探討癌症兒童學習適應之現況與影響因素

Abstract

中華民國兒童癌症基金會（2011）統計，每年有約600例兒童癌症新發病個案，其中學齡期與青少年期兒童者占40%以上。因癌症治療及身體症狀的變化，會影響癌症兒童學習適應，而產生缺席學校活動及與同儕分離的問題，但臨床護理照顧仍少見對此方面的重視。本研究旨在探討癌症兒童學習適應之現況及其影響因素，以提供護理人員發展返校轉銜照護模式之參考。 本研究採橫斷式調查，運用結構式問卷及「學習適應量表」之自陳量表作為研究工具，於民國99年8月至100年7月採方便取樣，納入收案條件為：1.中華民國兒童癌症基金會所登錄於台灣北部地區某教學醫院診斷之癌症兒童；2.施測時為四到九年級的癌症病童及其主要照顧者；3.癌症兒童及其主要照顧者能閱讀書寫中文者；4.於台灣北部地區某教學醫院接受住院治療或門診就診者；。5.癌症兒童及其主要照顧者能同時完成問卷者。分析方法使用統計軟體SPSS 13.0進行描述性統計、無母數二獨立樣本檢定(Mann-Whitney U) 、Pearson相關係數檢測、點二系列相關檢定(Point-biserial correlation)及列聯相關檢定。 本調查研究母群體共318人，符合納入條件者共83位，最後之有效研究樣本為61位。結果發現癌症兒童學習現況：61位個案中未正常就學的有20 人，其中1人休學，6人缺考學校考試；班級類型以普通班居多占91.8%，補救教學以接受在家教育為多數；學校成員中導師參與度平均76.24最高，校護參與度平均67.50最低。學習適應不論小學及中學或不分年級皆為學習環境最佳、身心適應及學習習慣次之，值得注意的是學習方法及學習態度皆最差。 學習適應影響因素，以兒童之一般特性、學習特性、家庭資源及學校資源加以探討。分析結果發現，兒童一般特性之不同診斷、治療階段、接受不同癌症治療以及不同就學階段的癌症兒童學習適應沒有差異。學習特性方面之正常就學的癌症兒童較非正常就學的癌症兒童在學習方法適應較佳(p<.05)。家庭資源中的父母親學歷與學習習慣(父母皆p<.05)、學習環境(父母皆p<.05)、身心適應(父p<.01；母p<.05)及學習適應(父母皆p<.05)有正相關；母親參與度越高癌症兒童學習環境(p<.01)及身心適應(P<.05)越好。學校資源部分，學校同學知情者學習方法(p<.05)、學習習慣(p<.05)、學習態度(p<.01)及學習適應(p<.05)較佳。 父母親參與度彼此為正相關(p<.05)，小學癌症兒童母親參與度較中學癌症兒童母親高(p<.05)。導師與同學參與度(p<.01)，以及同學與校護參與度(p<.001)彼此間互有正相關，而正常出席者其學校同學參與度較高(p<.05)，學校護理師知道病情可提升其參與度(p<.01)。 癌症兒童面臨學習適應之議題中，缺席是最主要問題，返校決策多由父母主導，母親影響大於父親；相對地，而學校教師、校護及同學在返校議題中參與少。提升癌症兒童學習適應應之策略，可從以下之面向著手：鼓勵病童在狀況許可下漸進式出席學校活動、初診斷時提供父母親正確觀念、發展返校轉銜照護模式、增強學校護理師功能以及開創學校專科護理師之新角色。建議將來研究者可探討癌症兒童發病後學習適應之連續變化，及統合家庭、醫療及學校資源，發展癌症兒童返校適應之轉銜護理照護模式。

According to the 2011 patient registries of Childhood Cancer Foundation, annually new cases of childhood cancer were estimated to be 600, among them the schooler and adolescence were more than 40%. The cancer treatments and physical symptoms will impact on the school adaptation of the children, who will have school abstentism and isolate from their peers. The purpose of this study is to explore the status of the learning adjustment and its correlates in children with cancer. It is hoped to provide a better reference for nurses to develop a school re-entry transitional care model. A cross-sectional study design is adopted in this research. The research tools are used by means of the structured questionnaires and the self-report inventory of Learning Adaptability Scale. From August, 2010 to July, 2011, convenience sampling is adopted. The inclusion criteria are: 1. children who are diagnosed with cancer by a teaching hospital in the northern region of Taiwan and enlisted by Childhood Cancer Foundation; 2. the children who suffer from cancer are 4th graders to 9th graders and their main caregivers when the experiment is tested; 3. the children of cancer and their main caregivers who can read and write in Chinese; 4. the children who are hospitalized or receive an outpatient treatment in a teaching hospital in the northern region of Taiwan; 5. the children and their main caregivers are able to complete the questionnaire test of the experiment at the same time. As for the analytical approach, the descriptive statistics, Test Type: Mann-Whitney U, Pearson correlation, Point-biserial correlation and contingency coefficient are conducted with the use of the statistical software SPSS 13.0. The target population is 318 in this study, 83 individuals who meet the inclusion criteria. In the end, the valid samples are 61 children. The learning situations of children of cancer is found that twenty children do not go to school regularly. Among them, one quits school, and six are absent and don’t take exams at school; as for the types of classes, regular classes are the most, accounting for 91.8%. As for remedial teaching, the most is accepting home schooling. Among school staff, the average level of mentors’ involvements is 76.24, which is the highest. The average level of school nurses’ involvements is 67.50, which is the lowest. In terms of learning adjustment, both in primary schools and high schools or the grades, the learning environment is the best, and followed by body and mind adaptation and learning habits. What deserves attention is that both the learning method and learning attitude are the worst. The factors influenced by learning adjustment are discovered by the general characteristics, learning characteristics, family resources and school resources of children. Results show that there is no difference of learning adjustment in the different diagnoses, stages of therapies, and treatment protocols, as well as at different stages of schooling. In the adaptation of learning methods, children suffering from cancer and going to school regularly are better than children suffering from cancer but going to school irregularly (p<.05). There are positive correlations in the habits of family resources (for both parents, p<.05), learning environments (for both parents, p<.05),physiological and pyschological adaptation (for fathers, p<.01; for mothers, p<.05) and learning adaptation (for both parents, p<.05). The higher the level of the maternal involvements is, the better the learning environments for children suffering from cancer (p<.01) and the body and mind adaptation (p<.05) is. As for the part of school resources, when schoolmates knows the situations, learning methods (p<.05), learning habits (p<.05), learning attitudes (p<.01) and learning adaptation (p<.05) are better. There is a positive correlation (p<.05) in the level of paternal and maternal involvements for each other. The level of maternal involvement for children suffering from cancer in primary schools are higher than that of maternal involvement for children suffering from cancer in high schools (p<.05). There are positive correlation in the level of mentors’ and classmates’ involvements (p<.01) and the level of classmates’ and school nurses’ involvements (p<.001) for each other. Also, for the children who go to school regularly, the level of schoolmates’ involvements are higher (p<.05). If the school nurses know their situations about their diseases, it can help to improve their involvements (p<.01). School absence is the major problem for children with cancer confronting the learning adjustment issues. The decision-making of school reentry is mostly managed by the parents; moreover, mother plays a leading role more than father does; In contrast, school teachers, school nurses and peers participate in this issue less. We can improve the learning adjustment of children with cancer by following methods: encouraging children with cancer to attend school activities gradually if health condition is allowed, providing the appropriate concepts for the parents during early diagnosis, developing school reentry transitional care model, facilitating the school nurse’s function and initiating the new role of school nurse practitioner. Recommendation for future researchers is to explore the continuous changes of learning adjustment of children with cancer, and to integrate family, medical and school resources to establish the school reentry transitional care model of children with cancer