| 摘要: | 醫學教育的發展需專業基礎知識的橫向建構與批判性思維的縱向連接，臨床醫學教育中批判性思維包含臨床推理(Clinical reasoning) 、臨床決策(Decision making)與臨床判斷(Clinical judgment)，皆在描述解決臨床複雜問題的過程與能做出合乎臨床判斷的決策，可視為同義詞。儘管臨床推理能力對醫事人員是重要的核心能力，然而無論是美國畢業後醫學教育評鑑委員會(ACGME)或是美國呼吸照護學會(AARC)皆未明確將臨床推理歸類為能力指標之一，且有關臨床推理能力的定義直到Daniel等人(2019)才明確定義臨床推理能力包含(1)資訊收集(2)問題假設(3)收斂問題與整合所有資訊(4)鑑別診斷(5)假設確立診斷(6)診斷評鑑(7)治療計畫與管理。在呼吸治療領域少見有關臨床推理能力的議題，然而，呼吸治療師根據醫師囑咐或照會，在臨床給予心肺功能損傷或異常者適當的治療計畫及醫療照護，具備臨床推理能力是重要的核心能力，能提升臨床照護品質。此外，尚無明確指引提及關於臨床推理能力測量工具與應用，因此本研究旨在將臨床推理導入呼吸治療教育中。此研究目的有三個：(1)針對呼吸治療專業發展有效的臨床推理之測量工具(2)瞭解實習學生實習後的臨床推理能力(3) 探索影響實習生之臨床推理的可能原因。研究設計屬量性研究並採縱貫性收案，分為三階段：兩份問卷填寫(臨床診斷思維問卷-RT與學習策略問卷-RT)、測驗一與測驗二施測。研究共收案67位兩校北部呼吸治療學系大四已完成實習的實習生，排除4位僅完成兩階段收案後，可分析樣本數共63位(94%)。研究使用SPSS Statics 22進行資?處?與分析，包括邏輯審查與實證審查。根據研究變項特性，採用t檢定、斯皮爾曼積差相關分析和線性回歸等統計方法，顯著性水準設定為p<0.05。本研究初步建立有關呼吸治療臨床推理能力的自編測驗題與問卷，經專家會議建立測驗工具內容效度，但測驗題的信度受限於題目數量。根據研究結果，實習後的呼吸治療學生仍具備臨床推理能力，然而目前的研究結果顯示僅有臨床診斷思維的記憶中知識結構程度可以預測測驗一的臨床推理能力，並且與延伸配合題(EMQs)具顯著相關性。雖然研究發現臨床推理能力與學習策略問卷存在負相關性，但影響結果可能包含自評問卷潛在猜題因素，或是學生無法有效率的執行學習資源管理。因此，未來的研究設計應加入質性研究與增加測驗題數量以提升測驗工具的信度，有助於進一步探索有關呼吸治療領域的臨床推理能力表現。
The development of medical education requires both the horizontal construction of professional knowledge and the vertical connection of critical thinking. Critical thinking in clinical medical education encompasses clinical reasoning, decision making, and clinical judgment, which can be considered synonymous terms. They describe the process of solving complex clinical problems and making clinical decisions. Although clinical reasoning ability is an important core competency for healthcare professionals, neither the Accreditation Council for Graduate Medical Education (ACGME) nor the American Association for Respiratory Care (AARC) explicitly classifies clinical reasoning as one of the competency. Furthermore, the definition of clinical reasoning ability was not clearly established until Daniel et al. (2019) defined it as including (1) information gathering, (2) hypothesis generation, (3) problem representation, (4) differential diagnosis, (5) leading or working diagnosis, (6) diagnostic justification, and (6) management and treatment. Clinical reasoning ability is seldom addressed in the field of respiratory therapy; however, respiratory therapists play a crucial role in providing appropriate treatment plans and healthcare to individuals with cardiopulmonary impairments or abnormalities based on physician orders or referrals. Possessing clinical reasoning ability is an important core competency for respiratory therapists and can enhance the quality of clinical care. Furthermore, there are absent guidelines regarding clinical reasoning ability measurement tools and applications. Therefore, this study aims to integrate clinical reasoning into respiratory therapy education. The objectives of this study were as follows: (1) to develop an effective measurement tool for clinical reasoning in respiratory therapy professional development, (2) to understand the clinical reasoning abilities of intern students after their clinical practicum, and (3) to explore possible factors influencing the clinical reasoning abilities of intern students. We designed the study with quantitative and longitudinal methods, consisting of three stages: two questionnaires (Diagnostic thinking inventory -RT and Motivated Strategies for Learning Questionnaire -RT) and two clinical reasoning tests (Test 1 and Test 2). A total of 67 intern students who completed their clinical practicum from two universities in northern Taiwan were included in the study. Four participants were excluded after completing two stages, resulting in a sample size of 63 (94%) for data analysis. Data processing and analysis were conducted using SPSS Statistics 22, including logical and empirical reviews. Based on the characteristics of the research variables, statistical methods such as t-tests, Spearman's rank correlation analysis, and linear regression were employed, with a significance level set at p<0.05. This study has initially established the clinical reasoning assessment tools and questionnaire in respiratory therapy. The content validity of the test instrument was established through expert meetings, but the reliability of the test items was limited by the quantity. According to the research results, intern students in respiratory therapy still possess clinical reasoning abilities after their clinical practicum. However, the current findings indicated that only the level of memorized knowledge structure in clinical diagnostic thinking can predict the clinical reasoning ability of test 1 and had a significant correlation with extended matching questions (EMQs). Although a negative correlation was found between clinical reasoning ability and the learning strategy questionnaire, the influencing factors may include potential guessing in self-report questionnaires or students` ineffective execution of learning resource management. Therefore, future research designs should incorporate qualitative studies and increase the number of test items to enhance the reliability of the measurement tool, facilitating further exploration of clinical reasoning performance in the field of respiratory therapy. |
