TOPS教育訓練對於團隊資源管理、跨領域教育及模擬 醫學教育態度的影響：以醫學系、護理系學生為例

Abstract

背景： 模擬醫學教育是一種體驗式學習(Experiential learning)，透過設計一個臨床情境，讓參與學員執行醫療任務，展現其醫學知識及技術，最後利用反饋的過程而進步。 本次實習於中山醫學大學醫學院，跟著蔡院長一同設計並執行跨領域學習課程。以落實醫學院宗旨「培養具備ACGME六大核心能力的醫療人員」為目標，設計「TOPS」課程。TOPS課程的目標不僅是擬真的臨床任務，更強調跨領域團隊合作。並發展課程專屬問卷，評量醫學系及護理系兩系學生參與課程前後，對於「團隊資源管理」、「跨領域醫學教育」、「模擬醫學」等三大構面的態度(attitudes)，是否有因為「TOPS」課程而改變。 方法： 本研究採前後對照方式，無對照組，在臨床情境模擬教學課程前後利用專屬的問卷進行前、後測。問卷完成專家效度及內在一致性Cronbach’s α係數評估信度。透過SPSS軟體進行資料分析，以Paired t-test評估課程對於醫學系學生、護理系學生在「團隊資源管理」、「跨領域教育」及「模擬醫學教育」三個構面態度影響。再利用雙變量分析與迴歸分析，分析各個學生背景和三個構面的關係。 結果： 本次實習共完成四例跨領域情境擬真教案，內容涵蓋急診、內科、外科及麻醉科等四科，每一例教案各進行兩場的操作。總計83位學員參與課程並完成前後測問卷，其中包含51位醫學系七年級學生及32 位護理系四年級學生。不論是問卷整體或三大構向的Cronbach’s alpha均大於0.7，都有不錯的內在一致性。 問卷評估態度衡量標準採用五分李克特量表，分數越高表示態度越好。透過paired t test分析，發現三大構面前後測分數的p值都小於0.05，具有統計上顯著差異，表示學員在接受「TOPS」課程前後，在這三個構面的態度有顯著差異。而學生背景不論是透過雙變量分析或迴歸分析，對於前後測的改變量都不具統計上顯著相關。 討論及結論 透過以臨床合作為導向設計的臨床情境擬真教案，提供不同科系的學員一個學習跨領域團隊合作的機會，從中認識彼此、了解對方工作進而溝通合作。模擬醫學的核心價值為提供一個安全，但高度擬真臨床工作的學習環境。透過本次實務實習，發展符合中山醫學院宗旨的跨領域團隊擬真教育課程，讓學員經由體驗臨床情境任務及反饋過程，分析自己及團隊的作為，進而發展出未來在臨床實務中改進的方案。經由本次課程特別設計的問卷，證明經由跨領域團隊模擬醫學課程，可以改善學員對於團隊資源管理及跨領域合作的態度。 臨床工作並非單一個人的能力特別優秀，就可以完成高品質的醫療服務，需要透過跨領域的團隊合作過程，各自扮演好自己的角色，為病患努力而提升醫療品質，透過以團隊合作為基礎的臨床擬真教案，不僅可以改善學員的知識技術，更可以改變其態度，落實培養具備ACGME核心能力的醫療人員。期待未來更多以團隊合作出發的模擬醫學教育課程，讓跨領域團隊資源管理態度深耕於學生階段。

Background: Medical simulation is a type of experiential learning where virtual scenarios similar to real-life clinical situations are constructed. Through medical simulation, students have the opportunity to carry out medical tasks, utilize clinical skills and knowledge to solve problems, and eventually gain improvements with repeated practices and feedback. This practicum study is one of the projects hosted by Dr. Tsai, Dean of the medical college in Chung Shan Medical University. To equip students with ACGME core competencies, a course titled TOPS was formulated. The TOPS course not only emphasizes medical knowledge but also attitude and skills of managing resources in a multi-disciplinary team. A questionnaire was designed and distributed to medical and nursing students to evaluate whether there were changes in students’ attitude toward “team resource management (TRM),“medical simulation” and “inter-professional education (IPE)” before and after attending the TOPS course. Method: This study adopts a before and after study design. Expert validity was established and internal consistency of the questionnaire was assessed with Cronbach's alpha test. Data collected was analyzed with paired t-test (using the statistical software SPSS) to find out if the course had any influence on medical and nursing students’ attitudes on the three facets. Using bivariate analysis and regression analysis to analyze the relationship each students background and the three facets. Result: In this practicum, four cases of inter-professional situational essays were completed, covering four subjects. A total of 83 participants, including 51 medical and 32 nursing students completed the questionnaire both before and after attending the TOPS course. The questionnaire demonstrated adequate internal validation with the Cronbach’s alpha coefficients above 0.7 on both the overall scale and 3 subscales. The average scores of students’ attitudes towards the three facets increased following their completion of the course. Results of paired t-test showed statistical significant improvement in the three facets. The student background, whether through bivariate analysis or regression model, was not statistically significantly correlated with the difference between pre-test and post-test. Discussion and Conclusion: Teamwork oriented simulation offers opportunities for students from different disciplines to learn from each other, communicate and work together closely in an environment with high-fidelity simulation but low risks. With the experiences of solving problems and the following debriefing sessions, students can have a better understand of their strengths and weaknesses. Student feedback regarding this study can hopefully lead to future improvements and reforms in clinical practices. In addition, the TOPS course conducted in this study resulted in markedly positive changes in developing students’ attitudes towards the three facets. Also, the introduction of teamwork oriented inter-professional simulation led to substantial improvements in medical and nursing students’ attitudes of ACGME core competencies before graduation. These findings suggest that more teamwork oriented simulated IPE training courses should be encouraged.