Contributors:
Miyuki Higashijima, RN, Diploma in Nursing
Chinatsu Iida, RN, BSN
Aya Imamura, RN, BSN, PHN
Hitomi Kaneko, RN, Diploma in Nursing, Advanced Midwife
Kaori Nitahara, RN, ADN, Certified Nurse in
Radiation/Oncology Nursing
Yoshie Shiotsuka, RN, Diploma in Nursing, Nutrition Support
Team Therapist(Certified from the Japanese
Society for Clinical Nutrition and Metabolism)

Practice/Theory Exemplar

Location – St. Mary’s College School of Nursing in Kurume, Japan

Description of the setting – Master’s Degree virtual course during which the learners explored their experiences based on the Roy Adaptation conceptual model of nursing. Noteworthy is that the St. Mary’s College research center is the Roy Academia Nursology Research Center.

Date of Implementation – February 2023

Theoretical Framework – Roy Adaptation Model

Miyuki Higashijima

Role function adaptive mode: [Primary role] Male in his 80s Developmental issue: ego integration [Secondary roles] Father: 2 sons, lives alone, does not want to bother his children. Brother: Sister lives nearby, they have supported each other.
Physiological adaptive mode: He has experienced physical changes in both upper limbs caused by a cervical fracture due to right renal cell carcinoma and a metastatic cervical vertebra tumor. He has numbness in his hands and decreased grip strength and is unable to grasp objects as he would like. He is blind in his left eye, has hearing loss in his left ear, and uses a hearing aid, but cannot hear very well Neck pain Numerical Rating Scale (NRS): 8/10
Self-concept adaptive mode: [Physical Self] Acknowledged a decline in self-respect.
“If it hurts this much, I’d rather die. ” “I can’t do anything with my hands. ” “I’m sorry to trouble you,” he said tearfully while helping him to eat. [Personal Self] Self-ideal is threatened. “I want to be able to do what I can do by myself until the end of my life.”.
“I want to be able to eat by myself. ” “I want to go home soon.” “Please stay by my side all the time.” “I want to be able to go to the bathroom by myself.” Fear of death
Interdependence adaptive mode:
He feels lonely because he has lost contact with his family. He longs to return home. [Support systems］Family: Eldest son and his wife, second son, sister. Health care staff: Nurses, rehabilitation and care workers, assistants, social workers, palliative care team staff
Focal stimulus: Neck pain.
Contextual stimuli: Anxiety about daily life due to numbness and loss of grip strength in both hands and muscle weakness in the lower extremities; and loneliness due to not seeing his family, and fear of death.
Nursing diagnoses: Low self-esteem, loss of self-respect and self-worth.
Goal of nursing: The man would be able to be proactive about what he can do for himself. The interventions were designed with an awareness of maximizing his existing functions so that he would not lose sight of his own value and the meaning of his life.
Management of stimuli: Prioritize what the man could do by himself; control pain and support self-medication; provide support to maintain usual activities of daily living—express support for use of a self-help device made by an occupational therapist so the man could more easily feed himself; post bedside notes about non-slip surfaces, placement of food and utensils, and eating posture so he could be assisted by others in eating in a consistent manner; talk with the man while he was eating by himself; assist with elimination of body wastes–standardize care so that the man could stand up and remove his pants by himself for toileting; support rehabilitation efforts, create opportunities for expressing anxieties
Adaptation level: The overall adaptation level was compensatory. Prioritizing what the man could do by himself increased his feelings of self-worth and quality of life. Pain was controlled by oral opioid and steroid therapy. Information that was shared with the palliative care team resulted in adjustment of the amount of opioids with outcome of gradual reduction of neck pain. The man became more confident in eating by himself using the self-help device. Talking with him during meals decreased his loneliness. Taking time to talk with the man resulted in the nurses observing is factial expression of less distress.

Chinatsu Iida

Role function adaptive mode: A man in his 50s. This man was an employed office worker until he was diagnosed with cecum and sigmoid colon cancer. At home, he helped with household chores. His wife works during the day, and the children are often away during the day at school and other activities.
Physiological adaptive mode: Prior to his surgery, this man had been independent in his activities of daily livings (ADLs). Postoperatively, his physical function decreased due to loss of appetite and motivation. Although he has contractures in his leg and experiences muscle weakness, he can stand and transfer by himself and move using a wheelchair.
Self-concept adaptive mode: “My legs don’t work. I want to go home but I don’t’ want to go home because it will only cause trouble for my family.” “I’m worried about what will happen to me in the future.” “I’m a very hesitant person.”
Interdependence adaptive mode: Lives with his wife and three children.
This man said to his wife: “I’m causing trouble to my family. I am sorry to have my family take care of me.” His wife said: “I want him to come home. I want to go out with him even if he’s in a wheelchair.”
Focal stimulus: Transitioning from hospital following surgery to home with emphasis on role transition.
Contextual stimulus: The man wanted to go home, but he did not want to inconvenience his family. Due to his disability, he had quit his longtime job, and his role at home changed, affecting his self-concept and interdependence by this change in his usual role as an employed office worker and contributor to household tasks.
Nursing diagnosis: Anxiety about whether he could live at home due to his declining physical functions.
Goal of nursing: Reduce anxiety about going home and not becoming a burden for his family.
Management of stimuli: Nursing intervention focused on determining any difficulties the man was experiencing in going home. Based on this information, we exchanged information and had discussions with the therapist in charge, the visiting nurses after discharge, care managers, and other professionals, and then we considered how to solve the problems. A therapist and nurse also planned to visit his home to provide direct guidance on how to move his wheelchair around the house and how his family could help him in the event of a fall or when going out. This man did not explain to his family why he did not want to go home, as he stated that he was hesitant to trouble his family. Therefore, the first step was for the nurse in charge to listen to him to find out what he thought bothered him. The nurse then scheduled a meeting with him and his family to discuss the future, with the nurse being present. The nurse encouraged him and his family to share their thoughts and feelings. After the discussion, he told us, “I thought I would only cause trouble for my family if I came home, but after hearing so many requests from my family for me to come home, I felt I had to come home.” In addition, by adjusting his life after discharge from the hospital, he began to talk about how he wanted to go home and became actively involved in rehabilitation. He was then safely discharged.
Adaptation level: The overall adaptation level was compensatory with progression to integration. One month after he was discharged from the hospital, the nurse visited him at home and talked with him and his family. He and his family said that they were glad he was able to come home. He happily stated, “I’m going to see cherry blossoms with my family.”

Aya Imamura

Role function adaptive mode: A woman in her 50s. This woman is a daughter and sister and has been in the role of patient for most of her life. She sometimes needs assistance with changing her clothes, with bathing (although she can wash herself partially), with oral care (as she sometimes bites and breaks her toothbrush, with toileting (guiding her to the toilet, transferring to the toilet, and helping her remove and then put on her undergarments).
Physiological adaptive mode: This woman had a diagnosis of tuberculosis meningitis at 10 months of age after experiencing cold symptoms at 8 months of age. She now has paralysis in both lower limbs and left upper limb. She has an Ejoji scale score indicating a developmental age of 2 years. She experiences constipation. She experiences considerable self-inflicted trauma of her forehead, neck, and feet; has a bite wound on the back of her right hand.
Self-concept adaptive mode: She experiences severe mood swings. When she is in a good mood, she repeatedly talks about the weather, menu, and sneezing. When she is in a bad mood (mainly early morning/evening), she says, “Everyone go home! I’m not going to the bathroom!” When in a bad mood, she also engages in self-injurious behavior such as biting her hands and pulling out her hair, as well as violent outbursts and severe agitation. She experienced many bad mood days, with violent outbursts and injuries, due to visitation restrictions during the coronavirus pandemic.
Interdependence adaptive mode: Her mother, who is divorced from her father, visited approximately once a week prior to the pandemic. Her younger siblings do not visit her. Her primary support system is the ward staff.
Focal stimulus: Risk of loneliness
Contextual stimuli: Although this woman likes to interact with others, her mood swings sometimes interfere with productive interactions and use of diversionary activities. There are few other patients or staff members with whom she can share her thoughts, feelings, and needs, especially due to her inability to communicate clearly, which easily frustrates her.
Nursing diagnosis: At risk for loneliness due to behaviors that do not encourage interactions with others.
Goal of nursing: Enhance her ability to express her feelings, exhibit fewer outbursts, and fewer self-injurious behaviors.
Management of stimuli: Motion sensors are used to determine when the woman wakes up during the night. The nurse made frequent visits to her room, communicated with her, engaged in skin-to-skin contact, and encouraged conversation and involvement with other patients, as well as used a calm tone of voice especially when she is agitated. The nurse shared her interpretations of this women’s behaviors with staff, recorded when and the reasons for the woman expressions of excitement, encouraged her to transition from negative to positive mood by offering opportunities for drawing, coloring, or talking about her favorite topics or unpleasant topics, emphasized what she can do and what she would like to have done without getting excited. The nursologist maintained frequent contact with the woman’s family and informed them that remote visitation was possible during the pandemic.
Adaptation level: The overall adaptation level is compensatory with progression toward integration. The planned interventions were effective, in that the woman talked with the nurse more often, she began to request physical contact such as handshakes and hugs, and to express her desire to listen to music, play CDs, or turn on the TV. Furthermore, when she was excited, the hurse listened to her carefully and found that the woman was able to calmly express her feelings such as wanting to go to the bathroom. Noteworthy is that when other patients became agitated while brushing their teeth, she tries to calm them down by holding their hands. She also waits for help from the staff when she wakes up or needs to go to the toilet at night, she no longer engages in self-harm, and she cries when saying that she misses her family.

Hitomi Kaneko

Role function adaptive mode: A male infant and his family. The infant is his parents’ child, a younger brother, and a grandchild.
Physiological adaptive mode: This male infant has congenital esophageal atresia with a diagnosis of 21 trisomy, treated with a gastrostomy. Continuous suctioning in the oral cavity and upper esophagus was performed, which was presumed to be accompanied by physical and emotional distress. Dysphagia has been seen with oral saliva retention, mucous, drooling, coughing, and vomiting. His facial expressions are interpreted as indicating pain and anguish. He has low abdominal muscle strength due to low muscle tone.
Self-concept adaptive mode. He is an infant, so oral communication is not possible.
He does not cry or laugh much. When he is in pain, he reacts by frowning. Low muscle tone. Mother is frightened because they are worried about their child’s mood swings.
Interdependence adaptive mode: The infant’s family members were very anxious about the infant’s risk of aspiration pneumonia and were reluctant to discharge him to home, saying “We can’t take him home,” thus resulting in prolonged family separation. Mother is the primary caregiver; she became pregnant after fertility treatment. Father lives separately and alone. The mother said, “I want you to take care of him at the hospital until I can breastfeed him directly.” The mother was frightened during the visit. Grandmother stated: “I am not comfortable taking her home because of the risk of aspiration pneumonia.”
Focal stimulus: Saliva entering trachea/vomiting. Pain and distress. Family emotional distress and role tension
Contextual stimuli; Environment (GCU admission). Overstimulation of external environment. Family separation. The infant’s health condition was an unexpected event.
Nursing diagnoses: Consideration of euthanasia. Infant motor development delay. Family dysfunction.
Goal of nursing: Ease of oral saliva evacuation and emotional stabilization signs (laughing, deep sleep, increased physical activity, etc.) Reduce distress and demonstrate neural and physiological development. Assist family members to express their psychological and social thoughts and show parental involvement.
Management of stimuli: Oral care. Due to dysphagia, the patient is receiving nutrition via gastrostomy and continuous suctioning in the oral cavity and upper esophagus. Positional drainage, light method. Positioning to avoid aspiration. Physical therapy to relieve muscle tension, maintain posture, and strengthen muscles. Observation of breathing, activity, sleep and wake patterns. Coordination of care to meet the physiological and psychological needs of the child. Care is provided collectively, and care is coordinated to ensure a period of sleep for the infant. When providing care that involves pain, the care is carried out by two people, with one person handling and holding the child as the child’s advocate.
Focus on the infant’s potential abilities. Continue listening and have dialogues to allow family members to express their concerns. Assess family functioning. Participation in care to be tailored to the parent’s psychological situation. Explain small changes to the family. Ensure playtime and reading time by childcare staff. Coordination of social services after discharge. Psychological interview for parents. Listening to the thoughts of the mother and other family members
Adaptation level: The overall adaptation level was compromised with progression toward compensatory. The results showed that the integrated coping process was a disabling process for physical, mental, and social distress. Newborns are human beings who must depend on someone else to survive and are unable to express their own will. We supported the newborn and his family through observation and dialogue to assess the distress experienced by newborns and how to relate to them together with their families. In addition, we believe that our support and care of the newborn child as an irreplaceable being helped to alleviate the family’s emotional distress and supported the connection between the child and his family.

Kaori Nitahara

Role function adaptive mode: Primary role: A man in his 50s. Secondary roles: Eldest son, not married; unemployed, having quit his job one year ago, no stated religion; Tertiary roles: No hobbies. Before he was　hospitalized, he did not brush his teeth or take a bath every day. Although he can walk, he often stays in bed. He spends most of his day at home and has no social activities. Inasmuch as he was unable to effectively convey his physical symptoms to the medical or nursing staff, he was not effectively performing the patient (or sick) role.
Physiological adaptive mode: This man is malnourished and had recently experienced 25% weight loss. Although he liked to eat, he had had trouble with eating due to an oral tumor and difficulty opening his mouth. His facial checks and gums were swollen. He had noticed a swelling in his mouth for 4 months but did not visit the hospital. He said, “I thought it would heal with time.” The oral tumor also created difficulty with talking.
Self-concept adaptive mode: He said, “I was worried about my bad breath.” He appears to not accept the changes in his body and living environment caused by oral cancer. He appears to be indifferent to treatment and oral care due to anxiety and fear.
Interdependence adaptive mode: The man’s only support is his younger brother, who helps him with the shopping on the weekends. His relationship with his brother is good. His parents are dead.
Focal stimulus: Physical changes associated with oral cancer.
Contextual stimuli: Side effects of treatment for oral cancer. Prolonged hospitalization in an environment in which it is easy to feel a sense of loneliness.
Nursing diagnoses: Diminished self-care ability. At risk of worsening malnutrition due to oral cancer treatment side effects.
Goal of nursing: Encourage this man to take an interest in his health situation and tell the medical staff that he wants to eat. Nurses should respect his wishes and allow him to express his anxieties in the process of accepting his medical diagnosis of oral cancer and the treatment plan.
Management of stimuli: This man received palliative radiation therapy from maxilla to cheekbone, along with chemical treatment. Observe the status of the oral tumor and monitor side effects. Relieve nausea, vomiting, and malaise symptoms. Administer medications for relief of pain. Plan meals based on symptoms. Maintain oral moisture and cleanliness. Explain the treatment plan and expected side effects and how to deal with them. Listen to him about his anxiety. Provide guidance based on his life after discharge and his individual circumstances.
Adaptation level: Overall level of adaptation was compensatory progressing to integrated. Interventions that satisfied his physiological need of eating led to motivation to overcome treatment side effects and promoted motivation to engage in increased self-care. By day 7 after initiation of treatment, this man experienced no nausea but had a sticky and dry mouth. He was eating approximately 30% of his meals. By day 14 after initiation of treatment, the man stated, “I was able to eat ice cream.” He expressed feelings of tingling pain and had oral mucositis. He was eating approximately 50% of his meals, and was ingesting jelly brought by family members. By day 21 after initiation of treatment, the oral tumor had become a little smaller. He was told he could use moisturizer for dry mouth symptoms. The nurse was able to convey the changes in his symptoms. Side effects such as oral mucositis appeared, but by relieving pain, this man was able to eat his meals. Gradually, he became able to provide oral cleanliness and use moisturizers to treat dry mouth symptoms.

Yoshie Shiotsuka　　

Role function adaptive mode: Primary role: 63-year-old, male, mature developmental stage. Secondary roles: Father, grandfather (family present but estranged). Tertiary role: Truck driver, company employee.
Physiological adaptive mode: This man had a sudden onset of disease with breathing difficulties. He was diagnosed with laryngeal cancer and underwent total laryngectomy with a permanent tracheal foramen. After chemotherapy and radiotherapy, a substitute speech device (Provox) was implanted but has not been practical. Continued humidification, inhalation, and occasional suctioning need. He had no teeth and needed to choose his diet. He experienced dysphagia due to edema of pharyngeal mucosa, and taste abnormality due to treatment.
Self-concept adaptive mode: This man stated: “I am prepared for this, but I am worried about what will happen to me and how long I will be able to live.” “I don’t want to bother people around me.” “I can endure the hard things if I am cured, but it’s difficult　I　can’t　be cured.” “After all, I don’t need home nursing.” He seemed to be frustrated.
Interdependence adaptive mode: Key person: His daughter, but she is also far away, so she is not actively cooperating, only keeping in touch. Thus, family support could not be expected. Support system: Only a friend/colleague.
Focal stimuli: After laryngeal cancer surgery, permanent tracheostomy, and radiotherapy, substitute speech method is not practical.
Contextual stimuli: Prolonged hospitalization, fatigue, and anxiety. Fear of illness, living alone, possibility of not being able to return to work. He was a single male who lived alone and was estranged from his family. He was alone when he received treatment and follow-up explanations. He had lost his vocal organs and was unable to fully express his thoughts in writing, and it was assumed that he was unable to fully express his frustration and anxiety. Perhaps because he had been living alone for a long time, he complained of anxiety about his life after discharge from the hospital, but he was reluctant to accept any support or intervention from others.
Nursing diagnosis: Spiritual pain. Although some time had passed since the onset of the disease, this man was in the process of changing his place of living from hospital to home. Considering that he was not able to fully express his conflicts, anxiety, and frustration through written communication, the nursing diagnosis was set as spiritual pain. He was ready to be discharged home after undergoing surgery and completing a series of chemotherapy and radiation treatments. He had listened to explanations about the diagnosis of cancer, surgery, and treatment, and had made his own decisions. Although he expressed anxiety about his life after discharge from the hospital, he was reluctant to accept intervention or support from others.
Goal of nursing: To alleviate physical pain and allow him to express his desire to be discharged home while he is ill.
Management of stimuli: At the beginning of the discharge support, complaints of rejection and other feelings such as “being kicked out” were heard from this man. After confirming the trend of improvement in physical condition by reducing physical pain, the cancer counselor and MSW together proposed a support system for the patient’s discharge from the hospital. He was living alone, and although he was anxious about his life after discharge from the hospital, there were some comments that he refused to allow others to intervene. However, there were some comments that the patient was open to the intervention of others, such as “I will ask a visiting nurse to come.” From the time of initial admission, the palliative care team and cancer counselors had been intervening, believing that a support system was needed that would continue to involve the patient after discharge. The patient also expressed that he wanted to talk to them and asked them to come to the hospital, and we believe that we were able to build a relationship of trust with them. Observation around the permanent tracheal hole, check of sputum status. Humidification, planned inhalation, and oral coughing. Observation of the degree of esophageal obstruction and food intake. Request for rehabilitation intervention to maintain muscle strength. Request for consideration of public support system and support in going home. During physical care, listen to the patient so that he can express his concerns about discharge and requests concerning home care. Share information within the support team.
Adaptation level: Overall level of adaptation was compensatory progressing to integrated. Continued physical pain relief. Continued humidification and inhalation in the patient’s room. Provided choice of diet and supplemental nutritional supplements. Improvement of edema of the mucous membrane of the pharynx, resulting in improvement of dyspnea and return of his sense of taste. Maintains nutritional status, and by improving passenger of food also taste. “I was able to eat food.” “I know what sweetness is.” “I can go home.” “I think I’ll leave the hospital around the 10th.” “I decided to have a home care nurse come in.” As his symptoms improved, he was able to express his feelings for home discharge. There has been no statement about returning to work, but retirement may be postponed.
His daughter is also being contacted by the support team to help bridge the continuity of role function for her father. Inasmuch as he lived alone, the palliative team’s intervention had been ongoing since his patient’s admission. He was also very anxious about his finances, so the cancer counselor and the medical social worker MSW in charge of the ward intervened and responded to the patient’s needs. Suggestions were made and implemented to set up home nursing intervention, referral to a family doctor, and arrangement for emergency calls to the fire department at the residence. The man’s physical condition improved, and he was able to establish a trusting relationship with the support system team.

Jacqueline Fawcett

Readers’ contributions to the discussion of ways to avoid a theory-practice gap are welcome.

Acknowledgement:

We acknowledge the excellent translation of the learners’ contributions from Japanese to English by St. Mary’s College faculty member, Eric Fortin.

Reference

Roy, C. (2009). The Roy adaptation model (3rd ed.). Pearson.

Contributors

Miyuki Higashijima, RN, Diploma in Nursing, Nursing administrator (Head nurse; orthopedic surgery ward) is a graduate student at St. Mary’s College of Nursing, working and studying as a nursing administrator in the Orthopedic Department of St. Mary’s Hospital. Her research interest is to explore the roles and behaviors of an administrator to create an environment where nurses working in a busy daily environment can establish their identity as a nurse, find meaning in their nursing careers, and continue to work.

 Chinatsu Iida, RN, BS is a graduate student at graduate school of St. Mary’s College and works as a faculty member (research assistant) at the St.Mary’s College　school of nursing. She is interested in the trajectory of self-esteem in stroke patients. She is trying her best to conduct research that will benefit patients as much as possible.

Aya Imamura, RN, BSN, PHN is a RN graduate St. Mary’s College and now is a graduate student at graduate school of St. Mary’s College.

Hitomi Kaneko, RN, Diploma in Nursing, Advanced Midwife , works as an Advance Midwife at St. Mary’s Hospital. As an Advance Midwife, she is exploring my roles and responsibilities as a midwife by reflecting on the value of life and human dignity at St. Mary’s Graduate School to ensure that all women and their unborn children receive appropriate care

Kaori Nitahara, RN, ADN, Certified Nurse in Radiation Oncology Nursing, Nursing administrator (Head nurse; infection disease and emergency unit) works as a nursing administrator in the infectious diseases and emergency unit of St. Mary’s Hospital and is engaged in research as a graduate student at graduate school of St. Mary’s College. As a certified radiation oncology nurse at the hospital, I provide consultation and education to nurses who are responsible for caring for cancer patients undergoing radiation therapy. Her research interests are exploring the nursing of elderly cancer patients undergoing radiation therapy.

Yoshie Shiotsuka, RN, Diploma in Nursing, Nursing administrator (Head nurse; mixed ward of otolaryngology, urology and dermatology), Nutrition Support Team Therapist (Certified from the Japanese Society for Clinical Nutrition and Metabolism). Yoshie is a graduate student while working as a nursing manager in a mixed ward of otolaryngology, urology and dermatology at St. Mary’s Hospital. She believes that assisting patients feeding and nutrition is an important nursing task. She is engaged in research to find out and clarify the thoughts and feelings of ward nurses working in acute care hospitals about patients’ eating and how they practice nursing care.