【作者】 吴菁；

【导师】 刘晓虹； Marcia Beaulieu； 唐洪泰；

【作者基本信息】 第二军医大学 ， 护理学， 2009， 博士

【摘要】 本研究来源于军队“十一五”B类课题(战创伤致残者早期心理康复模式的研究),旨在以平战时常见意外致伤——烧伤所致伤者早期负性心理反应及其主要影响因素为切入点,构建适用于临床护士操作的烧伤患者早期心理干预模式,以期为我国临床护士探索其促进烧伤患者身心康复进程的依据和应对策略,力求减少烧伤患者因伤后早期身心失衡所致其后永久性心理残障而给本人、家庭乃至社会造成重负等。本研究分三个部分:第一部分:烧伤患者早期心理干预模式的构建。在回顾大量国内外相关研究文献、分析多种干预策略的基础上,以应激理论为本研究的主要理论基础,借鉴Roy适应模式、危机干预、积极心理学等相关理论,初步构建烧伤患者早期心理干预的理论框架,形成便于护士掌握并操作、适用于烧伤患者早期身心修复的心理干预模式。烧伤患者早期心理干预模式需把握6个主要环节,包括①着眼于烧伤患者早期的心理应激特点;②针对烧伤患者早期心理反应的主要影响因素;③结合烧伤患者的应对表现及其结果;④把握心理干预的主要切入点;⑤明晰护患的角色功能;⑥拟定心理干预的主要步骤。第二部分:通过严重烧伤患者的质性访谈,追溯其伤后身心康复各阶段所亲历体验,进一步佐证伤者早期接受心理干预的重要意义,并为构建烧伤患者早期心理干预模式提供依据。采取半结构式访谈设计,非随机、目的性抽样8名严重烧伤患者作为访谈对象,深入探询其伤后早期及各阶段应对心理、生理创伤的详细信息。质性访谈的结果显示,严重烧伤患者伤后大多经历从迷失、适应到成长的心路历程;良好的人格特质、合理有效应对、利用社会支持及寻求精神寄托对其身心康复发挥重要作用。研究发现,与伤者有重要情感联系的人物在伤者的身心康复中的作用十分关键;伤者身心康复过程中使用应对策略需予以恰当引导,特别是伤者面对其创伤所致不可控状况时(如毁容、疤痕致不良身心反应),帮助伤者认同创伤康复历程中自身可获益之处、尝试赋予日常事件以积极意义、秉持“向下社会比较”理念等,均为促进伤者身心康复的有效应对策略。这部分研究较顺利达成预期成果:较全面勾勒了“严重烧伤患者伤后身心康复历程”并形成树形结构图,既可为烧伤患者早期心理干预的研究提供依据,也可为后续的相关研究形成铺垫。第三部分:烧伤患者早期心理干预的临床实验研究,旨在验证本研究所构建伤者早期心理干预模式的效用。将某烧伤科病房8个月内收治的所有符合纳入标准的伤者先后纳入对照组(n=23)和实验组(n=24),以两组伤者的个人特征、治疗方案、护理过程等基线资料无显著差异为基础,实验组伤者仅增加本研究所构建模式的心理干预措施。两组伤者均于入院1周内及1月后或出院前,接受医院焦虑抑郁量表、自我效能感量表、烧伤患者情绪表现及影响因素他评表的评估。结果显示,①烧伤患者伤后1周内:焦虑、抑郁状态明显,检出率分别为89.4%、78.7%;两组间伤者的总体情绪反应、焦虑、抑郁、自我效能感未见显著差异;烧伤体表总面积、学历等差异可导致伤者的焦虑、抑郁程度的显著差异(P<0.05)。②实施心理干预对照实验1个月后:实验组伤者的总体情绪反应、焦虑程度、抑郁程度显著降低,自我效能感水平显著升高,相较于对照组伤者均呈显著差异(P<0.05)。此结果提示,本研究所构建的心理干预模式,已初步显示其降低伤者的焦虑及抑郁水平、提升伤者自我效能感的效用。结论:重度烧伤患者的身心康复历程可面临多重生理、心理危机,且其早期的身心适应尤为关键,直接关系伤者此后能否顺利达成较理想身心康复目标、较完好回归社会等。本研究经质性访谈所形成“严重烧伤患者伤后身心康复历程树形结构图”、经文献回顾所构建且经临床实验验证其效用的“烧伤患者早期心理干预模式”,有望辅佐临床一线护士更关注伤者早期的心理评估和干预,以促进伤者的心理适应;协同临床护士充分调动伤者在身心康复历程中的主观能动性,最终达成较理想身心康复目标,即帮助伤者较完好回归社会,避免其因严重心理残障给本人及其家庭乃至社会造成重负等。更多还原

【Abstract】 This study is a part of“Study on Psychological Rehabilitation Model of Disabilities Caused by Trauma or War”. The aim of this study is to develop and test a psychological intervention model for burn patients at early stage of treatment, based on characteristics of psychological reaction and the positive factors promoting psychological adaptation of burn patients, in order to provide instruction and guide for nurses’providing psychological care and reduce heavy burden on patients, family and society because of psychological disorders of burn patients. This study has three parts.Part one, development of psychological intervention model of burn patients at early stage of treatment. Based on brief review of articles on psychological intervention of trauma and burn patients, with stress theory as theory foundation, combined with Roy’s adaptation model, crisis intervention techniques and positive psychology, theoretical structure of psychological intervention was developed. After analyzing various psychological intervention strategies, according to principles of nurse-administered and easily accepted by burn patients, psychological intervention model of burn patients was developed.Part two, qualitative study of burn patients with significant burn injury. The aim was to track the experiences of burn patients in every rehabilitation stage, forward testify the importance of early psychological intervention and provide proof for construction of intervention model. Descriptive phenomenological design was the methodological basis for this part. Eight purposively selected burn survivors were interviewed.Content analysis indicated that severely burned patients experienced loss, adaptation and growth process during the rehabilitation course. Optimistic personality, positive coping styles, and social support contributed to the positive adaptation of Chinese burned patients. Positive coping styles included downward social comparison and positive reappraisal. Social support included emotional support from a significant guy and proper information support. Instruction on coping strategies to patients were needed especially the situation was uncontrollable.Part three, experimental study of clinical intervention on burned patients. A sample of 47 burn patients admitted with TBSA more than 10% was distributed to attend either a 4-week psychological intervention program or no intervention after they were admitted and were assessed pre- and post intervention with HADS and General self-efficacy Scale (GSES). The majority of participants were male, married, and had sudden burn. Demographic statistics revealed that the incident of anxiety and depression were respectively 89.4% and 78.7%. T-test and ANOVA indicated that participants in both groups had no significant differences when admitted and improved significantly over time on overall HADS, anxiety subscale, and depression subscale (P<0.05). Participants in the intervention group showed more improvement than those in no intervention group on overall HADS, anxiety subscale, depression subscale and GSES (P<0.05). Correlation analysis revealed that education level and TBSA was associated with patients’anxiety and depression, which indicated that the psychological intervention model was helpful in enhancing self-efficacy and reducing anxiety and depression of burn patients.Discussion and Conclusion: Burn survivors experience a series of traumatic assaults to the body and mind which present extraordinary challenges to psychological resilience, especially that psychological reaction at early stage was related to the rehabilitation and outcome of the patients. Psychological rehabilitation process tree map developed on qualitative research and psychological intervention model for burn patients based on literature review and clinical tests can help emphasize the importance of early psychological assessment and intervention to promote psychological adaptation and guide them make full use of patients’self-efficacy to achieve better psychological and physical rehabilitation.更多还原