Patient ID: | Date: | 1st session: | 30th session: |
---|---|---|---|
Doll Therapy Intervention: | Sham Intervention (cube): | ||
 | Presence | Absence | |
1.Object presentation | |||
 1.a.Gaze direction: | |||
  Toward the nurse |  |  | |
  Toward the object |  |  | |
  Between the nurse and the object |  |  | |
  Immediately toward elsewhere |  |  | |
  Between the nurse and the object, then toward elsewhere |  |  | |
  Other |  |  | |
 1.b.Responses to the object presentation: | |||
  Acceptance |  |  | |
  Refusal |  |  | |
  Avoidance of the contact with the object |  |  | |
  Talking |  |  | |
  Asking the nurse for a meaning of the situation |  |  | |
2. Separation from the nurse | |||
 2.a Responses to the separation from the nurse: |  |  | |
  Acceptance |  |  | |
  Complain |  |  | |
  Worry |  |  | |
  Lack of interest |  |  | |
3. Behaviours during the interaction with the object | |||
 3.a. Exploration behaviours: | |||
  Exploration behaviours |  |  | |
  Duration of exploration behaviours (seconds) |  |  | |
  Types of exploration behaviours |  | ||
  Touching |  |  | |
  Smelling |  |  | |
  Looking at the object |  |  | |
  Moving the object around |  |  | |
  Relocating the object |  |  | |
  Other |  |  | |
 3.b. Caregiving behaviours: | |||
  Caregiving behaviours |  |  | |
  Duration of caregiving behaviours (seconds) |  |  | |
  Types of caregiving behaviours |  | ||
  Tightening grip on the object |  |  | |
  Caressing |  |  | |
  Cradling |  |  | |
  Talking |  |  | |
  Smiling |  |  | |
  Playing |  |  | |
  Other |  |  | |
4.Separation from the object | Â | Â | |
 Putting the object aside |  |  | |
 After how long does the patient puts the object aside (seconds) |  |  | |
 Looking for the nurse |  |  | |
 Calling the nurse |  |  | |
 Staying seated |  |  |