key: cord-0818894-by3i5iwk
authors: Callis, Annette M.
title: Application of the Roy Adaptation Theory to a care program for nurses
date: 2020-08-16
journal: Appl Nurs Res
DOI: 10.1016/j.apnr.2020.151340
sha: 25ca4ae520367b01a732cc48156290ad96560e7d
doc_id: 818894
cord_uid: by3i5iwk

Theory-guided nursing practice is foundational in providing the framework for the development of excellent nursing care. There is a need for effective care programs for nurses, whereby they are adequately supported within their workplace infrastructures as a professional group whose work is essential to the provision of healthcare worldwide. Likewise, there is a need for care programs for nurses to be theory-guided. In the current global pandemic climate, the well-being of nurses continues to become compromised evidenced by increasing moral distress, compassion fatigue, and burnout. Theory-based supportive programs are vital to the overall wellbeing, morale, and retention of nurses. The Roy Adaptation Theory may serve as a guide in the development and evaluation of a hospital-based program designed to support the needs of the healthcare team. This discussion will explore the application of the Roy Adaptation Theory-Group Identity Mode to the Tea for the Soul Care Model for nurses.

(2010) found that nurses expressed what helped them view death as a natural part of life was a religious or spiritual belief.

Multiple studies have shown that aggressive care in cases of futility is the leading cause of moral distress in nurses (Corley, 2002; Elpern et al., 2005; Hamric & Blackhall, 2007; Schluter et al., 2008) . The inappropriate use of life support may prolong patient suffering and their impending death. Nurses need emotional support in processing the increasing mortality and morbidity rates surrounding the present-day global pandemic, as well as needing a system that provides them with support in coming to terms with their own personal grieving related to dying patients.

Moral distress is frustration in nurses resulting from not being able to carry out an action believed to be morally correct, due to a variety of primarily organizational constraints, and causes nurses to leave critical care and the nursing profession. Browning (Callis) (2013) found that critical care nurses who felt more empowered in the workplace, experienced moral distress less frequently. One might hope interventional studies to empower nurses would decrease moral distress. Although this is a promising direction, a more recent study (Altaker et al., 2018) suggested that nurses with lower perceived empowerment may feel less moral obligation, and therefore less moral distress. There remains a need for interventional studies exploring methods to ameliorate moral distress and enhance job satisfaction and healthy work environments for nurses.

Nurses may be blamed by family or healthcare team members when situations involving a patient death do not result in what is perceived to be a favorable or ethically correct outcome J o u r n a l P r e -p r o o f (Yim et al., 2013) . According to Tranter et al. (2016) nurses experienced physical, emotional, and relationship changes at home due to stressors carried over from work.

Increased job satisfaction is associated with HWEs. Much of the literature prior to 2010 focused on the nurse's external environment. Studies on HWEs focused on managers being responsible for developing staff communication skills. Kupperschmidt, et al. (2010) developed essentials for nurses to take responsibility for their self-awareness, feelings of grief, need for reflection, and ability to hear and speak the truth. More recent studies (Ross, et al., 2019) are illuminating the need for nurses to engage in a personal self-examination to become more selfaware in the workplace. Perhaps program models conjoining a shared responsibility for nurse well-being between the employer and the nurse can best address nurse needs.

The need for care models for nurses has emerged from longstanding evidence of phenomena negatively affecting the well-being of nurses. These distresses affect nurse retention and cause nurses to leave the nursing profession. It is imperative that organizational chief nursing officers and administrators address the unique needs of their nursing staff, by providing programs to promote the emotional well-being of nurses. The current 2020 COVID-19 crisis has stress and adopted resiliency strategies. This program design was based on the principle that nurses need to excel in self-awareness to promote their own sense of well-being so as to engage and effectively impact the well-being of others. Discussing concerns in groups resulted in greater awareness that colleagues were experiencing similar difficulties. Results showed decreased CF, with statistically significant decreases in burnout and secondary traumatic stress. The authors recommended, "If health care organizations want their staff to take better care of their patients, it is incumbent upon leaders of those organizations to give them the tools to take better care of themselves (p. 332)."

The majority of the literature surrounding care programs for nurses is related to self-care programs (Blackburn et al., 2020) . Schwartz Rounds® is a program that has been implemented internationally to enhance hospital staff compassionate caring and psychological well-being (Lown, 2018) . Significant improvements were found in burnout and joy at work with the implementation of a mindfulness and compassion-oriented training program for nurses (Orellana-Rios et al., 2017) . TFS trained counselors may be well positioned to help meet the bereavement needs of nurses in various areas of practice by assisting them in identifying and articulating their feelings of grief and distress. TFS counselors may also help meet nurses' bereavement needs by offering them spiritual insights as a source of strength and adaptive coping. As previously discussed, studies have shown spiritual well-being was found to reduce emotional exhaustion (Rushton, 2015) and spiritual beliefs helped nurses in their view of death (Peterson, 2010).

Corley (2002) further developed her theory on moral distress by postulating acts of moral courage can mitigate moral distress. A strategy to enhance the development of moral courage in nurses is creating sacred spaces (Pijl-Zieber, 2008; Iseminger, 2010) . "A sacred space is a defined physical space that invites contemplation, encourages an attitude of openness, and encourages story telling for the specific purpose of connection, support, and healing" (Edmonson, 2010) , Collaborative partnerships between the hospital and the Spiritual Care Team can provide nurses with a space to build moral courage. TFS allows nurses time to reflect on situations from the clinical setting.

Reflective Practice involves facilitating nurses the opportunity to reflect on the what has occurred in their daily experiences. Studies have shown that reflective practice gives nurses a J o u r n a l P r e -p r o o f better understanding of their actions, which subsequently gives them a greater sense of purpose and adds to the development of their nursing skills and increased clinical competency (Smith & Jack, 2005) . Reflective practice promotes courage, to meet the needs of unique patients, and helps empower nurses (Gustafsson & Fagerberg, 2001) ; as well as being a way for nurses to discuss their feelings to better understand why they feel a certain way (Caldwell & Grobbel, 2013) . TFS allows nurses a safe space to regularly reflect and receive feedback from a professional.

Roy's concept of adaptation is based on scientific, philosophical and cultural assumptions. The scientific premises of Roy's Model are based on Bertalanffy's (1968) general systems theory and Helson's (1964) adaptation theory. Roy recognizes the need to adjust applications of the theory to enhance its relevancy and effectiveness in view of cultural diversity.

Roy originated the concept of veritivity (from the Latin word veritas), that innate in human nature is rooted a creative and purposeful drive for a common good that supports the dignity of all people groups and the sacredness of our shared humanity (Roy, 2009 ).

Primary concepts of the Roy Adaptation Model (RAM) are (a) stimuli, (b) coping processes, and (c) adaptive responses. Roy views the individual or group as a system with components that continually interact with stimuli present in the environment. Coping processes mediate the relationships between the stimuli and the adaptive modes.

Viewing nurses as an adaptive system provides a paradigm by which nurses interact in caring for people groups. Nurses themselves form a people group with care needs.

Nurses, as a professional group, possess holistic distinct characteristics, such as, shared J o u r n a l P r e -p r o o f responsibilities and goals, a Code of Ethics, normative behaviors and moral statutes. Nurses adapt effectively or maladapt according to events and human interactive stimuli in their environment. The human output responses to the environmental stimuli impact the nurse and provide feedback within the environment and therefore further input into the dynamic environmental system. For nurses, this input or stimuli in the workplace environment may be focal, contextual, or residual.

When focal stimuli are present a response is required, as the individual or group becomes immediately aware of the stimulus. A deterioration in a patient's status may serve as a focal stimulus for a nurse caring for a patient in the emergency department. Contextual stimuli are all of the other stimuli in the situation. A physician's order that a patient with a terminal illness be resuscitated, when the patient requested to the nurse that they did not wish to be on life support in the case of their demise, may serve as contextual stimuli. Residual stimuli are environmental factors, the effects of which are unclear or not validated by those affected by the stimulus. The nurse may feel a sense of moral distress, torn between advocating for the patient and following the doctor's orders.

A nurse may be required to float to a COVID designated unit. This becomes a focal stimulus for the nurse. The nurse is required to respond. A lack of orientation to the COVID unit, having to practice in an unfamiliar setting, a lack of personal protective equipment, a lack of knowledge perhaps in regard to the patient treatment plan may all be contextual stimuli, that is "other stimuli" present in the situation. Residual stimuli are possible uncertain variables. The nurse in this sequence of events may be fearful that they will test positive for the virus and become a potential threat to family members at home, or worse yet die from the virus and leave one's children orphaned. The stabilizer and innovator subsystems are applied to group coping processes.

According to Roy's theory groups have two major purposes that are related to stability and change. Just as there is a homeostatic drive in the individual, there is an adaptive process that drives the group to equalize and stabilize toward a common goal. The innovator subsystem moves toward thriving and growth in the group paradigm.

Adaptive Responses. The adaptive response of the nurse will vary within three levels:

integrated, compensatory and compromised (Roy, 2009, p. 37 ). The nurse may use all of one's available resources to meet the responsibilities imposed upon them and experience an integrated response (effective coping). In the second adaptation level, the nurse may compensate and suffer from physiological discomfort or pain, such as gastrointestinal distress or headache. Cohesive groups where there is a strong sense of common goals tend to remain in the community even when there are influences to leave (Kimberly, 1997). Compromised adaptive responses occur when groups suffer from low morale. In this third level of adaptation, the nurse may be compromised and experience mental exhaustion resulting in a leave of absence or permanently leaving the place of employment and the nursing profession.

To date, the RAM has been applied to the nursing care of patients, families and populations. Very few studies have applied the RAM to caring for nurses, either in the realm of self-care or hospital-based programs. The Roy Adaptation Theory Mode of Relating People (Roy, 2009 ) is comprised of four categories or needs (Physiologic-Physical, Self-Concept/Group Identity, Role Function, and Interdependence). These modes may be applied to the Tea for the Soul care program for nurses as an intervention to care for the individual and corporate needs of professional nurses. As nurses interact within their work environment, their adaptive responses may be compromised as interpreted within the framework of Roy's theory. TFS Program facilitators are positioned to assist nurses toward integrated adaptive responses.

The modes in the RAM can be thought of as needs. Roy terms the core need of the group identity mode identity integrity. This is defined as the ways in which the group behaviors are congruent with their awareness of the group identity. These congruent behaviors are manifestations of the group's shared goals and values. If a nurse performs an action that demonstrates an awareness of the group identity, this reinforces the group identity and advances the attainment of the group's common purpose and goals. Integral to the application of the RAM is being mindful of the interrelationship of the individual and group identities and the overlapping of the four modes. These concepts are to be viewed as dynamic and each one continually affecting the other.

Physiologic-Physical. The adaptation of nurses as a group system are affected by the basic operating resources of their workplace, physical resources, and workload, etc. Prolonged lack of support in a work environment can have dramatically negative consequences for a group J o u r n a l P r e -p r o o f over time as has been studied in regard to the effects of moral residue in nurses (Lackman, 2016) .

The physical strength and endurance of nurses employed in high patient acuity areas are repeatedly challenged and overtaxed. Twelve-hour shifts, staffing shortages, frequent encounters with death, the threat of violence, and risk of COVID-19 are a few of the stressors nurses are encountering. Nurses need to be regularly recognized and supported for the work they are doing.

TFS provides nurses with a brief time of rest and refreshment within their work facility, whereby a professional can listen to their stories, offer compassion to them, and comfort them in the indispensable work they do. Providing personal feedback to nurses in real-time can revive them and increase their overall sense of well-being.

Group Identity / Shared Identity. Shared Identity is a major component of the adaptive process in the Group Identity Mode. A shared group identity is more complex than the sum of the total self-identities of the group individuals and how they relate to one another in the group.

Social identity theory (SIT) as a framework for understanding group interactional relations is well established (Reicher et al., 2010) . This framework has paved the way of an increasing awareness and dire relevance to apply SIT to the world at large.

SIT is also a basis for social influence or what is called identity-based influence. This means that people are able to exert a more positive influence over others to the extent they are seen as embodied within the social identity to which they belong. This may well apply to the TFS Program facilitator. Viewed by the nurses as a support person and source of council within their group, as a hospital employee and member of the healthcare team, the chaplain may be in a highly effective position to provide encouragement to the nurses, and whose support may tend to be more meaningful than strategies coming from external assistance programs or methods.

J o u r n a l P r e -p r o o f Haslam (2014) developed the application of social identity theory to healthcare. He extracted five core lessons from the literature:

(1) Groups and social identities matter because they have a critical role to play in organizational and health outcomes. (2) Self-categorizations matter because it is people's self-understandings in a given context that shape their psychology and behaviour. (3) The power of groups is unlocked by working with social identities not across or against them.

(4) Social identities need to be made to matter in deed not just in word. (5) Psychological intervention is always political because it always involves some form of social identity management (p. 2).

It is imperative that nursing administrators take an active part in initiating and maintaining programs that meet the emotional needs and enhance the self-awareness of individual nurses, thus fostering the integral social identity of nursing groups within health organizations. Nurse managers are in a primary position to advocate for staff nurses who bear the brunt of traumatic events occurring at the bedside by developing strategies for programs such as TFS that facilitate reflective practice, supportive feedback, and positive action toward a unanimous sense of the collective self, reinforcing the values of the larger organization. Healthy nurses make healthier patients. Ross et. al. (2020) used Roy's Adaptation Model as a framework to guide researchers in evaluating depressive symptoms among RNs, stating, "A mentallyhealthy nursing workforce is vital to providing quality healthcare" (p. 207).

The adaptation or ineffective behaviors of the nurse may be influenced by self-concept.

Psychic and spiritual integrity as defined by Roy, influence the beliefs and feelings one has about themselves and subsequently their behavior. Group-identity is driven by the interpersonal J o u r n a l P r e -p r o o f relationships of the group, a sense of shared responsibility, and a solidarity of collective values and a common mission.

The TFS counselor is in a key position to reinforce to the nurse how they may be fulfilling their personal call to nursing and aiding in the fulfillment of the institutional mission as a social and collaborative community. Counselors can help nurses reflect on why they went into nursing and how their self-concept can be played out as they work together as a team.

Role Function. Social integrity is the basic need underlying the group identity mode of role function. This sense of integrity is influenced by the expectations of the individual in their role in relationship to the group to which they belong. This need is based on the need to know who one is in relationship to those in their workplace, so that they know how to respond. The perception of role function is the means by which the goals of the group, unit or institution are fulfilled, thus unit nurses constitute a primary part of the larger group infrastructure of the hospital. The group role function mode includes nurses, administrators, physicians, and the spiritual care team. The role function of the group's interrelatedness, interprofessional support, and the quality of communication all affect the group's common goals.

The regular presence of a counselor or spiritual care facilitator in the context of the TFS program can provide nurses, together with members of the healthcare team, a common area to gather apart from the workspace; yet nested within the work environment. This communal safe space can serve as "level ground" for the sharing of common goals and a like purpose. "I think that maybe just giving myself a minute to refresh allows me to pour out more as I go back out to the patients."

"It gives me a minute to get refreshed so that I can do my work well."

Increased Capacity for Compassionate Caring

Community "I feel like they're (TFS) a safe zone… it's kind of like what we say amongst ourselves is very sacred and with your peers there's always that question of being judged…and with spiritual care, it's not like that at all. They never make us feel like that, they are always very, very compassionate and listening…they give really, really good advice, which I am super personally grateful for."

"It is good to check in on one another when you've been through that [a traumatic event] and have it be the Chaplain who was also involved in the case made it that much more impactful."

"your interaction with other people reflects God's presence. You represent God in the workplace. It helps me show them God, you know, they see God in us."

"reminds me I represent…our institution that believes in God."

Open Conversation

J o u r n a l P r e -p r o o f Journal Pre-proof Improved Patient Care Outcomes "allows you to uh approach your patient care with a more level head, I think it affects your patient care in that regard umm… you know as opposed to a kind of task-oriented patient care…not getting overwhelmed, I think in that way it affects patient care."

Enhanced Nurse/patient Relationship Table 2 Examples of Core Themes as per Participant Interview Statements J o u r n a l P r e -p r o o f Journal Pre-proof Figure 1 

Moral courage and the nurse leader. The On-line

Moral distress of staff nurses in the medical intensive care unit

Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized

Reflection, the way to professional development?

Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate

Making good theory practical: Five lessons for an applied social identity approach to challenges of organizational, health, and clinical psychology

Adaptation level theory

Burnout, compassion fatigue, compassion satisfaction, and secondary traumatic stress in trauma nurses

Overview and summary: Moral courage amid moral distress: Strategies for action

Concept analysis: compassion fatigue and effects upon critical care nurses

Coping with compassion fatigue

Group processes and structures: A theoretical integration

A heathy work environment: It begins with you. The On-line

Ethics, law, and policy. Moral resilience: Managing and preventing moral distress and moral residue

Mission critical: Nursing leadership support for compassion to sustain staff well-being

Moral distress in critical care nursing: The state of the science

Mindfulness and compassion-oriented practices at work reduce distress and enhance self-care of palliative care teams: a mixed-method evaluation of an "on the job" program

Developing a systematic program for compassion fatigue

The social identity approach in social psychology

Systematic assessment of depressive symptoms among registered nurses: A new situation-specific theory

The Roy Adaptation Model

Burnout and resilience among nurses practicing in high-intensity settings

Nurses' moral sensitivity and hospital ethical climate: A literature review

Reflective practice: a meaningful task for students

Nurses experience bereavement too

Journal of Subthemes Core Themes Collaborative Work Environment Staff support and encouragement Safe Space / Open sharing of feelings Collegiality Socialization -all staff on equal footing Rapport w/Coworkers HCT Comradery

Collective / united vision Nurse-Patient Relationship Connect with patient on an emotional level Enables the human connection Relationship oriented vs. task oriented Patient Effect Patient satisfaction Human caring -Improved patient care Prioritization of care Nurse Self-Care Receiving Compassion Therapeutic Well-being Assists with Grieving Self-inventory Self-awareness Self-reflection Self-regulation Physical needs met Psychological needs met Inspirational written "Reflections" Resilience Reenergizing/Refreshing Community Ministry of Presence Open Conversation Sharing of Feelings Sense of "oneness" United Vision Prayer Soul Replenishment Sacred Space Professional Practice Interprofessional Job Satisfaction Human Connection Increased capacity for Compassionate Caring Reflective Practice Role effectiveness Improved prioritization of care Improved Patient Care Outcomes Insight into EOLC Increased patient satisfaction Patient's perception of being cared for Enhanced nurse / patient relationship Improved overall pt. care TFS Program Characteristics: Popular Engaging / Inspirational Need for Funding