【作者】 高杰；

【导师】 李惠萍； 庞自云；

【作者基本信息】 安徽医科大学 ， 护理， 2023， 硕士

【摘要】 目的基于家庭韧性过程模型,以应对为焦点,构建适合我国文化背景下的乳腺癌患者家庭韧性干预方案,并验证其有效性及可行性,以提升乳腺癌患者的家庭韧性水平,为乳腺癌患者的心理护理提供新的理论基础和干预方式。方法1.文献分析:通过系统文献回顾和分析进行证据总结,结合家庭韧性相关理论及课题组研究基础,形成乳腺癌患者家庭韧性干预方案草案。2.质性访谈:对安徽省某三级甲等医院乳腺癌相关科室的患者、家属和护理人员进行结构式访谈,从不同角度分析干预方案具体内容,根据访谈结果对干预方案进行调整,形成干预方案初稿。3.专家函询:邀请17名临床肿瘤治疗、临床肿瘤护理、护理学、心理学及行为学专家进行两轮专家函询,根据专家意见进一步调整,形成干预方案修订稿。4.预实验:从安徽省某三级甲等医院乳腺癌相关科室选取60个乳腺癌家庭,通过抽签随机分为干预组和对照组。对照组进行常规护理,干预组在常规护理的基础上进行家庭韧性干预。在干预开始前和干预结束后一周对两组家庭的家庭韧性、应对方式、疾病家庭负担、社会支持水平进行评估,并邀请干预组对干预方案进行满意度评价。根据干预过程中出现的问题及干预效果对干预方案进行进一步调整,最终形成乳腺癌患者家庭韧性干预方案。结果1.文献分析:共纳入8篇临床实验性研究,研究对象为各种慢性病患者家庭,实施者多为护理研究人员,干预方式以多家庭面对面小组会议为主,少数采用单家庭面对面或线上会议的干预方式。干预周期为5周～6个月、频率为每周1～2次或2～3周一次,干预次数为3～24次,干预时长为0.5～3小时不等,指标评价时间为干预前、过程中、结束时及结束后6个月。干预主题包括疾病相关知识及患者护理、疾病家庭特征、家庭沟通、情绪及压力管理、家庭问题及应对、家庭优势与资源、家庭目标及家庭计划等,虽部分研究结果显示研究对象的家庭韧性水平有所提升,但由于疾病人群差异、干预内容不详、主题不一、对乳腺癌患者的适用性尚不能确定。根据文献分析结果,结合家庭韧性理论及课题组研究基础形成干预方案草案。2.质性访谈:对乳腺癌相关科室12名临床护理人员、28对乳腺癌患者及家属进行一对一结构式访谈,从干预形式、频率及时间、会议内容及顺序、干预方案可行性等方面提出意见和建议。根据访谈结果结合小组讨论,对干预方案内容做出以下调整:(1)干预形式:面对面结合线上家庭会议。(2)会议时长:25～30min,根据具体情况适当调整。(3)公众号推送:针对不同患者及家庭需求,推送个性化疾病相关知识。(4)及时回复患者和家属的问题。形成干预方案初稿。3.专家函询:两轮专家函询专家积极程度分别为80.95%、100%,权威系数分别为0.822、0.840,意见协调系数Kendall’s W分别为0.061(P>0.05)、0.146(P<0.01),两轮专家函询的科学性、有效性、可行性变异系数均Cv<0.25。根据专家建议结合小组讨论,对干预方案内容做出以下调整:(1)会议名称:修改第1、4、6次会议名称。(2)参与者招募:患者及主要照顾者(一级亲属)。(3)干预形式:首次面对面,之后5次线上会议。(4)项目介绍:邀请乳腺癌治疗、护理专家及康复患者为研究对象答疑解惑。(5)干预过程:会议开始前简单回顾上次会议,并以提问或案例分享的形式引入主题。(6)公众号推送:推送内容与会议主题相结合。(7)针对每次会议内容进行详细调整。形成干预方案修订稿。4.预实验:干预组和对照组共纳入60个乳腺癌家庭,两组患者及家属的基线资料差异均无统计学意义(P>0.05),具有可比性。两组家庭结局指标的差异性对比采用两独立样本t检验,PP和ITT分析均显示,干预结束后,干预组患者和家属的家庭韧性、应对方式及社会支持水平显著高于对照组,疾病家庭负担水平显著低于对照组(P<0.05);每组家庭干预前后结局指标差异性对比采用配对样本t检验,PP和ITT分析均显示,干预组在干预后患者和家属的家庭韧性、应对方式及社会支持水平显著高于干预前,疾病家庭负担水平显著低于干预前(P<0.05);对照组干预后患者的家庭韧性水平略高于干预前(P<0.05),应对方式、疾病负担及社会支持水平较干预前无明显改变(P>0.05);家属的家庭韧性及社会支持水平略高于干预前(P<0.05),疾病负担水平略低于干预前(P<0.05)、应对方式较干预前无明显改变(P>0.05)。可行性结局指标显示,研究对象入组率、招募率、完成率、满意度、依从性从高到低分别为64.52%、75%、91.67%、100%、90%、3.33%、6.67%,说明干预方案具有有效性和可行性。干预方案调整内容如下:(1)干预形式:6次线上家庭会议。(2)干预内容:根据干预家庭的实际情况进行个性化选择会议内容。(3)家庭作业:以信息的形式发送给参与者并附以例句或指导语。结论本研究基于理论分析及课题组研究基础,通过文献分析形成干预方案草案,并进行质性访谈及专家函询对干预方案进行调整、预实验对干预方案进行验证,最终形成以应对为焦点的乳腺癌患者家庭韧性干预方案。干预方案构建过程科学合理,具有良好的有效性和可行性,为临床护理人员指导和帮助乳腺癌患者家庭合理调适提供了实践路径。更多还原

【Abstract】 ObjectiveThis study aims to construct a family resilience intervention program for breast cancer patients based on the family resilience process model and focus on coping under the cultural background of our country,and to verify its effectiveness and feasibility.This will improve the family resilience level of Chinese breast cancer families and provide new theoretical basis and intervention methods for the psychological care of breast cancer patients.Methods1.Literature analysis: Through systematic literature review and analysis,combined with family resilience-related theories and the research foundation of the research group,a draft family resilience intervention program for breast cancer patients was formed.2.Qualitative interview: Structured interviews were conducted with patients,family members and nursing staff in a breast cancer-related department of a tertiary hospital in Anhui Province,and analyze the specific content of the intervention program from different perspectives.According to the interview results,the draft intervention program was adjusted to form the first version of the intervention program.3.Expert consultation: Seventeen experts in clinical tumor treatment,clinical tumor nursing,nursing,psychology and behavior were invited to conduct two rounds of expert consultations.Further adjustments were made based on expert opinions to form a revised version of the intervention program.4.Pilot study: A total of 60 breast cancer families were selected from a breast cancer-related department of a tertiary hospital in Anhui Province,and randomly divided into an intervention group and a control group.The control group received routine care,and the intervention group received family resilience intervention on the basis of routine care.Before the intervention and 1 week after the intervention,the family resilience,coping style,family disease burden,and social support level of the two groups of participating families were evaluated,and evaluate the intervention group’s satisfaction with the intervention program.According to the problems existing in the intervention process and the intervention effect,the intervention program has been further adjusted,and finally an intervention program for the family resilience of breast cancer patients was formed.Results1.Literature analysis: A total of 8 clinical experimental studies were included,and the research objects were families of patients with various chronic diseases.Most of the research implementers were nursing researchers.Interventions were mostly delivered in the form of multifamily group meetings,with a few studies using one-on-one face-to-face or online meetings.The intervention period was 5 weeks to 6 months,the intervention frequency was 1～2 times a week or once 2～3 weeks,the number of interventions was 3～24times,and the intervention time was 0.5～3 hours.The evaluation time was before the intervention,during the intervention,at the end of the intervention and 6 months after the end of the intervention.Intervention topics included knowledge about illness and patient care,family characteristics of illness,family communication,emotion and stress management,family problems and coping,family strengths and resources,and more.Although some studies have shown improved family resilience among study participants,uncertainty remains about the applicability of these interventions to breast cancer patients due to differences in disease populations,unclear content of interventions,and varying themes.Based on the results of literature analysis,combined with family resilience theories and the research foundation of the research group,a draft intervention program was formed.2.Qualitative interview: One-on-one structured interviews were conducted with 12 clinical nurses from breast cancer-related departments and 28 pairs of breast cancer patients and their families.Put forward opinions and suggestions in terms of intervention form,frequency and time,meeting content and sequence,feasibility of intervention plan,etc.According to the interview results and group discussion,the contents of the intervention plan were adjusted as follows:(1)Intervention format: face-to-face combined with online family conferences.(2)Meeting length: 25～30min,depending on the specific situation.(3)Public account push: Push personalized disease-related knowledge according to the needs of different patients and their families.(4)Answer questions raised by patients and their families in a timely manner.The first version of intervention program was formed.3.Expert consultation: In the two rounds of expert consultation,the positive degree of the experts were 80.95% and 100%,respectively,the authority coefficients were 0.822 and0.840,and the Kendall’s W coefficients were 0.061(P>0.05)and 0.146(P<0.01).The coefficients of variation of scientificity,validity and feasibility of the two rounds of expert consultation were all Cv<0.25.According to expert recommendations,the contents of the intervention program were adjusted as follows:(1)Conference name: Modify the names of the 1st,4th,and 6th meetings.(2)Participant recruitment: patients and their primary caregiver(first-degree relatives).(3)Intervention format: 1st face-to-face meeting,remaining5 online meetings.(4)Project introduction: Invite breast cancer treatment,nursing experts and rehabilitation patients to answer questions for the research subjects.(5)Intervention process: Briefly review the previous meeting before the meeting,and introduce topics in the form of questions or case sharing.(6)Public account push: The push content is combined with the theme of the meeting.(7)Adjust the specific content of each meeting according to expert advice.The revised version of intervention program was formed.4.Pilot study: A total of 60 pairs of breast cancer patients and their families were included in the intervention group and the control group.There was no significant difference in baseline data and scale scores between the two groups of patients and their families(P>0.05),and they were comparable.Differences in outcome indicators between the two groups were analyzed using two independent samples t-tests.Both PP and ITT analyses showed that after the intervention,the family resilience,coping style and social support level of the patients and their families in the intervention group were significantly higher than those in the control group,and the level of family disease burden was significantly lower than that in the control group(P<0.05).The paired t-test was used to compare the differences in outcome indicators before and after the intervention in each group.Both PP and ITT analyses showed that in the intervention group,the family resilience,coping styles and social support levels of patients and their families after the intervention were significantly higher than those before the intervention,and the level of disease family burden was significantly lower than that before the intervention(P<0.05).In the control group,the level of family resilience of the patients after the intervention was slightly higher than that before the intervention(P<0.05),and the level of coping style,disease family burden and social support did not change significantly compared with those before the intervention(P>0.05).The level of family resilience and social support of family members was slightly higher than that before the intervention,the level of disease family burden was slightly lower than that before the intervention(P<0.05),and the coping style did not change significantly compared with that before the intervention(P>0.05).Feasibility results showed that the enrollment rate,acceptance rate,completion rate,satisfaction rate,and compliance rate from high to low of the research subjects were 64.52%,75%,91.67%,100%,90%,3.33%,and 6.67%,respectively,which means the intervention is effective and feasible.The intervention program was adjusted as follows:(1)Intervention Format: Six online family conferences.(2)Intervention content: The content of the meeting is selected according to the actual situation of the intervention family.(3)Homework: Send homework messages to participants with example sentences or instructions.ConclusionBased on the theories of family resilience and the research foundation of the research group,this study forms a draft intervention program through literature analysis.Adjust the intervention program through qualitative interviews and expert consultation,and verify the intervention program through pilot experiments.Finally,a coping-focused family resilience intervention program for breast cancer patients was developed.The construction process of the intervention program is scientific,with good effectiveness and feasibility.It provides a practical path for clinical nurses to guide and help family members of breast cancer patients make reasonable adjustments.更多还原