摘要
临床实习是护理教育的重要环节之一,是将护理理论知识与临床实践相结合的过程,是护生向护士角色转变的桥梁,对培养护理职业技能至关重要。然而,临床环境复杂多变,护理工作充满风险和压力,对刚步入临床的护理学生而言,实习无疑是一较大的应激源。由于护理理论与实践的差距、护理操作不熟练、缺乏临床经验和人际沟通技巧、以及青春期心理发展不成熟等,每位学生在此阶段或多或少经历实习适应的问题。实习适应不良是指护理实习学生在保持自身与临床实习环境之间的和谐而进行自我调整的过程中,主动或被动地改变自身认知结构或行为模式的能力不足,以致于在短时间内对临床学习环境的变化出现一系列适应不良的现象。实习适应不良不仅直接降低实习效率,严重者可诱发学生心理疾患,甚至影响生理功能和今后职业发展。有关护理学生临床实习的研究可追溯到上世纪70年代初,尤其是实习期间紧张和焦虑等心理问题,但关于实习适应不良,目前临床上缺乏有针对性的、客观有效的测量工具,相关研究报道不多。至于临床实习适应不良的研究内容、影响学生实习适应能力的危险因素、严重实习适应不良对学生学业和身心健康的影响,以及如何有效实施干预等,都有待于深入研究。护理学生的健康发展直接关系到护理事业的未来,关系到每个社会成员的健康。
第一部分护理学生临床实习适应不良量表的编制和应用
目的：编制能较客观、有效地评价护理学生实习适应不良的研究测量工具；并观察其临床应用情况。
方法：通过文献分析、访谈,确定护理学生临床实习适应不良的四个领域,并相应编写50个条目,所有条目均经专家审阅、讨论和实习学生试测。首先在南京、苏州五家医院随机抽取300名实习学生进行初试,运用临界比(Critical Ratio)、相关分析、探索性因素分析(Exploratory Factor Analysis, EFA)删减条目,并对最终建立的28条目正式量表进行信度分析,并采用普遍适应不良量表(GM)作为外在的效标工具,运用相关性分析,检验量表的效标关联效度。然后在常熟、吴江三家医院随机抽取469名实习学生测试,用验证性因素分析(Confirmatory Factor Analysis, CFA)检验量表模型结构。最后在苏州四家医院随机抽取200名实习学生,应用护理学生临床实习适应不良量表测试,观察临床应用情况,并分析量表与状态-特质焦虑量表(STAI)、GM、一般自我效能感量表(GSES)、社会支持评定量表(SSRS)和匹茨堡睡眠质量指数量表(PSQI)之间的相关性。
结果：①自编量表包括28条目和4维度(人际关系和社交、行为表现、认知、情绪方面),可解释51.218%总方差变异。所有的条目因子负载均在0.5以上。量表总的Cronbach's α系数为0.921,重测系数为0.885,各因子分别为0.743-0.877,0.716-0.890。验证性分析结果为x2/df=3.297, NFI=0.907, TLI=0.916, CFI=0.924, RMSEA=0.066。效标效度研究结果为自编量表与普遍性适应不良量表存在显著的相关性(r=-0.555,p<0.01)；②临床应用量表测试结果显示,实习适应不良量表得分呈正态分布,平均分为94.82±15.30。以实习适应不良为应变量,分别以SAI、TAI为自变量,所得直线回归方程为y=142.71-0.65X、y=134.96-0.54X(P均<0.01)。实习适应不良量表与GSES、PSQI、SSRS间亦均存在显著相关性(r值分别为0.247、-0.360、0.328,P值分别<0.05、<0.01、<0.01)。
结论：①护理学生临床实习适应不良量表符合心理测量学要求,具有较高的信度和效度,可作为评价护理学生临床实习适应不良的有效工具之一。②护理学生临床实习适应不良与实习焦虑之间密切相关,存在程度上的一致性,而且与学生的自我效能、主观睡眠质量、社会支持等方面也有相关性。
第二部分护理学生实习期间适应不良状况及相关因素
目的：了解护理学生临床实习适应不良状况,并调查与之相关的危险因素。
方法：以高职护理专业学生为例,随机抽取200名实习生为研究对象。在校期间曾进行STAI测试,在实习一个月后,统一完成护理学生临床实习适应不良量表、自编学生一般情况调查问卷(包括家庭一般情况、实习态度及其他情况等)和实习适应不良常见原因调查表、STAI、GSES、SSRS、GM、 PSQI。应用SPSS13.0进行数据统计,采用t检验、卡方检验、单因素方差分析、Student-Newman-Keuls法(q检验)及多元逐步回归分析等。
结果：①在参与有效问卷回答的184名学生中,根据实习适应不良量表分进行分组,适应良好的正常组94人(占51.1%),平均分为106.66±9.85,轻度适应不良组64人(占34.8%),平均分为87.09±3.87,中重度适应不良组26人(占14.1%),平均分为70.92±6.96。三组学生的实习适应不良量表总分和各因子得分经方差分析均显示有高度显著性差异(F值分别为258.08、101.65、119.42、94.68、97.22,P均<0.001)；②实习适应不良相关影响因素中,学生来源地(农村或城镇)、父母期望值(高或不高)、护士职业态度(喜欢或不喜欢)、就业前景态度(乐观或悲观)四个条目在三组学生中所占比例有显著差异(X2值分别为9.17、8.68、7.46、21.03,P值分别为<0.01、<0.05、<0.05、<0.001)；③三组学生实习前后状态-特质焦虑比较,正常组实习后SAI显著增加(t=-2.34,P<0.05),而TAI未见明显差异(t=-1.72,P>0.05)。轻度适应不良组实习后SAI有高度显著性增加(t=3.99,P<0.001),TAI亦有显著增加(t=2.58,P<0.05)。中重度适应不良组实习后SAI、TAI均有高度显著性增加(t值分别为8.41、6.71,P值均<0.001)；④三组学生的GSES、SSRS、 GM、PSQI方差分析均有显著性差异(F值分别为5.61、9.01、39.55、12.78,P值分别为<0.005、<0.001、<0.001、<0.001)；⑤实习适应不良有关因素分别进行多元逐步回归分析,得到回归分析方程分别为y(实习适应不良)=102.64—0.504X1(就业前景态度)-0.24X2(来源地)(F=54.45,P<0.001)和y(实习适应不良)=143.36—0.667X1(SAI)(F=139.34, P<0.001);⑥学生认为导致实习适应不良的常见原因,排在前5位的加权得分为害怕临床出错(44.64)、导师冷漠(19.88)、受到不公平待遇、不被尊重(19.48)、理论与实际脱节(18.38)、实习环境陌生(18.16)。
结论：护理学生实习适应不良的发生与许多内、外因素相关,如来自于农村、父母期望值过高、不喜欢护士职业、对就业前景悲观、状态-特质焦虑水平高、一般自我效能感低、普遍性适应不良分高、社会支持度低、主观睡眠质量差等是相对危险因素。其中学生实习期间状态焦虑水平是实习适应不良的重要预测变量之一。学生认为导致实习适应不良的主要原因有害怕出错,导师冷漠,受到不公平的待遇、不被尊重,理论与实际脱节,实习环境陌生,害怕被病人及家属责骂,当初期望值过高等。有效的干预措施应源于对上述诸影响因素的仔细研究和分析。
第三部分实习适应不良对护理学生免疫、内分泌功能的影响
目的：从心理-神经-内分泌网络调节机制,研究实习适应不良对学生的免疫内分泌功能的影响。
方法：研究对象同前,学生在问卷调查前,采集外周肘静脉血,应用流式细胞仪和化学免疫发光分析法检测外周血淋巴细胞及亚群百分率,包括CD3+、CD4+、CD8+、 CD4+/CD8+、CD19+和CD16+或56+,以及红细胞表面CD35分子百分率和血清皮质醇浓度等。应用spss13.0软件进行数据分析,采用方差分析和F检验、q检验等。
结果：①适应不良组学生外周血CD3+和CD4+T淋巴细胞百分率减少,与正常组间有显著差异(F值分别为5.34、3.90,P值分别为<0.01、<0.05),而随实习适应不良程度加重,CD8+T淋巴细胞百分率呈现增高趋势(F=0.85, P>0.05)、CD4/CD8比值呈下降趋势(F=2.83,P>0.05)；②适应不良组的学生中,外周血CD19+(B细胞)百分率增高(F=1.75, P>0.05), CD16+或56+(NK细胞)百分率下降(F=2.57,P>0.05),但均未达显著性差异；③与正常组比较,轻度适应不良组红细胞CD35百分率略有升高,而中重度适应不良组下降,但各组间未达到显著性差异(F=1.734,P>0.05)；④适应不良组学生血清皮质醇浓度有所增加,但各组间未达到显著性差异(F=0.881,P>0.05)。
结论：实习适应不良主要导致学生T淋巴细胞免疫功能下降,对B细胞、NK细胞和红细胞免疫功能也有一定影响。血清皮质醇浓度不像在急性应激状态下表现明显增高,但适应不良组的学生也有升高趋势。实习适应不良导致学生免疫功能变化,易于引发各种疾患,严重威胁学生身体健康,进而又加重心理紊乱,值得重视。
第四部分实习适应不良与学生自主神经调节功能
目的：研究学生发生实习适应不良时,交感-副交感神经调节功能的变化。
方法：在前一部分的研究对象中,选择140名自愿参加的学生,分组方法同前。完成各项问卷调查后,在同一时间段内,采用动态心电图进行心率变异性频域谱指标测定,包括低频功率标化值(LFnorm)、高频功率标化值(HFnorm)和LF/HF比值。应用spss13.0软件进行数据分析,采用方差分析和F检验、q检验等。
结果：实习适应不良组学生的LFnorm明显增高、HFnorm明显下降、LF/HF比值明显增高,各组间均达到高度显著性差异(F值分别为7.23、21.26、19.29,P值分别为<0.005、<0.001、<0.001)。
结论：HRV功率谱分析可检测学生交感-副交感神经调节功能的变化,其中实习适应不良学生的交感神经张力增高,副交感神经张力降低,体内自主神经调节功能失衡。应用HRV分析可作为客观评价学生实习焦虑和适应不良的重要指标之一。而且此结论对今后采用提高机体副交感神经兴奋性,干预学生实习适应不良有理论指导意义。
第五部分临床同辈支持并行调息训练对护理学生实习期间适应不良的影响
目的：实施临床同辈支持和调息训练并行的干预措施,观察护理学生实习适应不良改善情况。
方法：选择第四部分研究中的中重度适应不良组学生为研究对象,其中自愿参加干预的17名学生为研究组,其余5人为对照组。干预措施为临床同辈支持和调息训练并行。选取新近毕业的护士作为同辈支持者,给予学生一对一的帮助,同时安排专业教练指导学生进行有效的腹式呼吸训练。干预从实习一个月后开始,共10周时间。采用配对实验t-test比较干预前后两组学生实习适应不良量表、状态-特质焦虑量表、一般自我效能感量表、HRV的变化。
结果：①实施干预后,研究组学生实习适应不良、SAI、TAI状况,均有明显改善(t值分别为7.34、8.77、3.96,P<0.001、<0.001、<0.005),GSES未见显著改变(t=2.06,P>0.05)。而对照组学生的实习适应不良、SAI、TAI、GSES状况均未发生显著性改变(t值分别为1.77、2.75、1.24、-0.15,P值均>0.05)；②干预后,研究组学生的HFnorm显著增高(t=2.63, P<0.05)、 LF/HF比值显著下降(t=2.37,P<0.05),而LFnorm虽有下降,但未达到显著性差异(t=1.88,P>0.05)。
结论：临床同辈支持和调息训练并行的干预措施,将外部的社会支持和内部自我调整有效地结合,既提高了学生副交感神经张力,恢复了自主神经调节功能,又改善了实习适应不良和实习焦虑,具有较强的可操作性。为护理教育工作者提高学生临床实习效率提供了新思路,具有实践指导意义。
Clinical practice is one of the important part of nursing education, which combines theoretical knowledge and clinical experience, and facilitates nursing students to develop into the professional nurse role. However, the clinical setting is complex and nursing presents challenges. For nursing students, clinical practice undoubtedly is a large stressor. There are a variety of factors contributing to stress in nursing students in the clinical learning environment, such as theory gap, performing clinical skills, clinical experience, interpersonal skills, psychological immaturity, and so on. All students more or less encounter adaptation problems in clinical settings. Clinical practice maladjustment means that nursing students lack of ability to actively and passively change their cognitive structure, or behavior patterns to maintaining the harmony between themselves and the clinical environment, so exhibiting a series of maladaptive phenomenon in clinical practice. Nursing students clinical practice maladjustment not only reduces students' practice efficiency, but also induces some mental disorders, even affects physiological function and future career. The literature reveals many studies about nursing students in clinical practice dating back to the early1970s, especially investigating nursing students' stress an anxiety. But few researches mentioned nursing students' maladjustment in clinical practice, which may be related to the lack of specific, objective and effective research tools, As for the content of maladjustment in clinical practice, risk factors affecting students adaptability, adverse effects on students' physiological and psychological health and interventional strategies, all these need to in-depth study.
Part1The development of nursing students clinical practice maladjustment scale and application
Objectives: To develop a valid and reliable scale to assess nursing students' maladjustment in clinical practice, and to observe the application of the scale.
Methods:In light of the literature and interview, it was determined that clinical practice maladjustment included four fields, and accordingly50items were written. These items were discussed by experts, nurse and examined by students in clinical practice.300random samples engaged in primary testing. The Critical Ratio, Pearson Correlation and Exploratory Factor Analysis (EFA) were used to delete the items. The28items formal scale was set up, and further the scale reliability and validity were tested. Then another469random samples attended test, followed by Confirmatory Factor Analysis (CFA) for evaluating the model structure of the scale. Finally,200samples randomly were selected, and nursing students clinical practice maladjustment scale was administered. The correlation between nursing students clinical practice maladjustment and State-Trait Anxiety Inventory, General Self Efficiency Scale, Social Support Rating Scale and Pittsburgh Sleep Quality Index were analyzed.
Result:①The scale self-developed included28items with four dimensionalities (interpersonal, behavior, recognition, emotion), which could explained51.218%of the total variance. Factor loadings of items were above0.50. The general Cronbach's Alpha reliability and test-retest reliability were0.921,0.885, and the four subscale were0.743-0.877,0.716-0.890. The CFA indicated that the ratio of chi-square to degree of freedom was0.329, the norm fit index was0.902, the Tucker-Lewis index was0.916, the comparative fit index was0.924, and the root mean square error approximation was0.066. Criterion-related validity studies showed that the score of the scale self-developed was significantly correlated with General Maladjustment Scale (GM).(r=-0.555, p<0.01).②Using the scale self-developed, the samples' average score was94.82±15.30. Nursing students clinical practice maladjustment as dependent variables, and SAI, TAI as independent variables, the linear regression equation respectively were:y=142.71-0.65X (P<0.01), y=134.96-0.54X(P<0.01). The levels of Nursing students clinical practice maladjustment were related directly to GSES(r=0.247, P<0.05), and SSRS(r=0.328, P< 0.01), and inversely to PSQI(r=0.360,P<0.01).
Conclusion: This scale is entirely in accordance with the psychometric demands, which can be used as a tool to evaluate nursing students clinical practice maladjustment. Nursing students clinical practice maladjustment is related closely to students' anxiety in clinical settings, and also related to students' self-efficiency, social support, as well as objective sleep quality.
Part2Nursing students clinical practice maladjustment and relevant factors
Objectives:To assess the level of clinical practice maladjustment in a sample of vocational nursing students, and some associated risk factors.
Methods:Questionnaires including nursing students clinical practice maladjustment scale, STAI, GSES, GM, PSQI, and additional questions regarding general demographic, attitude for the clinical practice, and common causes of clinical practice maladjustment, were sent to200students practicing in four hospitals of SuZhou, who had finished STAI in school. The spss13.0was used to analyze data, with involved t-tests, chi-square test, one-way ANOVA analysis, Student-Newman-Keuls test, and multiple stepwise regression analysis.
Results:①Of the200students,184students'questionnaires were valid, who were grouped into the normal group (94,51.1%), the mild maladjustment group (64,34.8%), the severe maladjustment group (26,14.1%), according to the scores of nursing students clinical practice maladjustment scale. There were significant differences between the groups for the scores of nursing students clinical practice maladjustment scale (F=258.08, P<0.001) and four factors of the scale, in which interpersonal (F=101.65, P<0.001), behavior (F=119.42, P<0.001), recognition (F=94.68, P<0.001), emotion(F=97.22, P<0.001).②In relevant factors, coming from rural areas (X2=9.17, P<0.01), high parents' expectations (X2=8.68, P<0.05), disliking the nursing work (X2=7.46, P<0.05), being pessimistic for prospects (X2=21.03, P<0.001) were significant factors.③The scores of STAI in three groups were higher in clinical practice than in school. In the normal group, SAI scores significantly increased (t=2.34,P<0.05), but TAI did not show significant difference (t=1.72,P>0.05). In the mild maladjustment group, SAI scores (t=3.99,P<0.001), TAI scores(t=2.58,P<0.05)significantly increased. In the severe maladjustment group, SAI scores(t=8.41,P<0.001), TAI scores(t=6.71,P<0.001) highly significantly increased.④The variance analysis of the scores of GSES (F=5.61, P<0.005), SSRS (F=9.01, P<0.001), GM(F=39.55, P<0.001), PSQI (F=12.78, P<0.001) in the students of three groups were significantly different.⑤Multivariate analysis of regression showed: y (clinical practice maladjustment)=102.64-0.504X1(attitude for prospects)-0.24X2(coming from areas)(F=54.45, P<0.001); y (clinical practice maladjustment)=143.36-0.667X1(SAI)(F=139.34, P<0.001).⑥In the common items causing maladjustment in clinical settings, the weighted scores of the top five items were: fear of making mistakes(44.64), the mentors'apathy(19.88), being treated unfairly and not respected(19.48), theory gap(18.38), unfamiliar clinical environment(18.16).
Conclusion: Nursing students clinical practice maladjustment is related to many risk factors, such as coming from rural areas, high parents' expectations, disliking the nursing work, being pessimistic for prospects, high level of anxiety, low self-efficiency, low social support, high general maladjustment, poor sleep quality, in which students' state anxiety in clinical settings is one of the important predictors. In the clinical environment, fear of making mistakes, the mentors' apathy, being treated unfairly and not respected, theory gap, and unfamiliar clinical environment were viewed as the most maladjustment-producing situations. Effective interventional strategies should be derived from careful analysis of the influencing factors.
Part3The effects of nursing students clinical practice maladjustment on immune-endocrine function
Objectives: To explore the effects of nursing students'maladjustment in clinical settings on immune-endocrine variables.
Methods:Previous184nursing students were recruited. The immune profile including the percentage of CD3+T lymphocyte and subsets (CD4+、CD8+、 CD4/CD8)、 CD19+(B cell、 CD16+or56+(NK cell)、 RBCCD35were assayed by the flow cytometry, and serum cortisol levels were measured by Chemiluminescence Immunoassay (CLIA). The spss13.0was used to analyze data, with involved analysis of variance, F-test, Student-Newman-Keuls test.
Results:①Compared with in the normal group, the percentages of CD3+(F=5.34, P<0.01), CD4+(F=3.9,P<0.05) in the mild and severe maladjustment groups significantly reduced. Although it was not statistically significant, a increased tendency in CD8+(F=0.85,P>0.05), CD19+(F=1.75,P>0.05) and a decreased tendency in CD4+/CD8+(F=2.83,P>0.05), D16+or56+(F=2.57,P>0.05)were shown.②The percentages of RBCCD35+between the groups did not show significant differences(F=1.734,P>0.05), but compared with the normal group, the mild maladjustment group showed a increased tendency, and the severe maladjustment group showed a decreased tendency.③With the rise of the levels of maladjustment, serum cortisol levels showed a increased tendency(F=0.881,P>0.05), but it was not statistically significant.
Conclusions:During clinical practice nursing students maladjustment reduced T lymphocyte function, but the effects on B cell, NK cell and RBC were little. The increase of serum cortisol in clinical practice maladjustment is not obvious as good as in the acute stress. Maladjustment in clinical practice is a serious threat to nursing students' health, which is worthy of attention.
Part4Nursing students clinical practice maladjustment and the regulatory function of autonomic nervous
Objectives: To investigate changes of nursing students'autonomic nervous function, when clinical practice maladjustment occurring.
Methods:Of184previous subjects,140nursing students voluntarily participated in this study. Indexes of Heart Rate Variability (HRV), including the normalization of low frequency(LF) and high frequency(HF) powers, and LF/HF ratios, were calculated by analyzing short-term ECG segments in the frequency domains. The spss13.0was used to analyze data, with involved analysis of variance, F-test, Student-Newman-Keuls test.
Results:Between the groups, LFnorm(F=7.23,P<0.005), HFnorm(F=21.26,P<0.001) and LF/HF ratios(F=19.29,P<0.001) showed significantly differences. Compared with in the normal group, LFnorm, LF/HF ratios in the maladjustment groups significantly increased, and HFnorm significantly decreased.
Conclusion:Indexes of HRV reflects regulatory function of the autonomic nervous. Clinical practice maladjustment results in students' sympathetic tone increasing, vagal tone decreasing, and autonomic nervous function imbalance. Improving regulatory function of autonomic nervous may be increasing students' adaptability in clinical settings.
Part5The effects of clinical peer mentoring combined with breathing training on nursing students clinical practice maladjustment
Objectives:To determined the effectiveness of clinical peer mentoring combined with abdominal breathing training in improving nursing students'maladjustment in clinical settings.
Methods:In the previous severe maladjustment group,17students voluntarily were allocated in the intervention group, and other5students were in the control group. Clinical peer mentoring and abdominal breathing exercises were implemented for10weeks in the intervention group, but not in the control group. Peer mentoring was referred to appointing new nurses to help students one to one early in practice. Abdominal breathing was practiced10-15min everyday. The outcome measures were nursing students clinical practice maladjustment scale, STAI, GSES, and indexes of HRV in frequency domain.
Results:①After intervention, there was a significantly greater improvement of clinical practice maladjustment(t=7.34,P<0.001), state(t=8.77,P<0.001) and trait(t=3.96,P<0.005) anxiety in the intervention group, but not in the control group. Self-efficiency did not show significant changes in both groups.②The control group did not re-test HRV. In the intervention group, HFnorm(t=2.63,P<0.05) significantly increased, LF/HF ratios(t=2.37,P<0.05) significantly decreased post-intervention, but LFnorm only showed a decreased tendency.
Conclusions: The intervention of clinical peer mentoring combined with abdominal breathing training not only effectively restores students' autonomic nervous regulation, but also reduces students' maladjustment and anxiety in clinical practice, which provides new tools for nursing educators to improve students' learning efficiency in the clinical environment.
引文
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