臺大社區藥局實習教學成效探討

研究背景：先進國家之藥學經驗學習課程，係專業養成教育重要一環，涵蓋初階藥學經驗學習（introductory pharmacy practice experiences，IPPEs）與進階藥學經驗學習（advanced pharmacy practice experiences，APPEs），提供藥學生執業場所實務訓練之機會並引導主動學習。國立臺灣大學醫學院藥學系社區藥局實習之授課始自民國81年，歷經持續性教學經驗累積與改進，逐年考量社區執業實況與教學資源而適時調整教學計畫；迄今所開授社區藥局實習課程定位為「初階─中階」程度之社區執業經驗學習﹝大四上（暑期先修）、選修、2學分﹞，而對於98學年度新增之六年學制生則屬必修課程；社區藥局實習相關教育制度、實施辦法與實習場所或指導師資之遴選仍待推廣，藉深化教學課程，以期培育高素質社區執業人才。研究目的：本研究擬依歷年教學資料及99-101學年度間進行發展階段之教學評估問卷調查，探討社區藥局實習課程之教學演進並分析教學成效及其影響因子；期待研究成果，茲供進階社區藥局實習課程推動之參考。研究方法：回溯性分析社區藥局實習課程99-101學年度資料，研究對象納入實習學生及指導藥師，自變項包括課程參與指導藥師、實習學生之特質及教學藥局之特性，而學生實習評量之評值與其對課程回饋意見為依變項，以線性複迴歸模型進行分析。問卷分兩類、三式：實習學生與指導藥師雙向評估（兩式）及實習學生對課程之回饋意見（一式)；99-101學年度雙向評估，即實習學生對藥局或藥師之回饋（14項指標）、指導藥師對學生表現之綜合評量（20項指標，分專業素養與執業技能），評值採1-3分制（尚待改進、符合要求、表現優異）。而100-101學年度實習生對課程之回饋意見則包括課程安排（6項指標）、指導藥師（10項指標）、實習藥局（4項指標）、學習自我評估（22項指標）等四面向之滿意度調查，共42項指標，評值採1-5分制（極不同意、不同意、普通、同意、非常同意）。問卷回收後經匿名處理並彙整建檔，使用R 2.15.2統計軟體進行敘述性統計與迴歸分析，進而探討教學成效與其影響因子。本研究經臺大醫院倫理委員會審查通過。研究結果：研究之三學年期間共有105位學生修習社區藥局實習，曾參與實習指導之藥師34位及社區藥局34家。有關99-101學年度社區藥局實習之實習學生與指導藥師雙向評估計連鎖體系1家（11處）、多店體系3家（13處）與自營藥局（10處）參與教學，依學年度分別有14、20、25位藥師，指導23、41、41位實習學生；而有關100、101學年度實習學生對課程之回饋意見調查，則共有82位學生修課並受施測。99-101學年度指導藥師對實習生專業素養表現評量近乎優異（評值2.7 ± 0.5），尤以學習態度表現最為突出（2.8 ± 0.5），惟「與民眾溝通能自信表達」項目，在100、101兩學年度評為優異（評值3分）者比例偏低（分別為48.7% 與47.5%）；執業技能表現以「明瞭調劑作業流程與應用」為最佳（2.8 ± 0.4），而「藥品或醫材之資訊諮詢」（2.5 ± 0.6）與「全民健保藥品給付申報」（2.5 ± 0.6）兩項待加強。99學年度實習學生對實習藥局之「地點便利性」與其「空間與設備適當性」，認為尚待改進者分別佔13.0%、4.4%，觀諸其他學年度此兩項指標滿意度評值均偏低（2.3 ± 0.7、2.5 ± 0.6）；各學年間實習場所內工作人員，配合接納實習學生之評值屬良好或優異者介於82.1%~94.7%，學生多數認同其所實習之場所值得推薦予學弟妹（65.2%~84.2%）；指導藥師多數能給予實習學生學習所需之協助並給予適當指導與監督，且指導藥師是多數實習學生心目中值得民眾信賴的角色（82.6%~97.4%）。進而以迴歸分析探討，得知實習學生綜合表現評值、指導藥師教學與課程成效評估等，與地區別、指導藥師執業經驗或指導方式、學生先修課程經驗等有關；而實習學生對實習藥局或指導藥師之教學成效回饋評估，則與藥局經營型態及指導藥師執業背景與指導方式有關。而有關100-101學年度課程，學生對學習成效之自我評估（5分制），以「認識藥局內處方藥及非處方藥品項」（4.0 ± 0.6）與「調劑作業流程」（4.4 ± 0.7）兩項為佳，但「評估處方合理性」（3.5 ± 0.8）與「藥局財務管理與會計作業」（3.2 ± 0.9）兩指標待加強；101學年度學生實習前、後之自我評估，以「認識藥局內處方藥及非處方藥品項」、「調劑作業相關資訊系統應用」以及「管制藥品相關規定」等項目，自認學習有收穫，達統計上顯著差異（p值依序為0.001、0.001、0.004），另以「調劑作業流程」與「處方箋保存與歸檔規定」兩項目最佳（p < 0.001）。結論：現階段社區藥局實習課程能提供藥學生將專業知能應用於實務之訓練機會，學生於實習過程中得以陶冶專業素養、培養學習態度與精進執業技能；而實習教學成效則與課程安排、實習場所、指導藥師資歷、實習學生特質等因素息息相關。實習場所與指導藥師之遴選至為重要，而實習學生如能安排適當之先修課程，加強處方評估、經營管理或溝通諮詢技巧等執業技能，將更能結合藥學專業課程與實務執業應用，如假以時日持續進行學習成果評量研究，相信社區藥局實習課程之精進與深化指日可待。

關鍵字

社區藥局；實習教學；經驗學習；教學成效

並列摘要

Background Pharmacy practice experiential programs, whether introductory or advanced, is essential for pharmacy education. The Introductory Community Pharmacy Practice Experiences (ICPPE; elective, two credits) course at National Taiwan University has been developed and offered without interruption for each academic year since 1992. The continuation of existing educational collaboration and the recruitment of preceptors and search for new experiential sites for the course have been unremittingly carried out over the years. Objective The study aimed to document the progress of ICPPE development, to explore factors involved in educational outcomes, and to assess the impacts on both students and preceptors involved in the ICPPE course during 2010-2012. Methods A retrospective analysis was conducted of 105 students and 34 pharmacist preceptors in 34 experiential sites. Three types of questionnaires were administered, including (1) the evaluation of students by preceptors (categorized as professionalism and knowledge/skills, 20 items, 3-point scale; 2010-2012), (2) the evaluation of experiential sites and preceptors by students (14 items, 3-point scale; 2010-2012), (3) overall evaluation of course design (6 items), experiential sites (4 items), preceptors (10 items), and self-assessment (22 items) by students (5-point Likert scale; 2011-2012). The ICPPE outcomes and student-learning performance were analyzed by multiple marginal regression model for repeatedly measured response variables using the generalized estimating equations (GEE) method. Regression diagnostics was used to assure the quality of the statistical outputs. To compare the score differences between years, a non-parametric Wilcoxon signed-rank test was conducted. These analyses were performed using R 2.15.2 software. Two-sided p < 0.05 was considered statistically significant. The study received Institutional Review Board approval. Results The annual participants of students and pharmacist preceptors ranged from 23 to 41 and 14 to 25, respectively. Response rate achieved 80% and higher. The experiential sites consisted of one nationwide chain pharmacy (11 sites), three pharmacy alliances (13 sites), and ten independent retail pharmacies. Preceptors’ evaluation of students’ performance in professionalism were with high satisfaction (2.7 ± 0.5), except being confident in communicating with patients (2.5 ± 0.5). Regarding students’ performance in knowledge and skills, understanding and application of good dispensing practices were ranked the highest (2.8 ± 0.4); whereas skills in consultation services and reimbursement claims needed to be strengthened (2.5 ± 0.6). Students’ evaluation of experiential sites indicated locale convenience and teaching facilities were of lower satisfaction. Most students agreed that their experiential sites were recommendable (65.2%~84.2%). Preceptors were acknowledged highly by providing customized instructions to meet students’ needs and by serving as a dependable professional (82.6%~97.4%). The multiple linear regression analysis found that the experiential sites, the practice or teaching experiences of the preceptors, and students’ educational profiles were important factors to the evaluation of students-learning and course outcomes (p < 0.001). As for students’ self-assessment performed during 2011-2012, high satisfaction was observed in questionnaire items such as products recognition (4.0 ± 0.6) and process of dispensing practice (4.4 ± 0.7); whereas, verification of prescriptions (3.5 ± 0.8) and financial management (3.2 ± 0.9). Thirty-seven students filled out pre- and post- ICPPE self-assessment questionnaires (22 items) in 2012. Questionnaire items such as products recognition, application of pharmacoinformatics in dispensing, and understanding of laws and regulations regarding controlled substances differed significantly (p = 0.001, 0.001, 0.004). Conclusions The current ICPPE course provides students with opportunities to acquaint themselves in applying knowledge and skills in real practice settings. Student-learning outcomes and curricular effectiveness are related to relevant characteristics of students, course design, experiential sites, and preceptors. The appropriate recruitment of sites and preceptors is pivotal to the success of the course. Arranging relevant pre-requisite or simulation courses would also help students benefiting from experiential learning.