同理編碼系統應用於生理領域職能治療實習生之心理計量特性驗證

Abstract

背景及目的：「同理」是職能治療 (Occupational Therapy, OT) 人員需具備的重要臨床技能，然目前相關的工具缺乏，影響OT人員同理表現之評估。同理編碼系統 (Empathic Communication Coding System, ECCS) 相較其他工具，先透過「辨別同理時機」，再「判定醫療人員回應該時機之同理等級」，較為客觀且較深入明確，具應用潛力，但缺乏驗證。故本研究之目的為 (1) 檢視ECCS於國內生理OT情境之適用性，並 (2) 驗證ECCS應用於生理OT實習生之心理計量特性，包含：信度（評估者間／內信度、隨機測量誤差、最小可偵測變化值）與效度（收斂效度）。 方法：本研究分為兩階段：(1) 工具準備與可行性測試：進行ECCS編碼規則翻譯並測試其可行性；(2) 心理計量特性驗證：採用次級資料之30份錄音檔與逐字稿，每份內容為生理OT實習生與新收案病人前2次評估／治療之過程，每次約30分鐘。研究設計：評估者間信度部分，將30份資料以塊狀隨機分派給3位評估者，每人評估20份資料，且每份資料由2位不同的評估者分別評估；評估者內信度則抽取1位，於完成初次評估後間隔8週，再評一次；收斂效度另請1位新的評估者，使用Gap-Kalamazoo Communication Skills Assessment Form之「展現同理」次量表評估30份資料，就其結果進行驗證。 結果：階段一：完成《ECCS編碼及評分手冊》之編制，包含原有規則之翻譯及因應生理OT情境補充之文件，討論應用之困難與原因，並呈現評估結果以證明其可行性；階段二：ECCS之評估者間信度不佳［平均一致性百分比為34% (n=17)；ICC=0.14 (n=18)、最小可偵測變化值百分比為62%、最小可偵測變化值為2.18］，評估者內信度可接受［平均一致性百分比為71% (n=10)；ICC=0.77 (n=16)、最小可偵測變化值百分比為23%、最小可偵測變化值為0.83］，收斂效度中等［Pearson’s r=0.51 (n=28)］。 結論：因專業特性與文化語境不同，應用ECCS於生理OT之細節尚有可調整之空間。 ECCS之評估結果易受評估者之主觀判斷所影響，當評估資料來自同位評估者時，具可接受之穩定度；不同評估者間，評估結果則不適合相互比較。本研究提供ECCS之基本心理計量特性，未來研究可進一步驗證其他心理計量特性，以利OT領域同理表現之評估與教學。

Background and purposes: Empathy is an important clinical skill that occupational therapists should be equipped with. Yet there is a lack of relevant measures, affecting the evaluation of occupational therapist’s empathic communication skills. The Empathic Communication Coding System (ECCS), compared to other instruments, can be used to measure empathic skills more objectively, thoroughly and precisely. Raters have to identify three kinds of patient-created “empathic opportunities”, then code the health-care provider’s responses to the empathic opportunities as one of seven levels (0~6). The ECCS has relatively higher potential than other measures, yet its psychometric properties remain largely unexamined. Therefore, the aim of this study is to (1) check the applicability of ECCS in Occupational Therapy (OT) for physical dysfunction in Taiwan, and (2) examine the psychometric properties (including inter-rater and intra-rater reliability, standard error of measurement, minimal detectable change and convergent validity) of the ECCS in assessing the empathy skills of OT interns. Methods: This study was comprised of 2 phases: (1) Preparation and feasibility test: we translated the coding rules of ECCS and assessed its practicality; (2) Examining psychometric properties: we used collected data from a previous study. 30 audio-recording-and-transcription packs were included. The content of each pack of recordings and transcriptions included the interaction between an OT intern and his/her new patient during their first and second interviews. The length of each interview was approximately 30 minutes. The research design for examining the psychometric properties were as follows: (a) for inter-rater reliability, we applied block randomization to distribute the 30 packs to 3 raters. Each rater was responsible for 20 packs, and each pack was assigned to 2 different raters; (b) for intra-rater reliability, we randomly chose 1 rater to re-assess the same 20 packs again after 8 weeks; (c) for convergent validity, another new rater was invited to use the “Demonstrates Empathy” subscale in the Gap-Kalamazoo Communication Skills Assessment Form to assess the 30 packs. Results: In Phase 1, the ECCS Coding and Rating Manual was completed, including the translation of the original rules and the supplementary documents of the adjustments made under OT context. Also, there was discussion of the difficulties of ECCS application, and the evaluation results were shown to prove its practicality. In Phase 2, the results indicated that ECCS had poor inter-rater reliability [average agreement percentage=34% (n=17); ICC=0.14 (n=18), minimal detectable change (MDC) was 2.18, MDC%=62%], acceptable intra-rater reliability [average agreement percentage =71% (n=10); ICC=0.77 (n=16), MDC=0.83, MDC%=8%], and medium convergent validity [Pearson’s r=0.51 (n-28)]. Conclusions: Due to different professional characteristics and cultural contexts, there is still room for adjustment when applying ECCS in OT for physical dysfunction in Taiwan. The evaluation results of ECCS were easily affected by the subjective thoughts of raters. When the evaluation results came from the same rater, the stability was acceptable; but the results among different raters were not suitable for comparison. This study provided the basic psychometric properties results of ECCS. Future research can further examine other psychometric properties to benefit the evaluation and education of empathic skill in OT.