【作者】 王燕；

【导师】 罗碧如；

【作者基本信息】 四川大学 ， 护理学， 2023， 博士

【摘要】 背景:随着社会经济发展及二胎政策的全面开放,肥胖、高龄孕妇数量逐年增加,我国妊娠期糖尿病(gestational diabetes mellitus,GDM)的患病率逐渐上升。国际糖尿病联盟相关报告指出,2021年我国受到妊娠期高血糖影响的活产数高达870余万。GDM的发生、发展极大的降低了孕产妇及新生儿的生命质量,增加家庭和社会负担,是我国孕产妇面临的主要健康问题之一。适度的体力活动干预对于改善GDM母婴健康的益处已经在全世界范围内获得广泛共识,被视为GDM孕妇健康管理的主要内容之一。然而目前我国GDM孕妇的体力活动现状及管理呈如下特点:第一,GDM孕妇体力活动认知缺乏、形式单一、体力活动水平较低;第二,现有GDM孕妇体力活动干预相关证据适宜性欠佳;第三,现有GDM孕妇体力活动指南关键环节缺乏具体指导,应用缺乏相关资源支撑且受到多因素阻碍,GDM孕妇体力活动管理在临床实践受限。知识转化模式和实施科学方法学框架以最佳循证证据为核心,围绕证据转化的障碍/促进因素开展相关研究,可推动证据的应用和临床实践,在护理循证证据的临床转化方面得到广泛的应用。但目前国内关于GDM体力活动干预的知识转化和实施科学研究尚属空白,无法为临床实践提供指导。目的:1.了解GDM孕妇体力活动现状及指导需求,建立GDM孕妇体力活动证据总结的主题框架;2.以前期建立的证据总结主题框架为依据,基于JBI证据分级及推荐级别系统和FAME决策模式,筛选适合国内临床情景的GDM孕妇体力活动管理最佳证据;3.基于渥太华研究应用模式从利益相关者角度识别体力活动管理最佳证据应用的障碍/促进因素,并提取促进证据应用的针对性干预策略;4.构建GDM孕妇体力活动管理实践方案,从系统、实践者和患者三个维度验证该方案的可行性、适宜性和有效性,为国内GDM孕妇管理提供依据。方法:本研究采用多阶段混合研究方法,具体研究设计分为四个阶段:第一阶段:GDM孕妇体力活动现状和需求分析横断面研究。采用便利抽样法,抽取四川省成都市某妇女儿童医院(转化基地)的GDM孕妇参与调查。调查工具采用自制的一般资料调查表、妊娠期糖尿病孕妇体力活动现状及指导需求调查表(专家内容效度为0.98,内部一致性系数为0.902),以及Chasan-Taber的孕期身体活动问卷。通过现场问卷调查进行资料收集,采用描述性统计分析GDM孕妇体力活动现状、体力活动的障碍/促进因素以及体力活动指导需求和现存问题,为系统回顾现有知识提供参考,并构建证据总结主题框架。第二阶段:基于循证理念的GDM孕妇体力活动证据整合1.证据总结:围绕上一阶段构建的证据总结主题框架,参考JBI和复旦大学循证护理中心提出的证据总结制作方法,将临床问题转化为PIPOST循证问题,并根据循证资源的“6S”模型制定结构化检索策略,系统检索截至到2022年3月8日的指南、系统评价、证据总结、专家共识、推荐实践和原始研究证据。由两名经过循证医学培训的研究人员独立的根据纳入排除标准进行文献筛选,采用权威的评价工具进行方法学质量评价。根据证据总结制作方法进行证据提取,参照JBI证据预分级系统(2014)对证据进行证据分级,并采用描述性的证据总结表呈现证据信息。2.证据推荐等级评价:采用定性与定量混合评价法进行证据的遴选和推荐等级的评价。首先采用共识形成会议法,采用目的抽样和方便抽样相结合,抽取符合纳入排除标准的学科领域专家,由专家参照证据的FAME决策模式进行讨论,根据讨论结果遴选适合国内现有临床情景的证据;然后采用定量评价法,共识会后由研究者向专家发放论证表,由专家独立地对证据推荐的等级基于JBI推荐级别系统(2014)进行推荐强度评价。采用传统内容分析法对专家的意见进行分析和整理,采用频数、百分比分析定量论证结果,采用内部一致性系数描述专家之间意见的一致程度。对于未达成共识(<70%共识度)的证据根据专家意见进行补充检索、修改和整合,并进行第二轮专家共识会讨论和定量论证,对于仍未达成共识的证据删除,形成GDM孕妇体力活动管理最佳证据总结。第三阶段:GDM孕妇体力活动证据应用的障碍/促进因素研究描述性质性研究。以转化基地的利益相关者即医护人员和GDM孕妇为研究对象。采用目的抽样法的最大差异抽样策略,样本量按信息饱和原则确定。基于渥太华研究应用模式、证据总结内容以及文献回顾结果拟定访谈提纲,通过专家修改和预访谈对提纲修订完善形成最终问题。采用面对面半结构式访谈,访谈围绕三个核心主题展开:“证据的适用性和接受度”、“证据应用受到哪些因素的影响”、“促进证据应用的策略”。录音及笔记在访谈结束后48小时内转录为文本资料,使用Nvivo11.0对资料进行管理,资料收集与分析同时进行,采用定向内容分析法结合渥太华研究应用模式,深入挖掘证据应用的障碍/促进因素,以及促进证据应用的干预策略,为构建实践方案提供参考依据。第四阶段:GDM孕妇体力活动管理实践方案的发展、应用与评价1.实践方案的发展:本阶段研究将证据总结、质性访谈以及基线审查结果进行整合,形成实践方案:(1)采用问卷调查法及观察法,从系统、护士及GDM孕妇三个维度开展基线审查,比较证据与现有临床实践的差距;(2)整合利益相关者访谈及基线审查结果,在渥太华研究应用模式指导下从障碍因素管理、证据转化和随访措施三个层面着手完善针对性干预策略;(3)根据干预策略的具体内容和形式将证据转化为详细方案、流程及对应的辅助工具,经转化小组成员完善和修改,形成GDM孕妇体力活动管理实践方案。2.应用与评价:通过非同期对照设计从系统、护士和患者三个维度评价实践方案的可行性、适宜性和有效性。本阶段以前期研究构建的实践方案为干预载体进行小范围实证研究。研究时间为2022年10月开展基线调查,2022年11-12月将方案循序渐进引入临床实践,2023年1月开展效果评价。评价内容包括系统层面的改变;护士层面采用自身前后对照设计,采用重复测量方差分析、Dunnet-t检验、χ~2检验和Fisher确切概率法比较方案应用前及方案应用后2周、4周、8周护士对证据执行力、体力活动知识与护理行为的改变,并通过质性访谈探索护士对证据应用的实践体验,采用主题分析法对资料进行分析;患者层面采用历史对照试验,将2022年10月纳入的GDM孕妇作为对照组,2023年1月纳入的GDM孕妇作为转化组,采用χ~2检验、Fisher确切概率、t检验、Mann-Whitney U秩和检验比较方案应用前后GDM孕妇知识、体力活动水平与能量消耗的改变。结果:第一阶段:现状和需求分析结果回收有效问卷371份,GDM孕妇的运动达标率仅为27.42%,每周运动锻炼时长为1小时,低于指南推荐标准。影响运动的主要障碍/促进因素为:有利于血糖控制(88.9%)、怀孕症状或不适(32.1%),不适宜的天气(24.5%)、医生的建议(20.8%)、有专项孕期运动项目(18.1%)等。41%的GDM孕妇每日静坐时长超过6小时。GDM孕妇对运动指导的需求从高到低依次为运动安全事项、运动禁忌证、运动风险、运动效果监测等。GDM孕妇认为医疗机构在体力活动指导方面存在问题如缺乏专业科学的运动处方、缺乏多样化的宣教形式、缺乏个性化的指导。根据横断面调查结果构建16个证据总结主题进入下一阶段的证据整合研究。第二阶段:证据整合结果通过系统检索共发现相关文献31527篇,剔除不符合纳入排除标准的文献,经方法学质量评价后,共26部指南,19篇系统评价,14篇证据总结/专家共识等,16篇原始研究纳入下一步证据提取。证据总结初稿包括16个主题,62条推荐意见。根据专家遴选标准选取相关学科领域专家10人参与专家共识会,专家权威程度为0.92。第一轮专家共识会讨论和定量论证:共35条证据达成共识,13条未达成共识,删除14条证据,经修改、补充检索、内容整合后形成16条证据;第二轮专家共识会讨论及定量论证:共16条证据达成共识。经整合后的证据主题包括运动评估、运动处方、运动时机、运动期间血糖管理、久坐及日常活动、健康教育、运动促进策略、培训、效果评价8个主题,共计39条推荐意见。第三阶段:障碍/促进因素分析结果本研究共纳入转化基地医护人员12名和GDM孕妇14名。基于渥太华研究应用模式和访谈资料分析,共形成3个主题:证据的变革、潜在采纳者、实践环境。证据的变革包含证据契合临床需要、部分证据可操作性欠佳2个亚主题;潜在采纳者包含知识技能及动力不足、工作自主性不足、对证据应用持积极态度、护理人员的顾虑以及护理人力资源缺乏5个亚主题;实践环境包含实施氛围、现行实践流程与内容、人才培养、经济因素、患者因素5个亚主题。针对障碍因素的策略共析出3个主题:证据应用组织形式、护理人力资源优化、组织层面变革。证据应用组织形式包含试点转化、发展实践信息册2个亚主题;护理人力资源优化包含调整人员配置和开展相关培训及考核2个亚主题;组织层面变革包含组建多学科团队、制定基于证据的规范及流程、设立GDM专科门诊、改善物质环境和优化健康教育方案5个亚主题。第四阶段:实践方案发展、应用与评价结果1.实践方案发展:基线审查结果显示:(1)临床护理实践活动方面,科室缺乏孕期体力活动评估工作内容及对应的工具,对GDM孕妇体力活动的指导与健康教育不全面,缺乏合作与转介;(2)现有护理资料包括健康教育资料和辅助工具多为文字资料,时效性及便捷性不足。对10名护理人员的调查显示,产科门诊的护理人员接受孕期体力活动管理培训较少。护理人员未使用信效度高的工具对GDM孕妇进行体力活动评估;此外,体力活动指导相关护理行为较少。干预策略从障碍因素管理着手,制定了9条干预策略,包括发展实践信息册、调整人员配置等;从证据转化和随访措施着手,制定了2条监控、支持和评估策略。基于以上干预策略及最佳证据总结,构建GDM孕妇体力活动管理实践方案,形成3项流程:评估、指导、健康教育及转介;构建1项培训考核方案;设计开发5个辅助工具:最佳实践信息册、纸质信息图册、科普视频、线上管理平台、护理记录单。2.方案应用与评价:(1)系统层面包括相关流程的再造和完善、辅具及培训考核方案的开发与应用、岗位职责的调整。(2)实践者层面:参与证据转化的护士共计8名,纳入本次体力活动管理的GDM孕妇共计87名。护士对证据的执行力提高,除转介外(2.3%～8.1%),执行率在41.4%～87.4%之间。方案应用2周、4周及8周时护士的体力活动知识总体知晓率较应用前明显增加(58.3%、66.7%、65.6%vs 38.6%),护理行为依从性明显增加;护士对方案应用的实践体验共析出6个主题:(1)护士感到负担与压力,被动参与证据转化(项目初期);(2)护士主动性增加,逐渐胜任实践工作(项目开展期间);(3)护士职业成就感提升,愿意持续开展临床实践(项目结束时);(4)护士参与临床实践转化有助于提升专业素质;(5)完善GDM专科护士主导的专岗专职管理模式具有必要性;(6)改善物质环境并提供绩效激励有助于项目的持续开展。(3)患者层面:对照组61例,转化组58例。转化组GDM孕妇接受体力活动指导的比例大于对照组(χ~2=32.189,P<0.001)。转化组GDM孕妇体力活动知识总体知晓率高于对照组(χ~2=24.102,P<0.001);知识得分较对照组增加1.86分(t=-6.150,P<0.001)。与对照组相比,转化组GDM孕妇在中等强度活动时长、运动锻炼时长方面有增加的趋势,但差异无统计学意义。按年龄进行亚组分析,结果显示在年龄≤30岁的GDM孕妇中,转化组GDM孕妇较对照组的运动达标率增加34.4%(χ~2=5.598,P=0.018)。转化组孕妇的中等强度体力活动时长、中度+重度体力活动时长、运动锻炼时长与能量消耗较对照组明显增加(P<0.05)。转化组GDM孕妇的职业活动时长与能量消耗较对照组降低(P<0.05);年龄>30岁的孕妇中,转化组GDM孕妇的交通活动时长与能量消耗较对照组GDM孕妇明显降低(P<0.05),其余指标无统计学差异。结论:1.GDM孕妇体力活动水平不足,同时面临体力活动缺乏和长期静坐少动的健康风险。现有临床实践无法满足GDM孕妇对体力活动指导的需求。2.本研究基于GDM孕妇体力活动现状和需求制作的最佳证据总结适合国内现有临床情景,为GDM孕妇体力活动管理方案的构建提供了充分的循证依据。3.本研究构建的GDM孕妇体力活动管理方案,方法科学,可以提高护士对证据的执行力、改善护士相关知识和护理行为,改善GDM孕妇体力活动及知识水平,应用于国内临床情景具有可行性、适宜性和有效性,可作为我国GDM孕妇体力活动管理的参考方案。更多还原

【Abstract】 Background:With the social and economic development and the comprehensive opening up of the two-child policy,the number of obese and advanced pregnant women is increasing year by year.The prevalence of gestational diabetes mellitus(GDM)in China is gradually increasing.According to a report by the International Diabetes Federation,more than 8.7 million live births affected by hyperglycemia during pregnancy in 2021.The occurrence and development of GDM greatly reduces the quality of life of pregnant women and newborns,increases the burden of family and society,and is one of the main health problems faced by pregnant women in China.The benefits of moderate physical activity intervention on improving the health of GDM mothers and infants have been widely recognized worldwide,and it is regarded as one of the main components of the health management of pregnant women with GDM.However,the current status and management of physical activity in pregnant women with GDM in China are as follows:First,the awareness of physical activity in pregnant women with GDM is lack,the form of physical activity is single and the level of physical activity is low;Second,the existing evidence on physical activity intervention in pregnant women with GDM is not well suited to the sports culture and clinical situation in China;Third,the current physical activity guidelines for pregnant women with GDM lack specific guidance in key links,and the application of these guidelines lacks relevant resource support and is hindered by multiple factors,so the clinical practice of physical activity management for pregnant women with GDM is limited.The knowledge translation model and implementation science methodology framework take the best evidence as the core,and carry out related research around the barriers/promoting factors of evidence translation,which can promote the application of evidence and clinical practice,and be widely used in the clinical translation of nursing evidence-based evidence.However,the research on the knowledge translation and implementation science of physical activity intervention for GDM in China is still blank,which can not provide guidance for clinical practice.Objective:1.To understand the current status and guidance needs of physical activity in pregnant women with GDM,and to establish a theme framework for evidence summary of physical activity in pregnant women with GDM;2.Based on the previously established theme framework for evidence summary,the best evidence for physical activity management of GDM pregnant women suitable for domestic clinical scenarios was screened based on the JBI levels of Evidence and Grades of Recommendation and the FAME decision-making model;3.Identify the barriers/promoting factors to the application of the best evidence for physical activity management from the perspective of stakeholders based on the Ottawa model of research use,and extract the targeted intervention strategies to promote the implementation of evidence;4.Construct a physical activity management practice program for pregnant women with GDM,and verify the feasibility,suitability and effectiveness of the program from the three dimensions of the system,practitioners and patients,so as to provide a basis for the management of pregnant women with GDM in China.Methods:A multi-stage mixed method was used,and the specific research design was divided into four stages:Phase 1:Analyzing the status and demand for physical activity of GDM pregnant womanCross-sectional design was used.The convenience sampling method was used to select pregnant women with GDM from a Women and Children’s hospital(base of translation)in Chengdu City,Sichuan Province to participate in the survey.The survey tools included the self-design general information questionnaire,physical activity status and guidance needs questionnaire for pregnant women with gestational diabetes mellitus(expert content validity was 0.98,internal consistency coefficient was 0.902),and Chasan-Taber’s Pregnancy Physical Activity Questionnaire.Data were collected through offline questionnaire survey,and descriptive statistics were used to analyze the current status of physical activity,barriers/promoting factors of physical activity,guidance needs and existing problems of physical activity in pregnant women with GDM,so as to provide a reference for systematic review of existing knowledge and construct a theme framework for evidence summary.Phase 2:Evidence integration of physical activity in pregnant women with GDM based on evidence-based concept1.Evidence summary:Focusing on the theme framework of evidence summary constructed in the previous stage,referring to the evidence summary production method proposed by JBI and Evidence-based Nursing Center of Fudan University,the clinical questions were transformed into PIPOST evidence-based questions,and the structured search strategy was formulated according to the"6S"model.Guidelines,systematic reviews,evidence summaries,expert consensus,recommended practices and original research evidence were systematically searched up to March 8,2022.Two researchers who had been trained in evidence-based medicine independently screened the literature according to the inclusion and exclusion criteria,and the quality was evaluated by using authoritative methodological quality assessment tools.Evidence was extracted according to the evidence summary production method.The evidence was graded according to the JBI levels of Evidence and Grades of Recommendation(2014),and the descriptive evidence summary table was used to present the evidence information.2.2.Evaluation of recommendation level of evidence:qualitative and quantitative mixed evaluation method was used to select evidence and evaluate the recommendation level.Firstly,the consensus development method was used to select experts in the discipline field who met the inclusion and exclusion criteria by combining purpose sampling and convenience sampling.The experts discussed with reference to the FAME decision-making model of evidence,and the evidence suitable for the existing clinical situation in China was selected according to the discussion results.After the consensus meeting,the researchers distributed the demonstration form to the experts,and the experts independently evaluated the recommendation strength of evidence based on the JBI levels of Evidence and Grades of Recommendation(2014).The conventional content analysis method was used to analyze and sort out the opinions of experts,and the content and expression of evidence summary were reached.Frequency and percentage were used to analyze the quantitative argumentation results,and the internal consistency coefficient was used to describe the degree of agreement between experts.For the absence of consensus(<70%consensus)were searched,revised and integrated according to expert opinions,and the second round of expert consensus was discussed and quantitatively demonstrated.The evidence that still did not reach the consensus was deleted,and the best evidence summary for physical activity management of GDM pregnant women was formed.Phase 3:Analyzing barriers/promoting factors of physical activity evidence implementation in pregnant women with GDMA descriptive qualitative research design was used.The stakeholders of the base of translation,namely medical staff and pregnant women with GDM,were selected as the research objects.The maximum difference sampling strategy of purposive sampling method was used,and the sample size was determined according to the principle of information saturation.An interview outline was developed based on the Ottawa model of research use,evidence summary content and literature review results,and the final questions were formed through expert revision and pre-interview.Face-to-face semi-structured interviews were conducted around three core themes:"applicability and acceptance of evidence","what factors affect the implementation of evidence",and"strategies to promote the implementation of evidence".Nvivo11.0 was used to manage the data.Data collection and analysis were performed simultaneously.The directed content analysis method combined with the Ottawa model of research use was used to deeply explore the barriers/promoting factors to promote evidence implementation,so as to provide a reference for the construction of practical programs.Phase 4:Development,application and evaluation of physical activity management practice program for pregnant women with GDM1.Development of Practice Program:This study integrated evidence summary,qualitative interview and clinical audit results to form a practice plan:(1)Clinical audit was conducted from three dimensions of system,nurses and GDM pregnant women using questionnaire survey and observation method to compare the gap between evidence and existing clinical practice;(2)Integrated the results of stakeholder interviews and clinical audit,and improved the targeted intervention strategies from three levels of barrier factor management,evidence translation and follow-up measures under the guidance of the Ottawa model of research use.(3)The evidence was transformed into detailed program,processes and corresponding auxiliary tools according to the specific content and the form of intervention strategy.The physical activity management practical program for GDM pregnant women was formed after being perfected and modified by the members of the translation team.2.Application and Evaluation:The feasibility,suitability and effectiveness of the practical program were evaluated from three dimensions of system,nurse and patient through non-contemporaneous controlled trials.In this stage,the practical program constructed in the previous study was used as the intervention carrier to conduct a small-scale empirical study.The baseline investigation will be carried out in October2022,the program will be gradually introduced into clinical practice from November to December 2022,and the effect evaluation will be carried out in January 2023.The evaluation included system-level changes;A self-controlled design was used at the nurse level.Repeated measurement analysis of variance,Dunnet-t test,chi-square test and Fisher exact probability method were used to compare changes in nurses’evidence execution,physical activity knowledge and nursing behavior before and 2,4 and 8weeks after the application of the program.Qualitative interviews were used to explore nurses’practical experience of evidence application.Thematic analysis was used to analyze the data.A historical controlled trial was used at the patient level,with pregnant women with GDM enrolled in October 2022 as the control group and pregnant women with GDM enrolled in January 2023 as the translation group.Chi-square test,Fisher exact test,t test and Mann-Whitney U test were used to compare the changes of knowledge,physical activity level and energy expenditure of pregnant women with GDM before and after the application of the program.Results:Phase 1:A total of 371 valid questionnaires were collected.The compliance rate of exercise in pregnant women with GDM was only 27.42%,and the exercise time per week was 1 hour,which was lower than the recommended standard.The main barriers/promoting factors of exercise were beneficial to blood glucose control(88.9%),pregnancy symptoms or discomfort(32.1%),unsuitable weather(24.5%),doctor’s advice(20.8%),special exercise program during pregnancy(18.1%),etc.41%of women with GDM spent more than 6 hours per day on sedentary behavior.The needs of pregnant women with GDM for exercise guidance from high to low were exercise safety matters,exercise contraindications,exercise risk,exercise effect monitoring,etc.Pregnant women with GDM believe that there are problems in physical activity guidance in medical institutions,such as lack of professional and scientific exercise prescription,lack of diversified forms of education,and lack of personalized guidance.According to the cross-sectional survey results,16 themes of evidence summary were constructed to enter the next stage of evidence integration research.Phase 2:A total of 31,527 relevant literatures were found through systematic retrieval,and the literatures that did not meet the inclusion and exclusion criteria were excluded.After methodological quality assessment,a total of 26 guidelines,19 systematic reviews,14 evidence summaries/expert consensus,etc.,and 16 original studies were included in the next step of evidence extraction.The first draft of evidence summary included 16 themes and 62 recommendations.According to the expert selection criteria,10 experts in related disciplines were selected to participate in the expert consensus meeting,and the expert authority degree was 0.92.In the first round of expert consensus discussion and quantitative demonstration,a total of 35 pieces of evidence reached consensus,13 pieces of evidence did not reach consensus,14 pieces of evidence were deleted,and 16 pieces of evidence were formed after modification,supplementary retrieval and content integration.The second round of expert consensus discussion and quantitative demonstration:a total of 16 pieces of evidence reached consensus.The integrated evidence themes included 8 themes:exercise assessment,exercise prescription,exercise timing,blood glucose management during exercise,sedentary and daily activities,health education,exercise promotion strategies,training,and effect evaluation,with a total of 39 recommendations.Phase 3:A total of 12 medical staff and 14 pregnant women with GDM were included in this study.Based on the Ottawa model of research use and interview data analysis,a total of three themes were formed:evidence translation,potential adopters,and practice environment.The reform of evidence included two sub-themes:evidence meeting clinical needs and poor operability of some evidence.The potential adopters included five sub-themes:lack of knowledge,skills and motivation,lack of work autonomy,positive attitude towards evidence application,concerns of nursing staff and lack of nursing human resources.The practice environment included five sub-themes:implementation atmosphere,current practice process and content,talent training,economic factors,and patient factors.In view of the obstacle factors strategy eutectoid three themes:evidence implementation form,optimization of nursing human resources,organizational level change.The organizational form of evidence implementation included two sub-themes:pilot translation and development practice information sheet.Optimization of nursing human resources included two sub-themes:adjusting staffing and carrying out related training and assessment.The change at the organizational level included five sub-themes:forming a multidisciplinary team,formulating evidence-based norms and processes,establishing GDM specialist clinics,improving physical environment and optimizing health education programs.Phase 4:1.Development of practice program:the results of clinical audit showed that:(1)In terms of clinical nursing practice activities,the department lacked the work content and corresponding tools for the assessment of physical activity during pregnancy,the guidance and health education of physical activity for GDM pregnant women were not comprehensive,and there was a lack of cooperation and referral.(2)Most of the existing nursing materials,including health education materials and auxiliary tools,were written materials and lacked timeliness and convenience.The survey of 10 nurses showed that nurses in the obstetric clinic received less training in physical activity management during pregnancy.Nursing staff did not use a tool with high reliability and validity to evaluate physical activity of pregnant women with GDM.In addition,there were few nursing behaviors related to physical activity instruction.Intervention strategies started from the management of obstacles,and 9 intervention strategies were formulated,including the development of practice information sheet,adjustment of personnel allocation,etc.Starting from evidence transformation and follow-up measures,two strategies were formulated to monitor,support and evaluation.Based on the above intervention strategies and the best evidence summary,the physical activity management practice program for pregnant women with GDM was constructed,which consisted of three processes:assessment,guidance,health education and referral.A training and assessment plan was constructed.Five auxiliary tools were designed and developed,including best practice information sheet,paper information atlas,popular science video,online management platform and nursing record sheet.2.Program application and evaluation:(1)System level:Including the reengineering and improvement of related processes,the development and application of assistive devices and training and assessment programs,and the adjustment of job responsibilities of nurse.(2)Practitioner level:a total of 8 nurses participated in evidence translation,and 87GDM pregnant women were included in this physical activity management.Nurses’implementation of evidence was improved,and the implementation rate was between41.4%-87.4%except for referrals(2.3%-8.1%).After 2,4 and 8 weeks of the program application,the overall awareness rate of physical activity knowledge of nurses was significantly higher than that before the program application(58.3%,66.7%,65.6%vs38.6%),and the compliance of nursing behavior was significantly increased.The practical experience of nurses on the application of the program was summarized into6 themes:1)Nurses felt burden and pressure and passively participated in evidence translation(early stage of the project);2)Nurses’initiative increased and gradually qualified for practical work(during the project implementation);3)Nurses’career achievement was improved and they were willing to continue to carry out clinical practice(at the end of the project);4)Nurses’participation in clinical practice translation is helpful to improve their professional quality;5)It is necessary to improve the specialized post full-time management mode led by GDM specialist nurses;6)Improving the physical environment and providing performance incentives are conducive to the continuous development of the project.(3)Patient level:there were 61 cases in the control group and 58 cases in the translation group.The proportion of pregnant women with GDM in the translation group receiving physical activity guidance was higher than that in the control group(χ~2=32.189,P<0.001).The overall awareness rate of physical activity knowledge of GDM pregnant women in the translation group was higher than that in the control group(χ~2=24.102,P<0.001);The score of knowledge increased by 1.86 points compared with the control group(t=-6.150,P<0.001).Compared with the control group,the GDM pregnant women in the translation group had an increasing trend in the duration of moderate intensity activity and exercise,but the difference was not statistically significant.Subgroup analysis by age showed that in GDM women younger than 30 years old,the rate of exercise compliance in the translation group increased by 34.4%compared with the control group(χ~2=5.598,P=0.018).The duration and energy expenditure of moderate intensity physical activity,moderate&severe intensity physical activity and exercise of pregnant women in the translation group were significantly higher than those in the control group(P<0.05).The duration and energy expenditure of occupational activity of GDM pregnant women in the translation group were lower than those in the control group(P<0.05);For those older than 30 years old,the transportation duration and energy expenditure in the translation group were significantly lower than those in the control group(P<0.05),and there was no significant difference in other indicators.Conclusion:1.Pregnant women with GDM have low level of physical activity,and face the health risks of lack of physical activity and long-term sedentary behavior.The current clinical practice cannot meet the needs of physical activity guidance for pregnant women with GDM.2.The summary of the best evidence based on the physical activity status and needs of pregnant women with GDM is suitable for the existing clinical situation in China,and provides sufficient evidence-based basis for the construction of physical activity management programs for pregnant women with GDM.3.The physical activity management program for pregnant women with GDM constructed in this study has scientific methods,which can improve nurses’execution of evidence,nurses’related knowledge and nursing behavior,and improve the physical activity and knowledge level of pregnant women with GDM.It is feasible,suitable and effective when applied to clinical scenarios in China,and can be used as a reference program for physical activity management of pregnant women with GDM in 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