探討問題導向學習於健康照護專業促進臨床實務能力之成效

Abstract

近年來，問題導向學習(Problem-Based Learning, PBL)在醫學教育上的應用日漸普遍。PBL讓學生在問題情境中學習知識的使用與產出問題解決的原則。但部分研究顯示，PBL成效可能與傳統講述教學沒有差異。因此，為呼應醫學教育強調成果導向的教育，本研究主要欲深究的研究目的為發展規劃良好之PBL教案以幫助職能治療學生提升知識、技能與學習態度，同時基於健康照護專業學習模式的認識論，與學習成為實務社群一員之情境學習理論的觀點，以探究PBL的成效。本研究之參與對象為53位大學職能治療學生，在參與10週的職能治療專業課程後分別進入一般教學組及PBL組學習八週。一般教學組參與一般職能治療課程，而PBL組則參與依據職能治療核心能力所規劃之PBL模組。本研究使用於PBL評量上的研究工具，包含以認識論的觀點，由概念圖瞭解學生概念架構的改變。由情境學習理論的觀點以客觀臨床能力測驗(objective structure clinical examination, OSCE)及問題導向學習學生評估表，TutotestC，以瞭解學生在PBL中之臨床能力、內隱記憶，及學習態度之改變。結果顯示，PBL組的概念架構在「概念聯結」、「階層」、「交叉聯結」有較佳的表現，且傾向於統整型作圖；在參與PBL之態度方面，PBL能幫助發展「團隊工作的效能」與「同儕尊重」；在臨床實務能力上，PBL對於「臨床技能」與「臨床態度」上表現有很大的幫助，而且在內隱記憶的分析顯示，PBL於提升「程序性知識」與「知覺表徵系統」上較一般教學具有成效。因此，由研究結果可以推論，PBL奠基於認識論與情境學習理論的基礎，幫助學生由小組合作學習、實作學習，以及情境學習中獲得臨床實務能力，不僅幫助學生的概念架構的發展，而且更能達到同儕尊重與合作，也幫助臨床技能與態度的提升，研究結果亦發現，內隱記憶的學習亦獲得顯著提升，這些均能證明PBL可以幫助健康照護專業學生獲得良好臨床實務能力，以連結理論學習與臨床實務工作的最佳證據。最後，透過本研究所提出之理論與實務連結的PBL設計與評量規劃，期望可由多處著眼而成功地詮釋一個良好規劃之PBL的成效。Introduction: Problem-based learning (PBL) has been used increasingly and more widely in medical education in the recent years. PBL involves using context of problems that allows students to use their prior knowledge for producing principles of problem solving. However, the empirical researches show that the effectiveness of PBL is not conclusive. Objectives: In concern with the outcome-based medical education, the purpose of this dissertation was according to the epistemological and psychological perspectives to investigate whether PBL enhance clinical competencies. Methods: Fifty-three occupational therapy undergraduates were involved and divided into PBL and control groups. The PBL group joined a two case scenarios group discussion, while the control group continues conventional learning. Based on epistemological perspective, the concept maps was employed to investigate their knowledge structures. According to situated learning theory, the tutotestC questionnaire and the objective structured clinical examination (OSCE) were used to study students’ learning achievements. Findings: Students of the PBL group constructed more integrated mappings than the control group. It was also revealed that Hierarchy Levels and Cross Links of concept maps were higher in the PBL group. The attitude in PBL of effectiveness in group work and respect of colleagues in the PBL group was higher in the PBL group. The clinical competence in skills, attitudes, and the effect of implicit memory in procedural knowledge and perceptual priming were higher in the PBL group. Conclusions: From the perspective of theoretical dialectic, the epistemology of PBL stressed on learning by doing and constructive learning, corresponding to the medical education that fosters clinical competence of doctors. From the situated learning perspective, PBL applied clinical cases of real-life scenarios to demonstrate clinical practices and to facilitate learning transfer, which also fulfilled the needs of medical education in developing students’ core knowledge. PBL might not well help students to acquire more knowledge, but can help students to connect concepts and to merge related concepts into more complicate knowledge structure. Moreover, the self-directed learning in PBL may also help students to differentiate and integrate knowledge structures better than ordinary learning method. PBL helped students to strengthen the implicit memory to connect action-related processes and resulted in better clinical competence. Implicit memory is the basis of clinical skills, but hardly teaching in lectures. PBL is composed of the physical fidelity and the cognitive fidelity to form an situated occupational therapy context, helping students’ to bridge the gap of theoretical learning and clinical practice to gain practical experience and clinical competence. The findings should provide empirical evidence for PBL in health care professions.