| Abstract: | 應屆畢業護生雖然經過多次臨床實習的學習過程，但對即將成為臨床護士的角色，感到壓力及焦慮。某技術學院基於增加護生能力及培育產業人才所須，實施臨床選習制度，但臨床選習壓力過大，會影響護生職涯抉擇，產生不當因應策略，有憂鬱與焦慮情緒。因此，本研究目的主要有二：（1）瞭解臨床選習壓力、因應策略、輔導需求的現況與關係；（2）設計及實施認知行為團體輔導方案，探討方案對護專學生臨床選習壓力、因應策略、輔導需求與壓力反應之成效，作為未來選習壓力輔導方案的參考。
於臨床選習結束後1週內，選取327位五專五年級護生，以自編「臨床選習壓力、因應策略、輔導需求等量表」進行資料蒐集，運用單因子多變量變異數分析、皮爾森積差相關、多元逐步迴歸分析等，結果顯示如下：
1、五專選習護生有輕度臨床選習壓力，以「專業知識與技能」壓力最高，「有時」會使用因應策略，以「情緒抒發或認知調適」頻率最多，「有些」需要臨床選習輔導需求，最需要「行政與專業技能協助」。
2、在「重急症與特殊單位」選習護生，在「實際護理病人」或「專業知識與技能」的壓力，比「一般內外科病房」及「產兒與精神科」單位高。
3、畢業前計畫為「不確定」的選習護生臨床選習壓力，高於計畫「工作」或「就學」者。
4、「問題逃避或轉移」因應策略運用愈多及「教師與作業協助」輔導需求愈高，「整體臨床選習壓力」愈高；「情緒抒發或認知調適」因應策略運用愈多，「整體臨床選習壓力」愈低。
5、「問題逃避或轉移」、「情緒抒發或認知調適」策略、「教師與作業協助」輔導需求能有效聯合預測「整體臨床選習壓力」，聯合預測力為32％（F(4, 322) = 40.92, p < .001），其中以「問題逃避或轉移」策略最具預測力，單獨解釋量為28％，故實施認知行為團體方案有助於改善臨床選習壓力，增加因應策略。
在驗證認知行為輔導方案成效上，採實驗研究法，分實驗與控制組兩班，各30位，於臨床選習前兩個月對五專五年級實驗組班級護生實施8次，每次90分鐘單元活動，以「臨床選習壓力、因應策略、輔導需求、貝克憂鬱、貝克焦慮等量表」來資料收集，進行GEE分析、成對樣本t檢定及 McNemar-Bowker test、獨立樣本T檢定等檢定分析差異，結果顯示如下：
1、臨床選習前護生呈現輕度憂鬱與焦慮，實施認知行為團體輔導方案後，實驗組護生整體憂鬱有越來越低趨勢，焦慮也下降。
2、實施認知行為團體輔導方案，可提升臨床選習護生對「護理工作的喜好程度」，不影響畢業規劃，無法改善臨床選習壓力及臨床選習輔導需求程度，但可增加「情緒抒發或認知調適」及「整體選習壓力因應策略」，具立即及延宕成效；可改善憂鬱情緒，具立即及延宕成效；可降低焦慮的「主觀感受」，具延宕成效。
根據上述的研究結果，提出相關的建議。
Although the graduates of the nursing major have taken various clinical practicum courses along the five years during their college study, they still feel a huge amount of stress and anxiety when they are going to work as nurses. Due to the great stress from the preceptorship clinical practicum, the nursing students of one technical college have developed improper adjustment strategies which induce more anxiety and depression and, moreover, have impact upon their career choices. This study aims to (1) understand the relationship among the stress of the preceptorship clinical practicum, the adjustment strategies and the need for counseling; and (2) design and implement the cognitive-behavioral group counseling model to investigate its effectiveness for developing certain adjustment strategies and the need for counseling among the students facing the stress of the preceptorship clinical practicum.
After the nursing students of the fifth grade from one five-year technical college finished the practicum, 327 were selected to fill out “the stress of the preceptorship clinical practicum, the adjustment strategies, the need for counseling questionnaire” within 1 weeks. Through One-way MANOVA, Pearson product-moment correlation and Multiple Step Regression, data analysis shows:
1. The subjects listed “the professional knowledge and skills” the highest stressful, “sometimes” adopted certain adjustment strategies among which “venting emotions and cognitive adjustment” were used most frequently. “Some” subjects expressed the need for counseling. “The administrative and the professional assistance” was most needed.
2. The subjects proceeding the practicum at the emergency or critical care units felt more stressful about “clinical nursing” and “professional knowledge and skills” than those at the medical, surgical, obstetrical, psychiatric units.
3. The subjects whose plans after graduation were uncertain showed higher stressful levels than those who planned to work or continue the formal education.
4. The more the coping strategies of “avoiding problems” were adopted and the need for “the instructor and the assignment assistance” was demanded, the higher the overall stress level of the preceptorship clinical practicum was. The more the coping strategies of “venting emotions and cognitive adjustment” were adopted, the lower the overall stress level of the preceptorship clinical practicum was.
5. “The avoiding problems strategies”, “the venting emotions and cognitive adjustment strategies” and “the need for the instructor and the assignment assistance” could be combined to predict the stress level of the preceptorship clinical practicum. The joint predictability is 32％（F(4, 322) = 40.92, p < .001）. “The avoiding problems strategies” had the most predictability. It is anticipated that the cognitive-behavioral intervention model would reduce the stress and promote the coping strategies.
To prove the effectiveness of the cognitive-behavioral intervention model, the experiment group and the control group were composed of thirty nursing students separately. Before the experiment group students went to the preceptorship clinical practicum, they were requested to participate in a 90-minute activity section eight times. The data was evaluated through the preceptorship clinical practicum stress questionnaire, Beck depression inventory, Beck anxiety inventory, and was analyzed through Generalized Estimatig Equations, paired-samples T test, McNemar-Bowker test and Independent Sample t-test. The outcome was as following：
1. After the cognitive-behavioral intervention model was exercised, the anxiety level and depression level was reduced.
2. After the cognitive-behavioral intervention model was exercised, the interest in nursing is increased. Moreover, the immediate and delayed effectiveness of “venting emotions and cognitive adjustment” and “the coping strategies for the preceptorship clinical practicum”was increased. The depressive emotions were improved. The subjective feelings of anxiety were reduced. |
