【作者】 王蓉；

【导师】 徐慧兰；

【作者基本信息】 中南大学 ， 社会医学， 2022， 博士

【摘要】 目的(1)汉化修订关键性文化能力量表,分析中文版量表的信效度,为临床护士关键性文化能力的干预研究提供科学可行的评估工具。(2)描述湖南省临床护士关键性文化能力现状,分析其影响因素,为临床护士关键性文化能力干预模式的编制提供参考依据。(3)构建临床护士关键性文化能力线上融合线下(online merge offline,OMO)干预模式。(4)实施临床护士关键性文化能力OMO干预模式,评价干预效果,以期提高临床护士关键性文化能力,提升整体护理质量。方法(1)根据国际量表引进程序将英文版关键性文化能力量表(CCCS)翻译成中文版量表并进行修订。运用问卷调查法整群抽取2019年8月~10月湖南省某三甲医院580名临床护士进行问卷调查,对量表进行信度和效度分析,采用验证性因子分析构建结构模型;最终确定中文版关键性文化能力量表(CCCS)正式版本。(2)采用多阶段随机抽样方法选取2020年1月~6月湖南省14个市、自治州14所三级甲等医院临床护士进行调查,对其关键性文化能力、评判性思维能力、自我效能感、共情能力、工作压力源、社会支持、生活事件、焦虑和抑郁症状、人格特征和应对方式进行测评。采用t检验、方差分析、相关性分析和多元逐步回归分析临床护士关键性文化能力的影响因素。(3)通过文献研究、专家和临床护士访谈、专题小组讨论和预试验构建临床护士关键性文化能力OMO干预模式。采取多阶段整群抽样方法选取2020年9月~2021年2月湖南省2所三甲医院临床护士作为研究对象。对照组接受医院常规专业培训;试验组在医院常规专业培训的基础上实施为期6个月的关键性文化能力OMO模式干预。收集试验组和对照组的基线资料,在干预3个月、6个月后测评试验组和对照组的关键性文化能力、评判性思维能力和共情能力得分,评价关键性文化能力干预效果。采用重复测量方差分析和线性混合模型进行干预效果分析;采用AMOS23.0对临床护士的人口学特征、评判性思维能力、共情能力及关键性文化能力进行多重路径分析。结果(1)中文版CCCS信效度测评:(1)量表的信度:总量表和分量表的Cronbach’s a系数为0.811~0.878;分半信度为0.707~0.842;重测信度为0.815~0.873。(2)量表的效度:中文版CCCS测试版本的条目水平的内容效度I-CVI为0.833~0.944,量表水平的内容效度S-CVI为0.930。验证性因子分析结果中,调整后拟合优度指数(AGFI)=0.863,渐进残差均方和平方根(RMSEA)=0.076;表明验证分析模型拟合良好。4个分量表的平方差抽取量(AVE)分别为0.637、0.499、0.560、0.565;因素负荷量(STD)在0.592~0.873之间且具有统计学意义(P<0.001);组合信度(CR)分别为0.840、0.745、0.788、0.885。中文版《临床护士关键性文化能力量表》正式量表共有4个分量表,43个条目。4个分量表的维度和条目数均与原量表一致。(2)临床护士关键性文化能力现状:本研究共纳入14所三级甲等医院3858名临床护士,其平均年龄31.7±6.7岁,平均工作时间10.3±7.5年。83.2%的护士认为有必要进行关键性文化护理,进行关键性文化护理存在的困难中前三位依次是没有时间(66.5%),没有相关知识(62.4%),没有足够人员(58.9%);55.4%的护士从来没有接受过关键性文化培训。进行关键性文化培训的常用方式是医院组织讲座(40.1%)。临床护士关键性文化能力的百分制标化分65.3±5.6分。(3)临床护士关键性文化能力的影响因素:逐步多元回归结果显示,护理部护士(b=5.656;P=0.032)、女护士(b=3.401;P=0.037)、高职称护士(b=2.611;P<0.001),其关键性文化能力越高。评判性思维能力评分越高(b=2.564;P<0.001)、共情能力评分越高(b=1.373;P=0.014)的护士,其关键性文化能力越高。无所谓进行关键性文化护理(b=-5.868;P<0.001)、不愿意进行关键性文化护理的护士(b=-6.491;P=0.005)、没有接受过关键性文化培训(b=-1.342;P=0.017)、没有关键性文化护理相关知识(b=-1.372;P=0.011)的护士,其关键性文化能力较低。(4)干预效果评价:本研究选中的2所三甲医院各8个科室共694名临床护士纳入干预研究。线性混合效应模型分析显示,干预可提高临床护士的CCCS评分、CTDI-CV评分和JSE-HP评分;CCCS评分、CTDI-CV评分和JSE-HP评分会随着干预时间的延长而增加。评判性思维能力在职称和关键性文化能力间起部分中介作用(Bootstrap95%CI:0.525~2.507),中介效应值为15.5%;共情能力在职称和关键性文化能力间起部分中介作用(Bootstrap95%CI:0.635~3.450),中介效应值为32.5%;评判性思维能力在科室和关键性文化能力间起主要中介作用(Bootstrap95%CI:1.572~3.218),中介效应值为34.1%。结论(1)经过汉化、修订的中文版关键性文化能力量表正式版本,共有4个分量表,43个条目。量表信效度良好,与原量表的意思相符,可以作为临床护士关键性文化能力的评估工具。(2)临床护士的关键性文化能力处于中等水平。关键性赋能水平最高,关键性意识水平最低。临床护士认为进行关键性文化护理的主要困难是没有时间、相关知识和足够人员。常用的关键性文化培训方式是医院组织讲座。科室、性别、职称、是否愿意进行关键性文化护理、是否接受过关键性文化培训、评判性思维能力、共情能力状是关键性文化能力的影响因素。(3)OMO干预模式通过课程平台学习、线下课堂面授、全程学习督学和全程学习评价实现线上与线下学习融合,可以提高临床护士的关键性文化能力,增强其评判性思维能力和共情能力。临床护士的职称、科室、评判性思维能力和共情能力与关键性文化能力之间存在多重路径关系。图14个,表98个,参考文献268篇更多还原

【Abstract】 Objectives(1)To translate the Critical Cultural Competence Scale into Chinese and revise,and the reliability and validity of the Chinese version are to examined,in order to provide a scientific and feasible evaluation tool for the intervention study of clinical nurses’ critical cultural competence.(2)To report the current situation of clinical nurses’ critical cultural competence in Hunan Province and analyze its influencing factors,in order to provide a reference basis for the establishment of clinical nurses’ critical cultural competence enhancement program.(3)To construct an online merge offline(OMO)intervention model for clinical nurses’ critical cultural competence.(4)To implement the OMO intervention model and evaluate the effect of the intervention,so as to improve the critical cultural competence of clinical nurses and enhance the overall quality of care.Methods(1)The English version of the Critical Cultural Competence Scale(CCCS)was translated into the scale of Chinese version and revised according to the international scale introduction procedure.From August to October,2019,a total of 580 clinical nurses from a tertiary A hospital in Hunan Province were selected by cluster sampling using the questionnaire method.The reliability and validity of scale were analyzed,and confirmatory factor analysis was used to construct the structural model,then the final version of the Chinese version of CCCS was finalized.(2)A multi-stage random sampling method was used to select clinical nurses from 14 tertiary A hospitals in 14 cities and autonomous prefectures in Hunan province from January to June,2020,and to assess the current situation of critical cultural competence,critical thinking ability,general self-efficacy,empathy ability,job stressors,social support,life events,anxiety and depression symptoms,personality characteristics and coping styles.T-test,ANOVA,correlation analysis and multiple stepwise regression analysis were used to analyze the influencing factors of clinical nurses’ critical cultural competence.(3)The OMO intervention model of critical cultural competence of clinical nurses was constructed through literature research,interviews with specialists and clinical nurses,focus group discussion and pre-test.A multi-stage whole-group sampling method was used to select clinical nurses from September 2020 to February 2021 in 2 tertiary A hospitals in Hunan Province as the research object.The control group implemented regular professional training in the hospital;the experimental group used the OMO intervention model to train clinical nurses in critical cultural competence for 6 months on the basis of regular professional training in the hospital.The baseline data of the experimental group and the control group were collected.After 3 months and 6 months of intervention,the scores of CCCS,CTDI-CV and JSE-HP of the experimental group and the control group were evaluated in order to analyze the intervention effect of OMO model.Descriptive statistics was used to describe clinical nurses’ critical cultural competence,critical thinking ability and empathy ability.Using AMOS23.0,a multi-path analysis was performed on the demographic characteristics,critical thinking ability,empathy ability and critical cultural competence of clinical nurses.Results(1)The assessment of reliability and validity of Chinese version of CCCS scale:(1)Reliability of the scales: the Cronbach’s a coefficients of the total and subscales ranged from 0.811 to 0.878;the split-half reliabilities ranged from 0.707 to 0.842;and the retest reliabilities ranged from 0.815 to 0.873.(2)Validity of the scales: The item-level CVI of test version of CCCS(Chinese version)was 0.833-0.944,and the scale-level CVI l was 0.930.The results of confirmatory factor analysisshowed: AGFI was 0.863,RMSEA was 0.076,indicating that the validation analysis model fits well.AVE of the four subscales were 0.637,0.499,0.560 and 0.565 respectively.STD ranged from 0.592 to 0.873,which were statistically significant(P<0.001).The CR values were 0.840,0.745,0.788 and 0.885 respectively.The Chinese version of the clinical nurses’ Critical Culture Competence Scale has a total of 4 subscales and 43 items.The dimensions and number of items of the four subscales were consistent with the original scales.(2)The status quo of clinical nurses’ critical cultural competence: A total of 3858 clinical nurses from 14 tertiary A hospitals were enrolled in this study.The mean age of the study participants was 31.7±6.7 years,with a mean working time of 10.3±7.5 years.83.2% of nurses considered it was necessary to conduct critical cultural care.The three main difficulties during critical cultural care were the absence of time(66.5%),related knowledge(62.4%)and personnel(58.9%).55.4% of nurses had never received critical cultural training.The common methods of multicultural training were lectures organized by hospitals(40.1%).The percentage-based standardization score of clinical nurses’ critical cultural competence was 65.3±5.6.(3)The influencing factors of clinical nurses’ critical cultural competence: The stepwise multiple regression results of clinical nurses’ critical cultural competence showed that nurses in the nursing department(b=5.656;P=0.032),female nurses(b=3.401;P=0.037),and nurses with higher titles(b=2.611;P < 0.001)had the higher critical cultural competence.Nurses with higher critical thinking ability scores(b=2.564;P<0.001)and higher empathy ability scores(b=1.373;P=0.014)had higher critical cultural competence.Nurses who were indifferent to perform critical cultural care(b=-5.868;P<0.001),those who were not willing to perform critical cultural care(b=-6.491;P=0.005),those who had no training on critical culture(b=-1.342;P=0.017),and nurses without knowledge related to critical culture nursing(b=-1.372;P=0.011)had lower critical culture competence.(4)Evaluation of effect of critical cultural competence intervention: A total of 694 clinical nurses from 8 departments in 2 tertiary A hospitals selected for this study were included in the intervention study.Linear mixed-effects model analysis showed that the intervention increased the scores of CCCS,CTDI-CV and JSE-HP of clinical nurses;the the scores of CCCS,CTDI-CV and JSE-HP increased with longer duration of the intervention.Multiple pathway analysis of clinical nurses’ critical cultural competence: Critical thinking ability played a partial mediating role between title and critical cultural competence(Bootstrap 95%CI: 0.525~2.507),and the mediating effect value was 15.5%.Empathy ability played a partial mediating role in the relationship between title and critical cultural competence(Bootstrap 95%CI: 0.635~3.450),and the mediating effect was 32.5%.Critical thinking ability played a major mediating role between department and critical cultural competence(Bootstrap 95%CI: 1.572~3.218),and the mediating effect value was 34.1%.Conclusions(1)The official version of the Chinese version of Critical Culture Competence Scale for Clinical Nurses,which was formed after localization and revision,had 4 subscales and 43 items.The scale had high reliability and good validity,which was basically consistent with the original scale and could be used as an evaluation tool for the critical cultural competence of clinical nurses.(2)The critical cultural competence of the clinical nurses was at the medium level.Among them,the level of critical empowerment was the highest,followed by critical skills,critical knowledge,and the level of critical consciousness is the lowest.Clinical nurses believed that the main difficulties in performing critical cultural care were lack of time,relevant knowledge,and adequate staffing.Nurses had a strong willingness to receive critical culture training.The commonly training methods were lectures organized by the hospital,learning through the network or mobile phone,and learning through books or literature.Department,gender,professional title,willingness to engage in critical culture nursing,whether trained in critical culture,critical thinking ability and empathy ability were influencing factors of critical culture competence.(3)The OMO intervention model realized the integration of online and offline learning through course platform learning,face-to-face teaching in offline classrooms,whole-process learning supervision and whole-process learning evaluation.The critical cultural competence of clinical nurses was improved significantly,critical thinking ability and empathy ability were significantly enhanced by using the OMO intervention model.Multiple pathway relationships existed between clinical nurses’ professional title,department,critical thinking ability,empathy abilities,and critical cultural competence.更多还原