Iranian Journal of Medical Education

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Abstract Introduction. Hepatitis B is the most common cause of end stage liver disease in Iran. As a high-cost disease with a relatively high incidence, and the relative lack of community knowledge, it warrants initiation of a public health intervention in Iran. Methods. This was a Before-After educational intervention that analyzed the data obtained from questionnaires filled out by 80 patients infected by Hepatitis B and their family members. The patients were registered and invited by “Hamedan Society for Support of Hepatic Patients” for the educational program. The questionnaire was designed in order to evaluate the degree of knowledge according to patients’ needs and experts’ ideas i.e. means of transmission, preventive measures and their use and some basic practical knowledge of hepatitis B management. Nedelsky method and T-paired test were used to analyze the results. Results. The participants were aged between 11 and 59 (The age of the participants was from 11 to 59) and about half of them were females. The comparison between pre-test and post-test indicated a significant increase in the learners' level of knowledge concerning transmission of and prevention from hepatitis B and its management. 45% of the participants got an acceptable score in pre-test while in post-test it increased to 69% of them. 90% of the participants believed that the performed education had been effective in increasing their knowledge about hepatitis. 81% found the question-answer session effective in solving their problems. Moreover, 92.5% described the instructor's teaching method good or very good. Finally, 36% believed that they still had some questions about hepatitis B. Interestingly, both before and after education, about 90% thought they needed more education regarding hepatitis B. Conclusion. Group education is a useful tool for improving patients’ and their families’ knowledge of and attitude towards hepatitis B in an example of Iranian community situation.

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ارزیابی تصمیم‌گیری بالینی دانشجویان مامایی نفیسه‌السادات نکویی، مینو پاک گوهر، زهره خاکباران، محمود محمودی چکیده مقدمه: تصمیم‌گیری بالینی از سری تصمیم‌گیری مهارتی است که در ارتباط با وضعیت بیمار انجام می‌شود. ارزیابی کیفیت و نیز آموزش تصمیم‌گیری بالینی پرسنل بهداشتی می‌باشند. الگوی اداره مشکل بیمار PMP(Patient Management Prolem ) از جمله روش‌های ارزیابی تصمیم‌گیری بالینی است. این پژوهش با هدف ارزیابی تصمیم‌گیری بالینی دانشجویان مامایی با استفاده از PMP رایانه‌ای انجام گرفته است. روش‌ها: در یک مطالعه پیمایشی، کلیه دانشجویان سال آخر کارشناسی مامایی دانشگاه‌های علوم پزشکی تهران، ایران و شهید بهشتی که کلیه واحدهای خود را گذرانده‌اند به صورت سرشماری (40=N) مورد مطالعه قرار گرفتند. پرسشنامه PMP رایانه‌ای شامل 9 مورد بیمار فرضی در ارتباط با مراقبت قبل از بارداری طراحی شده در یک نرم‌افزار رایانه‌ای توسط دانشجویان تکمیل شد. نتایج حاصل از این داده‌ها با استفاده از آمار توصیفی و رگرسیون چندگانه با نرم‌افزار آماری SPSS آنالیز گردید. نتایج: به طور کلی میانگین نمره کسب شده توسط دانشجویان مورد پژوهش از 100 نمره کل، 01/7±62/35 بود و اکثریت واحدهای مورد پژوهش در سطح متوسط تصمیم‌گیری بالینی قرار داشتند. میانگین نمره کسب شده دانشجویان در ارزیابی خطر 14/9±17/40، آموزش و مشاوره 23/10±87/31 و نفیسه السادات نکوئی (مربی)، گروه مامایی دانشکده پرستاری و مامایی، دانشگاه علوم پزشکی و خدمات بهداشتی- درمانی استان اصفهان، اصفهان e-mail:nekuei@nm.mut.ac.ir و در مداخله 77/13±42/31 بود و اکثریت واحدها در این سه حیطه نیز در سطح متوسط تصمیم‌گیری بالینی قرار داشتند. بحث: از آنجا که تصمیم‌گیری بالینی عامل مهمی در ارائه بهتر خدمات توسط پرسنل بهداشتی (وهمچنین دانشجویان مامایی) می‌باشد که امکان آموزش و ارزیابی آن با استفاده از PMP میسر است، بنابراین، توجه به آموزش دقیقتر آن در برنامه‌های آموزشی ضروری به نظر می‌رسد. واژه‌های کلیدی: تصمیم‌گیری کلینیکی، دانشجویان مامایی، اداره مشکل بیمار، ارزشیابی. مقدمه تصمیم‌گیری بالینی یک جزو اصلی عملکرد بالینی است (1). و در واقع اساس کار برای بیمار و شاخصی برای قضاوت ماهرانه می‌باشد. این عملکرد یک مرحله شناختی برای حل مشکلات بالینی است. در واقع تصمیم‌گیری بالینی را می‌توان تصمیم‌گیری در مورد مداخلات و راه‌هایی دانست که به بیمار کمک می‌کند تا از شرایط فعلی به شرایط مطلوب نهایی انتقال یابد(2). با توجه به افزایش روز افزون هزینه مراقبت بهداشتی، امروز جوامع در کنار توجه به بیمار، به جنبه‌هایی اقتصادی توجه بیشتری می‌کنند. تصمیم‌گیری‌های درست می‌تواند به کاهش هزینه و پیشرفت بیشتر درمان کمک کند. باعث تسهیل و افزایش استفاده درست از منابع انسانی و مواد شده و بهبود کیفیت مراقبت را به همراه داشته باشد (3). محیط بالین دارای ویژگی‌های منحصر به فرد و از بسیاری جهان با سایر محیط‌ها تفاوت دارد. بنابراین، عملکرد کارکنان در این محیط از اهمیت ویژه‌ای برخوردار می‌باشد. در محیط بالین لازم است هر فردی تصمیم بالینی درستی اتخاذ نماید. این تصمیم درست در موارد خطرناک نقش و اهمیت خود را بیشتر نشان می‌دهد و در این حالت، عدم تصمیم‌گیری درست و به موقع می‌تواند مراحل درمان و مراقبت را طولانی و با مشکل مواجه سازد (4).یک متخصص بالینی باید تصمیم بگیرد که چه اطلاعاتی را جمع آوری کند؟ اطلاعات را چگونه تفسیر کرده و مداخله درست انجام دهد؟ و نهایتاً سرانجام کار را ارزیابی نماید (1). با توجه به مطالب ارائه شده پیرامون اهمیت تصمیم‌گیری بالینی، لزوم کیفیت آن در پرسنل بهداشتی برای ارائه بهتر خدمات بالینی توسط آنها احساس می‌شود. امروزه در سیستم ارزیابی از روش‌های مختلف استفاده می‌گردد. از جمله این روش‌ها الگوی اداره مشکل بیمار PMP(Patient Management Problem) است که به صورت‌های مختلف رایانه‌ای و کتبی ارائه می‌گردد. PMP از سال 1980 به عنوان روشی برای ارزیابی صلاحیت بالینی دانشجویان و فارغ التحصیلان به کار رفته است (5). PMP اولین بار در آمریکا برای امتحان بورد کالج پزشکان آمریکا استفاده شد. این امتحان یک روش قابل استفاده برای ارزیابی تصمیم‌گیری در موقعیت‌های مختلف پزشکی و بالینی می‌باشد و گاهی به عنوان یک الگوی شبیه سازی از آن استفاده می‌گردد که ابزار مناسبی در آموزش دانشجویان علوم پزشکی است. با استفاده از CPMP(Computerized PMP) بسیاری از اشکالات PMP برطرف شده است. CPMP برای آموزش و ارزیابی بالینی به راحتی استفاده می‌شود (6). یک PMP معمولاً با یک عبارت بالینی در ارتباط با مشکل موجود یک بیمار، همراه با خلاصه‌ای از شرح حال و اطلاعات مربوط به معاینه بیمار شروع می‌شود. بعد از آن چند مرحله در ادامه به صورت پی در پی مطرح می‌گردد و در هر مرحله از دانشجو خواسته می‌شود در مورد اداره و ارزیابی بیمار تصمیم بگیرد. وی باید تصمیمی را که به نظر او مناسب شرایط بیمار است، اخذ نماید. بعد از اینکه تصمیم گرفته شد، اطلاعات مخفی بیشتری مشخص می‌شود که نتیجه تصمیم گرفته شده را نشان می‌دهد. در مرحله بعد، دانشجو بر اساس اطلاعات به دست آمده، تصمیم‌ بعدی را خواهد گرفت. فرایند برنامه ریزی PMP به صورت زیر می‌باشد: - اطلاعات در باره بیمار و مشکل وی - تصمیم‌گیری در مورد مشکل توسط دانشجو - ارائه بازخورد به پاسخ ارائه شده - پایان مشکل این مراحل تصمیم‌گیری، ارائه بازخورد و اطلاعات بعدی تا چند مرحله تکرار خواهد شد(7). CPMP با توصیف یک مورد بالینی شامل: سن بیمار، شرایط قبلی وی، علائم و نتایج بالینی در قالب یک نرم افزار رایانه‌ای شروع می‌شود و یک سری نکات مهم برای اخذ تصمیم داوطلب، ارائه می‌دهد. پس از تصمیم‌گیری داوطلب بازخورد از طریق سیستم رایانه‌ای به وی داده می‌شود و به دنبال آن، داوطلب تصمیم‌گیری ‌های خود را در PMP ادامه می‌دهد. این مدل به صورت دقیقی مراحل تصمیم‌گیری را که در عملکرد بالینی لازم است در قالب یک برنامه رایانه‌ای به صورت تعامل بین کاربر و رایانه منعکس می‌کند (4،6،7). در یک تقسیم بندی PMP به دو نوع خطی و شاخه‌ای تقسیم می‌شود. در نوع خطی، سؤالی به فرد ارائه می‌شود که شامل چند قسمت است: در ابتدا اطلاعاتی در باره بیمار به وی ارائه می‌گردد و سؤالی پرسیده می‌شود. امتحان دهنده باید پاسخ سؤال را به صورت تشریحی و یا انتخاب گزینه بیان کند در مرحله بعد، به وی بازخورد ارائه می‌شود و قسمت بعد همین سؤال مطرح می‌گردد و تا چند مرحله این سیر ادامه می‌یابد. در هر مرحله، فرد باید تصمیم مناسب بگیرد. در نوع شاخه‌ای در هر مرحله بر حسب پاسخ فرد به سؤال، قسمت متفاوتی در مقابل وی گشوده می‌شود و مسیر جدیدی برای تصمیم‌گیری او مشخص می‌گردد (4،6،7). دانشجویان مامایی به عنوان نیروهایی که به زودی وارد سیستم ارائه خدمات بهداشتی- درمانی می‌شوند، لازم است از قدرت تصمیم‌گیری بالینی بالایی برخوردار باشند. ارزیابی قدرت تصمیم‌گیری آنها می‌تواند برنامه‌ریزی بهتر سیستم آموزش را به‌همراه داشته باشد. دراین مطالعه از میان مطالب مهم و قابل توجه درمامایی، مسأله مراقبت قبل از بارداری انتخاب‌ شده ووضعیت تصمیم‌گیری‌‌‌بالینی دانشجویان مامایی درارتباط با آن مورد بررسی قرارگرفته است. هدف از این مطالعه تعیین وضعیت تصمیم‌گیری بالینی دانشجویان مامایی با استفاده از CPMP است. منظور از مهارت تصمیم‌گیری بالینی در این پژوهش، انتخاب روش ارزیابی، آموزش و مشاوره و مداخله مناسب برای ارائه مراقبت‌های قبل از بارداری برای کلیه خانم‌های سن باروری می‌باشد که به وسیله پرسشنامه به روش CPMP رایانه‌ای بر اساس میزان پاسخ‌های صحیح و مقیاس خوب، متوسط و ضعیف اندازه‌گیری شده است. روش‌ها این پژوهش یک مطالعه پیمایشی- مقطعی، تک گروهی و یک مرحله‌ای بود که از مهر تا آذر ماه سال 1381 در دانشگاه‌های علوم پزشکی تهران، شهید بهشتی و ایران به صورت سرشماری انجام شده است (40=N). معیار ورود به مطالعه، دانشجویان سال آخر کارشناسی مامایی بود که واحدهای تئوری و کارآموزی اختصاصی خود را گذرانده بودند و معیار خروج از مطالعه، دانشجویان انتقالی یا مهمان از دانشگاه‌های دیگر، دارای سابقه کار دانشجویی مراقبت قبل از بارداری، دانشجویان کارشناسی ناپیوسته مامایی و دارای تجربه شخصی دوران بارداری بود است. ابزار گردآوری داده‌ها در این مطالعه، پرسشنامه CPMP خطی شامل 9 مورد (Case) بیمار فرضی بود. این موارد شامل ابتلا به بیماری قلبی، ابتلا به دیابت، سابقه صرع، ابتلا به آسم، ابتلا به فشار خون مزمن، ابتلا به عفونت ادراری، سابقه تولد نوزاد مبتلا به نقص لوله عصبی، سابقه تماس با فرد مبتلا به سرخچه و وجود سابقه ناسازگاری خونی بین مادر و نوزاد بود. بیماران فرضی به صورت مراجعه کننده برای مراقبت قبل از بارداری و شامل گروه‌های پرخطر حاملگی و نیازمند مراقبت ویژه بودند. هر مورد شامل ساقه و 4 زیر سؤال است که هر زیر سؤال دارای یک نمره بود. بنابراین، هر مورد کلاً 4 نمره پرسشنامه را به خود اختصاص می‌داد. در ساقه، هر مورد اطلاعاتی مربوط به شرح حال و معاینه فیزیکی مراجعه کننده ارائه شده بود. در هر سؤال، پرسش‌هایی در ارتباط با تصمیم‌گیری در مورد مراجعه کننده فوق مطرح می‌شد. این چهار زیر سؤال به یکدیگر مرتبط بودند. برای پاسخگویی باید دانشجو در کنار رایانه قرار می‌گرفت. پس از باز شدن برنامه، یک سری راهنمایی برای تکمیل پاسخ‌ها به دانشجو ارائه می‌شد و سپس اولین مورد قسمت اصلی پرسشنامه آغاز می‌گردید. مشخصه این سؤالات به گونه‌ای بود که در هر مورد بعد از اینکه کاربر یک زیر سؤال را پاسخ می‌داد، بازخوردی به وی ارائه می‌شد که شامل پاسخ ارائه شده توسط وی و پاسخ صحیح سؤال بود. بعد از ارائه این بازخورد، دیگر کاربر قادر به تغییر پاسخ داده شده خود نبود. بعد از این مرحله، زیر سؤال «ب» همین مورد بر روی صفحه نمایشگر ظاهر شده و تا زیر سؤال «د» و ارائه بازخورد برنامه، مورد بعدی شروع شده و به همین نحو 9 مورد با تعامل بین کاربر و رایانه ادامه می‌یافت. برای انجام نمونه‌گیری، دانشجویان هر یک در کنار یک رایانه شخصی قرار گرفتند و به آنها یک کد تعلق گرفت. با ارائه توضیحات و راهنمایی‌های لازم، هر یک از آنها وارد برنامه PMP شده و به تکمیل سؤالات پرداختند. بر اساس مطالعه مقدماتی، 60 دقیقه زمان برای تکمیل این پرسشنامه تعیین شد. در جریان تکمیل پرسشنامه در صورت نیاز راهنمایی‌های لازم توسط کارشناس رایانه حاضر در محل در جهت کار با نرم‌افزار مورد نظر ارائه شد. در نهایت، سؤالات پرسشنامه CPMP یک بار به صورت کلی و بار دیگر به صورت تقسیم‌بندی سؤالات در سه حیطه مربوط به مراقبت قبل از بارداری یعنی ارزیابی عوامل خطر، آموزش و مشاوره و مداخله مورد بررسی قرار گرفت. با توجه به اینکه هر مورد دارای 4 گزینه بود. از 36 گزینه کلی موجود، 17 مورد در حیطه ارزیابی عوامل خطر، 12 مورد آموزش و مشاوره و 7 مورد در مداخله قرار گرفتند. برای نمره‌گذاری این پرسشنامه از سیستم متداول در نمره‌گذاری PMP استفاده شد. به این صورت که به مواردی که بیان آنها مهم و ضروری است، 1+ مواردی که بیان آنها مهم و ضروری است، 1+ و به مواردی که مفید نبوده و ضروری نیز برای بیمار ندارد، صفر تعلق گرفته است. نمرات کمتر از تفاضل میانگین و انحراف معیار به عنوان ضعیف، نمرات در فاصله یک انحراف معیار از میانگین به عنوان متوسط و نمرات بیش از جمع میانگین و انحراف معیار به عنوان خوب در نظرگرفته شده‌اند. برای تأیید روایی پرسشنامه از روش اعتبار محتوی و اعتبار صوری و برای تأیید پایایی آن از روش آزمون مجدد (Test re test) و انجام یک مطالعه مقدماتی استفاده شد که ضریب همبستگی 8/92درصد برای پرسشنامه به‌دست آمد. آنالیز آماری اطلاعات با استفاده از روش‌های آمار و توصیفی و نیز رگرسیون چندگانه و نرم‌افزار آماری SPSS انجام شد. نتایج طیف سنی دانشجویان مورد مطالعه 24-21 سال بود و اکثریت آنها در سن 22 سال قرار داشتند (50درصد). از مجموع 40 نفر نمونه مطالعه، اکثریت آنها (70درصد) مجرد و به ترتیب از سه دانشگاه علوم پزشکی ایران، تهران و شهید بهشتی 45 درصد، 5/32 درصد و 5/22 درصد بودند. میانگین نمره کسب شده در هر سؤال تصمیم‌گری به صورت جداگانه مورد بررسی قرار گرفت. در کل سؤالات، بیشترین نمره کسب شده (66/1) از کل 4 نمره، مربوط به موضوع «تصمیم‌گیری در ارتباط با بیمار قلبی کلاس II با سابقه تعویض دریچه میترال که مایل به حاملگی است» و کمترین نمره کسب شده (16/1) از کل 4 نمره، مربوط به موضوعات «مشاوره قبل از بارداری برای خانم مبتلا به صرع» و «مراقبت قبل از بارداری برای خانم دارای فرزند مبتلا به نقص لوله عصبی» بود. سؤالات مربوط به مهارت تصمیم‌گیری بالینی بر اساس سه حیطه موجود در مراقبت قبل از بارداری (ارزیابی عوامل خطر، آموزش و مشاوره و مداخله) به سه دسته تقسیم شدند. میانگین نمره تصمیم‌گیری بالینی واحدهای مورد پژوهش در زمینه ارزیابی عوامل خطر 14/9±17/40 بود و اکثریت افراد در سطح متوسط تصمیم‌گیری قرار داشتند. نمره تصمیم‌گیری بالینی در حیطه آموزش و مشاوره 22/10±87/31 بود و اکثریت افراد در سطح متوسط تصمیم‌گیری قرار داشتند. در حیطه مداخله نمره تصمیم‌گیری 77/13±42/31 بود و اکثریت واحدها در این زمینه نیز در سطح متوسط تصمیم‌گیری قرار داشتند. نمره مهارت تصمیم‌گیری بالینی در کل مراقبت‌های قبل از بارداری 01/7±62/35 بود و به صورت کلی نیز اکثریت واحدها در سطح متوسط تصمیم‌گیری قرار داشتند. سطوح مهارت تصمیم‌گیری بالینی دانشجویان مامایی در جدول یک ارائه گردیده است. با توجه به اینکه نمرات در مقیاس 100 محاسبه شده است، نتایج نشان داد که میانگین به دست آمده در هر یک از سه حیطه و به صورت کلی از نظر تصمیم‌گیری بالینی کمتر از 50 درصد کل نمره است. جدول 1. مهارت تصمیم‌گیری بالینی در مراقبت قبل از بارداری سطح تصمیم‌گیری بالینی ارزیابی عوامل خطر آموزش و مشاوره مداخله کل مراقبت قبل از بارداری ضعیف 5/17% 20% 15% 5/17% متوسط 65% 70% 70% 5/67% خوب 5/17% 15% 15% 15% برای شناسایی سهم هر حیطه تصمیم‌گیری در مقدار کل تصمیم‌گیری، با استفاده از مدل رگرسیون، آزمودنی بین مهارت تصمیم‌گیری کلی و مهارت تصمیم‌گیری در سه حیطه ارزیابی عوامل خطر، آموزش ومشاوره و مداخله انجام شد. نتیجه این مدل به صورت زیر بود: در این معادله خط مهارت تصمیم‌گیری در ارزیابی عوامل خطر، x2 مهارت تصمیم‌گیری در آموزش و مشاوره و x3 مهارت تصمیم‌گیری در مداخله و y مهارت تصمیم‌گیری در کل مراقبت‌های قبل از بارداری است. طبق این معادله خطی تقریباً 41 درصد از کل تصمیم‌گیری به دست آمده مربوط به تصمیم‌گیری در ارزیابی عوامل خطر، 33درصد مربوط به آموزش و مشاوره و 25 درصد مربوط به مداخله است. بحث تصمیم‌گیری بالینی عامل مهمی در ارائه خدمات به بیمار می‌باشد و آن را می‌توان پایه‌ای برای نحوه استفاده یک متخصص از اطلاعات و تجربیات قبلی خود برای بررسی و نتیجه‌گیری در موارد جدید دانست. مواردی وجود دارد که تشخیص افتراقی مهم و مشکل است و در این حالت عدم تصمیم‌گیری درست و به موقع می‌تواند مراحل درمان و مراقبت را طولانی و با مشکل مواجه سازد (4). تصمیم‌گیری بالینی در مامایی نیز به عنوان یکی از شاخه‌های مهم علوم پزشکی قابل توجه است. نتایج این مطالعه نشان داد که نمره کسب شده توسط واحدهای مورد پژوهش در هر سؤال کمتر از 50 درصد کل نمره آن سؤال می‌باشد. (کل نمره 4 و حداکثر نمره کسب شده توسط واحدها 66/1 بوده است)، بنابراین، ضعف در پاسخ به کلیه سؤالات احساس می‌شود. البته این ضعف در موارد مربوط به مراقبت قبل از بارداری بیشتر بود. در تقسیم بندی واحدها به سه سطح خوب، متوسط و ضعیف در سه حیطه مربوط به موضوع مورد بررسی و نیز به صورت کلی، اکثریت واحدها در سطح متوسط قرار داشتند. در این زمینه در مطالعه‌ای که بر روی دستیاران داخلی و دستیاران خانواده در ارتباط با بررسی مهارت ارزیابی بالینی آنها در مراقبت قبل از بارداری انجام گرفته، به این نتیجه رسیده‌اند که از مقیاس کلی 14، میانگین نمره دستیاران داخلی 6 و دستیاران خانواده 7 بوده است. اطلاعات مطالعه آنها نشان داده که مقیاس مهارت ارزیابی بالینی هر دو گروه در ارتباط با موضوع فوق پایین بوده است (8). توجه به معادله خط رگرسیون تصمیم‌گیری نشان می‌دهد که سطح بیشتری از تصمیم‌گیری کلی مربوط به تصمیم‌گیری در آموزش و مشاوره و مداخله بود و بنابراین، برای تقویت مهارت تصمیم‌گیری در مراقبت قبل از بارداری در مرحله اول باید تصمیم‌گیری در ارزیابی عوامل خطر را افزایش دهیم و در مرحله بعد تصمیم‌گیری در آموزش و مشاوره و مداخله مد نظر قرار گیرد، وجود ضریب مثبت نشان دهنده ارتباط مثبت این سه حیطه با کل تصمیم‌گیری است. با توجه به اینکه در مطالعه حاضر دانشجویان مورد مطالعه در سال آخر دوره تحصیلی خود به سر برده و واحدهای تئوری و قسمت اعظم واحدهای عملی خود را گذرانده‌اند، انتظار می‌رفت که از قدرت تصمیم‌گیری بالایی برخوردار باشند در حالی که نتایج این مطالعه این مسأله را تأیید نمی‌کند. علی‌رغم اینکه درصد بالایی از واحدهای ارائه شده به دانشجویان علوم پزشکی به صورت عملی و بالینی است، اما به دلایل مختلف صرف ارائه این واحدها نمی‌تواند تصمیم‌گیری بالینی را در آنها افزایش دهد. در صورتی که آموزش کلاسیک عمدتاً بر پایه دروس نظری باشد و توجه لازم به آموخته‌های عملی دانشجویان نشود، می‌تواند باعث ضعف قدرت تصمیم‌گیری شود. ممکن است علت پایین بودن نمره تصمیم‌گیری بالینی واحدهای پژوهش ناتوانی در بکارگیری بالینی اطلاعات علمی باشد. از طرف دیگر، این احتمال وحود دارد که دانشجویان به دلیل اضطراب، عدم تمرکز و نگرانی از آسیب به بیمار در محیط بالین، قدرت تصمیم‌گیری درستی نسبت به مددجویان پیدا نکنند. از این جهت، استفاده از روش‌هایی همچون: OSCE(Objective Structured Clinical Exam)، PMP و شیبه سازی (Simulation) به دلیل اینکه عوامل مخدوش کننده فوق حذف می‌شوند، می‌تواند در افزایش مهارت تصمیم‌گیری بالینی و آمادگی دانشجویان در برخورد با مددجویان در محیط بالینی واقعی مؤثر باشد. با توجه به اینکه طبق نتایج این مطالعه میزان تصمیم‌گیری بالینی عده کمی از دانشجویان در سطح خوب قرار داشت، لازم است در ارتباط با ریشه‌یابی علل آن توجه بیشتری مبذول شود و برنامه‌ریزان آموزشی کشور با دقت بیشتر به ریشه‌یابی این مسأله بپردازند زیرا مهارت تصمیم‌گیری بالینی عامل مهمی در ارزیابی بیمار است و دانشجو به عنوان نیرویی که به زودی مسؤولیت اداره سیستم بهداشتی- درمانی را به عهده می‌گیرد، باید در دوران دانشجویی این قدرت ومهارت را در حد مناسب و خوب به دست آورد. پیشنهاد می‌شود مسؤولین آموزشی دانشگاه‌ها به آموزش موارد مختلف تصمیم‌گیر بالینی و موارد مشابه آن در آموزش بالینی دانشجویان توجه بیشتری نموده و با ارائه راه‌حل‌های مناسب و استفاده از شیوه‌های نوین آموزش و تکنولوژی جدید در جهت ارتقای سطح آموزش دانشجویان گروه پزشکی و در نتیجه ارتقای سطح ارائه خدمات بهداشتی- درمانی بکوشند. از طرف دیگر، دانشجویان نیز لازم است با دقت و تأمل بیشتری دروس را به صورت کاربردی آموخته و بیشتر به تقویت مهارت تصمیم‌گیری بالینی در خود و نیز کاربرد بیشتر رایانه در آموزش بپردازند. تصمیم‌گیری بالینی عامل مهمی در ارائه خدمات بهداشتی- درمانی می‌باشد، بنابراین، لازم است که آموزش آن در رأس برنامه‌های آموزش پزشکی قرار گیرد. و می‌توان PMP به عنوان یک روش مناسب برای آموزش و ارزیابی تصمیم‌گیری بالینی استفاده نمود و برای افزایش کاربرد آن در سیستم آموزش پزشکی توجه لازم مبذول کرد. قدردانی از معاونت پژوهشی دانشکده‌های پرستاری و مامایی دانشگاه‌های علوم پزشکی تهران، ایران و شهید بهشتی برای مجوز نمونه‌گیری، مسؤولین واحدهای رایانه دانشکده‌های پرستاری و مامایی تهران و شهید بهشتی و مسؤولین بیمارستان‌های وابسته به سه دانشگاه مورد مطالعه برای همکاری در نمونه‌گیری و نیز مسؤولین محترم مرکز مطالعات و توسعه آموزش پزشکی دانشگاه علوم پزشکی اصفهان برای همکاری در تهیه پرسشنامه صمیمانه تشکر و قدردانی می‌شود. منابع 1- Tracy K, Bucknall BN. Critical care nurses decision making activities in the natural clinical setting. J Clin Nurs 2000 9(1):25. 2- Huber D. Leadership and nursing care management. 2nd ed. Philadelphia: Sounders Co.2000:111. 3- Ellis JR, Hartley CL. Managing and coordinating nursing. 3rd ed. Philadelphia:Lippincott Co. 2000:2. 4- Robinson DL. Clinical decision making a case study approach. 2nd ed. Philadephia:Lippincott Co.2000:2. 5- Nufeld V, Norman GR. Assessing clinical competence. New York: Springer Co.1985:184. 6- Takabayashi K. Implementation and evaluation of computerized patient management problem. Med Info 19958(2):1218. 7- Afroza S. Use of a PMP manual as a teaching tool for accelerates pediatric teaching in Bangladesh. Medical Teacher 2000 22(4):366. 8- Conway T.Hu TC. Are primary care residents adequately prepaid to care for women of reproductive age. Family Perspective 199527(2):73-5. Evaluation of Midwifery Students' Clinical Decision Making Nekuei N, Pakgohar M, Khakbazan Z, Mahmudi M Abstract Introduction: Clinical decision making is one of the skilful decision makings which is made considering patients situation.Quality evaluation and clinical decision making education are two important elements in improving health personnel's decision-making process. PMP (Patient Management Problem) is one of the clinical decision making methods in -which some clinical conditions are taken from a disease and are put forward in the form of a multi- stage question. This study tried to use the computerized PMP to evaluate midwifery students' clinical decision making. Methods: In a cross- sectional census research, 40 Senior midwifery students from Tehran, Iran and Shahid Behshti Medical Universities were studied. A computerized PMP questionnaire, including 9 assumed clients referring for preconception care was designed as a software program and was given to the participants to fill in. The data were analyzed by descriptive statistics and multiple regression using SPSS software. Results: The mean score earned by the participants was 35.62±7.01 out of 100. Most of the subjects had an average clinical decision-making score. The acquired mean score of the subjects in risk assessment was 40.17 ±9.14, in education and counseling was 31.87±10.23 and in intervention was 31.42±13.77. Most of the subjects had average clinical decision making score in these three fields. Conclusion: Since clinical decision making as a major element in enhancement of health team services can be evaluated and taught by PMP and as most of the studied subjects regarding preconception care were not in an appropriate level, more precise education in this field seems necessary. Key words: Clinical Decision Making, Midwifery Students, Patient Management Problem, Evaluation Address: Nekuei N, School of Nursing and Midwifery, Isfahan University of Medicine and Health Services Source: Iranian Journal of Medical Education 2002, 6: 49-54.

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Introduction. The quality of doctor-patient relationship has a significant impact on patient satisfaction and medical outcomes. Communication skills training is not formally included in medical education curriculum in Iran and as a result physicians can not communicate properly with their patients and need to receive training in this regard. In this study a communication skills training program for general practitioners was designed and its effect on their patients’ satisfaction was evaluated. Methods. In a quasi- experimental two group post-test design study, a communication skills training program was designed and implemented as a three days workshop. The study sample included 32 employed physicians (16 physicians in each experimental and control groups) and 153 patients (72 patients in experimental group and 81 in control group). The physicians in the experimental group participated in the workshop and received training using new instructional methods combined with routine communication skills teaching methods. A valid and reliable questionnaire was used to measure patients’ satisfaction. Then, patients’ satisfaction from trained physicians was compared with the satisfaction in the control group by t-test using SPSS software. Results. The mean score of patients’ satisfaction from trained physicians was 86.2 with the standard deviation of 10.3 which was significantly higher than the mean score for control group (81.5±9.58). Patients’ satisfaction from their physicians’ general communication skills, at the beginning and end of session was greater for trained physicians compared with the ones who didn’t receive any training. Conclusion. Since, communication skills training for general practitioners increased patients’ satisfaction, and considering the fact that this kind of training is not included in medical education curriculum, it is recommended to consider it as an efficient and useful component in continuing medical education programs as well as undergraduate medical education.

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Introduction. Patient's satisfaction is considered as one of the hospital effectiveness indicators which has an important role in hospital productivity. Respecting patients' rights is necessary for gaining their satisfaction. The objective of this survey was to investigate the patients and physicians' awareness about patients’ rights and its implementation in Beheshti hospital in 2003. Methods. This cross-sectional survey was carried out using a questionnaire whose face and content validity was confirmed by experts and its reliability by test-retest, as the data collection tool. All physicians employed in Beheshti hospital (n=30) and 160 patients, selected through systematic random sampling, filled the questionnaires. The data analysis was done using t-test, frequency distribution, mean, standard deviation and Pearson Correlation Coefficient by SPSS 11 software. Results. Physicians and patients' knowledge about patients’ rights was 0.90±0.12 (excellent) and 0.32±0.17 (weak), out of 1, respectively. They scored implementation of patients' rights in the hospital as 0.33±0.1 (weak) out of 1. Conclusion. Patients are not aware of their own rights and need education in this regard. Although, physicians' information about patients' rights was in excellent level, the patients' rights was respected very little at the hospital. It is necessary to inform patients about their rights which in turn can improve hospital effectiveness and productivity.

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Introduction. Taking care of patients is a team work and in each team work the members’ performance has a direct impact on their relationship and efforts in achieving their common goal. It is necessary that medical interns as a member of health care team pay attention to the health care services provided by nurses. The purpose of this study was to determine the viewpoints of interns about nurses’ capabilities and behavior with patients and interns in teaching hospitals of Isfahan Medical University. Methods. In this descriptive study, 157 interns working in educational hospitals affiliated to Isfahan Medical University were selected by stratified random sampling method. The data collection tool was a Likert type valid and reliable questionnaire consisted of 25 questions about nurses’ performance towards patients and interns, and interns’ performance towards patients. The mean, standard deviation, t-test and spearman were used for data analysis by SPSS software. Results. The mean score of interns’ view about nurses’ performance was 3.06 out of 5. This score was 2.99 for professional skills of nurses, 3.12 regarding the nurses’ behavior towards patients and 3.14 for the nurses’ behavior towards interns. The score earned from interns’ viewpoint about their own performance towards patients was 3.32. The mean number of improper contacts between interns and nurses reported by interns in previous 5 days was 0.3. Conclusion. The overall score of interns’ view towards nurses’ performance was at an intermediate level which could be because of different reasons such as their undefined responsibilities towards nurses and patients. It is obvious that this defect could have a negative impact on patient management and team work. Therefore it is necessary to consider “the way of communicating with nurses” in the learning objectives and educational content of interns.

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Introduction. Most factors which make infants susceptible to pneumonia arise from incorrect infant care in the family and also insufficient knowledge of mothers about correct infant care which makes this problem even worse. The present research was carried out to determine the effect of a Designed Care Plan on mothers' performance in caring for the infants with pneumonia in Children Medical Center in Tehran. Methods. In a quasi- Experimental study 66 mothers of hospitalized infants aged between 1-12 month and suffering from pneumonia, were selected by convenience sampling method and assigned randomly to two experimental and control groups. Data collection tools included questionnaire and observational-interviewing checklist. The designed Care Plan was presented both theoretically and practically to the experimental group at home with an eye to the strengths and weaknesses of mothers’ performance and their need, while the control group received only the current care program. The mothers’ performance in infant care was assessed during repeated measurements before and after the intervention. All study subjects were followed for 3 months after the intervention. Results. The mean score for mothers' performance in infant care during pneumonia showed a significant increase in the experimental group and a significant decrease in the control group, after the intervention. While, there was a significant difference between the mean score of mothers' performance in prevention of reinfection with pneumonia before and after the intervention in the experimental group. Moreover, there was a significant difference between the total score of experimental and control groups in infant care during the disease and also in prevention of reinfection with pneumonia, after the intervention. Conclusion. Using a Designed Care Plan is an effective approach for improving mothers’ performance in caring for infants suffering from pneumonia moreover, the results indicated that home-training is a good strategy in the betterment of mother’s caring behaviors.

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Introduction. Today, the subject of patient education as well as education for their families is mainly about acceptance of self-care by patients. Therefore, proper conditions should be provided for patients to be able to take care of themselves. This study attempts to examine the effects of a self-care program on quality of life of patients having permanent pacemaker. Methods. A quasi-experimental study using two groups/two stages design was performed. Thirty four patients with pacemakers referred to Chamran Hospital Pacemaker Clinic in Isfahan, were selected through convenience sampling and divided to two 17 person groups. One week after installing the pacemaker, the quality of life of both experiment and control groups was studied by a valid and reliable questionnaire. Then, the self care program consisting of individual education, demonstration and practice, was held for the experimental group. After two months, the quality of life was checked again in both groups. The data was analyzed by descriptive statistics, independent and paired t-tests, and Chi square using SPSS software. Results. In both experimental and control groups, there was a significant difference between the qualify of life scores before and after intervention. However, two months after the intervention, the mean score of quality of life in experimental group was significantly more than control group. Conclusion. The self care program is effective in promoting the quality of life of the patients with permanent pacemaker. This is supported by other studies as well. It is suggested to include these educational programs in post-operative care plans of patients having permanent pacemaker.

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Abstract Introduction: The way nursing students communicate with patients can show their actual performance in the future. This research was performed to determine how nursing students communicate with hospitalized patients in hospitals affiliated to Kerman University of Medical Sciences in. Methods: In a descriptive study, 175 students who had medical surgical unit, were selected by census sampling method in the year 2005. Data gathering was done by a 29 item checklist. While interacting with patients, each student was observed by a trainer three times in the ward, and the results were recorded. Data analysis was done by SPSS software using mean, and standard deviation, and the comparisons were made by t-test, ANOVA and Tukey. Results: The mean and standard deviation of nursing students’ scores in communicating with patients were 58.98±13.76 out of 87. The students’ performance was desirable at the beginning of interview and in interaction skills, semi-desirable in problem follow up and disease description, and undesirable at the end of interview. There was no significant difference between the mean scores, according to different age groups, semester of study, year of the study and the type of ward they were attending. Conclusion: Although students’ communication skills are in a desirable level, revising educational programs and improving teaching methods with focus on communication skills are recommended. Teaching theoretical base of the related subjects at the same time with practice in clinical settings is also suggested.

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Abstract Introduction: In order to determine nurses’ educational needs in supporting family members of hospitalized elderly patients’, the needs of these care givers should be recognized. This study was performed with the goal to obtain and understand the lived experience of patients’ family caregivers regarding their needs. Methods: In a qualitative study with phenomenological method, the care givers of elderly patients hospitalized in one of the hospitals affiliated to Isfahan Medical University were selected by purposive sampling in the year 2004. By reaching data saturation the number of participant was 12. Data were gathered through in-depth interviews and analyzed by “Parse” method. Results: The care givers’ needs and the responses of environment to these needs showed the educational needs of nurses in five core concepts including empathy and emotional support, information and education, participation in decision making, receiving help in voluntary care, and welfare facilities. Conclusion: Although hospital staffs, especially nurses, are often in the best position to meet families’ needs, these needs are not always met. This study confirms the importance of educating health care team, especially nurses based on family caregivers’ needs. It also proposes a framework for teaching necessary skills, especially caring communication in response to care givers’ needs, to nurses and nursing students.

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  Introduction: Patients my feel uncomfortable toward discussing their diseases on their bedsides which is usually done by faculty members and students during clinical rounds. This study aimed to determine the viewpoints of internal ward patients about clinical rounds on their bedside in Alzahra hospital of Isfahan University of Medical Sciences.

  Methods: This descriptive study was performed on 110 patients hospitalized in internal wards of Alzahra hospital during September and October 2005. A valid and reliable questionnaire including 3 groups of questions about “attitude towards the events during the round”, “the list of events, patient experience during hospitalization” and “attitude towards the process of clinical round”. This questionnaire also asked about demographic characteristics and having a family caregiver during being hospitalized. The data was analyzed by SPSS software using frequency distribution, mean and standard deviation.

  Results: The questionnaires of 100 patients were complete. Most questions showed a positive attitude towards “the events during the round”. Most patients had experienced some events during the clinical rounds such as patient visit, and examination by a physician. Considering the process of clinical rounds, patients had more agreement on “the need to speak with the main physician”, “reducing the number of students” , and “the need to a change in educational method”.

  Conclusion: Patients’ satisfaction can be provided by increasing the number of visits or the duration of visits, meaning more attention to patients. In total, clinical rounds on bedside do not have a significant negative effect, and by making some improvements, they can lead to a more positive view in patients without damaging clinical rounds.

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Introduction: Educating patients is one of the nurses’ main duties. The educational pamphlets for patients have been less studied. In order to evaluate the students’ performance in preparing educational pamphlets for patients, this study was designed with the aim to determine the quality of these pamphlets designed for patients with chronic diseases in Semnan University of Medical Sciences. Methods: In a descriptive study, 120 pamphlets made by nursing students were gathered and evaluated using a self-made checklist including three parts of message content, organization of the content, and appearance and appeal of the pamphlets. The SMOG (Simplified Measure of Gobbledygook) readability formula was used for determining literacy level needed for reading this pamphlets. Results: The most selected subject for patient education, chosen by students was related to endocrine system, (15.8%) and the main item discussed in these pamphlets was about self-care actions ( 21.93%). The average literacy level needed for reading these pamphlets was at the level of 11/74th grade, while the average literacy level of patients was at the level of 5th grade. Conclusion: The prepared educational materials were written above patients’ literacy level. It is necessary to provide these materials more simple and understandable, and pay attention to other important aspects, in order to make them more usable for patients.

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Introduction: Good communication between doctor and patient is one of the fundamental skills which can lead to getting adequate information from the patient, correct diagnosis, gaining patients’ trust, and at the end, proper care and treatment. The aim of this study was to investigate interns’ communication with patients from the observer and patient’s view. Methods: In this cross-sectional study performed in 2004, the communication skill of 72 interns of Kerman Medical University, during interview with patients was studied. The research tools included a checklist filled through direct observation and a questionnaire which was completed through interview with patient. The data was analyzed by descriptive statistics, Spearman and Kappa coefficients using SPSS software. Results: In total, the performance of interns in communicating with patient during history taking was at an intermediate level, from both the observer and patients’ views. Also, according to their views, the most areas of deficit were at the end, during conducting and beginning of the interview, respectively. In most parts, there was no agreement between observer’s and patient’s views. With increasing patients’ age, the scores given to interns’ communication skills increased significantly. Conclusion: There are some deficiencies in interns’ communication skills during history taking. Considering the importance of communication skills, teaching them in Clinical Skills Learning Center before confronting real patients is necessary. It is recommended to perform interventional studies in order to find proper content and teaching methods for the education of communication skills.

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Introduction: Hypertension can accelerate other complications of diabetes mellitus, particularly cardiovas-cular disease and nephropathy. This study was carried out in order to determine the effect of applying Continuous Care Model on diabetic patients’ blood pressure. Methods: This clinical trial was performed as time series on 74 patients with diabetes mellitus type II, in Orumieh in the years 2003-2004. After matching the study variables, the patients were divided equally and with random allocation to two experiment and control groups. The Continuous Care Model which included 4 main steps of orientation, sensitization, performing and evaluation was performed for the experiment group through 10 sessions of education concerning self care in diabetes, each session lasting for 2 hours. The blood pressure of both groups was measured at the beginning and every month, for three times. The data was analyzed by SPSS software using repeated measure ANOVA. Results: There wasn’t any difference between the mean of systolic blood pressure in both study groups, but comparing the mean of diastolic blood pressure of the two groups showed a significant difference. Conclusion: Applying Continuous Care Model can reduce diastolic blood pressure in type 2 diabetic patients. Therefore, it is recommended to use this model on diabetic patients in order to control diabetes complications.

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Introduction: Clinical rounds as one of the clinical teaching methods, may cause adverse effects on patients and the medical team is able to report such problems. The purpose of this study was to determine the effects of clinical rounds on patients from medical teams' points of view. Methods: This descriptive cross-sectional study was conducted on 150 members of clinical care team including clerkship and internship students and nurses who were selected through convenient sampling method in educational hospitals affiliated to Isfahan Medical University. A questionnaire containing demo-graphic features, items asking the medical team's viewpoint about the method of running medical rounds, the list of events experienced by the patient, and medical team opinions regarding the patients' feelings toward the manner of clinical round was distributed as self-administered. The data was analyzed by SPSS software using frequency distribution, mean and standard deviation, and the comparisons were made by ANOVA. Results: The medical team believed that patients had the most satisfaction from performing procedures by interns and residents, precision and follow up in therapeutic affairs, general outcome of hospitalization, and the duration of visits. Their least satisfaction was about the number of examiners, the duration of patient's encounter with the main physician, explanation about the disease and taking the patient’s opinion into account in decision making. Conclusion: Based on the medical team's opinion, the current method of clinical rounds may cause dissatis-faction in patients and result in undesirable consequences. Revision and reforming the current situation of rounds can lead to the improvement of this process.

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Introduction: As world population gets older, caring for the elderly becomes one of the most important and challenging duties of health care system. This study was done to describe the educational needs of the elderly hospitalized in acute care settings, based on health care team and patient’s actual experiences. Methods: Using phenomenological approach, participants were selected from a teaching hospital in Isfahan. A purposive sample of 8 nurses, 4 elderly patients and 2 physicians were interviewed in depth. Colaizzi’s analysis method guided the essential activities of the researchers. Results: Following analysis of transcribed interviews, emerging themes were categorized in major concepts and related subconcepts including: interaction with instruments and interventions, hospital self-awareness, mobility and activity, risks management, treatment discipline, accessible care and treatment. Conclusion: The concept of “education” in hospitalized elderly is a vast concept. Provision of adequate and timely information for the hospitalized elderly about expected outcomes and behaviors, physical condition and ways to get help in challenging situations can promote their cooperation in health care procedures. Through educating nurses and medical staff, the goals of “providing comprehensive elderly health care” and “improving nursing care quality” could be achieved.

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Introduction: Employing supervision methods which focuses on educational aspects may increase the effectiveness of nursing personnel's educational activities, especially patient education. The aim of this study was to investigate the effect of clinical supervision on the effectiveness of nurses' educational performance. Methods: This quasi-experimental study was conducted using static groups' comparison in which the control and experiment groups were compared by a post-test. Study samples included 72 patients who were matched and assigned into two distinct groups. Clinical supervision system was implemented through three steps in 3 wards of Samen-al-Aemme hospital in Mashhad for 6 months. The data gathering tool included patient information sheet, patient satisfaction from nurses' educational practice and rating scale of self-care knowledge and practice of patients. Data was gathered through interview and observation methods and analyzed by SPSS software. Results: The mean scores of self-care knowledge and practice of the patients were 30.6 and 57.1 out of 100, in the control and experiment groups, respectively. The mean score of patients' satisfaction from nurses' educational practice was 19.6 in the control group and 20.9 in the experiment group, out of 24. So that, independent t-test showed a significant difference between these two groups. Conclusion: Implementing clinical supervision system through observation, feedback, discussion, and investigation, may develop nurses' knowledge and professional skills in patient education. Therefore, this supervision method could be regarded as an effective model for in-service education. More studies are required in order to investigate the effect of this model on other aspects of nurses' practice.

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Introduction: Reporting medication errors leads to saving patients' wellbeing and safety and also is counted as a valuable information source for preventing further mistakes in future. The aim of this study was to determine the causes for refusing to report medication errors from the viewpoints of nursing students. Methods: All nursing students of Arak University of Medical Sciences (n=76) were selected to participate in this descriptive cross- sectional study. Using a 17 item questionnaire based on 5-point Lickert scale, nursing students' viewpoints toward refusal in reporting medication errors were investigated. This questionnaire included 3 domains of fear from reporting consequences (10 items), administrative factors (4 items), and reporting procedure (3 items). Data was analyzed by SPSS software. Results: Nursing students estimated that 75% of medication errors were reported by them. Among all causes under investigation," fear from reporting consequences" had the highest score (4.13) among all. From 10 existing items in the domain of "fear from reporting consequences", "fear from evaluation score", and "academic consequences", were main causes for refusing to report medication errors. Among 4 items in the domain of "administrative factors", students had most agreement with the item of "lack of appropriate feedback following reporting medication fault". Conclusion: Some medication errors are not reported by the students and fear from reporting consequences and administrative factors are two main factors for refusing to report medication errors in nursing students. With regard to the fact that reporting medication errors could enhance the patients' immunity, nursing instructors should react positively towards the reports of medication errors by nursing students.

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Introduction: The effects of teaching communication skills using a specific model on nursing students' skill in communicating with mental patients has less been a subject of investigation. The aim of this study was to determine the effect of a communication skills' teaching model on nursing students' communicating with mental patients. Methods: This quasi-experimental study was conducted as pretest-posttest design, on 49 senior nursing students in two groups of control (24 students) and experiment (25 students). After performing the pretest of communication skills, both groups spent 12 days of clinical education for communication skills. The experiment group was taught using the mentioned model and the students of control group had the traditional training. After finishing the educational course, students' progress in communication skills in the two groups was compared. An integrated checklist was used for gathering data. Students' skills in interviewing mental patients were observed and the results were analyzed by SPSS software using Wilcoxon and MannWittney tests. Results: Both methods of training improved students' communication skills with mental patients. Comparing the two methods, the mentioned training model showed a significantly higher level of improvement in nursing students' communication skills. Conclusion: In spite of the significant effect of the mentioned model on improving nursing students' communi-cation skills, due to the lack of enough evidence in this regard, conducting further studies in this area is recommended.

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Introduction: Teaching through group discussion is one of the student-oriented (centered) instructional methods. This study was performed to compare the effect of teaching through lecture and group discussion on nursing students' communication skills with patients in year 2008. Methods: This was a quasi experimental study performed on a population of 57 students of first (n=29) and third semester (n=28) of school of nursing and midwifery in year 2008. Students of each semester were divided into two groups of experiment and control. Two modules of medical surgical courses were taught to the students through lecture (for control group) and group discussion (experiment group). Students' skills of communication with patients in both groups were assessed once before instruction and once again after that. Data derived from two groups was compared and students' skills of communication were inscribed using a questionnaire containing 35 phrases in Likert's original 5-point scale. Results: Mean scores of skill of communication with patients before and after instruction were as 85.1 and 85.56 respectively in lecture group which demonstrate no significant difference Mean scores of skill of communication with patients before and after instruction were as 84.7 and 91.33 respectively in group discussion cluster which revealed a significant improvement (p<0.05). The score of students' communication skills in two groups were similar before the instruction but students' communication skills were significantly higher in experiment group after the instruction. Conclusion: The results of this study showed that employing group discussion method helps to the development of nursing students' communication skills (areas of interactional skills and pursuing problems). Employing active educational methods and increasing students' involvement in discussions and contestations provides them with an opportunity to develop their communicational skills.

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Introduction: Using Standardized Patient (SP) in teaching history taking provides medical students with an opportunity to learn how to communicate with patients. A Standardized Patient is a person who has been carefully coached to simulate an actual patient so accurately. This study was performed to assess the effect of using SP on improving history taking skill of third year medical students. Methods: In a quasi-experimental study, 95 students of Introduction to Clinical Medicine were divided into two experiment and control groups in 2007-2008. The control group received instruction on history taking skills through usual method of lecture. The experiment group was instructed using SP. At the end of the course, the students’ history taking skills were evaluated through an Objective Structured Clinical Examination (OSCE) and the mean scores of the two groups were compared. Also the students viewpoints were investigated using a researcher-made reliable and valid questionnaire. Results: Although no significant difference was observed between the scores of individual items of checklist in the two groups, the total mean score of the experiment group (7.03± 1.349) was significantly higher than that of the control group (5.8± 1.473) (P<0.004). Most students (86.5%) preferred using SP for their instruction compared to lecture method. Conclusion: Standardized patient provides an appropriate opportunity for new medical students to experience and learn history taking and communication skills. It is highly recommended to use SP not only in teaching history taking and communication skills but also in physical examination course.