隨著國內社會變遷，人口結構改變，當失能老人家庭成員無法照顧或根本没有家人可以照顧時，提供可近性之社區型機構式照顧之小型養護機構就應運而生。台北市小型養護機構從未立案時期蓬勃發展，至民國86年「老人福利法」修正，政府開始透過法制化將小型養護機構管理制度化後，機構數從立案初期民國90年之203家降至98年6月之154家。依據內政部社會司民國98年6月統計資料顯示，全國養護機構養護床位平均進住率為73.84%，台北市則為82.37%；98年6月全國老年人口比率為10.52%，而台北市老人人口比率則已達12.43%，顯見台北市老人人口增加比率高於全國比率，且其養護機構占床率亦高於全國平均值。依上述數據合理推估，台北市老人對於養護機構需求應遠大於其他縣市，但統計資料卻顯示台北市養護機構卻逐年遞減。當機構負責人不斷反應，政府政策造成台北市機構經營困境。本研究想瞭解政府對小型養護機構管理政策在不同階段有何變演？進一步探討政策演變過程，對小型養護機構發展產生何種影響？再者探究除政府政策外，尚有那些因素會影響小型養護機構發展？ 本研究在著手進行文獻探討時，發現與台北市小型養護機構政策演變有關時間點，可以依時間序列分為五個階段；第一階段：民國80年以前，完全没有政策規範機構之政策空窗期；第二階段：民國80年至86年，台北市政府頒布「台北市私立老人養護所設置管理辦法」開始規範台北市小型養護機構之政策蘊釀期；第三階段：民國86年至88年，「老人福利法」修正後小型養護機構即將開始法制化規範之政策緩衝期；第四階段：民國88年至96年，小型養護機構邁入正式法制化管理之政策完備期；第五階段：民國96年以後，「老人福利法」再次修正之政策變革期。研究者再依據此五個時間階段，深度訪談機構負責人、地方政府及中央政府政策制訂者、學者專家，瞭解每一階段政府政策演變對小型養護機構發展有何影響。 研究發現，政策空窗期，小型養護機構不需立案、政府無法可管，機構自主性最高可以隨意發展；政策蘊釀期，台北市雖擬以地方法規規範小型養護機構，但因為没有罰則及強制力，機構配合度不高，政府政策對機構缺少制約力；政策緩衝期，老人福利法及子法已經修正通過，小型養護機構面對公權力即將強力規範，仍試圖抗爭以拖延政府管制時間，此階段機構與政府之間關係充滿衝突；政策完備期，政府對於小型養護機構從立案、評鑑、督導等各項法制完備，小型養護機構自主性大幅降低，發展意願也逐漸降低；政策變革期，老人福利法經10 年後再次修正，機構自主性再次限縮，許多理想性修法結果，尤其硬體設備部分對於屬都會型之台北市小型養護機構產生配合困難。本研究同時發現，對小型養護機構之管理政策，中央政府透過法制規範全力主導，地方政府自主性也相對降低，也就是政策完備期開始，影響小型養護機構發展之政策主要在於中央政府之法規。 本研究依據訪談結果，剖析後分別對相關人員提出建議如下，對政策制訂者：應正視台北市小型養護機構減少趨勢規劃因應策略、對於評鑑制度應檢討修正評鑑指標去蕪存菁、規劃小型養護機構專業分級制度、適時修正與小型養護機構發展扞挌之法令規章；對小型養護機構建議：關心政策對小型養護機構發展之影響、運用創新思維營造小型養護機構獨特競爭力、加強小型養護機構組成協會之整合資源能力、加強小型養護機構正面功能宣導；社會大眾則建議利用評鑑指標共同監督機構服務品質。 / With the change of the domestic society as well as the population structure, the small community nursing centers have been established as many family members or even no one can take care of the disabled elderly person. The development of the small nursing center was raised in the unregistered period. Since 1997, the “Senior Citizen Welfare Act” was revised and the government started to systematically manage the small nursing centers by regulations. As a result, the number of the nursing center decreased from 203 in 2001 to 154 in 2009. According to the statistic of the Department of Social Affairs in June 2009, the accommodating rate of the nursing bed of all nursing centers in Taiwan is 73.84% and 82.37% in Taipei City. In June 2009, the ratio of the senior population is 10.52% in Taiwan and 12.43% in Taipei City. It indicates that the proportion of the senior citizens in Taipei is greater than the national proportion. In addition, the accommodating rate of the nursing bed in Taipei is also greater than the average number of the country. Based on the above reasonable estimations, the demand for the nursing centers in Taipei City is greater than other cities and counties. However, the statistic shows that the number of the nursing center in Taipei gradually decreases. When the owners of the nursing centers in Taipei continuously emphasizing the government policy has created barriers to manage the nursing centers in Taipei City, this study aims to study how the government policy changes in each stage, and discuss how the policy change procedure and the remaining factors affect the development of the nursing centers. This research found that the development period of the small nursing center in Taipei City can be divided into 5 stages according to the time order; the first stage(vacancy period): before 1991, there was no policy to regulate the nursing centers; the second stage(preparation period): from 1991 to 1997, Taipei City Government announced the “Private Elderly Nursing Center Establishment Steps of Taipei City” and started to regulate the small nursing centers in Taipei City; the third stage(initial period): from 1997 to 1999, the small nursing centers started to be regulated after the “Senior Citizen Welfare Act” has been revised; the fourth stage(completion period): from 1999 to 2007,the small nursing centers were officially regulated by the acts; the fifth stage(reform period), after 1997, the “Senior Citizen Welfare Act” was once again amended. The researcher conducts several in-dept interviews of the owners of the nursing centers, local and central government policy makers, scholars and professionals of each stage to understand how the government policy affects the development of the small nursing center in each stage. In the completion period, the government has set up a complete system from registration, evaluation to supervision. As a matter of act, the independence of the small nursing centers significantly decreased which has resulted in a decrease of their willingness for development. During the reform period, the Senior Citizen Welfare Act was revised again after 10 years. The independence of the organizations was once again restricted. Many small nursing centers in Taipei City have had difficulties to cooperate with the ideal revised results such as the hardware facility. This study also found that the central government fully controlled the small nursing centers through the management policies while the local government started to lose the power of control. In the beginning of the completion period, the central government regulation was the key to affect the development of the small nursing centers. It is found that the registration was not required for the small nursing center in the vacancy period. The organizations were highly independent and could develop according to their interests. In the preparation stage, Taipei City has drafted the local regulations to regulate the small nursing center but the centers were not willing to cooperate due to the lack of penalty and government power over the restriction. In the initial period, although the Senior Citizen Welfare Act has been revised, the nursing centers still attempted to extend the government’s restriction. There were a lot of conflicts between the government and the nursing centers in this stage. Based on the interview results, this study provides the following recommendations to the related personnel after the analysis. To the policy makers: it is necessary to plan the strategies to cope with the decreasing trend of the small nursing center in Taipei City, review the evaluation system, revise the evaluation index, plan the professional classification of the small nursing centers and appropriately amend the regulations for the development of the small nursing center. To the small nursing centers: they should concern about the impact on the development of the small nursing centers, apply new thinking to create the competitive advantage, and improve the resource integration ability of the small nursing center association and the positive promotion of the small nursing center. It is recommended that the public should monitor the service quality of the organization based on the evaluation index. Keywords: small nursing center, evaluation system, senior citizen welfare

隨著高齡社會的來臨、85歲以上之「老老人」人數增長，具有長期照護需求者亦隨之增加；在眾多長期照顧資源中，目前以小型養護機構的所提供的服務量最為多，可見此種機構類型在長期照顧領域中的重要性。由於長期照顧機構間競爭激烈及評鑑期待等因素，使得服務品質成為目前小型養護機構發展的目標；社工員專業功能的發揮對於機構服務品質提升多有助益，但社工員的任用或許因為法源不足、成本考量、機構人員認識不足等因素沒有受到同等的重視，亦形成社工員高流動率與聘僱不易等問題。目前對於此研究對象的相關研究甚少，無法對於此種現象進行瞭解，且不能解答筆者過去一年多兼職工作經驗中所產生的疑慮，因而本研究以小型養護機構社工員為研究對象，探討其專業角色的發展歷程。本研究之目的如下：（1）試圖了解小型養護機構社工員在機構內的工作職責；（2）這些角色如何學習、建構與發展之歷程；（3）社工員的角色認知與其它工作人員角色期待磨合的過程；（4）此段過程中的各式影響因素；（5）期待本研究能使政策制定者、社工教育的學者及實務工作者關注社工員在小型養護機構內奮鬥的辛酸，並提出改善社工員所處情境之建議。 本研究因為過去相關研究甚少、據探索性研究特質、以生命經驗作為探索焦點及重視研究參與者觀點等因素採用質性研究典範，使用深度訪談方式蒐集資料，並以樣版式方法進行分析，在研究過程中亦有處裡研究倫理及信、效度等議題。本研究之研究結果為：（1）社工員於小型養護機構內的工作職責為「與個案一起工作」、「與家屬一起工作」及「與機構一起工作」；（2）專業角色發展歷程大致可歸納為兩主軸，其一為「角色不明確->學習」，初入機構時，多數社工員會感到角色不明確，而出現不知所措、挫折感、壓力、沒有成就感與緊張害怕等情緒，其運用正式教育訓練與非正式觀察模範、蒐集資訊、反思學習等方式進行社工員角色扮演、認識角色組成員、病理知識、組織運作資訊等相關學習，但由於機構內正式訓練不足、非正式學習並無相同專業之指導者，所以社工員紛紛表達需求督導支持；（3）專業角色發展歷程的第二主軸為「角色衝突->因應」，社工員對自己專業角色有所認知，進入機構後，部份機構主管因為對社工員專業角色認識不清、人力聘用不足、較不熟悉電腦操作等因素，對社工員有較高的行政角色期待，而引發角色衝突困境，令社工員感到抗拒、排斥、不滿、專業角色不被重視、想要離職、掙扎或對主管的角色期待產生疑惑等負面情緒，若干社工員以工時不足為由與機構主管溝通協調捍衛自己對於專業角色的認知，但多數仍不敵機構主管的期待而妥協接受機構主管角色期待，成為機構內的行政人員或社工兼任行政人員，在同時扮演兩種角色或捨棄原有專業角色轉而扮演自己不熟悉的角色之情況下，社工員會出現角色負荷過度的問題，並對自己專業成長沒有信心、付出收益不等值及引發自責等負面情緒。但仍有些社工員能運用說服的技巧、堅定拒絕的態度、事先避免等策略來堅持自己所認知的專業角色；（4）在上述的兩個主軸的影響因素中，社工員個人的人力資本、社會支持與自我認同會使得社工員較能堅持專業角色，同樣地組織內機構主管的學習經驗、接觸社工員的經驗也會讓機構主管較為清楚了解社工員的工作角色；但社工員重視人際合諧、畏懼權威等個人特質，會讓社工員妥協接受機構主管的角色期待，而機構內學習資源不足、社工員兼職工作身分等因素會阻礙社工員資訊之取得，機構內無行政專責人員、機構專業分工不清之文化，則會令機構主管對於社工員產生角色期待；除了個人與組織層次之助、阻力之外，社會環境層次中，規範小型養護機構的法規及評鑑項目等亦對於社工員專業角色發展有所影響；（5）學習是小型養護機構社工員專業角色發展歷程之核心機制，貫穿了「角色不明確->學習」主軸，也與角色衝突、因應策略息息相關，更是左右此歷程發展之重要因素。最後，研究者亦有針對上述研究結果之相關議題進行深入討論，並提出數點建議期待研究成果有較為實質的貢獻。 / With the approach of aged society and the growing number of senior citizens over 85, people with the needs of long-term care is also on the increase. Currently, among all the long-term care resources, the amount of service provided by small-scale nursing home is the largest. Therefore, we can realize the significance of such type of facilities in the field of long-term care. However, due to factors like the keen competition and the expectations of evaluation among long-term care facilities, the quality of service has become the goal of small-scale nursing home. The realization of social workers’ professional roles is beneficial to the enhancement of the service quality of facilities. Nevertheless, probably because of reasons such as the insufficient laws, the consideration of cost, and the insufficient knowledge of staff, the employment of social workers is not equally emphasized, and thus causes problems like the high mobility of social workers and the difficulty in hiring social workers. Since there are few related studies on social workers, I could not understand such phenomena and there is no answer to the problems raised from my part-time experience. Hence, studying social workers, this study aims to explore the developing process of the roles. The purposes of this study are as follows: first, understanding the duties of social workers in small-scale nursing home; second, the way social workers learn and construct roles as well as their developmental process; third, the role identification of social workers and the process they conciliate with the role expectations from other staff; fourth, the various influencing variables during the process; fifth, the hope that this study could make policy-makers, scholars in social worker education field and practician concern the hardship and struggle that social workers encounter in small-scale nursing home, and provide suggestions for improving the conditions of social workers in these workplaces. As a result of elements like few related studies, studies with exploratory features focusing on life experience and on the viewpoints of participants, this study adopts the qualitative paradigm, collects data with in-depth interviewing, and explains with the template analysis style. The study also deals with certain issues like ethics, reliability, and validity during the process. There are 5 findings in this study. First, the duties of social workers in small-scale nursing home include “working with the client,” “working with the family,” and “working with the facility.” Second, the developmental process of professional roles can generally be divided into 2 categorizes. One is “from uncertain role to learning.” At the beginning, most social workers feel uncertainty about the role and emotions like loss, frustration pressure, lack of achievement, nervousness and fear occur. With formal educational training, informal observing model, collecting data, and reflective learning, they learn through the role play of the social workers, knowing group members, pathological knowledge, and information about the running of organizations. Nevertheless, owing to insufficient formal training in the facility and no advisor with the same expertise for informal learning, social workers turn to supervisors for help one after another. Third, the other category is “from role conflicts to solutions.” After social workers realize their professional roles and work in facilities, due to facts like insufficient understanding of the professional roles of social workers, insufficient staff, and unfamiliarity of using computers, part of managers in facilities hold higher expectations of administrative roles on social workers, and thus causes social workers the dilemma of role conflicts and negative emotions like resistance, refusal, disaffection, despise of professional roles, resignation, struggle, or doubts about the role expectations from managers. Several social workers negotiate with the managers for the reason of insufficient working time to defend their recognition on professional roles. However, most of them still compromise and accept such role expectations. They become the administrative staff or social worker and part-time administrative staff. Under the circumstances of playing 2 roles at the same time or giving up the previous professional roles and turning into a less familiar role, social workers suffer from overload, become not confident in their professional development, feel inequality between devotion and reward, and have negative emotions like reproving themselves. Yet, some workers employ strategies like techniques in persuasion, firm refusing attitude, and prevention in advance to insist on the professional role in their mind. Fourth, among the variables in the 2 categories, the personal human capital of social workers, social support, and self-identification enable social workers to persist in their professional roles. By the same token, the learning experience of institute managers and their experience of contacting social workers also make managers understand the role of social workers better. Nonetheless, characteristics like emphasis on interpersonal harmony and fear of authority lead social workers to compromise and accept the role expectations of facility managers, while factors like lack of learning resources in the facility and the part-time role of social workers prevent social workers from access to information. The lack of full-time administrative staff and the culture of vague division of work in the facility cause facility managers to hold role expectations on social workers. In addition to the encouragement and obstruction from the personal and organizational level, in terms of social environmental level, the laws and evaluation items that regulate small-scale nursing home also affect the social workers professional role development. Fifth, learning is the core mechanism of the process of social workers’ professional role development in small-scale nursing home. It not only penetrates the category of “from uncertain role to learning,” but also is closely related to role conflicts and responding strategies. Moreover, it is the important element that affects the development of this process. At last, the researcher also has a deep discussion in terms of related issues about the results and proposes several suggestions in the hope that the results could have practical contributions.

小型養護機構是長期照護的提供者之一，近年來因評鑑制度與市場競爭，機構為提升服務品質，紛紛聘用社工員，社工服務漸受重視。由於小型養護機構社工員的任用誠屬新興的社會福利議題，因此，本研究欲以小型養護機構社工員的觀點，瞭解其工作價值與工作滿足為何。據此，本論文研究之目的為：一、瞭解小型養護機構社工員所抱持的工作價值觀為何。二、探究小型養護機構社工員如何實踐其工作價值，又社工員工作價值的實踐與機構服務品質關係為何。三、探討什麼因素影響社工員工作價值的實踐。四、探究小型養護機構社工員如何描述其工作滿足。五、依據本研究結果，作為服務單位改進措施及政策規劃之參考。 本研究使用質性取向的研究方法，由台北市與新北市地區篩選適合本研究之研究對象，採用半結構式的深度訪談法進行資料蒐集，共計訪談八位社工員。主要研究結果如下： 一、小型養護機構社工員普遍均能正向地看待老人與失能老人；認為家庭、政府及機構均應負起照顧失能老人的社會責任；社工員對於社會工作工具價值重視：服務、社會正義、維護個人的尊嚴與價值、保密及案主最佳利益考量。而社工員所重視的工作價值則是利他考量以及個人的自我提升。 二、社工員透過工作內容的執行、扮演適當的工作角色以及發揮角色功能以實踐自己的工作價值；而當社工員工作價值得以實踐，有助機構照顧服務品質的提升；又機構聘任社工員確能為住民提供心理與社會上的照顧，有助機構服務品質的提升；兼職社工因工作時間因素，對機構提供之服務不若專職社工員。 三、影響小型養護機構社工員工作價值實踐的因素包括人格特質因素以及環境因素。社工員若具備主動積極、樂觀活潑、有耐心、努力且堅持等特質，其工作價值較易實踐；在環境因素中，當社工員接受民主式領導，其工作自主性高，較有可能實踐自己的工作價值；其餘如組織價值信念、組織規範制度以及同儕關係均影響社工員在小型養護機構中工作價值的實踐；而社工員因應環境因素的方式則包括掌握老闆個性、機構不做，我來做、詢問督導或資深社工員、翻閱資料或詢問他人以及考慮離職。 四、小型養護機構社工員透過工作獲得工作滿足。社工員因工作產生：對工作意義的體認、對工作責任的體認以及對工作結果的瞭解等三種內在心理層次之體認，進而獲取對工作之滿足感；而社工員對工作滿足的描述則有：工作滿足來自成就感、來自心靈上的滿足以及自我價值的實踐。