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系統識別號 U0026-0702201723174600
論文名稱(中文) 早產兒視網膜病變檢查之發展性照護指引:臨床應用之建立、推動與評價
論文名稱(英文) The Guidelines of Developmental Care for Examinations of Retinopathy of Prematurity (ROP): Establishment, Promotion, and Evaluation of Clinical Application
校院名稱 成功大學
系所名稱(中) 護理學系
系所名稱(英) Department of Nursing
學年度 105
學期 1
出版年 106
研究生(中文) 武蕙蘭
研究生(英文) Huey-Lan Wuu
學號 t26994070
學位類別 碩士
語文別 中文
論文頁數 91頁
口試委員 指導教授-黃美智
口試委員-張瑩如
口試委員-王世豪
中文關鍵字 早產兒視網膜病變  發展性照護  轉譯研究  早產兒 
英文關鍵字 Retinopathy of prematurity (ROP)  Developmental care  Translation research  Preterm infants 
學科別分類
中文摘要 研究背景:研究證實早產兒執行視網膜病變篩檢過程中會導致疼痛壓力,影響生理及行為穩定,而發展性照護的概念即是依早產兒耐受度給予合適的照護措施,其目的是為了保護腦部的正常發育。本研究以實證為基礎,建立適用於本研究場域中早產兒執行視網膜病變檢查之發展性照護指引,並進行臨床實務推動與評價。
研究目的:藉由建立、推動及評價臨床指引過程,落實護理人員執行早產兒視網膜病變檢查之發展性照護指引,提升早產兒照護品質。
研究方法:採轉譯研究方法(Translation research),透過組成領導小組、整合實證知識,建立早產兒視網膜病變檢查之發展性照護指引、推動臨床應用與評價之轉譯步驟,將指引落實於臨床實務。研究場域在南部一所醫學中心新生兒加護單位,資料收集包含新生兒照護問卷調查該單位護理人員對發展性照護之態度認知、現行護理人員對早產兒視網膜病變檢查過程之滿意度、以及護理人員執行協助ROP檢查過程現況收集,以描述性及相關性統計分析,了解指引推行阻、助力,推動策略則以工作坊模式,包含引發動機、課程教育、影片、示範、評核、自學、改變流程等,並以海報、創意磁鐵、答問專區之推廣活動加深同仁們重視度,逐漸形成風氣,以達宣導與教育目的。
研究結果:本研究之轉譯步驟將推行此指引所運用的計畫與執行內容分述如下:
準備期:1.成立照護指引發展小組進行系統性文獻評讀,透過專家共識與審核,完成早產兒視網膜病變檢查之照護指引發展2.以新生兒護理照護問卷NICU Nursing Care Survey (NNCS)調查護理人員對發展性照護認知與態度,綜合45份問卷結果得知,護理人員都具備正向的發展性照護態度和理解(M>3),不同年齡層、年資及職級,其照護態度、措施提供頻率、照護影響因素及滿意度皆無顯著差異3.培訓臨床種子教師使其相互評核能力達90%一致性,並擔任指引宣傳、示範及評核4.設計並使用DOPS技術評量表監測人員執行ROP檢查正確性。
介入期:透過課程、影片及種子教師示範教學,護理人員有31人(31/45=69%)完成第一次評核,每項≧7分有26人,通過率83.9%,後續完成再評核有21人(21/31=68%),≧7分有21人,通過率100%。
追蹤監測期:人員對指引實施感到安全且滿意度達100%,政策面將ROP檢查流程改為雙人執行,並持續以DOPS定期性監測評量,以落實指引應用。
結論:透過轉譯研究將實證資料推動至臨床實務,指引的建立是ㄧ項能降低臨床照護結果變異性的重要方式,將具有實證基礎的有效臨床建議,進一步落實到病人照護上,對第一線健康照護提供者而言,別具意義。本研究延續發展性照護的實證成效將其整合建立知識 (Knowledge Creation),淬煉出臨床照護指引,並在行動應用階段(Knowledge Application)透過多元推動策略,強調將實證知識運用於臨床工作情境並評值成效,完成轉譯研究兩階段過程,並進而提升早產兒ROP檢查之照護品質。
英文摘要 Background:
The previous studies have found that the examinations of the retinopathy of prematurity (ROP) can cause pressure and discomfort. Subsequently, the preterm infant’ body and behaviors are affected. The concept of the developmental care is a comprehensive approach with a tailored care that is developmentally supportive and individualized to the goals of stability. Its purpose is to protect the brain development of the preterm infants.
Purpose:
This research aims to establish the guidelines of developmental care of ROP examinations by evidence-based knowledge that suitable for this field. Evaluation of the effectiveness on the clinical affairs is also conducted.
Method:
The translation research is adopted for this study. With leadership team and integrated evidence-based, the process of translation is to establish, promote and evaluate the guidelines of development care for ROP examinations, and apply to the clinical practice. The research is conducted at the neonatal intensive care unit (NICU) of a medical center in southern Taiwan. The data collection includes awareness and attitude of nurses by NICU nursing care survey (NNCS) and the satisfaction of the implementation of developmental care during ROP examination. Data are analyzed by the descriptive and correlation statistics. The guideline is promoted via the seminar, video, self-education, workshop, flyer, banner, essay and short film to increase the awareness, and becomes a culture in the working environment. In addition, the applicability of guideline will be evaluated and the outcomes will be monitored by the NNCS to investigate the care quality of developmental care in the NICU.
Result:
The translation research of this study within the development of guidelines and the procedures are shown below:
Preparation Stage: 1. To conduct a systematic reviews of literatures for establishing a guidelines of development care for ROP examine.The experts consensus and verification were applied to reach the expert validity to the guidline of developmental care for ROP examinations. 2. According to the perception and attitude of nurses by NICU nursing care survey (NNCS), the result revealed nurses have positive attitude and understanding of developmental care (M>3). Regarding to the different group of age, nursing experience and seniority, no significant differences were found on the attitude of caring, sequences of comprehensive approach provided and the elements of effects and satisfaction of caring. 3. Providing training to cultivate clinical trainer to show≧90% consistency in peer-review, and serve promoting guidelines, demonstrations and evaluation. 4. Formulate and utilize DOPS evaluating system to monitor for the accuracy of ROP.
Intervention Stage:Through courses, films and seed teachers’ demonstrations, 31 (69%) of nurses completed first evaluation, in each dimension 26 of nurses scored ≥7, the pass rate is 83.9%. Furthermore, 21 (68%) of nurses completed re-evaluation, 21 nurses scored ≥7 which means the pass rate is 100%.
Evaluation Stage: The nurses are secured in practice with the guidelines and the satisfaction reached 100%. In order to advance the guidelines, the ROP process examination will conduct by two nurses and monitor by DOPS periodically.
Conclusion:
Through translation research and integrate evidence-based data to clinical practice, guideline development is a critical approach which is able to decrease the outcome variables of clinical practice. Within evidence-based data to support as effective recommendation of clinical practice, acting in patients’ care is a meaningful move to those first-line health care professionals (HCPs).
This study continues the evidence-based result of developmental care and establishes “Knowledge Creation” which becomes the guidelines of developmental care. Moreover, on the stage of “Knowledge Application”, through multi-promotion strategies to emphasize the evidence-based knowledge that apply to clinical practice and also evaluate the performance. After accomplished two phases of translation research processes, this research also elevates the quality of care for ROP and examination.
論文目次 中文摘要 I
Abstract III
誌謝 VI
第一章 緒論 1
第一節 研究背景 1
第二節 研究動機與重要性 2
第二章 文獻查證 4
第一節 早產兒視網膜病變 4
一、早產兒視網膜病變檢查照護問題 4
二、早產兒視網膜病變檢查疼痛控制之相關研究 5
第二節 早產兒發展性照護 10
一、統合理論 10
二、新生兒個別化發展性照護及評估 11
三、發展性照護措施應用於早產兒視網膜病變檢查 13
四、發展性照護概念之評估工具 14
第三節 轉譯研究 16
一、轉譯研究的發展 16
二、轉譯研究的障礙 17
三、實證轉譯到臨床應用 18
第三章 研究設計 24
第一節 研究方法 24
第二節 研究目的 24
一、建立早產兒視網膜病變檢查之發展性照護指引(ROP檢查指引)25
二、轉譯ROP檢查指引於臨床實務推動 25
三、評價ROP檢查指引於臨床之可行性與困難度 25
四、落實ROP檢查指引於臨床使用 25
第三節 研究場域 25
第四節 研究者之背景與角色 25
第五節 計畫與執行步驟 26
一、準備期 27
二、介入期 40
三、追蹤監測期 44
第四章 研究結果 45
第一節 準備期 45
第二節 介入期 63
第三節 追蹤監測期 64
第五章 討論 66
第ㄧ節 早產兒視網膜病變檢查之發展性照護指引的建立 66
第二節 臨床實務推動成效 67
第三節 評價指引於臨床執行之可行性與困難度 68
第四節 落實ROP檢查指引於臨床使用 69
第六章 結論 71
第七章 參考文獻 73

表目錄
表 2-1 早產兒視網膜病變檢查疼痛控制之相關研究 8
表 2 2 新生兒護理照護子項內容說明 16
表 2 3 不同學者之實證轉譯步驟 23
表 3 1 Melnyk和Fineout-Overholt 實證證據分級 30
表 3 2 建議強度之評等 30
表 3-3 早產兒視網膜病變檢查之發展性照護指引臨床建議草案 31
表 3-4 DOPS評量表評分者間一致性 39
表 3-5 早產兒視網膜病變檢查之發展性照護DOPS評量重點 40
表 3 6 早產兒視網膜病變檢查之發展性照護指引工作坊教學活動 43
表 4-1 早產兒視網膜病變檢查之發展性照護指引專家意見 47
表 4-2 研究對象基本資料及照護態度、措施提供頻率、影響因素之相關性分析 52
表 4-3 照護態度各題分布情形 53
表 4-4 措施提供頻次分布情形 56
表 4-5 影響提供照護之決定因素分布情形 57
表 4-6 照護促進及阻礙影響因素 58
表 4-7 護理人員執行協助ROP檢查過程滿意度各題分布情形 59
表 4-8 研究對象基本資料及照護態度、措施提供頻率、照護影響因素及滿意度之差異性分析 60
表 4-9 早產兒視網膜病變檢查之發展性照護DOPS評核分數 65

圖目錄
圖 2 1 實證實務改變模式 19
圖 2 2 知識到行動架構 22
圖 3 1 本研究之實證轉譯研究步驟 24
圖 3 2 計畫執行分期及工作內容規劃 26
圖 3 3 ROP檢查之發展性照護指引團隊成員組織架構圖 27
圖 3-4 早產兒視網膜病變檢查之發展性照護指引發展流程圖 35

附錄
附錄 一 早產兒視網膜病變檢查過程之發展性照護措施評分量表 80
附錄 二 早產兒視網膜病變檢查過程之發展性照護措施 82
附錄 三 早產兒視網膜病變檢查過程之發展性照護措施執行現況滿意度調查 83
附錄 四 早產兒視網膜病變檢查之發展性照護臨床技能評量表 85
附錄 五 人體試驗委員會通過證明 88
附錄 六 早產兒視網膜病變檢查之發展性照護指引臨床建議 90
參考文獻 王淯汶、張瑩如(2015).發展性照護之理論發展與研究趨勢.護理雜誌,62(5),89-95。
周繡玲(2011).臨床照護指引的發展方法.腫瘤護理雜誌,11,5-14。
林貞秀、張瑩如、林佳霓、黃美智(2012).發展性照護於早產兒餵食之應用.護理雜誌,59(3),107-112。
林賢璋、翁書偉、張劭聿(2013).轉譯研究在臺灣的現況與發展臺.灣東亞文明研究學刊,10(1),347-359。
凃靜芬(2010).早產兒氣管內管抽吸實證照護指引發展與成效評值.成功大學護理學系學位論文。
袁朝蓉、華一鳴、李慈音 (2009).從氧化壓力重新思考早產兒氧氣的使用.護理雜誌,56(4),77-82。
陳可欣、高靖秋、陳杰峰(2016).實證知識轉譯—落實科學證據於護理臨床實務.護理雜誌,63(6),5–11。
鄒怡真、游婷芳、王桂芸(2014).轉譯研究在品質促進之應用與建議.源遠護理,8(3),19-24。
鄭浩民(2013).轉譯科學-一個未來實證照護及醫學研究的重要趨勢.榮總護理,30(2),111-120。
穆佩芬(2013).質性轉譯研究之臨床應用.護理雜誌,60(5),18-24。
Alam, D., Padhi, T. R., & Modi, R. R. (2014). Comment on oral sucrose and non-nutritive sucking goes some way to reducing pain during retinopathy of prematurity eye examinations. Acta Paediatrica, 103(12). e513 doi: 10.1111/apa.12793
Allegaert, K., Casteels, I., & Tibboel, D. (2010). Pain management during eye examinations for retinopathy of prematurity: What about procedural adaptations to blunt the pain response? Acta Paediatrica, 99(4), 488-489. doi:10.1111/j.1651-2227.2009.01672.x
Als, H. (1986). A synactive model of neonatal behavioral organization: Framework for the assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care environment. Physical & Occupational Therapy in Pediatrics, 6(3-4), 3-53.
Als, H. (1999). Reading the premature infant. Developmental interventions in the neonatal intensive care nursery. New York: Oxford University Press, pp. 18-85.
Boyle, E. M., Freer, Y., Khan-Orakzai, Z., Watkinson, M., Wright, E., Ainsworth, J. R., & McIntosh, N. (2006). Sucrose and non-nutritive sucking for the relief of pain in screening for retinopathy of prematurity: A randomized controlled trial. Archives of Disease in Childhood. Fetal And Neonatal Edition, 91(3), F166-F168.
Chuang, L. J. (2015). Effects of developmental care on reducing pain and stress for preterm infants during retinopathy of prematurity examinations (Unpublished master’s thesis). Tainan:Department of Nursing, College of Medicine, NCKU.
Cohen, A. M., Cook, N., Harris, M. C., Ying, G. S., & Binenbaum, G. (2013). The pain response to mydriatic eyedrops in preterm infants. Journal of Perinatology, 33(6), 462-465. doi: 10.1038/jp.2012.149
Cunningham, S., McColm, J. R., Wade, J., Sedowofia, K., McIntosh, N., & Fleck, B. (2000). A novel model of retinopathy of prematurity simulating preterm oxygen variability in the rat. Investigative Ophthalmology & Visual Science, 41(13), 4275-4280.
Darlow, B. A., Gilbert, C. E., & Quiroga, A. M. (2013). Setting up and improving retinopathy of prematurity programs: Interaction of neonatology, nursing, and ophthalmology. Clinics in Perinatology, 40(2), 215-227. doi:10.1016/j.clp.2013.02.006
Dempsey, E., & McCreery, K. (2011). Local anesthetic eye drops for prevention of pain in preterm infants undergoing screening for retinopathy of prematurity. Cochrane Database of Systematic Reviews, 7(9), 1-19. doi:10.1002/14651858.CD007645.pub2
Dilli, D., İlarslan, N. E. Ç., Kabataş, E. U., Zenciroğlu, A., Şimşek, Y., & Okumuş, N. (2014). Oral sucrose and non‐nutritive sucking goes some way to reducing pain during retinopathy of prematurity eye examinations. Acta Paediatrica, 103(2), e76-e79. doi:10.1111/apa.12454
Fierson, W. M., Saunders, R. A., Good, W., Palmer, E. A., Phelps, D., Reynolds, J., . . . Blocker, R. J. (2013). Screening examination of premature infants for retinopathy of prematurity. Pediatrics, 131(1), 189-195. doi:10.1542/peds.2012-2996
Glasziou, P. P., Chalmers, I., Green, S., & Michie, S. (2014). Intervention synthesis: A missing link between a systematic review and practical treatment(s). PLoS Medicine, 11(8), e1001690. doi:10.1371/journal.pmed.1001690
Gonçalves, R. L., Tsuzuki, L. M., & Carvalho, M.G. (2015). Endotracheal suction in intubated newborns:an integrative literature review. Revista Brasileira de Terapia Intensiva, 27(3), 284-292. doi: 10.5935/0103-507X.20150048
Hered, R. W., & Gyland, E. A. (2010). The retinopathy of prematurity screening examination: Ensuring a safe and efficient examination while minimizing infant discomfort. Neonatal Network, 29(3), 143-151.
Jordan, C. O. (2014). Retinopathy of prematurity. Pediatric Clinics of North America, 61(3), 567-577. doi: 10.1016/j.pcl.2014.03.003
Kandasamy, Y., Smith, R., Wright, I. M., & Hartley, L. (2011). Pain relief for premature infants during ophthalmology assessment. Journal of American Association for Pediatric Ophthalmology and Strabismus, 15(3), 276-280. doi:10.1016/j.jaapos.2011.03.009
Kataria, M., Narang, S., Chawla, D., Sood, S., & Gupta, P. C. (2015). Oral dextrose for pain management during laser treatment of retinopathy of prematurity under topical anesthesia. Indian Journal of Pediatrics, 82(8), 694-697. doi:10.1007/s12098-015-1718-2
Khoury, M. J., Gwinn, M., & Ioannidis, J. P. (2010). The emergence of translational epidemiology: From scientific discovery to population health impact. American Journal of Epidemiology, 172(5), 517-524. doi:aje/kwq211
Kirwan, C., O'Keefe, M., Prendergast, M., Twomey, A., & Murphy, J. (2007). Morphine analgesia as an alternative to general anaesthesia during laser treatment of retinopathy of prematurity. Acta Ophthalmologica Scandinavica, 85(6), 644-647.
Kleberg, A., Warren, I., Norman, E., Mörelius, E., Berg, A.C., Mat-Ali, E., & Hellström-Westas, L. (2008). Lower stress responses after Newborn Individualized Developmental Care and Assessment Program care during eye screening examinations for retinopathy of prematurity: A randomized study. Pediatrics, 121(5), e1267-e1278. doi: 10.1542/peds.2006-2510
Larrabee, J. H. (2009). Nurse to nurse: Evidence-based practice. New York: McGraw-Hill.
Lean, M., Mann, J., Hoek, J., Elliot, R., & Schofield, G. (2008). Translational research. British Medical Journal, 337: a863. doi: 10.1136/bmj.a863
Lin, C.N. (2014). Exploring clinical facts of individualized developmental care for preterm infants receiving retinopathy of prematurity (Unpublished master’s thesis). Tainan: Department of Nursing, College of Medicine, NCKU.
Lopez, O., Subramanian, P., Rahmat, N., Theam, L. C., Chinna, K., & Rosli, R. (2015). The effect of facilitated tucking on procedural pain control among premature babies. Journal of Clinical Nursing, 24(1-2), 183-191. doi: 10.1111/jocn.12657
Lyon, F., Dabbs, T., & O'Meara, M. (2008). Anesthesia in retinopathy of prematurity treatment. Eye, 22(1), 165-165.
Manjunatha, C. M., Ibhanesebhor, S. E., Rennix, C., Fisher, H., & Abara R. (2009). Pain control during retinopathy of prematurity screening: Double-blind, randomized, placebo-controlled study. Infant, 5(5), 155-158.
McManus, B., & Capistran, P. (2008). A case presentation of early intervention with dolichocephaly in the NICU: Collaboration between the primary nursing team and the developmental care specialist. Neonatal Network, 27(5), 307-315.
Meek, J. (2012). Options for procedural pain in newborn infants. Archives of Disease in Childhood-- Education & Practice Edition, 97(1), 23-28. doi:10.1136/archdischild-2011-300508
Mehta, M., Mansfield, T., & VanderVeen, D. (2010). Effect of topical anesthesia and age on pain scores during retinopathy of prematurity screening. Journal of Perinatology, 30(11), 731-735. doi:10.1038/jp.2010.36
Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare. Philadelphia : Lippincott Williams & Wilkins.
Mitchell, A., Stevens, B., Mungan, N., Johnson, W., Lobert, S., & Boss, B. (2004). Analgesic effects of oral sucrose and pacifier during eye examinations for retinopathy of prematurity. Pain Management Nursing, 5(4), 160-168.
Mitchell, G. A., Jeffs, D. A., Roberson, P. K. (2011). Physiologic effects of retinopathy of prematurity screening examinations. Advances Neonatal Care, 11(4), 291-297. doi: 10.1097/ANC.0b013e318225a332
Nesargi, S. V., Nithyanandam, S., Rao, S., Nimbalkar, S., & Bhat, S. (2015). Topical anesthesia or oral dextrose for the relief of pain in screening for retinopathy of prematurity: A randomized controlled double-blinded trial. Journal of Tropical Pediatrics, 61(1), 20-24. doi: 10.1093/tropej/fmu058
Olsson, E., & Eriksson, M. (2011). Oral glucose for pain relief during eye examinations for retinopathy of prematurity. Journal of Clinical Nursing, 20(7-8), 1054-1059. doi: 10.1111/j.1365-2702.2010.03529.x
O'Sullivan, A., O'Connor, M., Brosnahan, D., McCreery, K., & Dempsey, E. M. (2010). Sweeten, soother and swaddle for retinopathy of prematurity screening: A randomised placebo controlled trial. Archives of Disease in Childhood -- Fetal & Neonatal Edition, 95(6), F419-422. doi: 10.1136/adc.2009.180943
Pearson, A., Jordan, Z., & Munn, Z. (2012). Translational Science and Evidence-Based Healthcare: A Clarification and Reconceptualization of How Knowledge Is Generated and Used in Healthcare. Nursing Research and Practice, 2012, 792519. http://doi.org/10.1155/2012/792519
Punyawattanaporn, A., Tengtrisorn, S., & Sangsupawanich, P. (2009). Pupil dilatation after single and triple doses of mydriatic agent in preterm infants. Journal of Medical Association of Thailand, 92(11), 1458-62.
Rush, R., Rush, S., Farshid, I., Anderson, B., Irwin, M., & Naqvi, M. (2005). The effects of comfort care on the pain response in preterm infant undergoing screening for retinopathy of prematurity. Retina, 25(1), 59-62. doi:10.1097/00006982-200501000-00008
Rush, S., Nicolau J., Chapman K, Naqvi M. (2004). Systemic manifestations in response to mydriasis and physical examination during screening for retinopathy of prematurity. Retina, 24(2), 242-245.
Samra, H. A., & McGrath, J. M. (2009). Pain management during retinopathy of prematurity eye examinations: A systematic review. Advances Neonatal Care, 9(3), 99-110.doi: 10.1097/ANC.0b013e3181a68b48
Straus, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: Moving from evidence to practice: John Wiley & Sons, pp. 21-23.
Sun, X., Lemyre, B., Barrowman, N., & O’connor, M. (2010). Pain management during eye examinations for retinopathy of prematurity in preterm infants: A systematic review. Acta Paediatrica, 99(3), 329-334. doi:10.1111/j.1651-2227.2009.01612.x
Vicente, G. V., Bahri, M., Palafoutas, J. J., Wang, H., & Mehta, N. (2012). A randomized controlled trial to determine the lowest effective dose for adequate mydriasis in premature infants. Journal of American Association for Pediatric Ophthalmology and Strabismus, 16(4), 365-369. doi: 10.1016/j.jaapos.2012.02.017.
Wood, M. G., & Kaufman, L. M. (2009). Apnea and bradycardia in two premature infants during routine outpatient retinopathy of prematurity screening. Journal of American Association for Pediatric Ophthalmology and Strabismus, 13(5), 501-503.
Wu, C.L. (2009). A pilot survey of nurses' attitudes and practice of developmentally
supportive care in NICUs in Taiwan ( Doctoral dissertation). University of
Washington.
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