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Please use this identifier to cite or link to this item: http://hdl.handle.net/10285/6199

NII Resource type: Thesis or Dissertation
Title: 術後急性期患者の生活リズムの自然回復を促進させるモーニングケアの開発 - 歩行介助を要する整形外科患者に対する効果 -
Other Titles: Development of Morning Care to Promote the Natural Recovery of Daily Rhythms in Postoperative Acute Patients: The Effects on Orthopedic Ambulatory Assistance.
Authors: 大橋, 久美子
Advisor: 菱沼, 典子
Keywords: モーニングケア
生活リズム
睡眠覚醒リズム
覚醒
手術後看護
情動
食行動
An investigating method or the measure : 睡眠調査票(OSAMA版)
POMS短縮版
Issue Date: Mar-2010
Publisher: 聖路加看護大学
Abstract: Ⅰ.序論 1.研究の背景 高齢社会における日本において、手術を受ける患者も高齢化している。一般に術後の睡眠覚醒リズムは麻酔や手術侵襲により乱れるが、高齢者においては認知機能低下や体内時計である脳の視交叉上核(SNC)の変性が重なり回復が遅れる。また、術後急性期患者の生活リズムは、睡眠覚醒リズムの乱れや術後の身体症状や慣れない入院生活からのストレスによる睡眠障害や活動意欲の低下などから影響を受けている。さらに生活リズムの変調は術後せん妄と早期離床やリハビリ遅延につながり回復を妨げるため、予防的に術当日夜からの昼夜のリズムを考えた援助(山田,2008)が提案されている。 概日リズムはリズム同調因子である早朝の光により24時間周期に調節され、位相調節として活動期を昼間にセットしている(本間,2005)。朝は、生活リズムにおける夜の休息期から日中の活動期への移行時期であり、患者が日中の活動にむけ主体的に準備をする時間である。しかし、歩行介助を要する患者の場合、朝の環境づくりや身支度などの生活習慣行動が阻害され、さらに今朝の身体状態や今日の予定への気掛かりや睡眠で回復しきれない苦痛などからも、患者の主体的な活動準備が妨げられる(大橋,2008b)。 そのため、術後の生活リズムが変調しており朝から活動性が低下しやすい患者に対して行うモーニングケアは、高齢化する手術患者の回復促進という看護の観点から重要な日常生活行動援助になりうる。本研究は、現在の洗面介助を主とするモーニングケアを生活リズムの視点から見直し、歩行介助を要する術後急性期患者に対して看護師が行う生活リズムを活性化させるモーニングケアの開発に取り組む。 2.研究目的 本研究目的は、歩行介助を要する術後急性期(手術翌日から3日間)の整形外科患者に対する生活リズムを活性化させるモーニングケア(以下、快適起床ケア)の開発である。まず快適起床ケアと評価指標を作成し、次に通常のモーニングケアを行う群と快適起床ケアを行う群を生活リズムの活性化の点から比較することで快適起床ケアの有効性を検証し、さらに患者と看護師の評価から実用性を検討する。この過程を通してケア内容と概念枠組みの改善や洗練を行うことで、快適起床ケアを開発する。 3.概念枠組み 快適起床ケアの理論的基盤は、Westfall(1992)の時間治療学的・看護モデルとKlages(1944)のリズムの活性化に関する現象学的・心理学的・生哲学的視点である。Westfallのモデルからは生体リズムのリセット機構に関与する同調因子の活用と看護介入のタイミングについて参照した。介入時期を早朝としてケア内容に環境整備を含めることによって同調因子が取り入れられ、自然との外的同調と生体リズム同士の内的同調が維持され、生活リズムの基盤ができる。また、Klages(1944)の視点からはリズムを強化するためのアクセントとなる拍子とリズムを活性化させる精神の役割について参照した。拍子としての3日間の定期的なケアが、生活リズムに振幅(メリハリ)をつくる。また、抑制感情の解放のために、患者が一日の活動開始に必要としている早朝の援助ニーズに対応したケア内容を加えることで、朝の活動性が高まり生活リズムが活性化する。 本研究の生活リズムの活性化とは、夜の休息期から日中の活動期への移行が円滑に進むことであり、抑制感情が解放され朝の活動性が向上することと定義した。 4.研究仮説 A.快適起床ケア群は通常ケア群よりも抑制感情が解放される;a.快適感が高い、b.今日への活力が高い、c.術前から術後3日目の気分が改善する。 B.快適起床ケア群は通常ケア群よりも朝の活動性が向上する;a.朝の生活行動が増える、b.朝食行動が促進される。 Ⅱ.予備研究-快適起床ケアと評価指標の作成-  予備研究1では快適起床ケア(案)を作成し、臨床試用を通して内容の妥当性と評価指標を検討した。まず、歩行介助を要する術後の整形外科患者4名(通常ケア群)に病棟看護師が病棟のモーニングケアを実施し、研究者が看護師から実施内容を聞き取り記述した。次に、別の患者4名(快適起床ケア群)に研究者が快適起床ケア(案)を実施し、実施内容と患者の反応を記述した。両群の患者にはケア後の気分を評価する質問紙への記入と回答し易さに関する聞き取りを行った。その結果、内容の妥当性が確認され、修正を加えて完成版を作成した。通常ケアと快適起床ケアの内容を比較し、類似点と差異点を明確にした。 予備研究2では文献検討と予備研究1の患者の反応からケアの評価指標の抽出と質問紙(起床調査票:案)の作成を行い、臨床試用を通して観察体系と質問紙の実用性を検討した。整形外科の術後患者9名に試用して修正した結果、術後患者に早朝に実施可能な起床調査票が完成した。また本調査で使用予定の情報収集方法が実行可能であることを確認した。 Ⅲ.研究方法 1. 研究デザイン 簡易サンプリングによるランダム割り付けを行わない比較群をおいた準実験研究とした。 2. 対象 対象者は、都内近郊にある病院の整形外科病棟1箇所における、整形外科疾患で術後3日間程度の歩行介助を要する手術予定の入院患者、計80名(各群40名)を計画した。除外条件は、認知症や精神疾患患者、コミュニケーションや筆記に支障のある患者とした。 対象者数の見積もりは、Hulleyら(2007)の情報が不十分な場合の見積もり方を参考にした。研究者の過去の研究からの知識と経験を基に、アウトカム変数の値が中央値よりも高くなる人数の割合(P:期待割合)を、通常ケアはP1=0.45、快適起床ケアはP2=0.8と想定した。Hulleyら(2007)の2群の割合を比較する場合の各群に必要なサンプルサイズの簡易表から、α=0.05、β=0.2、P1とP2の差=0.35の場合に必要な対象者数はn=34(各群)となった。脱落率15%を加算して、対象数は各群40名(計80名)を目標とした。 3. 介入方法 1)対象者に実施するモーニングケア 病棟看護師が術後翌朝から3日間、「通常ケア」か「快適起床ケア」のどちらかを実施した。 (1)通常ケア 通常ケア群には、病棟のモーニングケアを通常通りに実施した。ケア内容:朝の挨拶、洗面の声かけ、採光(窓のカーテン開け,照明の点灯)、テーブル上の物品整備、洗面介助(ホットタオル・歯磨き道具・ガーグルベースン・うがい用の水の準備)、排泄介助。 (2)快適起床ケア 快適起床ケア群には、快適起床ケアを実施した。ケア内容:要素1.一日がはじまる環境づくり:活動開始の合図、夜から朝へ環境の切り替え、生活環境の整理整頓。要素2.苦痛の緩和:苦痛の確認、身体面と精神面への個別対応。要素3.活動にむけた身体的準備:体位調整と身支度。要素4.今日の生活の見通しをたてる:予定の伝達、過ごし方や目標の助言。 2)看護師に実施する快適起床ケア研修 通常ケア群のデータ収集後、ケア研修をガイドと実施リストを活用して約40日間行った。 4. データ収集方法 1)データ収集期間:データ収集は2009年6月上旬から11月下旬に行った。 2)介入の割り付け 各群への介入は、介入の汚染を防止するために同時期の実施を避けた。初めの2ヵ月間に比較群(通常ケア群)40名のデータを収集した。次に快適起床ケア研修後の2ヵ月間で介入群(快適起床ケア群)40名のデータを収集した。 3)従属変数の測定 以下の項目に関する情報を収集した。 (1)抑制感情の解放 ①「快適感/今日への活力」:起床調査票質問Ⅰ:16項目5段階リッカート。朝食前の対象者による記入。 ②気分:POMS短縮版。入院時(術前日)と術後3日目朝食後の対象者による記入。 (2)朝の活動性の向上 ①朝食行動:術後3日間の研究者による下記項目の観察と測定。 a.覚醒状態:5段階評価。配膳時(起床調査票実施日は配布時)に観察。 b.姿勢:6段階評価。配膳時(起床調査票実施日は配布時)と食事中に観察。 c.朝食に取りかかる様子:5段階評価。配膳時に観察。 d.食事中の気分:4段階評価。下膳時に聞き取り。 e.朝食摂取率:配膳前と下膳後に測量器で測定。 ②朝の生活行動:起床調査票(質問Ⅳ:21項目,実施有無)。朝食前の対象者による記入。 *なお、起床調査票は、術後の身体状態の負担を考慮し援助最終日に記入を依頼した。 4) 快適起床ケアのプロセス評価 (1)対象者による評価 看護師の実施内容(起床調査票質問Ⅲ:12項目)、ケア満足度(起床調査票質問Ⅱ:5段階)。 (2)看護師による評価 ①研修中の聞き取り調査:研修中の実行可能性と困難点について看護師からの聞き取り。 ②研究終了後のフォーカスグループインタビュー:今後の改善点を抽出するために、12月上旬に、病棟看護師5名による実用性と困難点などの話し合いの実施。 5)その他 基本情報と交絡因子に関する以下の情報を収集した。 (1)対象者特性:性別、年齢、疾患名、既往歴、不安特性(新版STAI)、入院前の日常生活(生活リズム,睡眠状況,起床後の生活習慣、気分)、療養生活(手術侵襲,治療経過,活動状況)、早朝の患者の体調(身体症状,OSA睡眠調査票MA版)、看護師との相性(起床調査票質問Ⅱ)。 (2)看護提供者特性:性別,年齢,臨床経験年数,当院病棟勤務年数。 (3)環境特性:看護状況(患者数,夜間の緊急入院・急変,重傷者,検査数,処置数,朝1番目の手術,モーニングケア実施数)。病室状況(部屋種類,同室者,べッド位置,天候,照度)。 5.分析方法 対象者/看護提供者/環境特性には、χ2検定、Mann-WhitneyのU検定、対応のないt検定を用いた。従属変数には、χ2検定、Mann-WhitneyのU検定、対応のないt検定、反復測定2元配置分散分析を用いた。起床調査票質問ⅠとⅣに対して因子分析を行った。また、交絡因子の影響を調整して効果を推定するために共分散構造分析を用いた。ケアに対する評価にはχ2検定とMann-WhitneyのU検定を用いた。検定の有意水準は両側5%とした。 看護師への聞き取り内容とインタビュー逐語録については、内容分析を行った。 6.倫理的配慮  聖路加看護大学研究倫理審査委員会の承認を受けて実施した(承認番号:09-012)。対象者と看護師に対して、文書と口頭にて説明し了承を得た。特に、対象者には術後の状態に過度な負担を与えないことを、病棟看護師には強制や業務の支障や過度な負担がないことを配慮した。 Ⅳ.結果 1.対象特性(対象者、看護提供者、環境) 条件を満たした患者(比較群45名,介入群42名)のうち、術前で落ち着かない等の理由による断りを除き、比較群39名・介入群38名が研究対象者となった。終了時点では比較群36名・介入群36名であった。脱落者は比較群3名(7.69%)と介入群2名(5.26%)だった。なお、比較群4名の各調査票のデータは記入前に自立したため欠損している。 対象者特性は、術後1日目の前夜の睡眠薬と調査票記入日のOSAの疲労回復得点においては両群に有意差が認められた。看護提供者特性は、両群において有意差は認められなかった。環境特性は、早朝の看護状況の血糖測定数に有意差が認められた。 2.仮説に関する分析結果 1)仮説A「抑制感情の解放」に関する結果 (1)a「快適感」,b「今日への活力」における群間差 16項目中14項目において、平均値は介入群が比較群より有意に高かった。因子分析にて「快適感」と「活力」の2因子が抽出され、各因子得点(快適感:比較群M=-0.60(SD=0.94),介入群M=0.53(SD=0.69)、活力:比較群M=-0.62(SD=0.88),介入群M=0.55(SD=0.61))に有意差が認められた(快適感:t(52.25)=-5.81,p=.000、活力:t(66.00)=-6.13,p=.000)。 (2)c「術前から術後3日目の気分」における群間差 POMSの術前と術後3日目の差得点において、緊張-不安(比較群M=0.44(SD=8.29),介入M=-3.97(SD=9.39))と活気(比較群Mdn=0.00(P25/75=-9.00/4.00),介入群Mdn=4.00(P25/75=-1.50/10.50))に有意差が認められた(t(70.00)=2.12,p=.038、U=428,p=.013)。 2)仮説B「朝の活動性の向上」に関する結果 (1)a「朝の生活行動」における群間差 21項目中9項目において、介入群は比較群より有意に多く実施した。因子分析から「活動準備」「自発的活動」「簡易洗面」の3因子が抽出され、各因子得点(活動準備:比較群Mdn=-0.84(P25/75=-0.95/-0.73),介入群Mdn=1.05(P25/75=-0.21/0.32)、自発的活動:比較群Mdn=-0.44(P25/75=-1.31/-0.01),介入群Mdn=0.66(P25/75=0.14/1.06)、簡易洗面:比較群Mdn=0.26(P25/75=-1.80/0.40),介入群Mdn=0.48(P25/75=0.29/0.62))に有意差が認められた(活動準備:U=100.00,p=.000、自発的活動:U=200.00,p=.000、簡易洗面:U=349.00,p=.005)。 (2)b「朝食行動」における群間差 術後3日間の各朝食行動に関して、術後1日目の朝食摂取率と術後3日目の食事中の姿勢以外の項目で有意差が認められ、介入群は比較群より有意に高かった 。交互作用(術後日数×ケア)は朝食の取り掛かり,食事中の姿勢,食事中の気分に認められた(F=3.32,p=.032、F=4.07,p=.027、F=5.83,p=.006)。交互作用のなかった覚醒状態,食事前の姿勢,朝食摂取率については2群とも術後日数に伴い上昇し、交互作用のあった朝食の取り掛かり,食事中の姿勢,食事中の気分は介入群が術後1日目から高い状態を維持した。 以上から、仮説A, Bは支持された。 3.交絡因子の調整による効果の推定 ケア内容と反応は類似すると仮定し両群を合わせたデータを用いて、交絡因子として起床時の体調である「質の良い睡眠」を含めたモーニングケアの効果(「朝の仕度の充実」「起床」「快適感」「今日への活力」「主体的食事準備」「朝食摂取促進」)に関するモーニングケア効果モデルを作成し、共分散構造分析を行った。適合度はCFI=0.921、RMSEA=0.077となり統計学的な許容レベルを満たした。有意なパス係数は「質の良い睡眠」→「朝の支度の充実」(β=0.46)、「朝の支度の充実」→「快適感」(β=0.73)、「朝の支度の充実」→「起床」(β=0.97)、「快適感」→「今日への活力」(β=0.57)、「起床」→「今日への活力」(β=0.49)、「今日への活力」→「主体的食事準備」(β=0.88)、「主体的食事準備」→「朝食摂取促進」(β=0.97)であった。 次に、交絡因子で調整された従属変数がケアによって差があるかを検討した。上記モデルに「快適起床ケア」の変数を投入して快適起床ケア影響モデルを作成して分析した結果、適合度はCFI=0.904、RMSEA=0.086となり許容できた。従属変数間の有意なパス係数は、「朝の支度の充実」→「快適感」(β=0.76)、「朝の支度の充実」→「起床」(β=0.99)、「快適感」→「今日への活力」(β=0.63)、「起床」→「今日への活力」(β=0.83)、「今日への活力」→「主体的食事準備」(β=0.53)、「主体的食事準備」→「朝食摂取促進」(β=0.93)となった。ケアから従属変数への有意なパス係数は、「ケア」→「朝の支度の充実」(β=0.83)、「ケア」→「主体的食事準備」(β=0.52)、「ケア」→「今日への活力」(β=-0.53)であった。 4.快適起床ケアのプロセス評価 1)対象患者による評価 看護師の実施内容は、身体面の対応以外の11項目で介入群では比較群より多かった。ケア満足度は、比較群Mdn=3.00(P25/75=2.00/3.00)、介入群Mdn=5.00(P25/75=4.00/5.00)であった(U=157.00,p=.000)。 2)看護師による評価 (1)研修中の聞き取り調査 聞き取った内容から実施困難点と実施可能性を検討し、研修中に予定表の修正を行い、具体例や取決めについて追加資料を配布した。 (2)研究終了後のフォーカスグループインタビュー 実施上の困難点は、患者によって時間がかかる、時間の制約があるなど、半数は時間に関することだった。良かったケア内容には、予定や目標の助言、環境整備、整容が挙げられ、術後患者への実施は適切という意見もあった。 資料に関して、ベッドサイドではガイドより実施リストが活用しやすいという意見や、予定表については読めない患者への説明についての意見が挙がった。 研修は適切であり、研修後の看護実践の変化として、普段の実践内容の意識化や日勤での活用が挙げられたが、研究期間を通しても習得は不完全という意見もあった。 Ⅴ.考察 1.モーニングケアの効果 モーニングケア効果モデルを作成して分析した結果、「朝の支度の充実」から「快適感」と「起床」が促進する、「快適感」と「起床」から「今日への活力」が高まる、「今日への活力」が「主体的食事準備」を促し「朝食摂取促進」に至るという関係が示された。モデルの変数間の関係の理論的な妥当性と術後急性期患者に対するモーニングケアの効果を考察する。 まず、「朝の支度の充実」が「快適感」を高めて「今日への活力」を高めるという関係は、Matthewsら(1990)の気分3因子モデルにおける快感度と主観的覚醒度2因子(緊張覚醒とエネルギー覚醒)との相関関係から説明できる。次に、「朝の支度の充実」が食事前の覚醒と姿勢を示す「起床」を促して「今日への活力」を高めるという関係は、感覚刺激による入力を受けて上行性網様体賦活系(ARAS)が大脳皮質を覚醒させる(Magoun,1963)ことから、「朝の支度の充実」による脳への刺激は覚醒を促し、また上体が起きている姿勢によって視野が広がり視覚情報による脳への刺激が覚醒状態をさらに高めると考えられる。また覚醒レベルが増せば情緒も増す(Hebb,1972)ため、「起床」から「今日への活力」への関係が説明できる。さらに「今日への活力」は「主体的食事準備」を促し「朝食摂取促進」に至るという関係は、気分一致効果(Bower,1981)のように活力が高まり気分の良くなった人は朝食を食べることができそうと評価して自らの意志・判断で準備を進めて朝食を食べることが考えられる。なお、モデル化の際に「主体的食事準備」の変数を媒介させなければ「朝食摂取促進」に至らなかったことから、患者が朝食の準備を主体的にできるような状況を看護師が整える必要がある。 以上から、モーニングケアの効果モデルは理論的にも妥当であり量的指標によって検証された。看護において従来以上に患者の自己回復力を引き出し支える働きかけや合併症予防のかかわりの強化が必要とされるなか、術後急性期患者の心身の覚醒と朝食行動の促進に効果をもたらすモーニングケアは、術後の生活リズムを整え、患者の潜在能力を引き出して術後の回復を促進する日常生活行動援助として非常に重要である。 2.快適起床ケアの有効性 快適起床ケア影響モデルの分析結果から、モーニングケアの効果における通常ケアと快適起床ケアの影響の違いとして、快適起床ケアには「朝の支度の充実」と「主体的食事準備」に対する直接効果と「朝の支度の充実」から「快適感」と「起床」の二つの経路による「今日への活力」に対する間接効果が明らかになった。快適起床ケアの有効性を考察する。 1)「朝の支度の充実」への直接効果 快適起床ケアは通常ケアより患者の援助ニーズに応じた意図的な項目が多いため患者の生活行動量が増加した。快適起床ケアは直接的に患者の朝の活動性を高めるため、通常ケアより有効である。 2)「今日への活力」への間接効果 快適起床ケアの直接効果「朝の支度の充実」が「快適感」を高めたことは、援助内容(要素1~4)の適切性を意味する。通常ケアと共通する要素(1,3)では患者への声かけ確認による確実な実施が患者の反応を増し、また術後患者を起こして身支度することに必須となる要素2の苦痛の緩和の実施は患者を楽にしたと考える。要素3の健康時に近い身支度を相手の希望に応じて進める方法は「快適感」「今日への活力」を高め、通常ケアでは行っていない要素4の予定の説明などが気がかりや不安を和らげたと考える。よって、快適起床ケアの要素1~4は「快適感」と「今日への活力」を高めるため、通常ケアよりも有効な内容である。 POMSの緊張―不安と活気得点は快適起床ケア群で有意に改善した。一般に、手術患者の不安は術後数日で自然に減少する。よって、通常ケア群はそのプロセスの前段階であり、快適起床ケアは通常ケアよりも術後の心理状態の自然回復を早めるため、抑制感情の解放がリズムを活性化(Klages,1944))し、術後の生活リズムの回復を促進するケアといえる。 「起床」の指標である覚醒状態と食事前の姿勢は両群とも術後経過日数に伴い上昇したが、術後3日間の各時点で快適起床ケア群は通常ケア群より有意に高かった。快適起床ケアは上体を高く起こして洗面器を使用して整容を行うため通常ケアより作業量が増え、脳への刺激の増加が覚醒水準を高めたと考える。また、ARASと関係する大脳皮質の辺縁系は情動や動機づけとも関係し(Hebb,1972)、大脳皮質での認知や思考過程がARASを賦活させることから、要素3の手術翌朝から体を起こす理由の説明と健康時に近い身支度の促しや要素4の活動目標の設定などが動機づけとなり「起床」を促したと考える。また、快適起床ケア影響モデルではモーニングケア効果モデルより「起床」から「今日への活力」へのパス係数が大きくなっていたことから、「起床」を媒介にした「今日への活力」への間接効果は快適起床ケアの有効性を特徴づけている。よって、快適起床ケアは「起床」を媒介に「今日への活力」を高めるため、通常ケアよりも有効である。 3)「主体的食事準備」への直接効果 「主体的食事準備」の指標である朝食の取り掛かりと食事中の姿勢と「朝食摂取促進」の指標である食事中の気分は、通常ケア群は術後経過日数に従い上昇するが快適起床ケア群は術後1日目から高かった。「朝食摂取促進」の指標となる朝食摂取率は両群とも術後経過日数に伴い上昇し術後2日目以降の摂取率は快適起床ケア群が有意に高かった。快適起床ケアは通常ケアより術後の朝食行動の回復を早めたといえ、その理由は「主体的食事準備」に対する快適起床ケアの直接効果と間接効果「今日への活力」が考えられる。 間接効果の影響については「今日への活力」をMatthewsら(1990)の主観的覚醒度と捉えるならば、快適起床ケアは最適行動のとれる中等度の喚起(覚醒)レベル(Hebb,1972)をもたらすケアであり、朝食行動を促進したと考える。また、Hebb(1972)は喚起系は大脳皮質が効果的に働くために必要であるがいかなる目標が求められるかを規定するのは大脳辺縁系であるとしており、通常ケアにはない快適起床ケアの要素4の予定表を用いた朝食前の関わりが直接的に術後患者を朝食行動へと方向づけ、「主体的食事準備」を促したと考える。行動リズムへの直接の影響はWestfall(1992)の時間治療学的・看護モデル内の体内時計を介さないマスキング効果に位置づけられ、また生活リズムの概念分析の先行要件として予定や動機付けが挙げられる。よって通常ケアにはない要素4を含む快適起床ケアは、通常ケアよりも術後の生活リズムの自然回復を促進させる有効なケアであるともいえる。 以上から、歩行介助を要する術後急性期患者への快適起床ケアは朝の活動性を向上させ、直接的にも間接的にも朝食行動を促進し、術後の心理状態の回復を促すことから、通常ケアよりも術後の生活リズムの自然回復を促進させる日常生活行動援助として有効である。 3.快適起床ケア内容及びケア研修における改善点 快適起床ケアは、患者評価として患者満足度が高く侵襲のないケアといえる。看護師評価からは、ガイドの削除項目はないが実用性を高めるために患者の状況に応じた対応例を追加し、ベッドサイドで使いやすいように実施リストをガイド短縮版へと修正した。文字の読めない患者の予定表の活用と研修方法が検討事項となった。 4.本研究の概念枠組みの修正 概念枠組みを修正した。理論的基盤には覚醒機序とWestfallのマスキング効果を、ケア内容には要素4による「活動に対する動機づけ」を追加した。「生活リズムの活性化」を「術後の生活リズムの自然回復」とし、ケアの名称を「生活リズム回復促進ケア」とした。 Ⅵ.結論 快適起床ケアを作成し、歩行介助を要する術後急性期の整形外科患者に対する有効性の検証を行い、以下のことが明らかになった。 1.介入群は比較群より「快適感」と「今日への活力」の各因子得点は有意に高く、POMSの緊張-不安得点の低下と活気得点の向上にも有意差が認められ、仮説「抑制感情の解放」は支持された。 2.介入群は比較群より「活動準備」「自発的活動」「簡易洗面」の各因子得点は有意に高く、術後3日間の「朝食行動」も術後1日目の朝食摂取率と術後3日目の食事中の姿勢を除き有意に高く、仮説「朝の活動性の向上」は支持された。 3.モーニングケア効果モデルを作成し、「朝の支度の充実」が「快適感」と「起床」を促進して「今日への活力」を高め、「今日への活力」が「主体的食事準備」を促し「朝食摂取促進」に至ることが示された。 4.快適起床ケア影響モデルを作成し、快適起床ケアの「朝の支度の充実」と「主体的食事準備」に対する二つの直接効果と「朝の支度の充実」から「快適感」と「起床」の二つの経路による「今日への活力」に対する間接効果が明らかになった。快適起床ケアは術後の生活リズムの自然回復を促す日常生活行動援助として有効であり、名称を「生活リズム回復促進ケア」として概念枠組みを修正した。 5.プロセス評価:患者満足度は高かった。看護師評価より、ガイドに対応例を追加し、実施リストをガイド短縮版として修正した。 6.今後の課題:看護師への導入方法、文字が読めない/体を起こせない/食事摂取可能ではない患者へのケア内容の検討、一般化に向けた他施設での研究成果の集積である。
Abstract-Alternative: I. Introduction 1. Background As Japan’s society ages, the age of patients undergoing surgeries has also increased, therefore it has become even more important to understand postoperative care for older patients. Normally, postoperative sleep-wakefulness cycles are disturbed by anesthesia and operative stresses. However, in the elderly, recovery is delayed because of degradation of cognitive functions and denaturation of the cerebral suprachiasmatic nucleus (SNC), which is the interior clock. Also, daily rhythms of patients during the early postoperative period are influenced by the disorder of the sleep-awakening rhythm and sleep disorder or degradation of activity motivation by stress due to physical symptoms and inexperience of residing in a hospital. Furthermore, alteration of daily rhythms causes: postoperative delirium, early postoperative ambulation and rehabilitation delays and disturbances in the restoration of health. Hence, Yamada (2008) proposed preventive supports to include daily rhythms beginning from the night of the operation. The circadian rhythm is regulated in a 24-hour cycle by the early morning light which acts as a synchronizer and the active phase of the cycle is thus set for the day by phase adjustment (Honma, 2005). The early morning is the time shift from the night rest-phase to the daytime active-phase in the daily rhythm, and the patient independently prepares to engage in daytime activities. However, this early morning active phase becomes obstructed for patients needing assistance with walking because they are unable to perform their activities of daily living such as washing or dressing. Furthermore, their physical condition in the morning leads to anxiety about their schedule for the day and the pain not eliminated by sleeping disturbs their independent preparation for activity (Ohashi, 2008b). Therefore, morning care for patients who have alteration of daily rhythms and delay of ambulation in the daytime could become important daily living activities support from the nursing viewpoint to promote recovery in the elderly. In this study, the author review current morning care which principally involves assistance with face washing from the aspect of daily rhythms, and develop morning care offered by nurses to activate daily rhythms in postoperative acute patients needing assistance with walking. 2. Purpose The purpose of this study was to develop “the comfort upon rising care” that activates daily rhythms of orthopedic patients who are in the postoperative phase occurring on the third day from the operation and needing assistance with walking. At first, the author made the comfort upon rising care and evaluation figures. Next, the effectiveness of the comfort upon rising care is verified by comparing the comfort upon rising care group with the usual morning care group in the activation of daily rhythms, and then the practicality is considered on the basis of the evaluation of patients and nurses. The comfort upon rising care is developed by improving and refining of the care content and the concept framework through these processes. 3. Conceptual Framework The theoretical base supporting the comfort upon rising care was Westfall's nursing chronotherapeutic model (1992) and Klages's phenomenological - psychological - life-philosophical viewpoint related to activation of rhythms (1944). From Westfall's model, the author referred to the use of time cues involved in the reset mechanism of biological rhythms and the timing of nursing interventions. Patients come in contact with synchronizers through environmental arrangements and physical preparations in early morning, so that synchronization of external and internal rhythms is maintained and the base of daily rhythms is made. Also, from Klages’ viewpoint, the author referred to the role of time as accent that strengthens rhythms and the role of mental variations such as release of suppressed emotions or joyful emotions that activates rhythms. Regular executions for three days as time make the amplitude in daily rhythms. And care contents designed to meet the support needs of patients to allow the release of suppressed emotions, so that patients’ activities in the early morning are improved, and daily rhythms are activated. Activation of daily rhythms in this study is defined as: the shift from the rest phase at night to the active phase in the daytime, which advances smoothly and suppressed emotions are released, so that activities in mornings can be improved. 4. Study Hypothesis A. If suppression of emotions for patients is related to comfort upon rising then the comfort upon rising care group will have released more emotions than those in the usual care group and their: (a) “feelings of comfort” will be higher, (b) “vitality for the day” will be higher and (c) mood before and on the third day after the operation will be more improved. B. If morning activities of patients in the comfort upon rising care group are related to improvement then they will exhibit more improvement than those in the usual care group, specifically: (a) activities of daily living in mornings will increase and (b) breakfast behaviors will be improved. II. Preliminary Study: making a comfort upon rising care and evaluation figures In Preliminary Study 1, the author made a comfort upon rising care plan and examined its content validity and evaluation figures through the trial by clinical. First, floor nurses comprising the performed morning care with four postoperative orthopedic patients comprising the usual care group (UC) who needed assistance with walking and the author interviewed and tape-recorded the nurses’ explanations about practice activities. Next, the author implemented the comfort upon rising care plan with four other patients comprising the comfort upon rising care group (CUR) and recorded practice activities and responses from the patients. The author interviewed patients in both groups regarding the ease of description and response to the questionnaire to evaluate their mood after receiving care. As a result, the adequacy of the contents was confirmed and the author created a full version of the questionnaire adding some revisions. The author compared the CUR and UC care contents, and clarified similar and different points in the two care methods. In Preliminary Study 2, at first, the author extracted evaluation figures and made the Wake-Up questionnaire based on reference studies and responses from patients obtained in Preliminary Study 1. Next, the author examined the practicability of the observation systems and the questionnaire through a clinical trial for nine postoperative orthopedic patients, so that they were revised. The post-operative early morning wake-up questionnaire was completed and it was confirmed that the information collection method in the main research was executable. Ⅲ. Method 1. Design of the Study The study design was a quasi-experimental research using convenience sampling and non-random group assignment. 2. Setting and Subjects Subjects were 80 inpatients (40 for each group) in a suburban Tokyo orthopedic ward. The inclusion criteria were: (a) orthopedic diseases, (b) scheduled for surgery and (c) would need ambulation assistance for about three days after the operations. Exclusion criteria were: (a) patients with dementia and psychiatric disorders and (b) those with communication difficulties in speaking and writing. To estimate the number of subjects when information is insufficient, the author referred to the estimation method, discussed by Hulley et al. (2007). As the outcome variable was treated as a dichotomous variable the ratio of subjects exceeding the median (P=expected ratio) was assumed to be P1=0.45 for the UC group and P2=0.8 for the CUR group. According to Hulley et al.’s (2007) simple sample size list, the number of subjects needed in the case of α =0.05, β =0.2 and the difference between P1 and P2 =0.35 was determined that 34 in each group was an adequate size. The target number set for the study was 40 subjects for each group (N=80) with an anticipated dropout rate of 15%. 3. Intervention 1) Morning care performed with subjects Floor nurses performed either "usual care" or "comfort upon rising care" for subjects beginning the next morning after surgery and continuing for three days. (1) Usual care Nurses carried out the standard morning care for the UC group. Care contents included: morning greetings, call for washing face, opening curtains, turning on the lights, arranging articles on their table, assistance with face washing (preparing hot towel and tooth brush) and assistance with elimination. (2) Comfort upon rising care Trained floor nurses implemented the nursing care for the CUR group. Care contents included: (Element 1) environmental arrangement for beginning of the day: signals beginning of activity, switching from the night to morning environments and organization of living environment. (Element 2) easing of pain: assessment of pain level and individualized support for their physical and mental status. (Element 3) physical preparations for activity: posture adjustment and dressing. (Element 4) providing the forecast for the days’ agenda: reviewing the daily schedule, and advising about goals and how to spend the day. 2) Training for CUR care performed by floor nurses After the data collection of the UC group, the author conducted 40-day training for providing CUR care using a practice guide. An itemized implementation list was also provided for the floor nurses. 4. Data collection method 1) Data collection period: June to November, 2009. 2) Assignment of intervention The author avoided simultaneous nursing practice to prevent contamination of the intervention. For the first two months the author collected data from the 40 UC comparison group. During the next, two months, which was after the training for the CUR group, the author collected data from the 40 subjects in the CUR group. 3) Measurement of dependent variables (1) Release of suppressed emotions ①"Feeling Comfortable” / “Vitality for the day" Wake-Up questionnaire - Question -Ⅰ:Completed by subjects before breakfast. ② Mood Profile of Mood States-Short Version (POMS-SV): 5-point Likert scale with 37 items. Completed by subjects, at the time of admission (a day before operations) and after breakfast on the third day after the operation. Note: The questionnaires were filled in on the final day of care because attempting to complete the questionnaire soon after surgery was too much of a burden on the subjects. (2) Improvement of activities in morning ①Breakfast behaviors: Observation and measurement by the author for three days after the operation a. Wakeful state, 5-point scale: observation at the time of setting the meal (at the time of distribution of Wake-Up questionnaire Q-I) b. Posture, 6-point scale: observation at the time of setting the meal and during meal (at the time of distribution of Wake-Up questionnaire Q-I) c. Beginning breakfast, 5-point scale: observation at the time of setting the meal d. Mood during meal, 4-point scale: interview at the time of clearing the table e. Breakfast intake amount: measurement with a digital scale before and after breakfast ②Morning Activities of Daily Wake-Up questionnaire Question-IV: completed by subjects before breakfast on the third day after the operation 4) Process evaluation of the CUR care (1) Evaluation by subjects Practice activities performed by the nurses (Wake-Up questionnaire Question-III), Care satisfaction rating (Wake-Up questionnaire Question-II) (2) Evaluation by nurses ① Qualitatively derived from training group interaction and focused discussions: The author documented the nurses comments regarding practicability and difficulties of providing CUR care during the training period. ② Focus group interview after completion of the study: early December. The author performed a focus group interview for around 30 minutes with five nurses to improve the care activity contents. 5) Other: Basic information and confounding factors were collected. (1) Subject characteristics: gender, age, disease, anxiety (new version State-Trait Anxiety Inventory [STAI]), activities of daily living (daily rhythm, morning living habits), recuperation history (operation, episode of treatment, activity level), early morning physical condition (symptoms, sleep status (Obstructive Sleep Apnea [OAS] questionnaire) (2) Staff nurse providing intervention characteristics: gender, age, years of experience in clinical practice, years of experience on the current surgical ward, patient-nurse compatibility (Wake-Up questionnaire Question-II) (3) Environmental characteristics: early morning staffing patterns (patient census, urgent admission/ sudden changes, examinations, patients needing morning care assistance), early morning hospital room condition (type of room, position of beds, weather, lighting quality (illumination photometry) ) 5. Analyses The author used: chi-square test, Mann-Whitney's U-test, f and unpaired t-test for characteristics of nurses providing CUR care, subjects and environment. For dependent variables: chi-square test, Mann-Whitney's U-test, unpaired t-test and two-way repeated-measures ANOVA were employed based on the hypothesis. A factor analysis was performed for Q-I and Q-IV of the Wake-Up questionnaire. Moreover, a covariance structure analysis was performed to estimate effects by adjusting the influence of confounding factors. For a care process evaluation, chi-square test and Mann-Whitney's U test were used. Significant levels were assumed at 5% for both sides. Content analysis was used for qualitative data from interviews. Codes and then themes were identified. 6.Ethical consideration St. Luke's College of Nursing Research ERB approved the study (approval number: 09-012). The author explained the study to the subjects and nurses including confidentiality, ability to leave the study at any time without prejudicing their care or employment and obtained signed informed consent. Also, the author gave extra consideration so that an excessive burden was not imposed upon subjects in a postoperative condition and other considerations so that actions related with this study could not be forced upon the nurses and become an obstacle to their duties and an excessive workload was not imposed. Ⅳ. Results 1. Characteristics of subjects (subjects, nurse care providers, environment) Meeting the inclusion criteria were 45 patients for the UC comparison group and 42 patients for the CUR intervention group. Agreeing to participate were 39 patients from the comparison group and 38 patients from intervention group. Completing the study were 36 (92%) patients from the comparison group and 36 (95%) patients from intervention group. Further, data from questionnaires of four patients from the comparison group were not obtained since they became independent before it was completed. For subject characteristics, significant differences between two groups were recognized in sleeping medication the night before surgery and fatigue recovery scores of OSA. There were no significant differences in characteristics between nurses from the control or intervention group. For environmental characteristics, a significant difference was recognized in the number of blood glucose measurements (nursing situation). 2. Analysis result for hypothesis 1) Result of Hypothesis A: "release of suppressed emotion" (1) Intergroup differences in a: "feeling comfortable" and b: “vitality for the day" The intervention group was significantly higher than the comparison group in the mean values in 14 out of 16 items. As a result of a factor analysis, two factors: "feeling comfortable" and "vitality for the day" were extracted. Significant differences were seen in each factor score (feeling comfortable: comparison group M=-0.60 (SD=0.94), intervention group M=0.53 (SD=0.69), vitality for the day: comparison group M=-0.62 (SD=0.88), intervention group M=0.55(SD=0.61)) (feeling comfortable: t (52.25)=-5.81, p=.000, vitality for the day: t(66.00)=-6.13, p=.000). (2) Intergroup differences in c: "mood before and on the third day after the operation" For score differences of POMS before and on the third day after the operation, significant differences were seen in tension-anxious (comparison group M=0.44, SD=8.29, intervention group M=-3.97, SD=9.39)) and animation (comparison group Mdn=0.00, P25/75=-9.00/4.00, intervention group Mdn=4.00, P25/75=-1.50/10.50)) (t (70.00) =2.12, p=.038, U=428, p=.013). 2) Result of the hypothesis B: "improvement of morning activity” (1) Intergroup difference in a: "living activities in mornings" The intervention group was significantly higher than the comparison group in the number of performances in 9 out of 21 items. As a result of a factor analysis, three factors, “preparation for activity (dressing and a schedule)", "spontaneous activity" and "simple face washing and brushing teeth” were extracted. Significant differences were seen in each factor score (preparation for activity: comparison group Mdn=-0.84 (P25/75=-0.95/-0.73), intervention group Mdn=1.05 (P25/75=-0.21/0.32), spontaneous activity: comparison group Mdn=-0.44(P25/75=-1.31/-0.01), intervention group Mdn=0.66 (P25/75=0.14/1.06), simple face washing and teeth brushing: comparison group Mdn=0.26 (P25/75=-1.8/0.40), intervention group Mdn=0.48 (P25/75=0.29/0.62)) (preparation for activity: U=100.00, p=.000, spontaneous activity: U=200.00, p=.000, simple face washing and teeth brushing: U=349.00, p=.005). (2) Intergroup difference in b: "breakfast behaviors" For each breakfast behavior for three days after the operation, significant differences were seen in items other than the posture, while eating on the third day after the operation and the breakfast intake rate on the first day after the operation. The intervention group was significantly higher than the comparison group. An interaction effect (day × care) was seen at the beginning of eating breakfast, posture while eating and mood during the meal (F=3.32, p=.032, F=4.07, p=.027, F=5.83, p=.006). The wakeful state, the posture before meal and the breakfast intake rate rose each day days with both groups, while the variables, beginning to eat breakfast, posture while eating and mood during meal, in the intervention group, were high from the first day after the operation. Thus, hypothesis A and B were supported. 3. Estimation of effect by adjustment of confounding factors Since the nursing care activities and patient’s responses are similar, by using the data from both groups, the author made a conceptual model for the effect of morning care. The model included: "high quality sleep” as a confounding factor, which consisted of “ample morning preparation", "rising", "feeling comfortable", "vitality for the day", "independent meal preparation" and "promotion of breakfast intake". A covariance structure analysis was performed on the model. Fit indexes were CFI=0.921, RMSEA=0.077 and a statistically acceptable level was obtained. Next, in order to discuss if dependent variables adjusted by the confounding factor were different depending on care, the author the applied the variable of CUR care to the above model. Fit indexes were CFI=0.904, RMSEA=0.086 and an acceptable level was obtained. Significant path coefficients between dependent variables were "ample morning preparation"→"feeling comfortable" (β=0.76); "ample morning preparation"→"rising" (β=0.99); "feeling comfortable"→"vitality for the day" (β=0.63); "rising"→"vitality for the day" (β=0.83); "vitality for the day"→"independent meal preparation" (β=0.53) and "independent meal preparation"→"promotion of breakfast intake" (β=0.93). Significant path coefficients from care to dependent variables were "care"→"ample morning preparation" (β=0.83); "care"→"independent meal preparation" (β=0.52) and "care"→"vitality for the day" (β=-0.53). 4. Process evaluation of the comfort upon rising care 1) Evaluation by subject patient Of the 12 practice activities performed by the nurses, 11 were significantly higher in the intervention group than the comparison group; only physical supports lacked significance. Care satisfaction rating was Mdn=3.00(P25/75=2.00/3.00) for the comparison group and Mdn=5.00(P25/75=4.00/5.00) for the intervention group (U=157.00, p=.000). 2) Evaluation by nurses (1) Interview during training From the interview about difficult aspects of practice and operability of care, the schedule sheet was revised during the training and additional materials about concrete examples and roles were distributed. (2) Focus group interview after completion of research When asked about the more difficult aspects of providing nursing care activities, half of the comments were about time, such as, ‘it takes time for some patients’ and ‘there is time pressure’. The respondents mentioned advice for schedules and goals, environmental arrangements and cosmetics as positive nursing activities and a number of them noted that it was appropriate to practice this type of care for postoperative patients. About the materials provided for the intervention group, some nurses mentioned that it is easier for them to use a nursing care activity item list than the guide at bedside. Some nurses commented that it was difficult to verbally explain the schedule sheet to the patient who was not able to read the sheet. The training was evaluated as appropriate. As a change of practice after the training, there was in increased awareness of the new practice for each day and application in the daytime. However, the floor nurses did not acquire the process perfectly during the study period. Ⅴ. Discussion 1. The effect of morning care Covariance structure analysis clarified that morning nursing care was linked to "ample morning preparation” which then increased “feeling comfortable” and “rising”. Furthermore, “vitality for the day” that arose from the previous three variables led to “independent meal preparation” and that led to "promotion of breakfast intake”. Next, the theoretically validity of the Morning Care Effect Model (MCEM) and the effect of morning care on postoperative acute patients is considered as follows The first set of relations is considered: "ample morning preparation” improved “feeling comfortable” and “feeling comfortable” improved “vitality for the day”. From the three-factor model of mood proposed by Matthews et al. (1990), I assumed that "feeling comfortable" was the condition whereby discomfort and uneasiness were removed allowing for an increase of the degree of pleasantness feeling. I also assumed that "vitality for the day" such as stable mood and motivation indicated a decrease in tension upon awakening of the subjective vigilance two factors that correlated with pleasantness degrees and rising of energy upon awakening. Next, the relations of “ample morning preparation” improved “rising” and “rising” improved “vitality for the day” are considered. The ascending reticular activating system (ARAS) receiving a number of stimulus inputs from various sensations awakens the brain cortex (Magoun, 1963), therefore stimulation to the brain resulting from ample morning preparation increases awaking and rising is promoted. The wakeful state also improves stimulation to the brain through visual information from the broader point of view attained by "rising". If evocation (awakening) levels increase, emotion increases (Hebb, 1972). Therefore, promotion of "rising" led to "vitality for the day”. Third, the relations of “vitality for the day” promotes “independent meal preparation”, which led to "promotion of breakfast intake” are considered. With an increase in “vitality for the day”, the postoperative patient was better able to engage their will power and use their judgment to enact the behavior necessary for independent meal preparation; as a result promotion of breakfast intake occurred. The patients possibly promoted the breakfast actions and gave higher scores for their good temper and by the mood congruity effect, which is the effect that emotion gives to perception (Bower, 1981). Nurses should arrange a situation in which patients can independently prepare breakfast. Thus, these flows of events support the logical consistency of the MCEM. Morning care that brings about an effect to postoperative acute patient's mind and body's awaking and promotion of breakfast behaviors is very important as daily living activities support to make postoperative daily rhythms and promote recovery. 2. The effectiveness of CUR care It has been confirmed that CUR care had a direct effect on "ample morning preparation" and "independent meal preparation". CUR had an indirect effect on “vitality for the day" that transmitted “feeling comfortable” or “rising” through "ample morning preparation". The effectiveness of CUR care is considered as follows. 1) Direct effect of CUR on “substantiality of preparation in morning" Patients' morning activities and behavior increased because CUR contained a number of nursing actions intended to support the patient’s needs. CUR care is more effective than usual care so that it may directly improve activities in the morning. 2) Indirect effect on "vitality for the day" "Feeling comfortable" improved by "substantiality of preparation in morning" an indirect effect of CUR care suggested that all four care elements were suitable. Steady implementation by voice imposing confirmation in element one and three which had commonality with usual care increased patient’s response. Element two needed before wake up and body preparation enhanced patient’s ease. An aspect of element three listening to each patient’s wish had an impact on "feeling comfortable" and "vitality for the day". Element four, the method that CUR care nurses only used, reduced anxiety of postoperative patients. Therefore, CUR care was more effective than usual care so that elements 1~4 improved "feeling comfortable" and "vitality for the day ". CUR care significantly improved the tension anxiety score and the vigor score in POMS. In general, anxiety of postoperative patients is reduced a few days after the operation. Therefore the UC group was experiencing post-operative anxiety before this process and the CUR care reduced the typical post-operative anxiety more than usual care. The wakeful state and posture before breakfast as the index of "rising" increased along with the postoperative days in both groups. The CUR care group wakeful state was significantly higher than the UC group each of the three days after the operation. In CUR care, patients sat up straighter before they prepared to wash and groom themselves. Therefore patients’ activities increased more than with usual care, which then increased the stimulation to their brain and improved arousal levels. The limbic cortex of the brain related to ARAS is related to emotions and incentives (Hebb, 1972) and perception and ideation performed in brain cortex activates ARAS (Hebb, 1972). Therefore "rising" was promoted because providing the postoperative patients with a reason for postoperative morning care and the usual morning preparation in element three and four (the activity plan) became motivations for activities. In the CUR care influence model, the path coefficients from “rising” to “vitality for the day” were larger than the MCEM. An indirect effect of "vitality for the day" through "rising" characterized the effectiveness of this care. Therefore, CUR care was more effective than usual care so that this care improved “vitality for the day" through "rising". 3) Direct effect on "independent meal preparation" The wakeful state and posture before breakfast as the index of "independent meal preparation" and mood during breakfast as the index of "promotion of breakfast intake" rose along with the postoperative course in both groups. The CUR care group was high from the next day of after the operation. Breakfast intake rate as the index of "promotion of breakfast intake" rose along with the postoperative days in both groups. Breakfast intake rate in the CUR care group was significantly higher than in the UC group after the second day of operation. This care, most likely, promoted the natural recovery of breakfast behaviors after the operation more than usual care because of a direct effect and an indirect effect (“vitality for the day") to "independent meal preparation". The indirect effect (“vitality for the day"), assumed that a decrease of tension upon awakening and a rise of energy upon awakening was supported by the three-factor model of mood proposed by Matthews et al. (1990). Middle-class evocation (arousal) levels for optimal actions were obtained through CUR care (Hebb, 1979) and it led to smooth breakfast actions. Hebb (1979) stated that the arousal system is a necessary effective brain cortex action however it is the limbic cortex that provides what goals are to be met; therefore, it is not only the indirect effect "vitality for the day" and it is necessary to attach importance to the direct effect to lead the patient to breakfast behaviors as the first step of activity of the daytime. Element four (using a schedule sheet before breakfast) can be a direction to breakfast behaviors and to directly promote "independent meal preparation" and "promotion of breakfast intake”. A direct effect on breakfast behaviors is not mediated by the body clock and is described as a direct drive or masking effect by Westfall (1992) in her discussion of chronotherapy nursing models. Therefore, CUR care is more effective than usual care as a method that promotes the natural recovery of daily rhythms after an operation. CUR care increases the mind and body's wakeful states, promotes the recovery of breakfast behaviors, and facilitates the recovery of patients’ mental state after the operation. In summary, CUR care was more effective than usual care as a daily living behavior support to promote the natural recovery of daily rhythms after an operation. 3. Evaluation of CUR care content and care training Patients evaluated the content of CUR. Patient satisfaction for CUR care as high and this care was not judged as invasive. Nurses' evaluated of the care content; thus, support examples for different patient conditions were added to the guide and the protocol was corrected becoming a short guide. In the future, researchers should consider developing and using a schedule by patients who are not able to read letters and improved training methods for nurses. 4. Revision of concept frame of this study The author revised the conceptual framework of this study. The mechanism of awaking, the masking effect of Westfall model and motivations for activities due to element 4 were added to a theoretical base. "Activation of daily rhythms" was changed to "natural recovery of postoperative daily rhythms" and the name of CUR care was corrected to "daily rhythms recovery promotion care". Ⅵ. Conclusion The effectiveness of CUR care for the assistance of postoperative orthopedics ambulatory patients was verified, and the following was clarified. 1. Intervention group's individual factor scores for "feeling comfortable" and "vitality for the day" were all significantly higher than the comparison group. A significant difference was seen in the tension anxiety score and the vigor score in POMS supporting study hypothesis A regarding CUR promoting "release of suppressed emotion". 2. Intervention group's individual factor scores for "preparation for activity”, “spontaneous activity" and "simple face and teeth washing” were all significantly higher than that of the comparison group. “Breakfast behaviors" of three days after the operation was significantly high, excluding the breakfast intake rate on the first day after the operation and posture while eating on the third day after the operation. Thus hypothesis B, CUR leading to "improvement of morning activity" was supported. 3. The morning care effect model was created. It was clarified that "ample morning preparation” through morning care improved “feeling comfortable” and “rising”. The next state, “vitality for the day”, improved “independent meal preparation” which led to "promotion of breakfast intake”. 4. CUR care influence model was created. It was confirmed that CUR care had a direct effect on "ample morning preparation" and "independent meal preparation" and had an indirect effect on “vitality for the day" that transmitted “feeling comfortable” or “rising” through "ample morning preparation". CUR care was more effective than usual care as a daily living behavior support to promote the natural recovery of the daily rhythms after an operation. The conceptual framework of this study was corrected and the name changed to "daily rhythms recovery promotion care". 5. The process evaluation indicated that patient satisfaction was high. From nurses' comments of the care content, support examples for different patient conditions was added to the guide and the protocol was corrected and became a short guide version. 6. Future tasks are to create an introduction method for nurses, develop care contents for patients who cannot read or independently sit-up or eat, and expand research to include other facilities for generalization.
Official announcement place: Ohashi, Kumiko.(2013). Effects of early morning care, named "comfort upon rising" care, on postoperative orthopedic ambulation and morning activity. Japan Journal of Nursing Science. DOI: 10.1111/jjns.12028
Degree field : 博士(看護学)
URI: http://hdl.handle.net/10285/6199
Appears in Collections:2-3-b:博士論文(要旨あり)

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