Roy s Adaptation Model: Effect of Care on Pediatric Patients

Review Article Introduction Roy s Adaptation Model: Effect of Care on Pediatric Patients Neha Saini 1, Veena Sharma 2, Smriti Arora 3, Fareha Khan 4 Abstract With focus on groups of children who have increased morbidity, Roy s adaptation model (RAM) is one of the most useful conceptual frameworks that guide nursing practice. It focuses on individual s adaptation to changeable environment and guides the assessment of individual s adaptation. The four modes of adaptation defined in RAM are physiologic, self-concept, role function and interdependence modes. Nurses help to meet the needs of individuals in these modes of adaptation. Keywords: Effectiveness, Care based on Roy s Adaptation Model, Physiological dimensions Nursing of infants, children and adolescents is consistent with the definition of nursing as the diagnosis and treatment of human response to actual or potential health problems. This definition incorporates the four essential features of contemporary nursing practice: attention to the full range of the human experiences and responses to health and illness without restriction to a problem focused orientation, integration of objective data with knowledge gained from an understanding of the patient or group s subjective experience, application of scientific knowledge to the process of diagnosis and treatment and provision of a caring relationship. 1 Recent concern has focused on groups of children who have increased morbidity, are children living in poverty, LBW children, children with chronic illness and homeless children. Therefore, the art of pediatric nursing care should focus on philosophy of care, family centered care, and traumatic care (prevent or minimize the child s separation from the family, promote a sense of control, and prevent or minimize bodily injury and pain) which can be guided and provided by theory-based nursing practice. 1 Nursing has made phenomenal achievement in the last century that has led to the recognition of nursing as an academic discipline and a profession. A move towards theory-based practice has made contemporary nursing more meaningful and significant by shifting nursing focus from vocation to an organized profession. The need of the knowledge base to guide professional nursing practice has been realized and many theoretical frameworks have been contributed by nurses. 2 Within nursing, the development and utilization of nursing models is an area of constant growth. A conceptual model deals with abstractions that are assembled because of their relevance to a common theme. It is supposed that the utilization of nursing models in clinical practice gives design to the nursing process. 1 MSc. Nursing Student, Child Health Nursing Department, 2 Associate Professor, 4 Tutor, Rufaida College of Nursing, Jamia Hamdard. 3 Professor, Amity College of Nursing, Haryana, India. Correspondence: Ms. Neha Saini, Rufaida College of Nursing, Jamia Hamdard, India. E-mail Id: nehasaini_06@yahoo.in Orcid Id: http://orcid.org/0000-0003-4235-2808 How to cite this article: Saini N, Sharma V, Arora S et al. Roy s Adaptation Model: Effect of Care on Pediatric Patients. Int J Nurs Midwif Res 2017; 4(1): 52-60. Digital Object Identifier (DOI): https://doi.org/10.24321/2455.9318.201708 ISSN: 2455-9318 ADR Journals 2017. All Rights Reserved.

Int. J. Nurs. Midwif. Res. 2017; 4(1) Saini N et al. It has also been proposed that nurses will become more autonomous and subsequently more accountable in what they do if they use the nursing model in practice. 3 In order for the nursing model to be rendered useful within a practice area, it must be examined and defined. Roy s adaptation model (RAM) is one of the most useful conceptual frameworks that guide nursing practice. It focuses on individual s adaptation to changeable environment and guides the assessment of individual s adaptation. RAM enhances a nurse s ability to improve a person s interaction with the surrounding environment to provide an effective adaptation. The RAM has a consistent nursing process that directs nursing practice towards providing a holistic care of patients. RAM facilitates communication among nurses and fosters the development of common goals of patients care. 3 Sister Callista in 1976 built the framework for RAM, where she viewed the client as an adaptive system. According to RAM, the goal of nursing is to help the person s adaptive system to change in physiological needs, self-concept, role function, and interdependent relationship during health and illness. Roy s Adaptation Model Adaptation is the primary concept of interest in RAM. It is defined as the process and outcome in which thinking and feeling persons use conscious awareness to create integration between human perception and their environment. RAM depicts the individual as a biopsychosocial being who is able to identify internal and external stimuli that are influencing the person s adaptive behaviors. An individual responds in two processes called the regulator and cognator subsystems. The regulator subsystem includes autonomic body responses. Cognitive subsystem responds through four cognitive emotional channels: perceptual and information processing, learning, judgment, and emotion. Adaptation occurs when both the subsystems are stimulated resulting in behavioral change measured in physiological, self-concept, role function, and interdependence as shown in Fig. 1. 3 Figure 1.Roy s Adaptation Model Concept of Roy s Adaptation Model There are numerous challenges in terms of caring for the pediatric patient. The first and most important question that flashes in a nurse s mind in a clinical setting is how they can help their clients and give them care. In this regard, scholars have suggested several important models and strategies. One of the nursing models that have vastly and deeply worked on adaptation in psychobiological and social dimensions is Roy s adaptation model, which aims at administration of nursing interventions for improvement of adaptive responses in each dimension (physiological, selfconcept, interdependence, and role function). 4 Based on RAM, the pediatric patient is precisely detected and his/her adaptive behaviors are increased through nursing intervention and manipulation of their causes as their stimulants, and consequently, a better physiological and psychological adaptation is obtained. 4 Based on this model, detection of unknown behavioral stimulants leads to precise exploration of the causes of patients maladaptive behaviors and helps the nurses to 53 ISSN: 2455-9318

Saini N et al. Int. J. Nurs. Midwif. Res. 2017; 4(1) design an accurate care plan to solve the pediatric patients problems (through adaptive behaviors). Therefore, it is predicted that adaptive behaviors (healthy behaviors) are increased in pediatric patients by application of interventions that are designed based on this model, which results in a reduction in complications. 4 A study was conducted by Clarke et al. 6 in which RAM focuses on a patient as a human being, the environment surrounding them, their present health, and nursing application or nursing responsibilities for that patient. Each aspect plays an important part in understanding the model as a whole. RAM is the theoretical framework that makes the combination of sciencebased activities a uniquely nursing activity, directing nursing care in a holistic direction. 5,6 According to Roy s and Andrews, adaptation is the primary concept of interest in RAM. It is defined as the process and outcome in which thinking and feeling persons use conscious awareness to create integration between human perception and their environment. Roy s depicts the individual as a bio-psychosocial being who is able to adapt to environmental stimuli categorized as focal or contextual. Individual responds to the stimuli through two processes called the regulator and the cognitive subsystems. The regulator subsystem includes autonomic bodily responses through neural, chemical and endocrine responses. Cognitive subsystem responds through four cognitive emotional channels: perceptual and information processing, learning, judgment, and emotions. Adaptation occurs when the cognator and regulator subsystems are stimulated resulting in behavioral changes measured in physiological, selfconcept, role function and interdependence. 7 Though it is all mentioned in books to provide care on the basis of nursing theories in order to follow principles of nursing care, still when we work in the clinical setting it is not followed. Through the evidence-based practice and a nursing theory is focused to guide assessment, interventions, evaluation, and implementation of nursing care, in order to improve the maladaptive behavior with the problems related to health, the RAM can be used. Modes of Roy s Adaptation Model 8 The four modes of adaptation defined in RAM are physiologic, self-concept, role function and interdependence modes. Nurses help to meet the needs of individuals in these modes of adaptation. The classification of the individual s positive physiologic mode adaptation indicators are as follows: Physiologic mode The physiological mode measures all bodily functions. Oxygenation Balanced ventilation period Balanced gas exchange style Sufficient gas exchange Sufficient compensation period Nutrition Balanced digestion period Sufficient nutrition style for body requirements Supplying metabolic and nutritional requirements with altered nutrition style Elimination Sufficient bowel evacuation period Balanced bowel evacuation style Sufficient urination period Balanced urinary elimination style Efficient coping methods in case of altered evacuation style Activity and Rest Sufficient activity period Sufficient empowerment of balancing movements during immobility Sufficient activity and resting style Sufficient sleep period Environmental changes effecting sleep disturbances Protection Intact skin Sufficient healing period Sufficient secondary protection against changes in immune status and skin integrity Sufficient immune period Sufficient heat regulation Senses Sufficient emotion period Efficient integration of emotional data input Balance of perceptive input and evaluation Efficient coping methods in case of altered sense ISSN: 2455-9318 54

Int. J. Nurs. Midwif. Res. 2017; 4(1) Saini N et al. Fluid-electrolyte and acid-base balance Sufficient period in fluid balance Balanced electrolyte levels of body fluids Balanced acid-base status Efficient organization of chemical buffering Neurologic Function Efficient response in sense, perception, coding, concept formation, memory, language, planning and motor response Integration of thought and sense processes Development of flexibility and functional effectiveness during neurologic system aging and alteration Endocrine Function Efficient hormonal regulation during body and metabolic processes Efficient hormonal regulation in reproductive development Negative feedback closed-circuit balance in hormonal regulation Balanced hormone cycle rhythm Efficient stress management methods Self-Concept Mode Focuses personal aspects of human system especially psychic and spiritual integrity. It deals with the perception of the physical self. The classification of the individual s positive self-concept mode adaptation indicators are as follows: Positive body image Effective sexual function Spiritual integrity in physical growth Sufficient compensation for body changes Sufficient coping methods in loss Efficient period in end-of-life Sufficient integration of own ideas Balanced consistency Efficient period in moral-ethic and spiritual development Functional self-respect Efficient coping methods in threat against oneself Role Function Mode It deals with the social integrity, focuses on performance of activities associated with various life roles. The classification of an individual s positive role function mode adaptation indicators are as follows: Identification of roles Efficient role changing period Combination of non-verbal and explanatory role movements Combination of primary, secondary and tertiary roles Efficient example in fulfilling roles Efficient coping methods in role changing Responsibility to fulfill roles Combining efficient roles Balanced role sufficiency Interdependence Mode It deals with social integrity and it focuses on affectional relationships, provision and receipt of social support. The classification of an individual s positive interdependence mode adaptation indicators are as follows: Sufficient love Balanced love, respect, giving and taking value Efficient dependent and independent examples Efficient coping methods in case of loneliness and separation Sufficient development for learning and maturation in relationships Sufficient communication and relation Providing developmental talent in formation of attention and care Trust in relationships Sufficiency of support systems and close individuals in providing development Application of Roy s Adaptation Model in Pediatric Care Waweru et al. 9 conducted a study to assess the adaptation of children living with AIDS in the selfconcept mode. They considered coping with AIDS as focal stimuli, the environment of care as the contextual stimulus, while the developmental level of the schoolaged children was the residual stimulus. Waweru et al. has completely supported the RAM in which various stimuli are affecting the self-concept mode. Also this study indicated that RAM could be used cross culturally. Ramini et al. 10 conducted a study to use the RAM to examine adaptive strategies of adolescents with cancer. 55 ISSN: 2455-9318

Saini N et al. Int. J. Nurs. Midwif. Res. 2017; 4(1) The questions have been used to reflect the physiological mode in the study related to the most distressing physical problems. The self-concept mode includes questions associated with feelings about body and self. The role function mode includes questions about the activities done by the breast cancer support group and the satisfaction level indicated these activities. The questions reflected the interdependence mode was related to the quality and quantity of support received from the support group. Results showed that adolescents and young adults reported evidences of positive adaptation. Linda 11 conducted a study and the purpose of this study was to link theory to practice by comparing the effectiveness of a theory-based nursing intervention with that of standard nursing practice. An intervention to address loss, guided by RAM, was tested for its effect on health outcomes among persons with chronic illness and found that the adaptation was increased. Afrasiabifar et al. 12 conducted a study and the aim of the present study was to examine the effect of RAM-based patient education on adaptation of hemodialysis. The results showed significant differences in the mean scores of physiological and self-concept models between the test and control groups (P=0.01 and P=0.03 respectively). Also a statistical difference (P=0.04) was observed in the mean scores of the role function mode of both groups. There was no significant difference in the mean scores of interdependence modes between the two groups. Radhamaniamma 4 conducted a study and described a detailed case application of RAM in the nursing care of patients with rheumatoid arthritis. The assessment and intervention were guided by RAM. An assessment tool for rheumatoid arthritis patient was prepared and administered to patients and found significant difference in the outcomes. Implications of Roy s Adaptation Model Nursing Education 1. Encourage the students for effective utilization of evidence-based practice, caring for pediatric patients. 2. Student nurses may be provided with learning experience for use of theory-based care as an intervention, caring for pediatric patients. 3. Student nurses and staff nurses can be educated for the use of care based on RAM for early identification and management of patients with a disease condition caring for pediatric patients. Nursing Practice 1. Nurses have a vital role in providing effective care to treat disease conditions for pediatric patients. This can be done by motivating nurses to understand the importance of theory-based care in the management of diseases. 2. Domains of the model are to be considered and assessed before providing care to the pediatric patient. 3. Based on RAM, the pediatric patient can be precisely detected and patient s adaptive behaviors are increased through nursing intervention and manipulation of their causes as their stimulant. Nursing Administration 1. The finding of the study could serve as a basis for administration to organize in-service education for nursing personnel to emphasize the importance of care based on RAM for pediatric patient. 2. The nurse administrators are in the pivotal position to formulate policies and implementation of this evidence-based practice at bed-side caring for pediatric patients. 3. They can also encourage further researches as per the recommendation. Nursing Research Promote more researches on theory-based nursing care in order to manage chronic as well as acute diseases in pediatric patients which can improve the base of professional knowledge in nursing. Promote effective utilization of research findings on management of diseases caring for pediatric patients. ISSN: 2455-9318 56

Int. J. Nurs. Midwif. Res. 2017; 4(1) Saini N et al. Developing a Nursing Care Assessment Tool and Planning Nursing Care for a Pediatric Patient Questionnaire Based on Roy s Adaptation Model (Physiological Modes) for Children with URTI Aspect of Physiological Modes to be Measured Problems associated with oxygenation Problems associated with nutrition Problems associated with activity and rest Area to be Evaluated Before After Intervention Intervention 1. Respiratory rate(12-18/min) 2. Depth of respiratory Deep (3) Moderate (2) Shallow (1) 3. Rhythm of respiration Regular (2) Irregular (1) 4. Chest retraction 5. Oxygen saturation of the child. <80% (1) 81-90% (2) >90% (3) 6. Capillary refill time <3 sec (2) >3 sec (1) 7. Cough 8. Dyspnea 9. Nasal discharge 10. Nasal flaring 11. Grunting 1. Weight of the child 2. Appetite Good (2) Poor (1) 3. Nausea and vomiting 1. Does the child have difficulty in getting up in the morning? 57 ISSN: 2455-9318

Saini N et al. Int. J. Nurs. Midwif. Res. 2017; 4(1) Problems associated with protection Problems associated with fluid and electrolyte 2. Duration of sleep <4 hours (1) 4-6 hours (2) 6-8 hours (3) >8 hours (4) 3. Activity intolerance? 5. General weakness 6. Irritability 7. Restlessness 8. Breathing worsens at night 1. Is there any dryness and crackling of the skin due to various procedures? 2. Is there any delayed wound healing process? 3. Temperature Normal temperature (2) Abnormal temperature (1) 4. WBC Count 1. Is there any episode of vomiting during the course of illness? 2. Is there any episode of loose motion during the course of illness? 3. Does the child have dry lips? 4. Does the child have poor skin turgor? 5. Serum Sodium 6. Serum Potassium ISSN: 2455-9318 58

Int. J. Nurs. Midwif. Res. 2017; 4(1) Saini N et al. 7. Serum Chloride Nursing Care on Questionnaire Based on Roy s Adaptation Model to Assess Physiological Dimensions Nursing Diagnosis Ineffective airway clearance related to increased mucous production as evidenced by cough Risk for imbalanced nutrition less than body requirements related to loss of appetite as evidenced by weight loss Activity intolerance related to acute or prolonged illness as evidenced by reduced physical mobility, exertional dyspnea, tachypnea Ineffective thermoregulation related to infection as evidenced by elevated body temperature Intervention Assess patient s condition Establish rapport to patient and SpO2 Monitor and record vital sign Assist patient to change position every 30 minutes Elevate head of bed and align head in the middle, position the patient in semi fowler s position Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds Encourage steam inhalation Encourage to increase fluid intake. Administer meds as ordered Suction nasal, tracheal or oral PRN Review client s chest X-ray for severity of acute/chronic Provide health teachings regarding effective coughing and deep breathing exercise. Assess the child weight. Evaluate general nutritional state, obtain baseline weight. Provide small, frequent meals, including dry foods and/or foods that are appealing to patient. Consider limiting use of milk products Elevate the patient s head and neck, and check for tube s position during NG tube feedings. Auscultate for bowel sounds. Observe for abdominal distension. Multivitamins can be provided in order to replenish lost vitamins. Teach the importance of feeding during illness. Determine patient s response to activity. Note reports of dyspnea, increased weakness and fatigue, changes in vital signs during and after activities. Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate. Assist patient to assume comfortable position for rest and sleep. Assist with self-care activities as necessary. Provide for progressive increase in activities during recovery phase and demand. Explain importance of rest in treatment plan and necessity for balancing activities with rest. Monitor vital signs 4 hourly. Assess skin temperature. Tapid sponge should be provided Instruct SpO2 to provide with loose clothing. Encourage fluid intake orally or intravenously as ordered. Measure intake and output Monitor WBC count. 59 ISSN: 2455-9318

Saini N et al. Int. J. Nurs. Midwif. Res. 2017; 4(1) Imbalanced fluid and electrolyte related to indigestion as evidenced by vomiting/ diarrhea To administer antipyretics as prescribed by physician. Check for the source of infection. Assess the general condition of the patient to check the base line data. Assess for hypotension and tachycardia. Assess skin turgor, moisture of mucous membranes. Investigate reports of nausea and vomiting. Monitor intake and output (I&O), noting color, character of urine. Calculate fluid balance. Be aware of insensible losses. Weigh as indicated. Administer medications as indicated: antiemetic s, antidiarrheal, antibiotics as needed Provide supplemental IV fluids as necessary Conclusion Recent concern has focused on groups of children who have increased morbidity, are children living in poverty, LBW children, children with chronic illness and homeless children. Therefore, the art of pediatric nursing care should focus on philosophy of care, family centered care and atraumatic care, which can be guided and provided by theory-based nursing practice. Within nursing, the development and utilization of nursing models is an area of constant growth. RAM is one of the most useful conceptual frameworks that guide nursing practice. It focuses on individual s adaptation to changeable environment and guides the assessment of individual s adaptation. RAM aims at administration of nursing interventions for improvement of adaptive responses in each dimension (physiological, self-concept, interdependence, and role function. Conflict of Interest: None References 1. Marilyn J, Hockenberry, Wongs. Essential of Pediatric Nursing. Elsevier Publication. 8 th edn. 10-12. 2. Basheer SP, Khan SY. A Concise Textbook of Advanced Nursing Practice. 2 nd edn. Emmess Medical 439-449. 3. Ramini S, Brown R, Buckner E. Embracing Changes: Adaptation by Adolescents with Cancer. Pediatric Nursing Journal 2008; 34: 72-79. 4. Radhamaniamma J. Nursing care of patients with rheumatoid arthritis: An application of Roy s adaptation model. Journal of Pharmaceutical and Biomedical Sciences 2013; 27(27): 486-92. 5. Kraszewski L. Sister Callista Roy and the Adaptation Model. Journal of Ferris State University 3: 22-27. 6. Clark, Barone, Hanna et al. Roy s Adaptation Model. Nursing Science Quarterly 2011; 24(4): 337-44. 7. Bartlett J. Nursing theories: A framework for nursing practice. 127-30. 8. Figen Erol Ursavaş, Özgül Karayurt, Özge İşeri. Nursing approach based on Roy Adaptation Model in a patient undergoing breast conserving surgery for breast cancer. J Breast Health 2014; 10: 134-40. 9. Waweru S et al. Perceptions of children with HIV/AIDS from the USA and Kenya: Self concept emotional indicators. Pediatric Nursing Journal 2008; 34: 117-24. 10. Ramini S, Brown R, Buckner E. Embracing changes: Adaptation by adolescents with cancer. Pediatric Nursing Journal 2008; 34: 72-79. 11. Linda MD. Loss associated with chronic illness: Application of the Roy Adaptation Model. Grand Valley State University 212. 12. Afrasiabifar A, Karimi Z, Hassani P. Roy s Adaptation Model-based patient education for promoting the adaptation of hemodialysis patients. Iran Red Crescent Medical Journal 2013; 15(7): 566-72. Date of Submission: 07 th Apr. 2017 Date of Acceptance: 22 nd May 2017 ISSN: 2455-9318 60