1.1 Research Subjects
Inclusion criteria: patients who also met the following conditions: (1) age ≥ 18 years and <65 years[22] (2) meeting the 2019 Chinese major cerebrovascular disease diagnosis points[23] . (3) stable disease; (4) modified Rankin Scale (mRS) score ≥3[24] ; (5) normal cognition; (6) informed consent to participate in this study. Exclusion criteria: Patients with one of the following conditions (1) patients with other major concomitant diseases, such as heart failure, respiratory failure, malignancy, severe trauma, and other critical illnesses; (2) patients who are participating in other studies. Withdrawal criteria: patients with one of the following conditions: (1) patients who were unable to participate in the subject study due to disease regression; (2) patients who voluntarily requested to withdraw from the study due to personal reasons; (3) patients who were lost to follow-up.
1.2 Research Methodology
This trial was registered on 01/02/2022 (registration number: 2022038004-FS01) and approved by the Clinical Research Ethics Committee of the Second People's Hospital of Shenzhen, China. The registration number of the Chinese Clinical Trials Registration Center is ChiCTR2200060103.
1.2.1 Establishment of the subject group
All members of the group received uniform training and a division of responsibilities. There is one researcher mentor (a nursing expert in the field of chronic diseases), one national level 2 psychological counselor, two rehabilitation specialist nurses (intermediate level or above), one rehabilitation physician (intermediate level or above), one rehabilitation therapist, and two graduate students in the program. The supervisor is responsible for the overall design of the program and quality control; the counselor is involved in the program design and training of the guiding language; the rehabilitation physician is responsible for the assessment of the disease; the rehabilitation therapist is responsible for the rehabilitation guidance; the rehabilitation specialist nurse is responsible for the routine care; and the two postgraduate students are responsible for the implementation of the program, including sending and receiving questionnaires, data statistical analysis, and thesis writing with the assistance of other members of the subject group.
1.2.2 Sample size calculation
By reviewing the literature, the subjective well-being score was 36.20+2.84 in the intervention group and 33.41+2.74 in the control group based on the results of an experimental study in the stroke patient category [25], the degree of certainty (Power=1-β)=90%, and the significance level of two-sided = 0.05 were set, and the total sample size was calculated using G*Power 3.1 software. It was 110 cases, and at a 20% shedding rate, 132 cases should be included, 66 cases each in the intervention and control groups.
1.2.3 Constructing an intervention program
The preliminary draft of the intervention program was formed through the results of the preliminary status survey combined with the literature review and the study of the PERMA model theory. To ensure the scientificity and feasibility of the intervention protocol, seven experts were invited to consult through face-to-face meetings, and the entries and contents of the protocol were improved and modified according to the experts' suggestions. In order to ensure the practicality and effectiveness of the program, 10 young and middle-aged stroke patients who met the inclusion and exclusion criteria were selected for pretesting, and the problems that occurred in the pretest were analyzed and revised to form the final draft of the PERMA model psychological intervention program.
1.2.4 Implementation method
1.2.4.1Control group
The control group received conventional rehabilitation treatment and care, including stroke disease knowledge education, prevention of common post-stroke complications, placement of an anti-spasticity position, rehabilitation exercise, medication instruction, rehabilitation compliance education, dietary instruction, psychological care, and discharge instruction.
1.2.4.2 Intervention group
The intervention group was based on the PERMA model of psychological intervention for young stroke patients in the control group, with two graduate students and other members of the group assisting in a one-on-one approach. The order of the topics and the length of the intervention were flexibly adjusted according to the patient's needs and mastery, and the interval between the two interviews was 2-4 days. The specific intervention plan is shown in Table 1.
Table 1 Psychological intervention program for young stroke patients in the PERMA model
Time
|
Subject
|
Intervention content
|
Suggested Guidance Language
|
1st
|
Understanding Stroke
|
1. Self-introduction of the subject group; introduction of the department staff and environment.
2. Explain the knowledge about stroke and rehabilitation to enhance the patient's confidence in the rehabilitation treatment of the disease.
3. Collect information about the patient, including the patient's basic information, disease information, psychological status, the degree of harmony with family members, and the degree of support from family members for the patient.
4. Establish a trusting relationship with the patient and leave contact information, such as a telephone number and WeChat, with each other. (e.g., patients with language dysfunction can communicate with each other through gestures, writing, or typing.)
|
1. Do you know about stroke?
2. You can tell me what questions you have about stroke rehabilitation.
3. I will be happy to help you if you are confused about the psychological aspects.
|
2nd
|
Discovering positive psychological qualities
(P)
|
1. Use the intake talk technique to understand the psycho-emotional state of the patient.
2. Analyze the psychological problems caused by the stroke for the patient and tap into the positive aspects of things.
3. Use non-verbal communication such as eye contact and touch to empathize with the patient and give encouragement and emotional support.
4. Encourage patients to share positive and happy things about themselves to tap into their positive psychological qualities.
5. For patients aged 18–44 years old with a higher monthly income before the disease, increase the communication time or frequency appropriately according to the talks.
|
1. You can think of me as your friend (a patient of similar age) or your junior (an older patient) and share your happy things with me.
2. It is reasonable for you to have such thoughts, and I can understand your feelings.
3. I can see that you are in a good state, for example, you just mentioned..., which is very positive.
|
3rd
|
Cultivate
positive
emotions (P)
|
1. Start the interview around the concept and role of positive emotion and talk about the benefits of positive emotion and optimism for the disease.
2. Cultivate positive thinking and a positive attitude towards stroke events. Recommend watching movies with positive themes, such as "How Steel is Made" and "When Happiness Comes Knocking," so that patients can cooperate with treatment and rehabilitation with positive emotions and increase the initiative of participation.
3. Provide patients with the opportunity to watch the stroke promotional film "Time = Brain" and stroke rehabilitation case videos.
4. Give recognition and praise to patients for their positive emotions.
5. For patients with dysarthria, practice pronunciation and mobilize positive emotions through vocalization.
|
1. If you are willing to share, I would love to hear some positive and happy things about yourself.
2. Think back to a time when you had a difficult event in your life, and let's try to analyze it from the positive side.
3. According to the stroke propaganda film, people can recover well with active treatment and rehabilitation exercises.
|
4th
|
Gratitude Exercise (P)
|
1. Talk about the positive effects of learning to be grateful for improving emotional states and enhancing the sense of well-being in life.
2. Focus on the events in life and during hospitalization for which one needs to be grateful as an entry point, and guide the patient to recall them together.
3. Encourage patients to pay attention to the good and happy things in their lives and record three good things that happen every day before going to bed in the form of a diary or a circle of friends, preferably for 21 days, or the patient can dictate them and the family can record them for them.
|
1. You think of things and people that have touched you in the past or during your hospital stay, and please tell us if it is convenient to share.
2. You can write a letter of appreciation, edit a WeChat message, or record a voicemail and send it to the person you appreciate.
3. You can keep a diary, send a WeChat friend circle, or any other form of record the happy and beautiful things that happen to you every day.
|
5th
|
Engagement Exercise
(E)
|
1. Explain the definition and positive effects of the "flow" state. 2. According to the rehabilitation needs of the patient, the rehabilitation therapist will assess the patient's condition and then perform rehabilitation activities together under the guidance of the rehabilitation therapist. Let the patient engage in positive emotions and experience a sense of well-being. For example, practice rehabilitation exercises for hand functions such as "picking up beans, screwing nuts, and buttoning". 3. Discuss with patients their hobbies and interests. Combine the patient's condition and hobbies to develop activities. For example, playing chess, reading books, listening to music, etc. After the patient enters the state of "flow", the patient's attention is distracted from the disease and the body and mind are relaxed, which is conducive to positive psychological changes.
|
1. We can communicate about what hobbies or things you are more interested in.2. How do you feel when we develop rehabilitation activities and do rehabilitation exercises together? You can communicate with me anytime if you have any ideas or suggestions.3. Now imagine that you are at home, sitting in your study reading your favorite book and listening to your favorite song.
|
6th
|
Foster Positive Interpersonal Relationships (R)
|
1. Talk about positive communication skills and how good communication promotes interpersonal relationships.
2. Communicate around interpersonal relationships, give examples of the physical and psychological benefits of good interpersonal relationships, and guide patients to realize the importance of interpersonal relationships.
3. Conduct role plays so that patients can appreciate positive communication and experience the joy of interaction.
4. Play small games with family members, patients, and friends, such as "finger catching," if the rehabilitation physician's assessment of their condition permits.
5. Invite stroke patients who have recovered well to communicate with each other.
|
1. Tell about someone you like or something tough or happy you experienced together. 2. I just heard you discussing with a patient lower-limb exercises; it's good to communicate and learn more. 3. XXX is in bed, he is cheerful, optimistic, and engaged in positive rehabilitation exercises; his recovery is good; you can communicate more freely.
|
7th
|
Perception Meaning
(M)
|
1. Discuss with patients the meaning of life, the meaning of living, the meaning of loved ones, and the meaning of health, and guide them to establish a correct view of meaning. A positive view of meaning will enable patients to develop a sense of mission and direction. 2. Discuss the importance of each person's role in the family and the meaning of that role to loved ones, friends, and society. 3. Stimulate the patient's sense of responsibility to loved ones and society. 4. Instruct patients to deal with the ups and downs of life with optimism. As in the case of stroke events, learning to grow in adversity is also the meaning of life. 5. Guide patients to self-evaluate and talk about their interpretation of meaning.
|
1. Talk about something meaningful in your life or work. 2. I see that your family members are very patient with you; they need you very much, and you have a very important meaning to them. 3. In fact, everyone's life will encounter some unsatisfactory things, so believe that the rainbow will appear after the storm.
|
8th
|
Experience the achievement (A)
|
1. Conduct an interview with the patient about achievement and explain the positive psychological effects of achievement. 2. Develop a "rehabilitation prescription" with the patient and, under the guidance of the rehabilitation therapist, help the patient achieve a sense of accomplishment through functional rehabilitation exercises. 3. Set achievable goals and encourage the patient to use their strengths under the guidance of the rehabilitation therapist to gain a sense of accomplishment. For example, dressing and undressing by themselves, eating by themselves, going to the bathroom, etc. within the limits of their ability. 4. Promptly acknowledge the patient's achievements and give recognition and praise even for the accomplishment of small goals.
|
1. I saw you exercising on your own in bed; that's great! 2. The rehabilitation physician even complimented you on your progress. You are doing great; keep up the good work! 3. Rehabilitation is very crucial in the early stages, and as long as you stick to it every day, a virtuous cycle will be formed. 4. What do you have in mind for the future? Now is the time for you to plan.
|
1.3 Data collection
Assessments were made by scale before the intervention, immediately after the intervention, 1 month after the intervention, and 3 months after the intervention. Inpatients were assessed in the rehabilitation medicine ward or health education room, and discharged patients were assessed by telephone or face-to-face (face-to-face assessments were conducted at the stroke follow-up clinic).
1.4 Evaluation tools
(1)General information questionnaire
The investigator's own design included two sections: demographic and sociological information (gender, age, marital status, education, occupation, place of residence, monthly income, type of health insurance, smoking, alcohol consumption, primary caregiver) and disease-related information (comorbid chronic diseases, number of strokes, family genetic history).
(2)Index of well-being(IWB)
Campbell created it in 1976, and scholar Xiaodong Fan translated it into Chinese [26]. It consists of two parts: the overall affective index scale (8 items) and the overall life satisfaction questionnaire (1 item). The scale is based on a 7-point Likert scale. The mean score of the overall affective index scale and the score of the life satisfaction questionnaire (with a weight of 1.1) were added to the total score. 2.1-6 scores were considered low happiness, 6.1-10 scores were moderate happiness, and 10.1-14.7 scores were high happiness, and the Cronbach's coefficient of the scale was 0.90.
(3)Post-Traumatic Growth Inventory(PTGI)
The scale was designed and developed by the American scholar Tedeschi et al. [9], and Chinese scholars Wang Ji et al. [27] Chineseized it. It has 5 dimensions and 21 items, which are used to assess the level of post-traumatic growth of individuals, including relationships with others (7 items), new possibilities (5 items), personal strength (4 items), spiritual change (1 item), and appreciation of life (3 items), with each item rated 0-5, and the total score ranging from 0 to 100. Higher scores indicate higher levels of post-traumatic growth. Cronbach's coefficient of consistency reliability ranged from 0.611 to 0.874 for each dimension and total scale.
1.5 Statistical methods
All data in this study were statistically analyzed using SPSS 25.0 software at the level of significance (α=0.05).
(1) Count data were statistically described by the number of cases, and measurement data were statistically described by the mean ± standard deviation.
(2) The chi-square test was used to compare the general information of the two groups, and the rank sum test was used to compare the rank information.
(3) The data followed a normal distribution, the variance was unity, and an independent sample t-test was used to compare two groups at the same point in time.
(4) Repeated measures ANOVA was used to compare changes at different time points and to observe the interaction effects between groups over time.