比較高擬真模擬教學與個案分析教學對護理學生知識獲得及臨床判斷之成效

Abstract

目的：臨床判斷是護理教育培育的核心能力之一。本研究目的是以類實驗研究設計驗證高擬真模擬教學及個案分析教學與臨床判斷的因果關係；及比較這兩種教學策略對臨床判斷學習及知識獲得的影響；同時瞭解研究樣本對兩種教學策略的看法。 方法：本研究採用類實驗前後測試研究設計並結合焦點訪談進行研究。研究樣本為澳門某學院二年級大學部護理系修讀課程單元“成人護理I---氧合作用與維持”的69名學生，他們被隨機分配到高擬真模擬教學組或個案分析教學組。兩組在“充血性心臟衰竭疾患病人護理”課程單元理論學習後，一組於高擬真模擬實驗室接受高擬真模擬教學，一組於教室接受個案分析教學，兩種教學策略都以全心臟衰竭病人護理案例教導臨床判斷。兩種教學策略介入前、後都採用Lasater Clinical Judgment Rubric臨床判斷量表及自擬的知識問卷評價學習成效；最後，訪談15名研究樣本對兩種教學策略的看法。並以滿意自信量表評估高擬真模擬教學組對教學的滿意及自信程度。 結果：本研究結果顯示：高擬真模擬教學組在介入措施後臨床判斷總分平均分數達到“初級至發展中水平”。臨床判斷總分中位數在介入前後沒有統計上的顯著差異(p=0.42)；僅有臨床判斷中反應階段分數於介入後呈顯著進步(p=0.01)；介入後知識分數也呈顯著進步。個案分析教學組在介入措施後臨床判斷總分平均分數達到“發展中水平”。臨床判斷總分中位數在介入後顯著高於介入前(p<0.01)，而且介入後臨床判斷中注意階段、解釋階段及反應階段分數呈顯著進步(p<0.01)；介入後知識分數也呈顯著進步。比較兩組的介入成效發現高擬真模擬教學組與個案分析教學組在介入後的臨床判斷總分中位數及知識分數中位數没有統計學差異；僅有的差異是介入後個案分析教學組臨床判斷中解釋階段分數優於高擬真模擬教學組。另外，焦點訪談發現研究樣本對兩種教學策略都呈滿意態度。 結論：個案分析教學教師以即時提出引導的問題讓研究樣本討論及思考，能營造合適學習的氣氛，這有利於研究樣本在臨床判斷中注意階段、解釋階段及反應階段分數的提升；而且更使得他們的解釋階段分數優於高擬真模擬教學組。另外，理論教學結合兩種教學策略的任一種，均可以讓研究樣本通過教育、個人經驗、共享、複習，而使知識分數顯著提高。未來進一步以長期追蹤研究瞭解高擬真模擬教學/個案分析教學執行次數對臨床判斷能力提升的效果。研究者並依據研究結果對高擬真模擬教學的設計及安排提出建議。

Background: Clinical judgment is one of the core competence of nursing education. The aim of this study is to validate the causality of the high fidelity simulation teaching / case study teaching and clinical judgment; to compare the impact of two teaching strategies on clinical judgment and knowledge; and to explore the students’ view of the two teaching strategies through a quasi-experimental research. Method: This is a quasi-experimental pre-test and post-test study with a focus group interview. 69 year two BSN students who took the subject “Adult Nursing --- Oxygenation and Maintenance” in a nursing college in Macau were willing to participate in this study; they were randomly assigned to the high fidelity simulation group and the case study group. After studying the lecture “Patient Care of Heart Failure”, one group received high fidelity teaching in nursing lab and the other group received case study teaching in classroom to learn “heart failure patient care” with clinical judgment approach respectively. And the learning outcomes of two groups were evaluated with Lasater Clinical Judgment Rubric and self-designed knowledge questionnaire. Finally, total 15 students joined the focus group interview to express their view of two teaching strategies; and the high fidelity simulation group completed satisfaction and self-confidence questionnaire. Result: The results show: The high fidelity simulation group achieved the “beginning to developing level” of clinical judgment after intervention. In this group, there is no significant improvement (p=0.42) on the median of clinical judgment, only the median of “responding stage” of clinical judgment and knowledge indicate significant improvement (p=0.01, p<0.01). The case study group achieved the “developing level” of clinical judgment after intervention. In case study group, the median of clinical judgment shows significant improvement (p=0.01), the median of “noticing stage”, “interpreting stage” and “responding stage” of clinical judgment and knowledge also show significant improvement (p<0.01). On the other hand, there is no statistical difference on the median of clinical judgment between high fidelity simulation group and case study group, but the score of the“interpreting stage” of clinical judgment in case study group is better than the high fidelity simulation group significantly. The students expressed the satisfaction of the two teaching strategies in the focus group interviews. Conclusion: The guiding questions for discussion and thinking in case study group create an atmosphere of learning; it is good for students to improve the score of “noticing stage” “interpreting stage” and “responding stage” of clinical judgment; and it cause that the score of“interpreting stage” of clinical judgment in case study group is better than the high fidelity simulation group especially. On the other hand, the two teaching strategies combined with theoretical teaching enable the students to acquire knowledge through teaching, experience, sharing and reviewing. For the future, a longitudinal study should be executed to validate the times of high fidelity teaching/case study teaching to improve students’ clinical judgment. Researcher also suggest the design and the arrangement of high fidelity simulation teaching based on the result of this study.