senior professional titles (36 individuals), bachelor′s degree or above (212 individuals), monthly income >5 000 yuan (97 individuals), and more than 10 years of working experience (105 individuals) had a higher proportion of high-learning individuals within their respective groups compared to other types, at 36.11%, 29.72%, 31.56%, and 30.48%, respectively, demonstrating stronger active learning awareness and active service behavior. Structural equation analysis showed that primary care physicians′ professional identity and job resilience had direct effects on the construction of learning organizations, with effect values of 0.255 and 0.273, respectively (both P<0.01). Simultaneously, professional identity positively influenced job resilience, with an effect value of 0.637 (P<0.001). Effect decomposition showed that professional identity could partially and positively affect the construction of learning organizations among primary care physicians through the mediating role of job resilience, with an indirect effect value of 0.174 (P<0.001).

Conclusions

Currently, the construction of learning organizations among primary care physicians needs to be further strengthened. Comprehensively cultivating and shaping primary care physicians′ professional identity and job resilience can effectively enhance their active learning awareness and active service behavior, thereby contributing to the overall framework of supply-side structural reform in the primary healthcare system.

, authors=Yunlong SUO, Chaoyi CHEN, Zhanchun FENG, authorsList=Yunlong SUO, Chaoyi CHEN, Zhanchun FENG, authorCompany=null, correspAuthors=Zhanchun FENG, authorNote=null, correspAuthorsNote=
FENG Zhanchun, E-mail:
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目的

分析基层医生职业认同和岗位韧性对学习型组织建设的影响，为基层医疗卫生供方能力改革提供参考依据。

方法

于2022年8—10月，采用立意抽样方法在湖北宜昌、河南中牟、四川内江、山东济南抽取400名基层医生，并应用AMOS 28软件构建结构方程模型并分析基层医生学习型组织建设的影响因素。

结果

有效调查387名基层医生，其中高学习型基层医生人群占比为27.65%（107人）。高级职称（36人）、本科以上学历（212人）、月收入>5 000元（97人）以及10年以上任职年限（105人）的基层医生相较于其他类型，组内高学习型占比更高，分别为36.11%、29.72%、31.56%和30.48%，主动学习意识和主动服务行为更为强烈。结构方程分析表明，基层医生的职业认同和岗位韧性对学习型组织建设存在直接效应，效应值分别为0.255和0.273（均P<0.01），同时职业认同正向影响基层医生岗位韧性，效应值为0.637（P<0.001），效应分解显示，职业认同可通过岗位韧性的中介作用对基层医生的学习型组织建设产生部分正向效应，间接效应值为0.174（P<0.001）。

结论

当前基层医生学习型组织建设有待进一步加强，全面培育与塑造基层医生职业认同和岗位韧性能够有效增强基层医生主动学习意识与主动服务行为，从而反哺于基层医疗卫生体系供给侧结构性改革的全局架构。

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索云龙（2000—），硕士，研究方向：卫生政策与管理

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冯占春，E-mail：
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Journal of Employment Counseling, 2004, 41(3): 98-104., articleTitle=null, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1321170836585828556, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, xref=null, ext=[AuthorCompanyExt(id=1321170836594217165, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, companyId=1321170836585828556, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China), AuthorCompanyExt(id=1321170836598411470, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, companyId=1321170836585828556, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=华中科技大学同济医学院医药卫生管理学院，武汉 430030)])], figs=[ArticleFig(id=1321170838058029286, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=EN, label=Fig.1, caption=Standardized coefficient structural path diagram, figureFileSmall=KoVBvnzvHfJwuJYjvdrl5g==, figureFileBig=nr8YCuhRfi7+kWpOrMJLcA==, tableContent=null), ArticleFig(id=1321170838125138151, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=CN, label=图1, caption=标准化系数结构路径图

注：图示椭圆形代表潜变量，长方形代表测量变量，圆形代表残差，箭头数字代表标准化路径系数。

, figureFileSmall=KoVBvnzvHfJwuJYjvdrl5g==, figureFileBig=nr8YCuhRfi7+kWpOrMJLcA==, tableContent=null), ArticleFig(id=1321170838217412840, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=EN, label=Tab.1, caption=

Comparison of basic characteristics of the survey subjects by age, gender, ueban/rural, professional title level, education, monthly income (Yuan), years of service (years), employment form

, figureFileSmall=null, figureFileBig=null, tableContent=
组别低学习型组中学习型组高学习型组χ2值P值
人数百分比/%人数百分比/%人数百分比/%
年龄/岁
　18～34105.6811967.614726.715.5860.232
　35～4995.2611869.014425.73
　≥5041020501640
性别
　男性108.557564.103227.352.0530.358
　女性134.8118267.417527.78
居住地
　城市125.0615565.407029.541.6780.432
　农村117.3310268.003724.67
职称级别
　初级74.2211368.074627.7110.5660.103
　中级118.159469.633022.22
　高级002363.891336.11
　无510.002754.001836.00
学历
　（中专）高中及以下24.543272.731022.734.0710.667
　大专96.878867.183425.95
　本科及以上125.6613764.626329.72
月收入/元
　≤3 00077.296264.582728.1314.7410.064
　3 001～5 00073.6113871.134925.26
　>5 00099.285758.763131.56
任职年限/年
　0～5179.8310963.004727.1710.1540.038
　6～1054.597669.722825.69
　>1010.957268.573230.48
用工形式
　事业编146.9013365.525627.588.1180.230
　合同制68.964161.192029.85
　人事代理32.867773.332523.81
　其他00650.00650.00
合计235.9425766.4110727.65
), ArticleFig(id=1321170838301298921, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=CN, label=表1, caption=

调查对象基本特征比较

, figureFileSmall=null, figureFileBig=null, tableContent=
组别低学习型组中学习型组高学习型组χ2值P值
人数百分比/%人数百分比/%人数百分比/%
年龄/岁
　18～34105.6811967.614726.715.5860.232
　35～4995.2611869.014425.73
　≥5041020501640
性别
　男性108.557564.103227.352.0530.358
　女性134.8118267.417527.78
居住地
　城市125.0615565.407029.541.6780.432
　农村117.3310268.003724.67
职称级别
　初级74.2211368.074627.7110.5660.103
　中级118.159469.633022.22
　高级002363.891336.11
　无510.002754.001836.00
学历
　（中专）高中及以下24.543272.731022.734.0710.667
　大专96.878867.183425.95
　本科及以上125.6613764.626329.72
月收入/元
　≤3 00077.296264.582728.1314.7410.064
　3 001～5 00073.6113871.134925.26
　>5 00099.285758.763131.56
任职年限/年
　0～5179.8310963.004727.1710.1540.038
　6～1054.597669.722825.69
　>1010.957268.573230.48
用工形式
　事业编146.9013365.525627.588.1180.230
　合同制68.964161.192029.85
　人事代理32.867773.332523.81
　其他00650.00650.00
合计235.9425766.4110727.65
), ArticleFig(id=1321170838385185002, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=EN, label=Tab.2, caption=

Factor loadings and cumulative contribution

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潜变量观察变量题型条目因子载荷累计贡献率/%Cronbach′s alpha系数
学习型组织A1我身边的同事重视日常专业知识学习与技术业务提升0.75519.0980.865
A2为了拓宽知识获取渠道，我会主动寻求信息，以其他学习型科室为标杆、
聘请外部专家讲解、学习诊疗规范获取知识		0.697
A3我们通过团队学习新技术新项目，实现效率与效能的提升0.819
A4单位支持能够提供学习机会并创造知识的特别业务科室或者业务项目0.829
A5我会借助现有的基层卫生管理信息系统，使我的工作变得更容易0.678
职业认同B1为了单位发展，我愿意尽全力履行超过一般岗位要求的工作任务和职责0.75952.6960.938
B2我会尽所能地努力工作，即使要花很长的时间或牺牲休息时间0.731
B3我以我现在的这份工作为荣0.848
B4我对这份工作还比较满意且对工作前景充满希望0.826
B5当我和朋友谈起单位时我很自豪地给他们介绍我所服务的单位0.772
B6我相信我的成功是依赖在单位的成功上0.816
B7我很高兴最终进入了这家单位，而不是其他单位0.827
B8我非常关心单位的未来发展和命运0.752
B9我对本单位的发展具有十足的信心0.747
岗位韧性C1相信自己有足够知识胜任工作，有信心战胜困难0.77267.3280.834
C2即使面对职业压力，我也会满怀热情工作0.804
C3当面对职业压力时，我萌生过离职的意愿（反向）0.608
C4我能够从困境中不断提升自我0.751
), ArticleFig(id=1321170838464876779, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=CN, label=表2, caption=

因子载荷与累计贡献

, figureFileSmall=null, figureFileBig=null, tableContent=
潜变量观察变量题型条目因子载荷累计贡献率/%Cronbach′s alpha系数
学习型组织A1我身边的同事重视日常专业知识学习与技术业务提升0.75519.0980.865
A2为了拓宽知识获取渠道，我会主动寻求信息，以其他学习型科室为标杆、
聘请外部专家讲解、学习诊疗规范获取知识		0.697
A3我们通过团队学习新技术新项目，实现效率与效能的提升0.819
A4单位支持能够提供学习机会并创造知识的特别业务科室或者业务项目0.829
A5我会借助现有的基层卫生管理信息系统，使我的工作变得更容易0.678
职业认同B1为了单位发展，我愿意尽全力履行超过一般岗位要求的工作任务和职责0.75952.6960.938
B2我会尽所能地努力工作，即使要花很长的时间或牺牲休息时间0.731
B3我以我现在的这份工作为荣0.848
B4我对这份工作还比较满意且对工作前景充满希望0.826
B5当我和朋友谈起单位时我很自豪地给他们介绍我所服务的单位0.772
B6我相信我的成功是依赖在单位的成功上0.816
B7我很高兴最终进入了这家单位，而不是其他单位0.827
B8我非常关心单位的未来发展和命运0.752
B9我对本单位的发展具有十足的信心0.747
岗位韧性C1相信自己有足够知识胜任工作，有信心战胜困难0.77267.3280.834
C2即使面对职业压力，我也会满怀热情工作0.804
C3当面对职业压力时，我萌生过离职的意愿（反向）0.608
C4我能够从困境中不断提升自我0.751
), ArticleFig(id=1321170838536179948, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=EN, label=Tab.3, caption=

Convergent and discriminant validity

, figureFileSmall=null, figureFileBig=null, tableContent=
潜变量职业认同岗位韧性学习型组织
职业认同0.794
岗位韧性0.637 a0.746
学习型组织0.429 a0.436 a0.757
AVE0.6310.5570.573
C.R.0.9390.8340.868
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聚敛效度与区分效度

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潜变量职业认同岗位韧性学习型组织
职业认同0.794
岗位韧性0.637 a0.746
学习型组织0.429 a0.436 a0.757
AVE0.6310.5570.573
C.R.0.9390.8340.868
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Standardized path effect decomposition test

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项目点估计值系数相乘积自助法
标准误Z值偏差矫正95%CI分位数95%CI双侧显著性
直接效应
职业认同→学习型组织0.2550.0813.150.100～0.4150.091～0.408<0.01
岗位韧性→学习型组织0.2730.0773.550.122～0.4250.126～0.429<0.01
职业认同→岗位韧性0.6370.03916.330.554～0.7050.558～0.709<0.01
间接效应
职业认同→学习型组织0.1740.0533.280.077～0.2840.079～0.287<0.001
总效应
职业认同→学习型组织0.4290.0597.270.312～0.5410.311～0.540<0.001
岗位韧性→学习型组织0.2730.0773.550.122～0.4250.126～0.429<0.01
职业认同→岗位韧性0.6370.03916.330.554～0.7050.558～0.709<0.01
), ArticleFig(id=1321170838737506543, tenantId=1146029695717560320, journalId=1319373219989389464, articleId=1321170520670851958, language=CN, label=表4, caption=

标准化路径效应分解检验

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项目点估计值系数相乘积自助法
标准误Z值偏差矫正95%CI分位数95%CI双侧显著性
直接效应
职业认同→学习型组织0.2550.0813.150.100～0.4150.091～0.408<0.01
岗位韧性→学习型组织0.2730.0773.550.122～0.4250.126～0.429<0.01
职业认同→岗位韧性0.6370.03916.330.554～0.7050.558～0.709<0.01
间接效应
职业认同→学习型组织0.1740.0533.280.077～0.2840.079～0.287<0.001
总效应
职业认同→学习型组织0.4290.0597.270.312～0.5410.311～0.540<0.001
岗位韧性→学习型组织0.2730.0773.550.122～0.4250.126～0.429<0.01
职业认同→岗位韧性0.6370.03916.330.554～0.7050.558～0.709<0.01
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基层医生学习型组织建设影响结构方程模型分析
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索云龙 , 陈超亿 , 冯占春 *, *
中国公共卫生 | 流行病学研究 2025,41(3): 303-310
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中国公共卫生 |流行病学研究 2025 , 41 (3) : 303 -310
基层医生学习型组织建设影响结构方程模型分析
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索云龙（2000—），硕士，研究方向：卫生政策与管理

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索云龙, 陈超亿, 冯占春*, *
作者信息
  • 华中科技大学同济医学院医药卫生管理学院，武汉 430030
通讯作者:
冯占春，E-mail：
作者简介:

索云龙（2000—），硕士，研究方向：卫生政策与管理

A structural equation model analysis of the influence of learning organization construction for primary care physicians
Yunlong SUO, Chaoyi CHEN, Zhanchun FENG
Affiliations
  • School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
    • Corresponding Author:
    FENG Zhanchun, E-mail:
出版时间: 2025-03-10 doi: 10.11847/zgggws1143377
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摘要
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目的

分析基层医生职业认同和岗位韧性对学习型组织建设的影响，为基层医疗卫生供方能力改革提供参考依据。

方法

于2022年8—10月，采用立意抽样方法在湖北宜昌、河南中牟、四川内江、山东济南抽取400名基层医生，并应用AMOS 28软件构建结构方程模型并分析基层医生学习型组织建设的影响因素。

结果

有效调查387名基层医生，其中高学习型基层医生人群占比为27.65%（107人）。高级职称（36人）、本科以上学历（212人）、月收入>5 000元（97人）以及10年以上任职年限（105人）的基层医生相较于其他类型，组内高学习型占比更高，分别为36.11%、29.72%、31.56%和30.48%，主动学习意识和主动服务行为更为强烈。结构方程分析表明，基层医生的职业认同和岗位韧性对学习型组织建设存在直接效应，效应值分别为0.255和0.273（均P<0.01），同时职业认同正向影响基层医生岗位韧性，效应值为0.637（P<0.001），效应分解显示，职业认同可通过岗位韧性的中介作用对基层医生的学习型组织建设产生部分正向效应，间接效应值为0.174（P<0.001）。

结论

当前基层医生学习型组织建设有待进一步加强，全面培育与塑造基层医生职业认同和岗位韧性能够有效增强基层医生主动学习意识与主动服务行为，从而反哺于基层医疗卫生体系供给侧结构性改革的全局架构。

基层医生  /  职业认同  /  岗位韧性  /  学习型组织
Objective

To analyze the influence of primary care physicians′ professional identity and job resilience on the construction of learning organizations, and to provide a reference for the reform of primary healthcare supply-side capacity.

Methods

From August to October 2022, 400 primary care physicians were selected from Yichang in Hubei province, Zhongmu in Henan province, Neijiang in Sichuan province, and Jinan in Shandong province using purposive sampling. Structural equation modeling was constructed using AMOS 28 software to analyze the influencing factors of learning organization construction among primary care physicians.

Results

A total of 387 valid questionnaires were collected from primary care physicians, of which 27.65% (107 individuals) were classified as high-learning primary care physicians. Primary care physicians with senior professional titles (36 individuals), bachelor′s degree or above (212 individuals), monthly income >5 000 yuan (97 individuals), and more than 10 years of working experience (105 individuals) had a higher proportion of high-learning individuals within their respective groups compared to other types, at 36.11%, 29.72%, 31.56%, and 30.48%, respectively, demonstrating stronger active learning awareness and active service behavior. Structural equation analysis showed that primary care physicians′ professional identity and job resilience had direct effects on the construction of learning organizations, with effect values of 0.255 and 0.273, respectively (both P<0.01). Simultaneously, professional identity positively influenced job resilience, with an effect value of 0.637 (P<0.001). Effect decomposition showed that professional identity could partially and positively affect the construction of learning organizations among primary care physicians through the mediating role of job resilience, with an indirect effect value of 0.174 (P<0.001).

Conclusions

Currently, the construction of learning organizations among primary care physicians needs to be further strengthened. Comprehensively cultivating and shaping primary care physicians′ professional identity and job resilience can effectively enhance their active learning awareness and active service behavior, thereby contributing to the overall framework of supply-side structural reform in the primary healthcare system.

primary care physicians  /  professional identity  /  job resilience  /  learning organization
索云龙, 陈超亿, 冯占春. 基层医生学习型组织建设影响结构方程模型分析. 中国公共卫生, 2025 , 41 (3) : 303 -310 . DOI: 10.11847/zgggws1143377
Yunlong SUO, Chaoyi CHEN, Zhanchun FENG. A structural equation model analysis of the influence of learning organization construction for primary care physicians[J]. Chinese Journal of Public Health, 2025 , 41 (3) : 303 -310 . DOI: 10.11847/zgggws1143377
正文
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《“健康中国2030”规划纲要》指出，坚持“以全科医生为重点，加强基层人才队伍建设”，进一步明确基层医生在基层医疗卫生体系建设中的核心地位与维护人民群众生命健康的“守门人”角色。随着医疗技术的不断迭代与基层信息化的持续普及，促使基层医生在日常工作中面临着更为开放和复杂的工作环境与医疗需求，集体合作与交流学习在医疗大数据加持下显得尤为重要，势必需要基层医生持续构筑自身学习力以应对职业发展与变化。实践证明，通过搭建学习型组织能够有效增强医务工作者的学习力[1]，从而提升其医疗质量与工作效能[2]。本研究依托科技部国家重点研发项目“健康管理综合服务应用示范”，于2022年8—10月选取湖北宜昌、河南中牟、四川内江、山东济南4个监测点的社区卫生服务中心和乡镇卫生院共400名全科医生和公卫医师并进行问卷调查，应用结构方程模型探究基层医生学习型组织建设的影响因素及能力提升路径。现将结果报告如下。
1　对象与方法
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1.1　对象
本研究采用立意抽样方法整群抽取湖北宜昌、河南中牟、四川内江、山东济南4个监测点的社区卫生服务中心和乡镇卫生院的基层全科医生和公卫医师共400人，发送线下实体问卷400份，回收有效问卷387份，有效率为96.75%，满足结构方程模型样本量要求。为充分了解当前基层医生学习型组织建设的基本构成，详细区分不同学习型分组下基层医生现状特征，对387份问卷的学习型组织模块进行评估，总得分在0～10、11～20以及21～25分的基层医生群体分别被设定为低、中、高学习组，分别为23、257和107人，得分越高证明基层医生自主学习和服务能力越强。研究获得华中科技大学同济医学院医学伦理委员会伦理审批，批准文号：[2023]伦审字（S065）号，所有调查对象均知情同意。
1.2　方法
1.2.1　关键知情人访谈
为充分了解基层医生学习型组织建设的影响因素并构建理论框架与模型假设，在问卷设计前，随机选取湖北宜昌、河南中牟、四川内江、山东济南28名基层医生，含社区卫生服务中心全科医生6人，公卫医师8人，乡镇卫生院全科医生7人，公卫医师7人，进行个体定向结构性访谈。访谈内容包括：（1）基层医生相关职业热情与满意度以及职业发展前景等职业认同模块；（2）基层医生相关岗位需要、工作困窘以及离职意愿等岗位韧性模块；（3）基层医生主动学习意识、学习交流与合作以及主动服务开展等学习型组织建设模块。访谈发现，基层医生对职业当下的满意程度与未来发展前景以及岗位稳定性等因素会深刻影响其主动学习、主动服务等行为。
1.2.2　问卷编制与预调查
结合已有成熟量表，学习型组织模块问卷参考Marsick V J等[3]的学习型组织多维度问卷，从个人、团队和组织3个方面构建，分别涉及个体学习态度、团队协同水平和组织学习支撑等内容；职业认同模块问卷参考王晔安等[4]的职业认同量表，从依恋、认知、支持3个领域构建，分别涉及职业自我奉献、职业认知骄傲、职业前景期许等内容；岗位韧性模块问卷参考宋国学[5]的职业韧性量表，从情感、认知和行为3个维度构建，分别涉及工作情感表达、岗位自我效能、韧性行为模式等内容，均采用李克特五点计分，1表示“完全不认同”，5表示“完全认同”，自评数字越高认可度越高。基于以上，编制出基层医生学习型组织及其影响因素的初测量表，并从正式调查的400名基层医生中随机进行100人次预调查。与正式调查形式相同，共发放100人次预调研实体问卷，回收有效问卷98份。经分析，题项均未存在逻辑混乱、故意引导、选择率过低（<5%）、选择过于集中（>80%）等问题。
1.2.3　Delphi专家咨询
根据初测量表和预调查结果共进行2轮德尔菲咨询。专家纳入标准：（1）中级职称且在本专业领域工作>10年，或具有副高级及以上职称且在本专业领域工作>5年；（2）本科及以上学历；（3）年龄≤65岁；（4）自愿参与本研究。共选取20名相关专业的专家参与咨询。依据积极性、权威性、代表性和专业性原则，线上邮件邀请20名专家填写专家咨询表（函），对于所列题项进行逐个打分。为确保专家构成全面专业、学科完整，预先设定专家组成标准：（1）监测点区级卫健系统从事基层卫生工作的分管领导4人；（2）基层医疗机构管理者2人；（3）从事卫生政策、卫生经济、公共卫生、基层卫生教学和科研的高校教师各2人，共8人；（4）社区卫生服务中心和乡镇卫生院从事全科医学及公共卫生工作的基层医生各3人，共6人。第1轮专家咨询旨在收集题项打分初始数据和专家意见进行初步分析；第2轮专家咨询旨在针对第1轮结果再次打分，并按照相应标准进行题项筛选，2轮专家人数与组成保持一致，未出现中途退出、更换专家的情况。2轮打分均对各题项重要性、可行性、敏感性分别打分（1～5分），分别从指标综合得分（Xij）、变异系数（CV）、专家权威系数（Cr）以及问卷整体专家积极系数和协调系数（W）考评，若题项的Xij均值≤4.0、CV≥0.2且Cr<0.8予以剔除，专家积极系数>80%且协调系数取值趋向1（P<0.05）说明专家积极一致性高[6]。
1.2.4　问卷修订
根据德尔菲专家咨询结果，两轮咨询各发放20份问卷，规定时间内均回收20份，专家积极系数为100%，说明专家具有较强的认可度与可靠性；各级指标权威系数（Cr）为0.86，体现专家对本研究提出的相关题项较为熟悉；指标的重要性、可行性和敏感性的协调系数（W）分别为0.356、0.321和0.309，差异均具有统计学意义（P<0.001），表明专家意见的协调一致性良好。根据评判标准和专家意见，结合课题组讨论，2轮专家咨询后对部分题项进行如下修订：（1）对学习型组织中条目A2、A3，职业认同中条目B2、B7以及岗位韧性中条目C2进行修改并去除冗杂表述，题项内涵进行完善；（2）将初测问卷学习型组织、岗位韧性中删除条目3项（综合得分Xij均低于4分，且指标CV值高于0.2），包括业务知识外自主探索、岗位管理决策等题项；（3）将初测问卷职业认同中增补条目2项，涉及团队职业支持与个人职业信念。最终形成“基层医生学习型组织建设影响因素调查问卷”，以充分反映我国基层医生的实际现状。
1.3　统计方法
使用SPSS 25进行描述性分析，计量资料以$ \bar x \pm s$形式表示，计数资料以频数和百分比（%）形式表示，计数资料组间比较采用χ2检验。利用探索性以及验证性因子分析进行信效度检验。信度检验主要依据探索性因子分析中Cronbach′s alpha系数与KMO和Barlett球形检验进行判别，Cronbach′s alpha系数>0.7，KMO值>0.5，Barlett球形检验P<0.05即表明问卷题项具有较高的可靠性[7]。效度检验主要依据验证性因子分析中聚敛效度与区分效度，前者组成信度C.R.值需>0.8，潜变量AVE需在0.5以上；后者需计算各潜变量间相关系数，若各潜变量AVE平方根均大于所在同行列相关系数绝对值则说明问卷题项具有较好的区分程度[8]。探索性因子分析和验证性因子分析需使用不同数据源[9]，因此从387份样本数据中随机抽取150份样本进行探索性因子分析，全样本进行验证性因子分析。采用AMOS 28进行结构方程模型构建、检验与分析，采用最大似然估计法进行参数估计，以P<0.05为差异有统计学意义。
2　结　果
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2.1　基本情况（表1）
共调查的387名基层医生中，低、中、高学习组人数分别为23人（5.94%）、257人（66.41%）和107人（27.65%），3组平均年龄分别为（38.87±9.61）、（37.84±8.00）和（39.16±8.81）岁；男性117人（30.23%），女性270人（69.77%）；居住在城市237人（61.24%），农村150人（38.76%）；初级职称166人（42.89%），中级职称135人（34.88%），高级职称36人（9.30%），无职称50人（12.92%）；（中专）高中及以下44人（11.37%），大专131人（33.85%），本科及以上212人（54.78%）；月收入≤3 000元96人（24.81%），3 001～5 000元194人（50.13%），>5 000元97人（25.06%）；任职年限为0～5年173人（44.70%），6～10年109人（28.17%），10年以上105人（27.13%）；用工形式中，事业编203人（52.45%），合同制67人（17.31%），人事代理105人（27.13%），其他12人（3.10%）。将年龄、性别、居住地、职称级别、学历、月收入、任职年限、用工形式与3组学习型类别进行χ2检验，结果所示，3类学习型组人群的年龄、性别、居住地、职称级别、学历、月收入、用工形式均无统计学差异（均P>0.05），而任职年限在学习型类别上的差异有统计学意义（P<0.05）。
2.2　问卷检验
2.2.1　探索性因子分析（表2）
由表2可知，学习型组织、职业认同和岗位韧性3个潜变量的Cronbach′s alpha系数分别为0.865、0.938和0.834，均>0.8，KMO=0.905，>0.9，Barlett球形检验的χ2=1 872.727，df=153，P<0.001，表明问卷具有较强的可靠性并适合进行探索性因子分析[10]。各观察变量的因子载荷均>0.6，在各自潜变量上呈现出较强的集聚性，因子组成同模型假设保持一致。同时，Harman的单因素检验下未出现能够解释大部分变异（>40%）的因子[11]，认为此量表不存在严重的共同方法偏差，方差累计贡献率>60%，说明提取出的主成分能够较好地反映原始数据。
2.2.2　验证性因子分析（表3）
利用AMOS对测量模型进行验证性因子分析。由表3可知，从聚敛效度来看，各项观察变量的组成信度C.R.值>0.8，收敛效度AVE均>0.5[12]，表明问卷各部分内部变量具有较强的一致性。从区分效度来看，学习型组织、职业认同和岗位韧性之间具有相关性（P<0.001），各项潜变量AVE平方根均大于所在同行列相关系数绝对值[13]，表明各潜变量之间具有一定的相关性，且彼此之间又具有较为清晰的区分程度。
2.3　模型分析
2.3.1　模型拟合度检验
模型拟合指数主要考察结构模型与拟合程度的统计指标。经检验，问卷Chi-square=375.969，DF=132，Chi/DF=2.848<3，GFI=0.917>0.90，RMR=0.028<0.05，RMSEA=0.069<0.08，CFI=0.944>0.90，IFI=0.945>0.90，RFI=0.904>0.90，NFI=0.917>0.90，TLI=0.936>0.90，模型所有的拟合度指标均在要求范围之内[14]，表明模型结构效度良好，设计较为合理。
2.3.2　模型路径检验（图1）
运用AMOS构建并检验基层医生学习型组织的影响因素模型，结构模型的3条路径的临界比值C.R.绝对值，即T值均>1.96[15]，表明估计值至少达到0.05的显著水平。由图1可知，所有观测变量的标准化系数均>0.6（P<0.001），表明测量模型中的各项数据均能有效反映观察变量特征。路径分析结果显示，职业认同对基层医生的学习型组织建设产生正向影响（β=0.255，P<0.01），即职业认同感每提升1个单位，学习型组织建设会提升0.255个单位。岗位韧性对基层医生的学习型组织建设产生正向影响（β=0.273，P<0.01），岗位韧性高的基层医生会有更强的意愿推动学习型组织建设。职业认同对基层医生的岗位韧性产生正向影响（β=0.637，P<0.001），职业认同与岗位韧性存在密切的正相关。
2.4　Bootstrap效应检验（表4）
采用Bootstrap法对各路径的直接效应、间接效应和总效应进行分解检验，在95%CI上采用重复随机抽样的方式再从原始数据中抽取5 000次样本并估计，若95%CI区间值中不包括0，则证明路径效应显著[16]。由表4所示，Bootstrap检验结果证实岗位韧性在职业认同与学习型组织关系中存在部分正向中介效应，标准化间接效应为0.174，P<0.001。
3　讨　论
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本研究结果显示，72.35%（280人）的基层医生主动学习意愿仍旧不强，调查对象中高学习组人群占比仅为27.65%（107人）。值得注意的是，高级职称、本科及以上学历、月收入>5 000元、任职年限>10年的基层医生相较于组内其他对象人群，其高学习组人数占比均为最大，分别为36.11%、29.72%、31.56%、30.48%，尤其是任职年限在3组学习型人数上的差异有统计学意义（P<0.05），可能职称、收入、学历以及任职年限与基层医生自主学习呈一定相关关系，后续研究可持续关注。基层医生的学习型组织建设是职业认同和岗位韧性的共同作用结果。良好的职业认同有助于营造良好的集体学习氛围，为个体到团队再到组织构筑起沟通交流、互惠共助的学习型组织平台。当前学界认为，良好的职业认同能够实现组织整体的认知塑造，并促使基层医生采取积极主动的工作策略，帮助其在面对学习型、开放性的工作环境中妥善平衡常规性医疗服务与突发性医疗事件[17]，实现自我效能的全面发挥与组织效能的全面再造，这一导向也符合学习型组织的未来发展要求[18]。同时，岗位韧性高的基层医生会有更强的意愿推动学习型组织建设。原因在于，一方面岗位韧性能够帮助基层医生妥善处理医患矛盾、工作超负等职业挫折与压力并激发其对抗逆境、主动学习的自我效能，另一方面，这种特质所外延出的岗位稳定会为学习型组织建设提供一个良好的权变环境[19]。职业认同可通过提升岗位韧性进一步正向作用于基层医生学习型组织建设。从现实来看，受制于工作环境与职业属性，基层医生不仅长期负载繁重的基层医卫工作，而且其待遇保障与晋升发展存在困难，导致这一群体的离职倾向普遍高于医生平均水平[20]。相关研究表明，基于职业认同的就业力与面对工作变化时的积极情感、积极承诺呈现显著正相关[21]，这一结果与本研究一致，即职业认同水平越高，其更倾向于积极面对职业压力和职业威胁[22]。基于此，随着高职业认同的基层医生的岗位韧性得到持续强化，个体的价值定位与组织期望被充分融入，有利于促进基层医生在相对稳定与同质环境下，从个体到团队的主动学习意识增强与主动服务行为的提升，打造良好的学习型组织环境。
本研究具有以下边际贡献：（1）针对基层医生这一群体，探讨和验证了职业认同与学习型组织建设的正向影响作用。现有研究基层医生学习型组织建设文献鲜有，多数研究从医院文化[23]和个人行为[24]层面入手探索医生学习氛围营造与价值共创。因此，本研究将视角聚焦至基层医生群体，充分弥合其职业认同与学习型组织两者间的价值诉求，从个体职业认同拓展延伸至集体组织学习，通过检验职业认同与学习型组织的作用机制，丰富了职业认同效能研究。职业认同越强，基层医生的学习型组织建设越有效，这也与已有研究所发现的职业认同对学习型组织的预测作用保持一致[25]。（2）本研究探索了岗位韧性在职业认同与学习型组织建设之间的部分中介效应机制，揭示了基层医生“职业认同–岗位韧性–学习型组织”的建构路径。当前对职业认同与学习型组织的中介关系的研究多从情感特征、个人性格、职业倦怠以及领导力等视角入手[26–27]。本研究则依托“职业韧性是维系职业认同和行为改变之间的重要因素”[28]这一整体性逻辑框架，将岗位韧性融入职业认同和学习型组织的研究当中，丰富了基层医生学习型组织建设的职业影响因素和正向预测视域，进一步拓展了岗位韧性的前因后效研究内涵。
总之，串联“职业认同–岗位韧性–学习型组织”的基层医生能力建设模型是提升基层医疗卫生供方主动学习意识、主动服务能力的重点实践路径。本研究的主要发现是，高职业认同的基层医生会在工作中强化自身价值与职业满意度，提高应对职业挫折与压力的能力，形成自身的岗位韧性，从而逐步实现自我超越、团队学习等学习型组织建设目标，最终为基层医疗卫生体系的全局建设提供良好的人力资本基础，这一观点为搭建基层医生学习型组织建设路径提供一定的学理依据。基于此，提出针对基层医生学习型组织建设的实践启示：一是持续塑造基层医生在健康管理与服务中的职业认同感，搭建学习型组织建设的职业平台，切实保障基层医生岗位薪酬待遇[29]，加强基层医生职业身份认同；二是不断培育和提升基层医生的岗位韧性，营造学习型组织建设的坚实环境，支持基层医生外部心理干预、内在韧性激发与认知行为转化[30]，从而打通从认知转化到行为改变的基层医生学习型组织建设的通路。但本研究亦存在一定局限性，如潜变量设置较为主观灵活，样本量仍需进一步扩充，此外，基层医生学习型组织建设因素具有复杂性，本研究未能将更多的影响因素纳入其中，望后续研究不断完善补充。

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doi: 10.11847/zgggws1143377
  • 接收时间：2023-10-23
  • 首发时间：2026-10-25
  • 出版时间：2025-03-10
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  • 收稿日期：2023-10-23
  • 修回日期：2024-09-18
  • 录用日期：2024-11-21
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    华中科技大学同济医学院医药卫生管理学院，武汉 430030

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冯占春，E-mail：
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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