類別:

麻醉科預立特定醫療流程之觀點探討:質性研究

2026-01-01T00:00:00Z

標題: 麻醉科預立特定醫療流程之觀點探討:質性研究; A Qualitative Study on Anesthesiology Perspectives Regarding Pre-Established Medical Processes 作者: 賴彥均; Yen-Chun Lai 摘要: 背景：因應台灣麻醉專科護理師制度化，推動「預立特定醫療流程（pre-established medical processes, PMPs）」乃確保適法性與病人安全之關鍵；同時，臨床上亦逐漸關注如「可信賴專業活動（entrustable professional activities, EPAs）」等客觀授權機制的發展。本研究旨在探討麻醉臨床團隊對於執行 PMPs 之真實觀點、對相關授權工具的接受度，以及可能面臨之系統性障礙。方法：本研究採質性研究設計，以立意取樣招募 21 位來自不同層級醫院之核心關係人，包含麻醉醫師、麻專師主管與一般麻專師。資料蒐集運用深入半結構式訪談；資料分析則採取「歸納與演繹並行」取徑：先透過反思性主題分析（reflexive thematic analysis, RTA）執行歸納、編碼與主題萃取，繼以實施研究綜合框架（Consolidated Framework for Implementation Research, CFIR）為理論架構，對實務障礙進行演繹剖析與系統性討論。結果：文本分析結果歸納出四大核心主題：一、從「口頭默契」到「法理保障」的轉型陣痛，凸顯法規保護網與傳統臨床慣性間之拉扯；二、流程制定的理想與現實落差，揭示跨職類權力角力及「技術別」與「症狀別」任務之標準化困境，並伴隨「臨床僵化」與盲目「治療數據」的隱憂；三、EPAs 作為評核工具的信賴與侷限，指出評核實務易流於「文書作業化」及「人情信任」，且單一標準的評核框架易引發資深人員之專業認同剝奪與心理抗拒；四、行政推動與整合的關鍵因素，證實科部領導者之支持與消弭「資訊孤島」現象為制度落地之樞紐。結論：落實 PMPs 與相關客觀授權機制（如 EPAs），實為一場牽涉資源、文化與權力分配的系統性變革。欲達兼顧病人安全與學習成效之實質授權，應揚棄單向規範，轉向「系統性賦權」。具體優化策略建議包含：「先易後難」的漸進式推行與任務分層、建構在地化跨職類總結性授權機制、落實資訊系統無縫接軌，以及實施分層教育以滿足不同年資人員之內在動機。; Background: With the institutionalization of anesthesia nurse practitioners in Taiwan, the implementation of pre-established medical processes (PMPs) is crucial for ensuring legal compliance and patient safety. Simultaneously, there is growing clinical attention to the development of objective authorization mechanisms, such as entrustable professional activities (EPAs). This study aims to explore the genuine perspectives of clinical anesthesia teams regarding the implementation of PMPs, their acceptance of related authorization tools, and the potential systemic barriers they may encounter. Methods: This qualitative study employed purposive sampling to recruit 21 core stakeholders across varying hospital levels, including anesthesiologists, NANP supervisors, and general NANPs. Data were collected through in-depth semi-structured interviews. Data analysis followed a hybrid inductive and deductive approach: reflexive thematic analysis (RTA) was initially used for inductive coding and theme extraction, followed by the application of the Consolidated Framework for Implementation Research (CFIR) as a theoretical framework to perform a deductive analysis and systematic discussion of implementation barriers. Results: Textual analysis yielded four core themes: 1. The transitional pains from "implicit verbal agreements" to "legal protection," highlighting the tension between the regulatory safety net and traditional clinical inertia. 2. The discrepancy between idealized protocol design and clinical reality, exposing interprofessional power dynamics and the inherent challenges of standardizing "skill-based" versus "symptom-based" tasks, while also highlighting the latent risks of "clinical rigidity" and the detrimental tendency to blindly "treat the numbers." 3. The trust and limitations of EPAs as an assessment tool, indicating that assessment practices easily devolve into "mere paperwork" and "interpersonal trust," and that a single-standard assessment framework often triggers a sense of professional identity deprivation and psychological resistance among senior staff. 4. The key factors of administrative promotion and integration, confirming that the support of department leaders and the elimination of "information silos" are pivotal for successful institutional implementation. Conclusions: Operationalizing PMPs and related objective entrustment mechanisms, such as entrustable professional activities (EPAs), is essentially a systemic paradigm shift that implicates resource allocation, organizational culture, and power dynamics. To achieve substantive authorization that balances patient safety and learning outcomes, institutions must transition from unidirectional regulations toward "systemic empowerment." Specific recommended optimization strategies include: a stepwise implementation approach paired with task stratification, the establishment of localized, interprofessional summative authorization mechanisms, the seamless integration of information systems, and the adoption of stratified education to foster the intrinsic motivation of personnel across varying levels of seniority.

針對診斷為高血脂的病人，醫病共享決策與服藥順從性之間的關係

2022-01-01T00:00:00Z

標題: 針對診斷為高血脂的病人，醫病共享決策與服藥順從性之間的關係; Examining the association between shared decision-making and medication adhesion 作者: Ying-Na Hsiao; 蕭吟娜摘要: 背景介紹服藥順從性指的是，病患是否按醫師處方規定次數服用藥物，以及他們是否持續照醫師處方服用藥物，好的服藥順從性比起新型的治療方法更能增進病人的健康。影響服藥順從性的因素有很多面項，病人、藥物、看診醫師及一些系統性因素等皆會影響服藥順從性。增加服藥順從性的策略也有很多，舉凡病人教育、藥物管理及認知行為療法等等策略。近年來醫病關係變化，醫師不再像過去是主要的單一決策者，醫病共享決策此種以病人為中心的看診模式更逐漸被提倡，而認知行為的介入方式也漸被納入探討其和服藥順從性的關聯性。由過去的文獻回顧可以發現，醫病共享決策對於高血壓的病人可以增加其服藥順從性，但對於糖尿病的病人卻沒有辦法增加其服藥順從性，且主動式及共享式的醫病決策關係比起較為被動式的醫病決策關係更能增加病人的服藥順從性。然而過去的文獻較少提到醫病共享決策對於高血脂病人其服藥順從性是否有影響。過去的研究也顯示，對於高血脂症或其他慢性疾病的病人而言，高服藥順從性的病人比低服藥順從性的病人增加了 26%健康狀況的改善。因此可以知道，好的服藥順從性對於高血脂症的病人來說可以有較好的健康狀況，也因此增加高血脂症病人的服藥順從性是至關重要的議題。因此，本研究針對高血脂病人去探討醫病共享決策是否會影響其服藥順從性。研究方法與材料本研究的受試者來自於臺大醫院金山分院門診病人。我們收集 182 例於門診具備高血脂診斷的病人，請病人於看診結束後填答問卷，請病人填寫自覺其看診時和醫生之間的醫病關係為何種醫病共享決策關係，共分成五個層次的醫病共享決策關係分別對應不同的醫病共享決策模式(主動式、被動式、共享式)，排除一例於醫病共享決策題目填錯答案者，排除 29 例於宗教信仰、婚姻狀態、醫療保險、月收入、疾病嚴重度等未填答完整有缺漏者，最終可納入分析之個案為 152 人。年齡分佈從 27 歲到 94 歲，平均年齡 64.1 歲，女性 92 位，男性 60 位。服藥順從性的部份則是用藥物持有率來計算，藥物持有率越高表示其服藥順從性越好。本研究以簡單及多重迴歸分析來探討藥物持有率及醫病共享決策之關係，並探討問卷中各個變項和藥物持有率之關聯性。結論本研究之結果顯示，對於高血脂的病人而言，醫病共享決策並無法增加病人的服藥順從性，對於高血脂的病人來說，影響其服藥順從性的因素為月收入差異和不同的門診醫師，月收入高的病人其服藥順從性相對較差，而不同門診醫師之間即便醫病共享決策的方式類似，仍存在不同的服藥順從性差異，故不同門診醫師對病人服藥順從性的影響仍需待後續研究加以深入探討。; Introduction Medication adherence refers to whether patients take the medication as prescribed by the physician. Good medication adherence can improv the patients health more than new treatment methods. There are many factors that affect medication adherence. Patients , drugs, physicians, and some systemic factors can all affect medication adherence. There are also many strategies to increase medication adherence, such as patient education, medication management, and cognitive behavioral therapy. In recent years, the doctor-patient relationship has changed. Physicians are no longer the main decision-makers as in the past. The concept of shared decision making between doctors and patients is gradually being promoted, and this cognitive behavioral intervention had gradually been included to explore its relationship with medication adherence. From the literature review , it can be found that the policy of shared decision making can increase the medication adherence rate among patients with Hypertension, but it cannot increase the medication adherence rate among patients with Diabetes mellitus. Compared with passive shared decision making policy, active and shared decision making policy increased medication adherence rate . However, previous literatures seldom mentioned about whether the policy of shared decision making affects the medication adherence rate among patients with hyperlipidemia. Previous studies have also shown that for patients with hyperlipidemia or other chronic disease, patients with high medication adherence rate increased their health status by 26% compared with those with low medication adherence rate. Therefore, it can be known that good medication adherence can lead to better health status for patients with hyperlipidemia. It is important to increase the medication adherence rate among patients with hyperlipidemia. Therefore, our study aimed at examining the association between shared decision making policy and medication adherence among patients with hyperlipidemia. Material and Method The subjects of this study were enrolled from outpatient clinics from the Jinshan Branch of National Taiwan University Hospital. We collected 182 participants who were diagnosed with hyperlipidemia in the outpatient clinic. The patients were asked to fill in the basic questionnaires after visiting the outpatient clinic, and the patients were asked to fill in what they think about the doctor-patient relationship during this outpatient clinic. The relationship was divided into five levels according to the questionnaires. The decision making relationships correspond to three different decision making modes(active, passive and shared). One case was excluded due to wrong answer about the questionnaires of shared decision making, and 29 cases were excluded due to wrong answer or unanswered about the questions related to religion, marital status, medication insurance, monthly income, and disease severity. There were 152 cases that could be finally included in the analysis. The age of patients ranged from 27 to 94 years old, with an average age of 64.1 years, 92 females and 60 males. The medication adherence rate is calculated by the Medication Possession ratio(MPR). The higher the Medication Possession ratio(MPR) means the better the medication adherence rate. Our study use simple and multiple linear regression analysis to analyze the relationship between Medication Possession ratio(MPR) and shred decision making. Our study also analyze the relationship between each variable in the questionnaire and Medication Possession ratio(MPR). Conclusion The result of this study show that for patients with hyperlipidemia, the policy of shared decision making cannot increase the medication adherence rate. Factors that affect the medication adherence rate are differences in monthly income and different outpatient physicians. Patients with higher monthly income have poor medication adherence rate. Even if similar policy of shared decision making among different outpatients physicians, there are still differences in medication adherence rates. It still need further research about the influence of different outpatients physicians on medication adherence rate .

醫學人文學習動機之影響因素：科系、性別與知識信念

2021-01-01T00:00:00Z

標題: 醫學人文學習動機之影響因素：科系、性別與知識信念; "The Factors Associated with the Motivation to Learning Medical Humanities: Major, Gender, and Epistemic Beliefs" 作者: Yu-Ting Tsao; 曹玉婷摘要: "「醫學人文」是在醫學教育範疇內一個重要領域，研究顯示，接觸醫學人文可幫助醫師、醫學生來應對壓力、減少倦怠，培養韌性和促進幸福感。學生的「知識信念」，也就是學生如何看待知識、獲取知識、建構自己的知識體系，會影響學生的學習成效、學習方法，包含他們的學習動機。本研究以問卷調查為基礎，使用修改後的醫學知識信念量表，研究對象為台大醫學院醫學人文課程的一年級學生。以學生參與醫學人文課程的體驗式學習活動次數多寡來表示其具有深度學習動機（參與次數多，致力於學習）或淺層學習動機（參與次數少，以合格為目標）。以探索性因素分析驗證本研究問卷的建構效度，並計算Cronbach’s α值以檢驗每個構面的內部一致性信度。以獨立樣本t檢定、卡方檢定，及多變數邏輯回歸分析等統計方法，探討學生的知識信念、科系、性別，與學習動機之關聯。本研究共收集172份有效問卷，其中130位參與者是醫學系學生（75.58％），42位參與者是非醫學系學生（24.42%），有110位是男性（63.95％），62位是女性。研究結果發現，與非醫學系學生相比，醫學系學生更不可能具有深度學習動機（調整勝算比= 0.29, p = 0.02），對醫學知識的確定性抱持簡單信念者，更不可能具有深度學習動機（調整勝算比= 0.43, p = 0.04），對醫學專家的可性度抱持簡單信念者，更可能具有深度學習動機（調整勝算比= 2.30, p = 0.01）。男醫學生比女醫學生更不可能具有深度學習動機（調整勝算比= 0.26, p = 0.01）。本研究的貢獻在於驗證醫學知識信念問卷之信效度，可提供日後相關研究使用，並發現在醫學人文課程，學生的知識信念、科系，與性別，都是學習動機的影響因子，建議第一線教師及課程制定者，能留意這些因素在醫學人文教育中的角色，營造合適的教學環境，深化學生對醫學人文的學習動機。"

運用高擬真模擬假人系統於見習醫學生之兒童初始評估及基本救命術教學

2016-01-01T00:00:00Z

標題: 運用高擬真模擬假人系統於見習醫學生之兒童初始評估及基本救命術教學; Application of high fidelity patient simulator in the teaching of pediatric initial assessment and basic life support to medical clerks 作者: Yu-Chun Chiu; 邱郁淳摘要: 研究背景及目的情境模擬(simulation)訓練在臨床醫學的進階訓練中是很受歡迎的教學方式，並被認為可以減少學習過程中出現的醫療失誤。兒童醫療的初學者往往對於評估和處理兒童患者覺得陌生且缺乏信心，因此，本研究的目的在探討以高擬真情境模擬假人(high-fidelity patient simulator)系統介入的醫學情境模擬訓練在醫學生實習醫學生教學的可行性，及此教學方式是否能幫助實習醫學生學習對病童的初步評估和處置。研究方法研究對象為從2014.09至2015.08在台大醫院小兒部實習的台大醫學系五年級實習醫學生共141名。每一梯次的學生被平均分成兩組，對照組為常規教學組S(-)接受以病童影片及急救教學模具輔助的兒童評估三角(Pediatric assessment triangle, PAT)初始評估、初步處置及基本教命術(Basic life support, BLS)教學；研究組為情境模擬教學組S(+)在常規課程後增加30分鐘以高擬真情境模擬假人系統介入的情境模擬練習並加上教師及同儕的討論回饋。一共有三位教師輪流參與課程。學生於課前課後皆填寫評量病童評估、處置之能力與信心的自評問卷，並在課後問卷中調查對課程的滿意度及課程對其學習助益。各問題的答案以李克特量表(Likert scale)1至5分表示，分數愈高表示愈同意，當問卷中所有問題皆為同樣答案時被定義為無效問卷。經卡方檢定(Chi-square test)、學生t檢定(Student t test)、變異數分析(Analysis of variance, ANOVA)及線性回歸分析(Linear regression)等統計方法分析，p值<0.05定義為具有統計上顯著的差異。研究結果共有141名學生填寫問卷，其中有108份(76.6％)有效問卷。S(-)組有44位學生而其中的37份為有效問卷；S(+)組有97位學生而其中的71份為有效問卷。在所有的學生中，課前愈同意模擬教學能增加其學習動機者，在課後愈覺得此課程對其學習有助益(p值<0.01)。針對學員課前問卷對「模擬教學能增加學習動機」的看法，課前Likert scale>3分的學生比≦3分的學生課後更同意「此課程對學習有助益」(4.55分 v.s. 4.31分，p值= 0.04)。此外，在課後「整體臨床能力」較課前分數進步≧2分的學生中，課前「整體臨床能力」與課後「此課程對學習有助益」的Likert scale分數有臨界值的相關性(p值= 0.06)；但對其中S(+)組的學生來說，則達到統計上顯著的相關性，當學生的課前「整體臨床能力」分數愈高，課後愈覺得「這堂課對學習有助益」(p值= 0.03)。討論高擬真情境模擬訓練是一種受歡迎和有趣的學習/教學方法，並可以減少訓練過程中出現的醫療失誤。在本研究中，以高擬真情境模擬假人系統介入教學的S(+)組學生滿意度和S(-)組一樣好，S(+)組其課後學習助益的評價則較S(-)組稍高但尚未達到統計學上顯著的差異。經進一步統計分析證實，愈符合學習者興趣引發學習動機的教學方式愈能提高其課後的課程滿意度和學習成效。此外，課前愈具備先備知識能力的學習者，愈能在課程內獲得良好學習成效。結論運用高擬真情境模擬假人系統介入的情境模擬教學做為醫學系實習醫學生的臨床教育，為一具體可行的教學模式，且課後學員滿意度及對學習助益的評價高；此外，此教學方式對於課前學習動機或先備知識能力較高的學生教學成效更高。; Background and Aim Simulation is popular in advanced clinical training and considered to reduce errors made during learning. Medical beginners feel more unfamiliar in assessing and managing the pediatric patients. This study aims to explore the feasibility of using high-fidelity patient simulator in the teaching of medical clerks , and whether this new course helps them to learn the initial assessment and management for the sick children. Material and Method A total of 141 fifth-year medical students rotated pediatric clerkship in National Taiwan University Hospital from Sep.2014 to Aug.2015 were enrolled. Students were separated into two groups. Students in the conventional group S(-) received video and teaching aid-assisted teaching of pediatric initial assessment, initial management and basic life support(BLS). Students in the simulation group S(+) had an additional 30-minutes of practice and debriefing with high-fidelity infant simulator after the conventional course. There were 3 teachers involved in this course. The self-evaluated ability and confidence for pediatric patient assessment and management, the attitude for learning, and the evaluation and satisfaction for this course were evaluated by pre and post-course questionnaires which were not included into the semester score. The answer of each questions were scored with Likert scale 1 to 5. The questionnaire with all the questions have same answers of Likert scale was defined as invalid questionnaire. Data of the questionnaires were analyzed by Chi-square test, Student t test, Analysis of variance(ANOVA) and Linear regression. A p value<0.05 was considered statistically significant. Result One hundred and forty-one students were enrolled with 108 (76.6%) questionnaires were valid. Forty-four students were in the S(-) group and 37 valid questionnaires were obtained. Ninety-seven students were in the S(+) group and 71 valid questionnaires were obtained. For all students , the pre-course scale of “simulation increases learning motivation” had positive association with the scale of “this course is helpful for learning” (p value <0.01) after the course. Students who have scale of pre-course “simulation increases motivation” >3 stated significantly higher score for ‘this course is helpful for learning’ (4.55 v.s. 4.31, p value=0.04). In addition, for students with “overall clinical capacity” scale improvement≧2, the pre-course scale of“overall clinical capacity”had borderline association with the agreement of “this course is helpful for learning” (p value=0.06) but had significant association specifically for students in the S(+) group (p value=0.03). Students who stated higher scale of pre course “overall clinical capacity’, scored higher scale of “this course is helpful for learning”(p value=0.03) after the course. Discussion High-fidelity simulation is a popular and interesting learning / teaching method which reduces error made in training. In this study, the student satisfaction was high in both group. The rating of “this course is helpful for learning” was higher in the S(+) group but had not reached statistically significance. Supported by further analysis, the learning / teaching method meets the learner’s preference and leads to learning motivation is crucial for the course satisfaction and good learning outcome. Moreover, the learner’s prior knowledge and ability are important for gaining learning effectiveness. Conclusion High-fidelity patient simulator-assisted teaching is a feasible teaching method in the training of medical clerks and the student’s satisfaction is high. Besides, simulation is more beneficial in the teaching of students with active motivation or having prior knowledge and ability.