臺灣博碩士論文加值系統

由於人口社會結構的變化，面對高齡化社會來臨，疾病的複雜度也會大增，近年來醫療快速地發展，護理專業知識的進階及醫療系統的快速轉變，護理人員在臨床照護中所面臨的情況也日趨錯綜複雜，除了要具備護理專業知識與技能外，臨床推理能力是臨床中必須發展的核心能力及專業展現，以提升醫療的完善照護品質。因此本文針對臨床護理人員臨床推理能力之評估進一步的探討。本研究透過文獻探討、臨床護理同仁及專家訪談將臨床推理能力之評估架構成四個構面及十五項準則。並運用問卷的方式及訪談統整意見，透過決策實驗室分析法找出關鍵因素，建立評估模型以改善護理人員臨床推理能力評估的優先順序，研究結果發現四個構面中，構面的主要影響源是察覺臨床表徵，在四個構面的準則中，分別為具有敏銳的觀察力、收集主客觀資料、確認其優先順序、評估問題解決的有效性(改善程度)為主要影響源的準則，因此研究結果對於提升護理人員臨床推理能力之評估都具有理論和實務上的意義。

Due to changes in demographic social structure and the advent of an aging society, the complexity of diseases has also greatly increased. In recent years, due to the rapid development of medical treatment, the advancement of professional nursing care knowledge, and the rapid transformation of the medical system, and situations encountered by nursing staff have also become increasingly complex. In addition to having professional nursing care knowledge and skills, clinical reasoning is also a core ability and a demonstrating of professionalism that needs to be developed clinically. In order to improve the complete medical care quality, this paper further explored the clinical reasoning ability of clinical nursing staff.
Through a literature review, clinical nursing staff and expert interviews, the clinical reasoning ability assessment framework was divided into four dimensions and 15 criteria. Through questionnaires, interviews, and Decision-making Trial and Evaluation Laboratory (DEMATEL), the key factors were found, and an assessment model was established to improve the priority order of the assessment of nursing staff’s clinical reasoning ability. The research results show that among the four dimensions, the main impact source was “perceiving clinical signs”; among the criteria in the four dimensions, “keen observation,” “collection of objective and subject data,” “confirming the priority order, and “evaluation of problem-solving effectiveness (degree of improvement)” were the main impact sources. Therefore, the research results are said to possess theoretical and practical significance in evaluating “improving nursing staff’ clinical reasoning abilities.”

目 錄
摘要......................................................................i
Abstract.................................................................ii
謝辭.....................................................................iii
目錄......................................................................iv
表目錄.....................................................................vi
圖目錄................................................................... vii
第一章 緒論.................................................................1
第一節 研究背景與動機....................................................1
第二節 研究目的.........................................................2
第三節 研究範圍與限制....................................................3
第四節 研究流程.........................................................3
第二章 文獻探討.............................................................4
第一節 現代護理臨床推理內涵與影響.........................................4
第二節 臨床實證的推理概論與過程...........................................5
第三節 臨床推理架構之構面與準則...........................................7
第四節 臨床推理教育課程架構與規劃........................................14
第五節 臨床推理構面與準則彙整............................................16
第三章 研究方法............................................................17
第一節 決策實驗室分析法介紹..............................................17
第二節 決策實驗室分析法分析步驟..........................................18
第三節 研究對象........................................................20
第四節 研究工具........................................................20
第五節 研究步驟........................................................22
第四章 實證分析............................................................23
第一節 前測問卷與正式指標架構之建立......................................23
第二節 前測...........................................................23
第三節 資料收集.......................................................26
第四節 研究結果.......................................................27
第五節 討論...........................................................34
第五章 結論與建議..........................................................37
參考文獻..................................................................40
一、中文部分..............................................................40
二、英文部分..............................................................40
三、網路部分..............................................................43
附錄 研究問卷.............................................................44
附錄一、指標系統說明與各準則重要程度評分(前測問卷)............................45
附錄二、正式問卷..........................................................46
附錄三、個人基本資料......................................................50

表 目 錄
表2-1 護理人員臨床推理能力構面及準則彙整......................................16
表3-1 護理人員臨床推理能力構面及準則評估之內容.................................21
表4-1 護理人員臨床推理能力評估之檢核表........................................24
表4-2 前測專家名單.........................................................25
表4-3 構面及準則定義說明....................................................26
表4-4 正式施測專家名單......................................................27
表4-5 構面的平均直接影響關係矩陣與正規化影響關係矩陣...........................27
表4-6 構面的總影響總關係矩陣與影響程度........................................28
表4-7 臨床表徵構面的平均直接關係矩陣與正規化影響關係矩陣........................29
表4-8 臨床表徵準則的總影響關係矩陣與影響矩陣..................................29
表4-9 臨床問題準則的平均直接關係矩陣與正規化影響關係矩陣.......................30
表4-10 臨床問題準則的總影響關係矩陣與影響程度.................................30
表4-11 護理計畫準則的平均直接關係矩陣與正規化影響關係矩陣......................31
表4-12 護理計畫準則的總影響關係矩陣與影響程度................................32
表4-13 評值改善準則的平均直接關係矩陣與正規化影響關係矩陣.....................33
表4-14 評值改善準則的總影響關係矩陣與影響程度................................33


圖 目 錄
圖1-1 研究流程圖...........................................................3
圖4-1 四大構面因果圖.......................................................28
圖4-2 臨床表徵準則因果圖...................................................30
圖4-3 臨床問題準則因果圖...................................................31
圖4-4 護理計畫準則因果圖...................................................32
圖4-5 評值改善準則因果圖...................................................34

一、中文部分
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2.林馥郁、林建亨、徐武輝、楊義明(2016)‧實用的臨床推理教學方法。台灣醫學，20(5)，493-506。
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4.屈蓮、李惠玲、何瓊芳、嚴惠予、羅筱芬、呂莉婷、林素戎、林玉惠、潘婉琳、陳貞秀、楊木蘭、游秀珍、嚴毋過、呂麗卿等合著(2017)‧護理學導論(第七版)‧新北市：新文京開發出版股份有限公司。
5.陳玉枝(2010)‧護理人員應具備的專業核心能力‧護理雜誌，57(5)，12-17。

二、英文部分
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12.Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical educators' perceptions. Nurse education in practice, 18, 73-79.
13.Ilgen, J. S., Eva, K. W., & Regehr, G. (2016). What’s in a label? Is diagnosis the start or the end of clinical reasoning?. Journal of general internal medicine, 31(4), 435-437.
14.Kahneman, D., Slovic, S. P., Slovic, P., & Tversky, A. (Eds.). (1982). Judgment under uncertainty: Heuristics and biases. Cambridge university press.
15.Kahneman, D. (2011). Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2011. this book, Kahneman provides an extensive and accessible development of the dual process theory and the application of automatic processing to choice behavior.
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17.Killam, L. A., Luhanga, F., & Bakker, D. (2011). Characteristics of unsafe undergraduate nursing students in clinical practice: an integrative literature review. Journal of Nursing Education, 50(8), 437-446.
18.Kulatunga-Moruzi, C., Brooks, L. R., & Norman, G. R. (2001). Coordination of analytic and similarity-based processing strategies and expertise in dermatological diagnosis. Teaching and learning in medicine, 13(2), 110-116.
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三、網路部分
1.馮靖惠(2019)。臺灣每年600件醫療糾紛，北醫開課讓律師學醫.聯合報.取自https://udn.com/news/story/7266/4008981, 2020/05/09.