儿童接种工作中采用小丑照护模式的效果分析

中文摘要 目的: 探讨小丑照护对儿童接种焦虑、疼痛、接种依从性及哭闹时间的影响,深入了解儿童照顾者、医务人员及干预实施者对小丑照护的内心体验,为小丑照护的推广应用提供理论依据。 方法: 本研究分为两个部分。 第一部分:通过查阅文献、质性访谈、小组讨论,初
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  中文摘要

  
  目的:

  
  探讨小丑照护对儿童接种焦虑、疼痛、接种依从性及哭闹时间的影响,深入了解儿童照顾者、医务人员及干预实施者对小丑照护的内心体验,为小丑照护的推广应用提供理论依据。
  
  方法:
  
  本研究分为两个部分。

  
  第一部分:通过查阅文献、质性访谈、小组讨论,初步制定适合接种儿童的小丑照护方案,对形成的初步方案进行专家咨询和预实验,根据专家的意见及预试验中发现的问题对方案进一步完善,形成小丑照护方案终稿。方便抽样选取2019年3月至2019年10月在某三甲医院预防保健科进行预防接种的儿童作为研究对象,按照接种先后顺序,选取前四个月来接种的儿童作为对照组,后四个月来接种的儿童作为干预组,对照组给予常规接种措施,干预组在常规接种措施的基础上实施小丑照护方案,包含干预环节、干预地点、干预措施和干预形式,每名接种儿童干预时长约为 30min。比较两组儿童接种焦虑、疼痛程度、接种依从性、哭闹时间、照顾者焦虑程度和对接种护理工作的满意度。采用SPSS 21.0统计分析软件分析数据,统计方法包括两独立样本t检验、Mann-Whitney U检验、χ2检验。以P<0.05为差异有统计学意义。



儿童接种工作中采用小丑照护模式的效果分析

  
  第二部分:目的抽样选取接受过小丑照护干预的接种儿童的照顾者、目睹小丑照护实施的医务人员和干预实施者进行半结构访谈,将获得资料采用Colaizzi七步分析法分析整理,提炼主题。
  
  结果:
  
  第一部分:
  
  1.一般资料比较:两组接种儿童在性别、年龄、注射方式、疫苗种类方面差异均无统计学意义(均P>0.05),具有基线可比性。两组儿童照顾者在年龄、文化程度、与儿童的关系方面差异均无统计学意义(均P>0.05),具有基线可比性。
  
  2.儿童焦虑程度比较:干预前两组儿童VAS-A得分(照顾者报告)差异没有统计学意义(P>0.05),具有可比性;注射前干预组VAS-A得分(照顾者报告)低于对照组,差异有统计学意义(P<0.05)。
  
  3.儿童疼痛程度比较:(1)行为学评估:干预前两组儿童MBPS评分差异没有统计学意义(P>0.05),具有可比性;注射时干预组MBPS评分低于对照组,差异有统计学意义(P<0.05)。(2)自我报告:注射时干预组Wong-Baker得分低于对照组,差异有统计学意义(P<0.05)。
  
  4.儿童接种依从性比较:干预组儿童接种依从性高于对照组,差异有统计学意义(P<0.05)。
  
  5.儿童哭闹时间比较:干预组儿童整个接种过程哭闹时间短于对照组,差异有统计学意义(P<0.05)。
  
  6.照顾者焦虑程度比较:干预前两组儿童照顾者S-AI评分差异没有统计学意义(P>0.05),具有可比性;干预后干预组照顾者S-AI评分低于对照组,但差异没有统计学意义(P>0.05)7.
  
  照顾者对接种护理工作的满意度比较:干预组照顾者对接种护理工作的满意度评分高于对照组,差异有统计学意义(P<0.05)。
  
  第二部分:
  
  对访谈资料进行整理分析,最终萃取出2个主题和11个亚主题。
  
  1.小丑照护在预防接种过程中对不同人群的正性影响:对接种儿童(1)抚慰心灵;(2)分散注意力;对儿童照顾者(1)缓解身心压力;(2)促进亲子关系;对医务人员(1)改善工作氛围;(2)和谐医患关系;对干预实施者(1)培养护理职业价值观;(2)提升人文关怀素养。
  
  2.实施小丑照护过程中的不足:(1)防控医院感染意识不足;(2)即兴创作能力有待提高;(3)安全意识有待增强。
  
  结论:
  
  1.小丑照护可有效缓解儿童注射前的焦虑情绪,减轻接种疼痛,提高儿童接种依从性,缩短哭闹时间,同时能提高照顾者对接种护理工作的满意度,值得在临床推广应用。
  
  2.小丑照护可优化儿童及照顾者的接种体验,增强护生人文关怀能力,改善医患关系,值得在医院及社区推广应用,但仍存在干预实施者防控医院感染理念不足、即兴表演能力有待提高、安全意识有待增强问题。未来需要加大培训力度,努力提高干预实施者专业知识及实践技巧,增强小丑照护的干预效果。
  
  关键词: 小丑照护;儿童;预防接种;焦虑;疼痛;体验。
  

  Abstract

  
  Objective:

  
  To explore the influence of clown care on children's vaccination anxiety, pain,vaccination compliance and crying time, and to further understand the inner experience ofchildren's caregivers, medical staff and intervention practitioners on clown care, so as to rovide theoretical basis for the promotion and application of clown care.
  
  Methods:
  
  This study is divided into two parts.
  
  The first part: Through literature review, qualitative interview and group discussion,the clown care plan suitable for children inoculation was initially developed, and thepreliminary plan was developed through expert consultation and preliminary experiment.
  
  The final draft of clown care plan was further improved according to the expert's opinions and the problems found in the preliminary experiment. The children who were vaccinatedin the preventive health care department of a third class hospital from March 2019 to October 2019 were selected as the research objects by convenient sampling. According tothe sequence of vaccination, the children who were vaccinated in the first four months were selected as the control group, and the children who were vaccinated in the last fourmonths were selected as the intervention group. The control group was given routine vaccination measures, and the intervention group was given clown care program on thebasis of routine vaccination measures, including intervention links, intervention sites,intervention measures and intervention forms. The intervention time of each vaccinatedchild was about 30 minutes. The anxiety, pain degree, vaccination compliance, crying time,caregivers' anxiety degree and satisfaction of vaccination nursing were compared between the two groups. SPSS 21.0 software was used to analyze the data. The statistical methods included Mann Whitney U test, χ2 test and two independent samples t test. P < 0.05 wasconsidered statistically significant. The second part: Objective to select the caregivers of vaccinated children who have received clown care, the medical staff who have witnessed the implementation of clown care and the intervention implementers for semi-structured interviews. The data obtained were analyzed and sorted out by Colaizzi seven step analysis method, and the theme was extracted.
  
  Results:
  
  The first part:

  
  1. Comparison of general data: There was no significant difference in gender, age,injection method and vaccine type between the two groups (all P > 0.05), with baseline comparability. There was no significant difference in age, education level and relationship between caregivers and children between the two groups of caregives (P > 0.05).
  
  2. Comparison of children's anxiety degree: Before the intervention, there was no significant difference between the two groups in VAS-A score (reported by caregivers) (P > 0.05), which was comparable; The VAS-A score (reported by caregivers) of the intervention group before injection was lower than that of the control group, and the difference was statistically significant (P < 0.05).
  
  3. Comparison of children's pain degree: (1) Behavioral evaluation: there was no significant difference in MBPS scores between the two groups before the intervention (P >0.05), which was comparable; MBPS scores of the intervention group at the time of injection were lower than those of the control group, which was statistically significant (P < 0.05). (2) Self report: the Wong Baker score of the intervention group was lower than that of the control group at the time of injection, the difference was statistically significant (P < 0.05).
  
  4. Comparison of children's vaccination compliance: The compliance of children in the intervention group was significantly higher than that in the control group (P < 0.05).
  
  5. Comparison of crying time of children: The crying time of intervention group was shorter than that of control group (P < 0.05).
  
  6. Comparison of caregivers' anxiety: There was no statistical significance (P > 0.05) in caregivers' S-AI score of the two groups before intervention, which was comparable;After intervention, S-AI score of caregivers in the intervention group was lower than that in the control group, but the difference was not statistically significant (P > 0.05).
  
  7. Comparison of caregivers' satisfaction with vaccination nursing work: the satisfaction score of caregivers in the intervention group was higher than that in the control group, the difference was statistically significant (P < 0.05).
  
  The second part:
  
  After collating and analyzing the interview data, 2 themes and 11 sub-themes were extracted.
  
  1. Positive effects of clown care on different populations in the process of vaccination: For vaccinated children(1) Soothe the mind; (2) Distract the mind; For parents of children(1) Relieve physical and mental pressure; (2) Promote parent-child relationship;For medical staff(1) I mprove working atmosphere; (2) Make the doctor-patient relationship harmonious; For clown doctors(1) Cultivate nursing professional values; (2) Improve humanistic care quality.
  
  2. The deficiencies in the process of clown care are as follows: (1) Lack of awareness of prevention and control of hospital infection; (2) Improvisation ability needs to be improved; (3) Safety awareness needs to be enhanced.
  
  Conclusion:
  
  1. Clown care can effectively relieve children's anxiety before injection, relieve the pain of vaccination, improve the compliance of children's vaccination, shorten the crying time, and improve the satisfaction of caregivers with vaccination care, which is worthy of clinical application.
  
  2. Clown care can optimize the inoculation experience of children and caregivers,enhance the humanistic care ability of nursing students and improve the relationship between doctors and patients, which is worth promoting and applying in hospitals and communities. However, there are still some problems such as insufficient concept of prevention and control of hospital infection, improvisational performance ability and safety awareness. In the future, we need to strengthen the training, improve the professionals' knowledge and practical skills of the intervention practitioners to enhance the intervention effect of clown care.
  
  Key words :
Clown care; Children; Vaccination; Anxiety; Pain; Experience。
  

  引 言
  

  1.1、研究背景。
  
  1.1.1、儿童预防接种的必要性。

  
  预防接种是法律赋予每个儿童的权利,是保障儿童身体健康的重要手段,在控制传染病的发生和流行中发挥着不可替代的作用。
  
  2005年我国颁布的《疫苗流通和接种管理条例》中,将入学入托检查接种证上升到法律层次。《“健康中国2030”规划纲要》中明确提出:“5岁以下儿童死亡率要由2015年的10.7‰下降到2020年的9.5‰,再到2030年的6.0‰。”要实现这一目标,减少感染性疾病对儿童的威胁是至关重要的一步,而接种疫苗是预防、控制甚至消灭感染性疾病最经济、安全、有效的手段[1]。由此可见,接种疫苗对儿童意义重大。
  
  1.1.2、预防接种产生的不良影响。
  
  接种疫苗的方式多为针剂注射,儿童常把与针刺有关的操作描述为诊疗活动中最痛苦的回忆[2]。作为一种侵入性操作,在预防疾病的同时,给儿童造成了一定的疼痛刺激[3]。疼痛涵盖了生理、心理、情绪、认知及行为等各方面,是一种复杂多样的主观感觉[4]。有研究表明,由于儿童认知能力有限,缺乏自控力,依赖父母,惧怕疼痛等特点,使得接受医疗操作的儿童比其他人群更易受到医源性焦虑、疼痛和压力等影响[5]。
  
  预防接种的主体是 7 岁以下的儿童,接种的阶段性、反复性特点使得该人群在生长发育期间反复经历疼痛刺激,极易造成儿童出现抵触、紧张、恐惧等心理变化,这些心理变化不仅可以引起生理反应、神经内分泌及代谢反应,还可以对儿童的认为行为产生影响,导致其认知改变、做出躲避与反抗行为等[6]。由于害怕疼痛刺激,儿童在接种疫苗过程中往往表现为焦虑、恐惧等负性情绪,加之儿童心理活动的不稳定性,等待注射的儿童在听到其他儿童的哭声时也会引起恐惧和不安[7]。研究表明,人的情绪与疼痛紧密相关,消极的情绪使儿童痛阈降低,对疼痛刺激的敏感性增高[8],从而形成疼痛-焦虑-疼痛的恶性循环;负性情绪还会抑制机体器官功能活动及免疫机制,使其免疫功能下降[9]。其次,疼痛刺激使儿童行为发生变化,出现大声哭闹、抗拒等现象,使接种部位偏离,造成组织损伤、针眼出血多甚至断针等不良后果[10]。儿童时期的就医恐惧、疼痛经历与其成人期对痛觉过敏、回避医疗行为等现象显着相关[11]。
  
  此外,接种时儿童的恐惧、焦虑等情绪反应会不可避免地转移到父母身上,这在一定程度上引发父母的情绪紊乱,进而导致延迟或拒绝带孩子进行预防接种的情况[12]。相关研究表明,24%~40%的父母因接种带给儿童的疼痛而感到担心与不安,85%的父母认为卫生保健人员在减轻儿童疫苗接种疼痛中起着重要作用,95%的父母希望了解采取何种方式能减轻儿童接种时产生的疼痛。因此,减轻儿童接种注射时的操作性疼痛,缓解其对接种的恐惧、焦虑等不良情绪,使接种顺利进行,对保障儿童的身心健康具有重要意义。
  
  《WHO关于减轻疫苗接种疼痛的意见书》中强调了发挥非药物干预措施在减轻儿童接种疼痛中的作用,对于<6岁的儿童,建议通过玩具、视频、音乐或与成年人对话等非药物干预方法将其注意力从疼痛转移到较愉快的事情上[13]。
  
  1.1.3、小丑照护逐渐受到关注。
  
  小丑照护(Clown Care),也被称为小丑疗法(Clown Therapy),是近年来发展起来的一种跨学科的治疗方法,Dionigi A将其定义为将马戏团的小丑技术应用到疾病环境中,改善人们的情绪和心理状态[14]。通常运用幽默、时事讽刺、想象、游戏、角色扮演及其他技巧来帮助病患[15]。这种方法的目的是在医疗过程中分散患者的注意力,诱导积极情绪,减少消极情绪,以及帮助克服住院治疗为患者及其家人带来的困难,从而促进康复[16]。实施小丑照护的人员被称为小丑医生(Clown Doctor)、医疗小丑(Medical Clown)、小丑护士(Clown Nurse)、健康照护小丑(Health Care Clowning)[17]。作为一种非药物干预手段,小丑照护对患者的正性作用逐渐受到学者的重视和关注,已被多个国家的医疗保健机构推广应用。
  
  小丑照护起源于美国,早在希波克拉底时代就有小丑在医院工作,那个时代的医生认为好心情对疾病治疗有积极作用。被称为“医疗小丑之父”的美国传奇医生帕奇·亚当斯经常装扮成小丑在医院儿科病房逗乐患儿,缓解其对医院环境及对医疗操作的恐惧,使患儿心情愉悦。直到1986年加拿大儿童生活专家Karen Ridd于在温尼伯医院建立了国内第一个医疗小丑项目,与此同时,纽约马场大苹果马戏团的着名小丑Christensen创立了大苹果马戏团小丑护理中心,标志着小丑医生成为医疗团队的一部分,正式开始在医疗机构实施小丑照护干预[16]。此后,小丑医生的数量不断增加,法国、德国、英国、意大利、以色列等多个国家纷纷将小丑医生引进医院,尤其在儿科病房中,但不限于儿童,被证明能有效缓解患儿由于医疗操作产生的焦虑、恐惧等负性情绪[18]、减轻疼痛感[19]、减少哭闹[20]、提高治疗的依从性[21],同时能缓解患儿父母的压力和不良情绪[22]。
  
  儿科病房中的小丑医生通常运用彩虹帽子、红鼻子、彩色服装、面部绘画等元素扮成滑稽的小丑,以幽默为基础,通过多种形式(如游戏、音乐、舞蹈、魔术、角色扮演、插科打诨、虚拟现实技术、意象、情景模拟、模仿医疗程序、恶作剧、肥皂泡、讲故事、即兴创作等技巧)分散患儿的注意力,引患儿大笑,改善其负性情绪。对于小丑医生来说,除了在参加培训时学习到的小丑技巧外,其最重要的技能是即兴表演,能根据患儿的年龄、性格、气质、身体状况、认知发展、兴趣爱好、情绪状态等灵活运用周围环境中一切可以运用的事物进行表演。目前在临床中,小丑医生主要有两种工作模式:单人工作和成对工作,但以成对工作居多,即两名小丑医生与一名患儿及其照顾者互动提供照护服务[23]。
  

  【由于本篇文章为硕士论文,如需全文请点击底部下载全文链接】

  
  1.2、国内外研究现状
  1.3 、研究目的及意义
  1.4 、本研究的创新之处.
  1.5 、相关概念
  1.6、研究方法
  1.7、 技术路线图.

  第一部 分小丑照护对儿童接种焦虑、疼痛的影响.

  1、对象与方法.
  1.1、 研究类型.
  1.2、 研究对象
  1.3、 研究方法.
  1.4 、研究工具
  1.5 、伦理原则
  1.6 、资料收集方法.
  1.7 、质量控制.
  1.8 、统计学方法
  2、结果
  2.1、两组研究对象脱落情况
  2.2 、研究对象- 般人口学资料比较.
  2.3、两组儿童接种焦虑程度比较
  2.4、两组儿童接种疼痛程度比较.
  2.5、两组儿童接 种依从性比较.
  2.6、两组儿童哭闹时间比较
  2.7、两组儿童照顾者焦虑程度比较
  2.8、两组儿童照顾 者对接种护理工作满意度比较
  3、讨论
  3.1、小丑照护对儿童接种焦虑的影响
  3.2、小丑照护对儿童接种疼痛的影响
  3.3、小丑照护对儿童接种依从性、哭闹时间的影响
  3.4、小丑照护对儿童照顾者焦虑情绪的影响.
  3.5、小丑照护对儿童照顾者接种体验满意度的影响

  第二部 分儿童照顾者、 医务人员及干预实施者对小丑照护体验的质性研究

  1、对象与方法
  1.1 、研究类型
  1.2 、研究对象
  1.3 、研究方法
  1.4、 资料收集
  1.5、 资料分析.
  1.6 、质量控制.
  2、结果
  2.1、小丑照护在预防接种过程中对不同人群的正性影响
  2.2、实 施小丑照护过程中的不足.
  3、讨论
  3.1、小 丑照护可优化儿童及照顾者接种体验,值得在医院及社区推广应用.
  3.2、小 丑照护可增强护生人文关怀能力,改善医患关系
  3.3、完善培训,有利于提高小丑照护的干预效果

  第三部分 结 论

  (1)小丑照护可有效缓解儿童疫苗注射前的焦虑情绪,减轻接种疼痛,提高接种依从性,缩短哭闹时间,提高照顾者对接种护理工作的满意度,可为医院提供一种有效的非药物干预手段。

  (2)小丑照护可改善儿童及照顾者的接种体验,增强护生人文关怀能力,改善医患关系,值得在医院及社区推广应用,但仍存在干预实施者防控医院感染理念不足、即兴表演能力有待提高、安全意识有待增强问题,未来需要加大干预实施者培训力度,努力提高干预实施者专业知识及实践技巧,增强干预实施者的服务能力。

  参考文献

  原文出处:小丑照护在儿童预防接种中的应用研究[D]. 李军莉.山西医科大学 2020 点击下载全文 转载请注明来源。原文地址:http://www.lw54.com/html/zhlw/20200906/8365109.html   

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