【作者】 杨芳；

【导师】 刘晓虹；

【作者基本信息】 第二军医大学 ， 护理学， 2013， 博士

【摘要】 【目的】以冠脉支架植入患者为研究对象，深入了解我国文化背景下感恩概念、内涵和此类人群感恩理念、现状水平对其术后心理体验、生命的感知和术后生活的影响，探讨患者面对支架植入的创伤应激事件，患者如何运用感恩减轻其术后负性情绪反应、提升幸福感水平和健康行为能力，明晰感恩对其健康相关变量的作用机制并构建患者术后健康促进的感恩模型，以期为临床和社区护士了解感恩对冠脉支架植入患者术后健康促进的保护机制、应用可操作性感恩心理干预方案提供依据。【方法】1、以文献回顾，描述国内外感恩的研究进展及关注热点，总结归纳感恩的健康促进的靶标和效应。应用理论分析，探讨感恩对相关研究变量的可能作用机制及用于指导本研究的理论依据。2、采用横断面研究设计，在慢性病领域引进六项目感恩问卷并进行量表汉化修订、文化调试和信效度测定，以检测该问卷在我国慢性病群体尤其冠脉支架植入患者中的适用性；使用修订后的感恩问卷，大五人格量表，心理韧性量表修订版、医院用焦虑抑郁量表、特质应对方式问卷、纽芬兰幸福度量表、领悟社会支持量表、健康行为能力量表等测评工具，收集175例冠脉支架植入患者感恩、人格特质、韧性、焦虑抑郁、社会支持、应对方式、主观幸福感、健康行为能力等资料。采用SPSS18.0软件统计分析调查性研究数据。以应用相关分析探讨感恩与人口统计学资料及介入手术相关特征变量、不同人格特质、韧性、焦虑和抑郁、社会支持、不同应对方式、主观幸福感、健康行为能力的相关性。以阶层多元线性回归分析探讨感恩对健康促进主要相关变量的独立预测作用和解释力。3、纵向研究设计，以量性和质性研究相结合的方法收集资料。量性研究采用问卷调查，基于文献分析、理论指导及横向研究，深入探究冠脉支架植入患者术后3天、出院后3个月的感恩、韧性、抑郁、幸福感等健康相关变量的变化趋势和时间轨迹；呈现了冠脉支架植入患者感恩与健康相关变量之间的关系模型。明晰感恩对韧性、抑郁、幸福感等健康相关变量影响机制和作用路径，构建感恩对医院-社区冠脉支架植入患者健康促进的作用模型。4、质性研究采用叙事研究分析法，深入访谈感恩水平高于调研均值20%及以上的8名冠脉支架植入患者，挖掘其术后感恩体验、对感恩内涵的理解及回归社区和家庭后，感恩对其术后心路历程、生命的感知及术后生活的影响，进一步澄清冠脉支架植入患者的感恩对其健康促进的作用，较深入诠释前期量性研究形成的感恩-健康促进路径模型。5、基于文献研究、理论研究和对感恩水平较高患者的质性访谈，初步构建本土化感恩干预方案，并通过专家小组会议修改完善后试点运行。采用质性研究的合众法，深入访谈13名实施感恩干预方案的冠脉支架植入患者，以及对此13名患者感恩日记的分析，探讨冠脉支架植入患者术后接受感恩干预的心理体验及对其术后生活的影响，了解患者接受感恩干预后生命态度、健康感知、术后康复和健康促进过程中认知和行为的转变，进一步探究适用于我国冠脉支架植入患者术后健康促进的感恩干预策略。【结果】1、在文献分析及理论研究基础上形成指导本研究的理论框架。2、横断面研究结果：①简体中文版感恩问卷Cronbach’s α系数0.651，Guttman折半系数0.730；重测信度0.971；各条目内容效度指数（I-CVI）0.850-1.000；经探索性因素分析得到两个公因子，累计方差贡献率66.513%；以纽芬兰幸福感量表（MUNSH）为效标，简体中文版感恩问卷总分与MUNSH总分及相应各维度呈中度相关。②本组冠脉支架植入患者的感恩水平不高，得分为27.25±4.32分；其感恩水平与人口学特征中的医保状况（F=2.729，P＜0.05）、饮酒（F=5.862，P＜0.01）、运动（F=2.839，P＜0.05）和服药依从性的相关（F=3.062，P＜0.05）有显著性。本组患者的感恩与其人格特质有关，较宜人、责任感强和较少神经质的患者感恩水平较高，其中与责任感（r=0.360，P＜0.01）和宜人性（r=0.322，P＜0.01）维度显示的相关性最强。感恩与冠脉支架植入患者的韧性、抑郁和焦虑、主观幸福感、社会支持、应对方式和健康行为能力具有一定的相关性。③回归分析结果显示，控制本组患者的人口统计学变量、大五人格以及其他各相关变量作用下，感恩对抑郁总分、韧性总分、主观幸福感总分、健康行为能力总分、社会支持总分的独立预测力分别为25.0%、13.9%、5.1%、1.8%和2.5%。3、纵向研究结果：冠脉支架植入患者术后3天的焦虑、抑郁得分各为13.36±4.87和13.70±4.96，出院后3月的焦虑、抑郁得分各为13.12±5.09和13.52±5.12；出院后3个月较术后3天焦虑和抑郁略有下降；本组患者术后以消极应对为主；本组患者术后3天和出院后3个月的主观幸福感水平均不高；且其术后3个月的健康行为能力总分及营养、运动和健康责任得分均低于术后3天。4、基于纵向研究和横断面研究结果呈现的3个模型，①冠脉支架植入患者术后3天的感恩与健康相关变量之间的关系模型；②冠脉支架植入患者出院后的感恩与健康相关变量之间的关系模型；③冠脉支架植入患者术后3天-出院后3个月的感恩与韧性、抑郁和幸福感的纵向路径模型。5、质性研究结果：①本组患者的感恩体验的心理历程呈现为“审视生活质量、积极自主、品位幸福和爱的真谛”4个主题；②本组患者对感恩的诠释不同于国外文化背景下个体，具有较明显本土化特点；③本组患者利用其感恩有效应对生活事件的作用轨迹为：以重新认识生活、自我调适、自立自主、回味真情和人际和谐等作用途径，减轻其负性情绪，提升其幸福感知及增进其健康行为能力；④高感恩的患者有表达感恩的自发行为，并从其表白中体验更多的幸福，感受爱的真谛。6、感恩干预效果的质性评价结果：①本组患者术后的感恩经历及其干预效果主要呈现为“生活态度改变、认知信念、人际关系改变和生活方式改变”4个主题；②本研究构建的感恩干预方案适用于我国冠脉支架植入患者，干预过程中患者对研究设计的干预方案认同性较好，参与热情较高，尤其在干预后期效果显现阶段，患者依从性明显增强，感恩对躯体症状如睡眠的影响在干预第一周患者感知效应最明显。③本研究感恩干预方案的实施可促进患者个人及社会环境资源的利用与挖掘，改善其更好的健康适应状态回归社区和家庭，减轻负性情绪，提升其幸福感知及增进其健康行为能力；干预结果主要围绕于促进患者生活态度、认知信念、人际关系和生活方式等4个方面。【结论】1、本研究修订的简体中文版感恩问卷内部一致性、重测信度、内容效度、结构效度、效标效度较好；各条目的区分度较好，鉴别力较高，可用于我国文化背景下的老年慢性病群体。2、本研究通过对本组患者术后感恩与其健康变量作用机制的探讨，可明晰冠脉支架植入患者的感恩是其韧性的保护因子，有益其成长和应对逆境；验证患者的感恩是其韧性、术后抑郁、主观幸福感及健康行为能力的独立预测因素。3、本研究呈现的冠脉支架植入患者感恩与健康相关变量之间的关系模型，可帮助临床和社区护士了解我国特定文化背景下冠脉支架植入患者的感恩对其健康促进的作用，可指导临床和社区护士将感恩理念与心理护理有效整合，为制定冠脉支架植入患者健康促进的可操作性感恩干预的方案提供依据。4、本研究通过纵向路径模型初步证实感恩对韧性的独立预测作用和直接单向的因果关系。5、本研究提示本组患者对感恩的诠释具有较明显东方文化特点，质性研究勾画的感恩水平较高的患者对其术后心理体验、生命的感知及健康促进的作用过程和影响轨迹，可充实量性研究结果，为今后构建感恩干预的临床策略提供有价值依据。6、本研究结合感恩理论和文献研究、专家小组访谈，以及本研究第五部分的质性访谈结果，构建了适用于我国冠脉支架植入患者的本土化感恩干预方案并试点运行，通过对干预效果的质性评价，验证了感恩干预促进冠脉支架植入患者健康的效果。作用效应主要包含患者生活态度、认知信念、人际关系和生活方式的转变。感恩干预有效实施可成为该领域患者健康促进有效手段，有望为冠心病患者促进健康和提升幸福感水平拓展新的视角，也可为下一步尝试在我国开展感恩心理护理提供循证基础。更多还原

【Abstract】 【Objectives】Taking patients after coronary artery stent implantatation as research object，this papertries to gain an intimate knowledge of the related mechanism between the gratitude and itshealth correlated variables;explore how the patients after coronary artery stentimplantatation apply the gratitude to build the capital of the patients’ psychologicalgrowth,relieve the depression and anxiety,and raise the feeling of happiness as well as theability of health behavior ability; and then explores the interaction mechanism of thegratitude on its health correlated variables to construct the gratitude model of healthpromotion of post-operation patients after coronary artery stent implantatation.The studyaimed to help clinical nurses and community nurses have a better understanding of theprotection mechanism that gratitude plays its role in promoting the health of patients aftercoronary artery stent implantatation,further to provide evidence and proof to the implementof psychological intervention program on gratitude.【Methods】1. Based on literature review,the paper describes the research progress and theconcern of the gratitude at home and abroad and summerizes the health variables thatgratitude can influence.Using theory analysis this study explores the possible interactionmechanism of the gratitude on its health correlated variables and the theoretical frameworkthat can guide this research.2. By the questionnaire survey,carrying out a cross-sectional study,the paper tests theapplicability of the gratitude scale in older age groups of China.To collect the data such asgratitude,personality traits,depression and anxiety,social support,coping styles,Subject WellBeing (SWB),health behavioral competence,etc,175patients after coronary artery stentimplantatation were tested by assessment tools such as modified gratitude questionnairesurvey,NEO PI-R,the revised edition of the mental toughness scale,hospital anxiety anddepression scale (HADS),traits coping styles questionnaire (TSCQ),Newfoundlandhappiness scale,understanding social support scale(PSSS),and health behavioralcompetence scale,etc. Data were analyzed by SPSS18.0(Statistic Package for SocialScience).The correlation of the gratitude and human demography,the correlatedcharacteristic variables of intervention operation,different personality traits,toughness,depression and anxiety,social support,different coping styles,SWB,and health behavioralcompetence were analyzed by correlation analysis.The effects of the gratitude on the correlated variables of health promotion were determined by the hierarchical analysis.3. Through the longitudinal study design,the data were collected by both qualitativeand quantitative stusy.Based on the literature review,the theory analysis and the outcome ofquestionnaire survey,we continued to explore the track and dynamic changes of healthcorrelated variables,such as gratitude,resilience,depression,and wellbeing during the periodfrom discharging and three months after returning back to the community;a gratitudepromotion model of patients after coronary artery stent implantatation in both the hospitaland community were also built.4. Narrative analysis was used in Qualitative study, and8Coronary artery stentingpatients was in-depth interviewed to explore their experience and understanding ofgratitude and the affection of gratitude to the postoperative mentality course,the perceptionof life and their postoperative life when they returned to communities and families.Itclarified the role of gratitude in health promotion process of coronary artery stentingpatients and made the further interpreting of gratitude model which built on quantitativeresearch.5.Localization gratitude intervention framework was build based on literature research,theoretical research, qualitative interviews, as well as the expert panel for somemodification.Then Triangulation method was used for the both in-depth interviewed andgratitude diary analyse of13Coronary artery stenting patients who had alreadyexperienced the whole process of gratitude intervention. It aims to explore psychologicalexperience and the influence on the post-operative life, to get aware of their life attitude,health awareness as well as the change of cognition and behavior during the process ofpost-operative rehabilitation and health promotion after gratitude intervention so that tofurther explore the more suitable strategies of gratitude interventions for health promotionfor the Chinese patients with coronary stenting implanted.【Results】1. Forming a theoretical framework to guide the study on the basis of the literaturerevivew and theory analysis.2. Achievements of cross-sectional study:①The Cronbach’s alpha for the totalrevised Chinese version of GQ-6was0.651(N=261),0.737(N=175).The test-retestreliability of the total scale was0.971.The content validity index of the Chinese version ofGQ-6were item-CVI,I-CVI0.850-1.000; In the exploratory factor analysis,a two-factorsolution was found to be reasonable with the subdimensions gratitude which accounted for total66.513%of the variance in the the Chinese version of the Revised GQ-6.Using theNewfoundland Happiness Scale (MUNSH) as criterion validity,the score of Chineseversion of GQ-6are relate to the total score of MUNSH.②The general level of gratitude inpatients after coronary artery stent implantatation in this study is not high with the score of27.25±4.32. It is related to the medicare(F=2.729,P＜0.05),drinking (F=5.862,P＜0.01),exercises(F=2.839,P＜0.05) and medication compliance(F=3.062,P＜0.05) ofdemographic characteristics.The gratitude of Coronary artery stenting patients has relationswith different personal traits.The more affinity and sense of responsibility and the lessnervousness the patients have,the more gratitude they tend to show,and patients who havethe sense of responsibility (r=0.360,P＜0.01) and agreeableness personality (r=0.322,P＜0.01),show the strongest correlation.The gratitude among patients with coronary arterystenting also has correlations with anxiety and depression,subjective well-being,socialsupport,coping and health behavior ability.③In the regression analysis,by the action ofthe controlling the demographic variables,NEO PI-R and others correlation,theindependent predictive power of gratitude to the overall grade ofdepression,toughness,SWB,social support,health behavior ability is25.0%,13.9%,5.1%,1.8%and2.5%respectively.3. Achievements of longitudinal study: the scores of anxiety of patients after coronaryartery stent implantatation in there days after surgery and three months after surgery were13.36±4.87and13.70±4.96,and the scores of depression were13.12±5.09and13.52±5.12.Although the anxiety and depression declined three months after surgery compared withthree day after surgery,however,the decline was sligh and the symptoms appares noobvious ease.The patients after operation mainly adopted negative copping strategy;theSWB of patients three days and three months after operation were not high; and the overallgrade of the health behavioral competence,nutrition,exercises and health responsibility ofpatients declined compared with that of three days after operation.4. On the basis of the results of the above studies,three models were built,namelygratitude model of health promotion when patients discharging from the hospital,afterdischarge and the longitudinal pathway model of patients’ gratitude with resilience,depression,wellbeing when discharging from the hospital and three months after thedischarge.5. Qualitative study results:①G ratitude experience ofpatients with coronary arterystenting can be included into four themes which were acceptance of life,positive self strength,taste happiness and the interaction of love.②U nder the Chinese culture outlinethe gratitude interpretation of patients with coronary stent placement,the gratitude objectsmainly include the party,country,family,friends,and doctors and nurses,etc,and the gratitudefor god,nature,and themselves were not included.③P atients with high gratitude was goodat developing his or her potential to deal with the stressful events in the life effectively andwith less negative emotions; they can achieve good social adaptation and interpersonalsupport,perceive happiness in the life,and act health behavior by themselves.④Threemonths after discharge,patients with high gratitude have interpersonal interaction which isspontaneous expression of gratitude,and express experience of happiness,satisfaction morelove others in the interaction.6.Result of the effect on gratitude intervention for qualitative evaluation：①Gratitudeexperience of13patients with coronary artery stenting can be included into four themeswhich were life attitude change, interrelationships change, cognition and beliefs change aswell as the life style change.②T hisgratitude intervention scheme was considered suitablefor patients with coronary artery stenting in China. All these patients participatedenthusiasmly in the gratitude intervention,especially during the process of the late phasefor the significant compliance enhancement for the patients.③The gratitude interventionframework which designed in this study can promote patient’s personal and socialenvironment of the utilization of resources and mining, improve their better adaptation toreturn to the community and family, imcrease their happiness and health behavior ability.Major results of the gratitude intervention lies in four aspects including promoting patients’attitude towards life, cognitive beliefs, interpersonal relationship and life style change.【Conclusion】1. The revised Chinese version of the gratitude scale has good internal consistency,test-retest reliability,content validity,construct validity,criterion validity. Each term has abetter discrimination and higher discernment,which is suitable for the use of older agegroups under the Chinese culture.2. The gratitude theory was introduced into the chronic diseases in this study. And thestudy makes it clear that gratitude is the toughness protection factor of patients withcoronary artery stenting to adjust to the adversity. And also validates that gratitude is theindependent predictive element of toughness,post operation depression and anxiety,SWBand health behavioral competence.3. The relational model of the gratitude on its health correlated variables in patients after coronary artery stent implantatation in this study can help clinical and communitynurses have a better understanding of the gratitude on its health promotion in patients aftercoronary artery stent implantatation in a particular culture,as well as guide them tointegrate the gratitude concept with clinic psychological care effectively and provide theevidences of a better implementation of the gratitude intervention program.4. This research clarifies the independent predicative function and unidirectionalcausal relationship of gratitude in resilience.5. The study suggests that gratitude in patients after coronary artery stentimplantatation is more obvious characteristics of oriental culture. The process of patients’postoperative psychological experience,the perception of life and health promotion aredescribed and sketched out through qualitative research. It further improves and enrichesthe quantitative findings and provides an empirical basis for the construction of clinicalgratitude strategy and the psychological care of gratitude.5. The study indicate that the localization gratitude intervention framework which wasbuild based on literature research, theoretical research, qualitative interviews, as well as theexpert panel for some modification was suitable for the patients after coronary artery stentimplantatation in tranditional background in China.It actually verified the effect ofgratitude interventions for coronary stenting in patients with health promotion whichcontained promoting patients’ attitude towards life, cognitive beliefs, interpersonalrelationship and life style change.through the qualitative evaluation for13participants. Theeffective implementation of the field of gratitude intervention for health promotion isexpected to be the efficient way to improve the subject wellbeing of patients and be as thefoundation of evidenced based for psychological care which focus on gratitude.更多还原