| Clinical practice is one of the important part of nursing education, which combines theoretical knowledge and clinical experience, and facilitates nursing students to develop into the professional nurse role. However, the clinical setting is complex and nursing presents challenges. For nursing students, clinical practice undoubtedly is a large stressor. There are a variety of factors contributing to stress in nursing students in the clinical learning environment, such as theory gap, performing clinical skills, clinical experience, interpersonal skills, psychological immaturity, and so on. All students more or less encounter adaptation problems in clinical settings. Clinical practice maladjustment means that nursing students lack of ability to actively and passively change their cognitive structure, or behavior patterns to maintaining the harmony between themselves and the clinical environment, so exhibiting a series of maladaptive phenomenon in clinical practice. Nursing students clinical practice maladjustment not only reduces students’ practice efficiency, but also induces some mental disorders, even affects physiological function and future career. The literature reveals many studies about nursing students in clinical practice dating back to the early1970s, especially investigating nursing students’ stress an anxiety. But few researches mentioned nursing students’ maladjustment in clinical practice, which may be related to the lack of specific, objective and effective research tools, As for the content of maladjustment in clinical practice, risk factors affecting students adaptability, adverse effects on students’ physiological and psychological health and interventional strategies, all these need to in-depth study. Part1The development of nursing students clinical practice maladjustment scale and applicationObjectives: To develop a valid and reliable scale to assess nursing students’ maladjustment in clinical practice, and to observe the application of the scale.Methods:In light of the literature and interview, it was determined that clinical practice maladjustment included four fields, and accordingly50items were written. These items were discussed by experts, nurse and examined by students in clinical practice.300random samples engaged in primary testing. The Critical Ratio, Pearson Correlation and Exploratory Factor Analysis (EFA) were used to delete the items. The28items formal scale was set up, and further the scale reliability and validity were tested. Then another469random samples attended test, followed by Confirmatory Factor Analysis (CFA) for evaluating the model structure of the scale. Finally,200samples randomly were selected, and nursing students clinical practice maladjustment scale was administered. The correlation between nursing students clinical practice maladjustment and State-Trait Anxiety Inventory, General Self Efficiency Scale, Social Support Rating Scale and Pittsburgh Sleep Quality Index were analyzed.Result:①The scale self-developed included28items with four dimensionalities (interpersonal, behavior, recognition, emotion), which could explained51.218%of the total variance. Factor loadings of items were above0.50. The general Cronbach’s Alpha reliability and test-retest reliability were0.921,0.885, and the four subscale were0.743-0.877,0.716-0.890. The CFA indicated that the ratio of chi-square to degree of freedom was0.329, the norm fit index was0.902, the Tucker-Lewis index was0.916, the comparative fit index was0.924, and the root mean square error approximation was0.066. Criterion-related validity studies showed that the score of the scale self-developed was significantly correlated with General Maladjustment Scale (GM).(r=-0.555, p<0.01).②Using the scale self-developed, the samples’ average score was94.82±15.30. Nursing students clinical practice maladjustment as dependent variables, and SAI, TAI as independent variables, the linear regression equation respectively were:y=142.71-0.65X (P<0.01), y=134.96-0.54X(P<0.01). The levels of Nursing students clinical practice maladjustment were related directly to GSES(r=0.247, P<0.05), and SSRS(r=0.328, P< 0.01), and inversely to PSQI(r=0.360,P<0.01).Conclusion: This scale is entirely in accordance with the psychometric demands, which can be used as a tool to evaluate nursing students clinical practice maladjustment. Nursing students clinical practice maladjustment is related closely to students’ anxiety in clinical settings, and also related to students’ self-efficiency, social support, as well as objective sleep quality. Part2Nursing students clinical practice maladjustment and relevant factorsObjectives:To assess the level of clinical practice maladjustment in a sample of vocational nursing students, and some associated risk factors.Methods:Questionnaires including nursing students clinical practice maladjustment scale, STAI, GSES, GM, PSQI, and additional questions regarding general demographic, attitude for the clinical practice, and common causes of clinical practice maladjustment, were sent to200students practicing in four hospitals of SuZhou, who had finished STAI in school. The spss13.0was used to analyze data, with involved t-tests, chi-square test, one-way ANOVA analysis, Student-Newman-Keuls test, and multiple stepwise regression analysis.Results:①Of the200students,184students’questionnaires were valid, who were grouped into the normal group (94,51.1%), the mild maladjustment group (64,34.8%), the severe maladjustment group (26,14.1%), according to the scores of nursing students clinical practice maladjustment scale. There were significant differences between the groups for the scores of nursing students clinical practice maladjustment scale (F=258.08, P<0.001) and four factors of the scale, in which interpersonal (F=101.65, P<0.001), behavior (F=119.42, P<0.001), recognition (F=94.68, P<0.001), emotion(F=97.22, P<0.001).②In relevant factors, coming from rural areas (X2=9.17, P<0.01), high parents’ expectations (X2=8.68, P<0.05), disliking the nursing work (X2=7.46, P<0.05), being pessimistic for prospects (X2=21.03, P<0.001) were significant factors.③The scores of STAI in three groups were higher in clinical practice than in school. In the normal group, SAI scores significantly increased (t=2.34,P<0.05), but TAI did not show significant difference (t=1.72,P>0.05). In the mild maladjustment group, SAI scores (t=3.99,P<0.001), TAI scores(t=2.58,P<0.05)significantly increased. In the severe maladjustment group, SAI scores(t=8.41,P<0.001), TAI scores(t=6.71,P<0.001) highly significantly increased.④The variance analysis of the scores of GSES (F=5.61, P<0.005), SSRS (F=9.01, P<0.001), GM(F=39.55, P<0.001), PSQI (F=12.78, P<0.001) in the students of three groups were significantly different.⑤Multivariate analysis of regression showed: y (clinical practice maladjustment)=102.64-0.504X1(attitude for prospects)-0.24X2(coming from areas)(F=54.45, P<0.001); y (clinical practice maladjustment)=143.36-0.667X1(SAI)(F=139.34, P<0.001).⑥In the common items causing maladjustment in clinical settings, the weighted scores of the top five items were: fear of making mistakes(44.64), the mentors’apathy(19.88), being treated unfairly and not respected(19.48), theory gap(18.38), unfamiliar clinical environment(18.16).Conclusion: Nursing students clinical practice maladjustment is related to many risk factors, such as coming from rural areas, high parents’ expectations, disliking the nursing work, being pessimistic for prospects, high level of anxiety, low self-efficiency, low social support, high general maladjustment, poor sleep quality, in which students’ state anxiety in clinical settings is one of the important predictors. In the clinical environment, fear of making mistakes, the mentors’ apathy, being treated unfairly and not respected, theory gap, and unfamiliar clinical environment were viewed as the most maladjustment-producing situations. Effective interventional strategies should be derived from careful analysis of the influencing factors. Part3The effects of nursing students clinical practice maladjustment on immune-endocrine functionObjectives: To explore the effects of nursing students’maladjustment in clinical settings on immune-endocrine variables.Methods:Previous184nursing students were recruited. The immune profile including the percentage of CD3+T lymphocyte and subsets (CD4+、CD8+、 CD4/CD8)、 CD19+(B cell、 CD16+or56+(NK cell)、 RBCCD35were assayed by the flow cytometry, and serum cortisol levels were measured by Chemiluminescence Immunoassay (CLIA). The spss13.0was used to analyze data, with involved analysis of variance, F-test, Student-Newman-Keuls test.Results:①Compared with in the normal group, the percentages of CD3+(F=5.34, P<0.01), CD4+(F=3.9,P<0.05) in the mild and severe maladjustment groups significantly reduced. Although it was not statistically significant, a increased tendency in CD8+(F=0.85,P>0.05), CD19+(F=1.75,P>0.05) and a decreased tendency in CD4+/CD8+(F=2.83,P>0.05), D16+or56+(F=2.57,P>0.05)were shown.②The percentages of RBCCD35+between the groups did not show significant differences(F=1.734,P>0.05), but compared with the normal group, the mild maladjustment group showed a increased tendency, and the severe maladjustment group showed a decreased tendency.③With the rise of the levels of maladjustment, serum cortisol levels showed a increased tendency(F=0.881,P>0.05), but it was not statistically significant.Conclusions:During clinical practice nursing students maladjustment reduced T lymphocyte function, but the effects on B cell, NK cell and RBC were little. The increase of serum cortisol in clinical practice maladjustment is not obvious as good as in the acute stress. Maladjustment in clinical practice is a serious threat to nursing students’ health, which is worthy of attention. Part4Nursing students clinical practice maladjustment and the regulatory function of autonomic nervousObjectives: To investigate changes of nursing students’autonomic nervous function, when clinical practice maladjustment occurring.Methods:Of184previous subjects,140nursing students voluntarily participated in this study. Indexes of Heart Rate Variability (HRV), including the normalization of low frequency(LF) and high frequency(HF) powers, and LF/HF ratios, were calculated by analyzing short-term ECG segments in the frequency domains. The spss13.0was used to analyze data, with involved analysis of variance, F-test, Student-Newman-Keuls test.Results:Between the groups, LFnorm(F=7.23,P<0.005), HFnorm(F=21.26,P<0.001) and LF/HF ratios(F=19.29,P<0.001) showed significantly differences. Compared with in the normal group, LFnorm, LF/HF ratios in the maladjustment groups significantly increased, and HFnorm significantly decreased.Conclusion:Indexes of HRV reflects regulatory function of the autonomic nervous. Clinical practice maladjustment results in students’ sympathetic tone increasing, vagal tone decreasing, and autonomic nervous function imbalance. Improving regulatory function of autonomic nervous may be increasing students’ adaptability in clinical settings. Part5The effects of clinical peer mentoring combined with breathing training on nursing students clinical practice maladjustmentObjectives:To determined the effectiveness of clinical peer mentoring combined with abdominal breathing training in improving nursing students’maladjustment in clinical settings.Methods:In the previous severe maladjustment group,17students voluntarily were allocated in the intervention group, and other5students were in the control group. Clinical peer mentoring and abdominal breathing exercises were implemented for10weeks in the intervention group, but not in the control group. Peer mentoring was referred to appointing new nurses to help students one to one early in practice. Abdominal breathing was practiced10-15min everyday. The outcome measures were nursing students clinical practice maladjustment scale, STAI, GSES, and indexes of HRV in frequency domain.Results:①After intervention, there was a significantly greater improvement of clinical practice maladjustment(t=7.34,P<0.001), state(t=8.77,P<0.001) and trait(t=3.96,P<0.005) anxiety in the intervention group, but not in the control group. Self-efficiency did not show significant changes in both groups.②The control group did not re-test HRV. In the intervention group, HFnorm(t=2.63,P<0.05) significantly increased, LF/HF ratios(t=2.37,P<0.05) significantly decreased post-intervention, but LFnorm only showed a decreased tendency.Conclusions: The intervention of clinical peer mentoring combined with abdominal breathing training not only effectively restores students’ autonomic nervous regulation, but also reduces students’ maladjustment and anxiety in clinical practice, which provides new tools for nursing educators to improve students’ learning efficiency in the clinical environment. |
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