醫學生臨床倫理經驗之分析:結構式「關鍵事件報告」之應用

Abstract

醫學生在實習過程中的倫理經驗，常常成為教師探討與教學的主要內容。過去，醫學教育者常常讓學生以自由書寫的作業方式整理其實習經驗。沒有固定的格式要求。本研究首度嘗試以「關鍵事件報告」的形式，深入分析學生面對臨床倫理問題時的各種認知與心理反應。研究參與者：臺灣北部某大學醫學系六年級修息必修科目「醫學倫理」學生26位。其中男生17位，女生9位。工具：Griffin(2003)所設計的「關鍵事件報告」。其中包含「事件」、「情緒」、「原因」、「分類」、「一般意涵」、「專業標準」、「個人立場」、「行動」八個結構式欄位。研究過程：修息醫學倫理課程的某醫學院六年級學生，依老師要求，用「關鍵事件報告」的格式書寫五年級實習期間一件印象深刻的倫理事件。徵情同意後納為本研究之分析對象。資料分析：專家先為每個事件列出相關的倫理原則，在比較研究者與學生在倫理原則歸類上的一致性，並進行有關情緒、信念及行動等作業內容的質性分析。結果：(1)醫學生與專家在倫理原則歸類上的一致性並不高，(2)倫理事件及衝突大多與「不傷害」、「尊重自主」倫理原則有關；(3)學生對倫理事件的信念為以病人為本位、醫師應具備專業素養、醫師應重視病人身心的全人照護；(4)學生常見的情緒包括：對病患的困惑為難與同情不捨之感受；對醫師的生氣、不認同、及失望感受；(5)學生面對倫理問題的行動意向主要是「溝通」。結論：醫學生的臨床倫理經驗包含內容豐富的認知、個人信念、情緒及行動意向。結構式的「關鍵事件報告」有助於學生完整的呈現這些經驗，增進教師對於學生臨床倫理經驗的理解，提升臨床倫理教師的教學品質。

Background: In the past, teachers used to ask medical students to reflect on their clinical experience through free-fonn writing. In this study, a stractured form called multi-dimentional writing, better understanding of students' psychological and cognitive reactions toward clinical ethical problems could be expected. Methods: Twenty-six medical school students who were taking the compulsory course “Medical Ethics" participated in the current study. Seventeen of them were males and 9 of them were females. Participants were asked to each complete a Critical Incident Report (CIR) (Griffin, 2003) on an ethically sensitive event they had found unforgettable during their practicum in their 5th year of medical school. The CIR contained eight columns: what, emotions, why, classification, general meaning, professional standards, position, and actions. The data obtained from the CIR written by these 26 students with consent was subjected to a qualitative analysis. Both the experts' and the students' classification of the events on their CIRs were compared to ethical principles listed by medical ethics experts according to each student's event report.