Effectiveness of Nurse-led Person-centered Behavioral Risk Modification on Secondary Prevention of Coronary Heart Disease

研究背景：冠狀動脈性心臟病（簡稱冠心病）是一種常見的疾病。它佔發展中國家及發達國家的發病率和死亡率一個重要因素。冠心病，不但為醫療體系帶來了沉重的負擔，亦影響了個人生理、心理及社會適應的健康狀況。雖然，有大量文獻證明冠心病二級預防措施能有效地去改善患者的行為風險因素、心臟生理指數及心理健康，但卻忽略了個人化的保健需求和能力去改善這些行為風險因素。本研究共分兩個階段，當中包括系統化綜述及試驗性研究。此二法皆用來探索以人為本的護理干預對冠心病二級預防所帶來的影響。系統化綜述：為全面探討由護士主導以人為本的護理干預對冠心病二級預防所帶來的影響，系統化綜述共挑選出十三篇隨機對照試驗文獻作出整合分析。從該結論得出，由護士主導以人為本的護理干預對戒菸(相對風險：1.36；95％信賴區間：1.14-1.63；p值：0.0008)、吸煙率(勝算比：0.60；95％信賴區間：0.40-0.89；p值：0.01)和遵從運動的建議(勝算比：1.96；95％信賴區間：1.35-2.85；p值：0.0004)均有所改善。此外，結合以人為本的護理干預及優化治療方案，亦有助於改善患者的總膽固醇含量和血壓水平。不過，以人為本的護理干預對於患者的運動時間和頻率、飲食攝取量、低密度脂蛋白水平及健康相關生活質量的成效卻未能達至一致性的結論。再者，現時所囊括的文獻當中，並未包括檢視患者的自我效能和血糖水平。試驗性研究目的：本試驗性研究，旨在探索以人為本的護理干預在本地臨床上的可行性及初步評估相關的干預對於患者的行為風險因素、健康相關生活質量和自我效能的影響。試驗性研究方法：本試驗性研究採用了隨機對照試驗方式，從急症臨床環境中，邀請了三十名符合資格的冠心病患者參加，並以區段隨機分派的方式分配到干預組或對照組中。期間，干預組會接受以人為本的護理干預及恆常治療，而對照組則只會接受恆常治療。在以人為本的護理干預措施當中，包括了以下四個階段：1)收集訊息並瞭解患者；2）制定和施行個人化的護理計劃；3）提供資訊及情緒支援；4）檢討結果。所有研究指標數據都會在干預前(基線資料，T0)和初始評估後的十二至十三週(T1)被採集。本研究採用了廣義估計方程模型來調整潛在的混淆變項和比較檢驗組之間的行為風險因素、健康相關生活質量和自我效能的跨時差異。此外，本研究亦就由護士主導以人為本的護理干預作出可行性的評估，其中包括該項護理干預的安全程度和參加者的滿意度。研究主要結果：參加者的平均年齡為65.2±8.7歲，當中大部分是男性。在比較干預組和對照組兩者之間的基本屬性，兩組在社會人口狀況和臨床數據上並沒有統計學上的差異(p>0.05)。雖然，兩組在行為風險因素、健康相關生活質量和自我效能並沒有顯著的差異。但干預組仍傾向於改善參加者的總活動量、體重指標及數項遵從食物份量的建議。不過，本研究亦發現兩組在健康相關生活質量和自我效能都在 T0 到 T1 這兩個階段有所下降。從該項護理干預的可行性而言，本護理干預仍是一個安全和廣為參加者接受的冠心病二級預防措施。研究結論：這項試驗性研究，突顯了以人為本的護理干預對冠心病二級預防的成效。因為個人經歷、替代經驗、鼓勵及情緒反應都會影響患者對改善行為風險因素的觀感和行為。故此，這項試驗性研究將會為日後發展及推動本地由護士主導以人為本的冠心病二級預防措施提供了重要的訊息。此外，該項護理干預亦對於臨床實務上及發展冠心病二級預防策略起著重要的作用。Background: Coronary heart disease is a globally prevalent disease. The disease has put considerable pressure to the healthcare system, and hampered individuals’ physio-psycho-social well-being. Although mounting evidence suggested secondary preventive measures are effective in improving the patients’ behavioral risks, cardiac physiological parameters and psychosocial wellbeing, limited attention was focused on individuals’ healthcare needs and capabilities in modifying the behavioral risks. This study consists of two phases, which include a systematic review and a pilot study in examining the feasibilities and effects of a nurse-led person-centered care intervention on secondary prevention of coronary heart disease in a local clinical setting.Systematic review: A systematic review was conducted to comprehensively examine the effectiveness of nurse-led person-centered care interventions on secondary prevention of coronary heart disease. A total of 13 randomized controlled trials were included in this review. Meta-analyses of included studies showed that nurse-led person-centered care interventions were effective in improving individuals’ behavioral outcomes on smoking cessation (RR: 1.36; 95% CI: 1.14 to 1.63; p=0.0008), smoking prevalence (OR: 0.60; 95% CI: 0.40 to 0.89; p=0.01), and adherence towards physical activities advice (OR: 1.96; 95% CI: 1.35 to 2.85; p=0.0004). Also, person-centered care interventions with medical regime optimization were shown to be more favorable in improving the individuals’ total cholesterol and blood pressure level. However, mixed intervention effects on exercise duration and frequency, dietary intake, low-density lipoprotein level, and health-related quality of life were observed from individual study results. None of the included studies measured the intervention effects on patients’ self-efficacy level and blood sugar level.Aims of pilot study: A pilot study was conducted to assess the feasibility and logistics of a newly designed person-centered care intervention in a local clinical setting. The study was also aimed to preliminary estimate the intervention effects on patients’ behavioral risks, health-related quality of life and self-efficacy level to gather information for planning a future full-scale study.Pilot research plan: This pilot study adopted a randomized controlled trial as the study design. A total of 30 eligible subjects were recruited from an acute clinical setting and were randomly assigned into intervention and control groups by using computer-based permuted block randomization. The intervention group received a program of person-centered care intervention with usual care, whereas the control group received usual care only. The program of person-centered care interventions included four main sessions: 1) Collecting information and understanding of a person; 2) developing and implementing an individualized healthcare plan; 3) providing informational and emotional support; and 4) performing outcome evaluation. Data were collected at baseline (T0), and at 12 to 13 weeks after the initial assessment (T1). Generalized estimating equations model was used to compare the outcome variables of behavioral risks, health-related quality of life, and self-efficacy level between the study groups across time with adjustment for potential confounding factors. The feasibility of the program was assessed in terms of participants’ completion rate, satisfaction and safety in regard of the intervention.Key findings of the pilot study: The mean age of the subjects was 65.2 ± 8.7 years old and majority of them were males. The homogeneity of the intervention and control groups has been examined, and showed no incomparable difference on sociodemographic and clinical data between the two groups (all p>0.05). Although no statistically significant difference was found on all behavior risks, health-related quality of life and self-efficacy level between the intervention and control groups across the study time points, the intervention group was generally found to have better improvement on total volume of physical activity, weight control and several food categories on dietary compliance. However, both study groups showed a decrease in health-related quality of life and self-efficacy levels from T0 to T1. In examine the feasibility of the program, person-centered care intervention was considered as a safe and well-accepted intervention for secondary prevention of coronary heart disease.Conclusion: This study highlighted the important roles of nursing and person-centered care interventions on secondary prevention of coronary heart disease. Individuals’ perceptions regarding on behavioral risk modification were influenced by various fChiang, Chung Yan.Thesis D.Nurs. Chinese University of Hong Kong 2016.Includes bibliographical references (leaves ).Abstracts also in Chinese.Title from PDF title page (viewed on …).Detailed summary in vernacular field only.Detailed summary in vernacular field only.Detailed summary in vernacular field only.Detailed summary in vernacular field only.Detailed summary in vernacular field only.Detailed summary in vernacular field only