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

Abstract

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.