Development Of Grading Psychological Nursing Care Model For Adult Patients With Selected Cardiac Thoracic Surgery

Objective:To analyze the psychological status and related influencing factors of adult patients with selected cardiac thoracic surgery; To develop the grading psychological nursing care model for adult patients with selected cardiac thoracic patients and test the feasibility and effectiveness of the model; to provide evidence for the widely use of grading psychological nursing care in future.Methods:the study was divided into four phases.PhaseⅠ:to investigate the psychological status and related influencing factors of adult patients with selected cardiac thoracic surgery and provide basis for the development of grading psychological nursing care model.204 qualified adult patients with selected cardiac thoracic surgery were selected. Questionnaires were used to collect data including symptom checklist(SCL-90), Eysenck personality questionnaire(EPQ), simplified coping style questionnaire, Reasons for Negative Mood Questionnaire in Non-psychiatric Settings,Pittsburgh Sleep Quality Index(PSQI), "changhai" pain rating scale, et al.PhaseⅡ:The grading psychological nursing care model for adult patients with selected was developed based on the data collected in phase I, reviews of literature and clinical practice. There are three grades in this model including third grade, second grade and first grade of psychological nursing care. The lower the grade was, the more comprehensive care the patients need. The model was reviewed and revised by experienced clinical nursing experts and psychological professionals.PhaseⅢ:To test the feasibility of the model. Subjects included 204 patients involved in Phase I and 40 experienced clinical nurses.Modified clinical psychology nursing scale-patients (CPNS-P) were used to investigate the patients'needs for psychological nursing care. A questionnaire was developed according to the grading psychological nursing care model to investigate the feasibility among clinical nurses, and a 5-point Likert-type scale was used for each item. If the mean score for each item was=3.5, then the item was assumed to be feasible.PhaseⅣ:To test the effectiveness of the model. Subjects:111 patients,who are from two different wards of the cardiac thoracic department in the second Xiangya Hospital, were enrolled from April to August,2009,59 from one ward as intervention group and 58 from another ward as control group. In the intervention group, there were 20 patients matching the third grade psychological nursing care standard before operation,30 matching the second grade standard, and 9 matching the first grade standard. In control group there were 20 for the third grade standard before operation,30 for the second grade and 8 for the first grade.Methods:regular psychological nursing was provided for the control group, and grading psychological nursing care was provided for the intervention group.The evaluation index included patients' psychological status measured with SCL-90, patients'satisfaction with nursing care measured by the questionnaire of patients'satisfaction with nursing care and biological index such as post-operation pain grade, quality of sleep, diet, complications, post-operative activity, ICU days and hospitalization days.Results:PhaseⅠBefore operation:The mean scores of all the sub-scales of SCL-90 in this study were significantly higher than Chinese norm. There were 37.75% patients whose total scores of SCL-90 was higher than norm, 32.84% patients whose total mean score or at least one sub-scale's mean score was higher than norm; 0.49% patients with their total mean scores higher than 3;0.98% patients whose all the sub-scales'mean scores were higher than 2, nobody without any psychological symptom. The most obvious negative feeling of patients before operation was somatic symptoms.There were 22.55% (46) patients whose diet change scores=6, and 21.08%(43) patients whose PSQI scores=7. The total score of SCL-90 was significantly correlated with the score of PSQI, r=0.36. By using regression analysis, the patients'cognition of disease and their social support system had significant influence on their SCL-90 score, R2=0.332,F=37.599,p=0.000.After operation:There were no significant differences between SCL-90 score in this study and Chinese norm. There were 35.78% patients whose total scores of SCL-90 was higher than norm,30.39% patients whose total mean score or at least one sub-scale's mean score was higher than norm; 0.49% patients whose all the sub-scales'mean scores were higher than 2, nobody without any psychological symptom. There were 26.47%(54) patients whose diet change scores=6, and 40.20%(82) patients whose PSQI scores=7,43.14%(88) patients still suffered from moderate to severe pain 2-3 days after operation. The total score of SCL-90 were significantly correlated with the score of PSQI, diet change and pain, the r value were 0.55,0.25,0.36 respectively. By using regression analysis, the patients'cognition of disease and hospital environment had significant influence on their SCL-90 score, R2=0.233, F=29.713,p=0.006.There was no significant differences in SCL-90 score before and after operation, but the pre-operative score wad slightly higher than that of post-operation. The scores of depression sub-scale and paranoid sub-scale decreased significantly after operation. The PSQI score increased significantly after operation. PhaseⅡBy using nursing process as framework, the standards for three s were set up based on above mentioned evidence, and the corresponding psychological nursing intervention outlines were provided for each grade. The lower the grade was, the more serious the patients'psychological symptoms were and they need more comprehensive interventions.PhaseⅢThe most acceptable measure for psychological assessment was face-to-face interviewing; the next one was psychological tools such as questionnaire.No more than 30 minutes every time was acceptable for assessment. General and individualized psychological nursing were both necessary for the patients, but they need general psychological nursing more.According to the investigation, the clinical nurses thought the model was feasible, the mean score for every item was>3.5.The best time for assessment was the admission day, the day before operation, and 1-2 days after operation. The primary nurse and patients were both responsible for psychological assessment, and the time period was no more than 30 minutes every time. The mean scores for instruments used in this study were>3.5, implying those instruments could be used for assessment. The mean score for the feasibility of every standard varied from 3.79 to 4.03, and 3.65 to 4.13 for every psychological nursing care outlines. PhaseⅣAfter operation, the scores of SCL-90 of subject in the intervention group decreased significantly, especially the mean scores of the following sub-scales:obsessive-compulsive behavior, interpersonal sensitivity, depression, anxiety, hostility, and psychoticism. There were no significant differences in scores of SCL-90 of control group before and after operation, except the sub-scales of somatization(which significantly increased after operation) and psychoticism (which decreased significantly after operation).There were no significant differences in changes of negative feelings between intervention group and control group for those subjects matching pre-operative third grade standard.Results for subjects matching pre-operative second grade standard: The total SCL-90 score decreased significantly after operation in the intervention group, especially the mean scores of the following sub-scales: obsessive-compulsive behavior, interpersonal sensitivity, anxiety, depression, and psychoticism. No significant change appeared in the control group before and after operation,instead the mean score for somatization sub-scale increased significantly after operation. The decreased degree of SCL-90 total score and mean scores of all sub-scales after operation was much higher in the intervention group than that in the control group. After operation, the scores of negative feelings for subjects who were in the intervention group matching second grade psychological care before operation were still much higher than the scores of negative feelings for those who need third grade psychological nursing care before operation, but the formers'decreased degree of negative feelings'scores was significantly higher than that of the latter.Results for subjects matching pre-operative first grade standard:the subjects'negative feelings improved significantly in the intervention group after operation, but no significant change for the control group. There was no significant difference between two groups in changing degree of negative feelings before and after operation. The scores of SCL-90 of both groups were much higher than the Chinese norm regardless of before or after operation. No significant difference existed between two groups in the grade change of psychological nursing care.By using regression analysis, grading psychological nursing care was one of the important factors which influenced the pre-post operative differences of psychological status of subjects who met the second and first grade of psychological nursing care before operation. For subjects who accepted the grading psychological nursing care, their negative feelings improved significantly after operation.Biological index:There were no significant differences in biological indexes between intervention group and control group for subjects who met the third grade and first grade of psychological nursing care before operation. For subjects who met the second grade of psychological care before operation, the score of post-operative pain and the hospitalization days were much lower in the intervention group. By using regression analysis, post-operative pain was significantly influenced by psychological nursing care, pre-operative PSQI score and post-operative PSQI score, R2=0.211,F=4.826,P=0.005.The mean hospitalization days were significantly influenced by ICU days, psychological nursing care, types of disease and education level, R2=0.543,F=19.279,P=0.000.The scores of patients'satisfaction with nursing care were much higher in the intervention group than that in the control group, except the sub-scales of ward environment and aesthetic perception toward nurses. By analyzing the satisfaction data of subjects matching the second and first grade of psychological nursing care, the total satisfaction scores foe intervention group and control group were 9.06±0.98 and 8.57±0.98 respectively, t=2.74,p<0.05.The satisfaction degree of intervention group was much higher that that of control group in sub-scales of patient education(t=-2.47) and humanistic care(t=-2.12), p<0.05.By analyzing the satisfaction data of subjects matching the third grade of psychological nursing care, the total satisfaction scores foe intervention group and control group were 8.50±1.92 and 7.46±1.96 respectively, no significant difference existed between the two groups, but the satisfaction degree with patient education sub-scale in intervention group was much higher than that in control group, t=-2.30,p<0.05.Conclusion:1.Regardless of pre-operation or post-operation, patients with selected cardiac thoracic surgery all suffered from obvious psychological symptoms.But the needs of psychological nursing care were different, showing that it was very necessary implement grading psychological nursing care.2. The study showed patients'psychological status could be influenced by the following factors such as cognition of disease, social support, hospital environment, coping style and personal characteristic. Meanwhile, the patients'psychological status was significantly correlated with their quality of sleep and post-operative pain.3.Under the framework of nursing process, the grading psychological nursing care model was set up based on evidence.4. By successful testing, the model is feasible. According to grading standard, patients with different needs could be graded precisely, and the outlines provided psychological nursing care was effective.