ORIGINAL RESEARCH

Psychosocial adaptation of older adults in hemodialysis treatment: an analysis in the light of Roy's Model

Rosângela Alves Almeida Bastos^I; Francisca das Chagas Alves de Almeida^II; Maria das Graças Melo Fernandes^III

^I Nurse. Master of Nursing. Federal University of Paraíba. João Pessoa, Brazil. E-mail: rosalvesalmeida2008@hotmail.com
^II Nurse. Master of Nursing, Professor, Department of Clinical Nursing, Federal University of Paraíba. João Pessoa, Brazil. E-mail: falves.almeida@hotmail.com
^III Nurse. PhD, Professor of the Department of Clinical Nursing, Federal University of Paraíba. João Pessoa, Brazil. E-mail: gracafernandes@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.23118

ABSTRACT

Objective: in the light of Roy's model, to examine psychosocial adaptation of older adults undergoing hemodialysis treatment. Method : in this qualitative, descriptive study with a sample of 15 older adults undergoing hemodialysis treatment at a hospital in João Pessoa, Paraíba, the thematic analysis technique was used on the guiding principle of Roy's psychosocial model. Results: the older adults were found to display ineffective psychosocial behavior. In the subcategory physical self, the self-concept mode, they demonstrated negative perception of body image, and sadness. With respect to personal self, some showed effective coping with the disease. In the real-life function and interdependence mode, they displayed negative behaviors evidenced by lifestyle changes. Conclusion: the older adults undergoing hemodialysis treatment encountered difficulties adapting to the illness and to the therapy. Keywords: Nursing; elderly; kidney dialysis; nursing theory.

Keywords: Nursing; elderly; kidney dialysis; nursing theory.

INTRODUCTION

Aging can be understood as a dynamic and progressive process, typical of all members of a species and characterized by morphological, functional, biochemical and psychological changes. These changes determine the progressive loss of the ability to adapt to the environment, causing higher susceptibility and increased incidence of pathological processes, which may eventually lead the individual to death^1,2. Currently, the proportion of people over 60 years of age in Brazil is growing faster than any other age group. This growth is followed by changes in the demographic and epidemiological profile of the population³.

The epidemiological transition is centered on complex changes in health-disease patterns and on the interactions between these patterns and their geographic, economic, and social determinants. In Brazil, the epidemiological transition has generated significant changes in morbidity and mortality, and has led chronic non-communicable diseases, such as chronic renal failure, to become the main causes of morbidity, disability and mortality.⁴

Given the high prevalence and incidence of Chronic Renal Failure (CRF), as well as its physical, psychosocial and economic implications, this health problem has become one of the major worldwide public health challenges of this century⁵. CRF is a pathological condition in which the kidneys are unable to remove the metabolic waste of the body due to a typical decrease of glomerular filtration, during a period equal to or greater than three months or more, and also unable to maintain the metabolic and hydroelectrolytic balance, resulting in uremia. The problem makes it necessary that the affected person perform renal replacement therapy, dialysis (hemodialysis or peritoneal dialysis) or kidney transplant, in order to survive^6,7.

Hemodialysis consists of a process of artificial filtration of blood toxins and removal of excess water from the body. It is a highly complex treatment that partially replaces the renal function, generating physical and psychological consequences for the individual who experiences it due to the need for a long process of adaptation and drastic changes in the lifestyle. In the case of elderly people, these changes are even more complex due to the aging process itself that implies less resistance and adaptation to the disease and the treatment ^7-9.

In this perspective, nurses have an important role in the care of older people undergoing hemodialysis, and it is opportune to understand the multiple dimensions of the patient that may be affected by this therapy. Nursing interventions should aim the improvement of the elderly's health and well-being, focusing on the enhancement of this care, especially on the psychosocial dimension, which is sometimes neglected.

This article is an excerpt from a master thesis whose objective was to analyze, in the light of the Roy Model, the psychosocial adaptation of elderly patients undergoing hemodialysis. The response to this objective will favor the construction of guidelines for nurses working in hemodialysis units, assisting them in the implementation of individualized interventions for these people, providing them with adaptive responses.

THEORETICAL FRAMEWORK

The assumptions of the Roy adaptation model have consistent theoretical frameworks that provide scientific support for nursing actions.

The roots of this model lie on Roy's professional and personal background, who engaged in the formulation of scientific and philosophical prepositions. The formation of the basis of the scientific assumptions of the Roy Model is attributed to the works of Harry Helson, in 1964, on the Theory of Adaptation and of von Bertalanffy, in 1968, on the General Theory of Systems; in turn, the philosophical assumptions come from humanism and the search for the truth^10-12.

In the propositions of this model, it is verified that the environment is responsible for emitting stimuli that affect people, who will show either adaptive responses through coping mechanisms, or inefficient responses. These responses are described by Roy on the basis of the interrelationship of four adaptive systems: physiological adaptation mode, self-concept mode, real-life function mode, and interdependence mode. These three modes correspond to Roy's psychosocial mode. The physiological mode of this theory explains the physiological responses and the way the person responds to environmental stimuli; in turn, the psychosocial mode involves aspects related to the physical and personal self: self-image, spiritual integrity, patterns of values, beliefs, role function, and social interactions^10-12 .

Nurses must ground their professional practice on scientific principles, based on nursing theories and methods that allow the operationalization of these theories.

In this perspective, Roy's theoretical reference evokes much interest, offers adequate elements to nursing care and provides subsidies for the implementation of a qualified clinical care, helping the patient in his path of illness. In this way, it contributes to promoting the adaptation of the patient to the new conditions of health and disease.

METHODOLOGY

This is an exploratory and descriptive research with a qualitative approach. Qualitative research allows us to understand and interpret phenomena, their meanings, motives, aspirations, beliefs, values ​​and attitudes in a deep space of relationships and processes that cannot be reduced to the operationality of variables¹³.

The present study was carried out in the specialized clinic for chronic renal patients of a philanthropic hospital, a reference in dialysis treatment, located in the city of João Pessoa/Paraíba. The participants were 15 elderly people of both sexes who were randomly selected and who were able to understand and respond to the questions formulated in the interview script. The number of participants was defined based on the principle of data saturation, i.e. when the collection started producing no new but rather redundant information.

Data collection was carried out from January to April 2012, using recorded interviews with aid of a semi-structured instrument composed of open and closed questions addressing sociodemographic and clinical aspects related to the Psychosocial Adaptation Mode of the Roy Model.

The empirical data generated in the interviews were transcribed by the researcher. Regarding the ethical principles adopted in this study, the project was evaluated and approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Paraíba under protocol Nº 0381/11, Presentation Certificate for Ethical Assessment (CAAE): 0281.046246211. The precepts of Resolution nº 466/12 of the National Health Council were respected¹⁴.

The thematic analysis technique proposed by Laurence Bardin was used to analyze data. This method consists in a set of techniques of analysis of communications aiming at systematic procedures and description of the content of the messages, which allow the inference of knowledge regarding the conditions of production/reception of such messages ¹⁵.

For the operationalization of this technique of data analysis, the following phases were followed: selection of the material or corpus resulting from the 15 interviews, where the participants' statements were identified by means of the vowel "I" and the number corresponding to the order of the interviews, in order to preserve the confidentiality and anonymity of the participants.

After establishing contact with the documents, the material was overviewed to better familiarization with the text. After this phase, the data were separated into units of analysis, which corresponded to small segments of the content or themes in which the elderly expressed their psychosocial process of adaptation to the hemodialysis treatment.

In the last phase, the categorization was conducted. It is noteworthy that, in this research, the thematic categories were pre-established and corresponded to the components of the Psychosocial Adaptation Mode of the Roy model: self-concept, real-life function, and interdependence. These categories gathered, respectively, the subcategories physical self and personal self, the role function and the social interaction and the person's affective needs.

RESULTS AND DISCUSSION

The analysis of the data gave raise to three categories, which emerged from the corpus of the interviews: self-concept, real-life function, and interdependence, components of the Psychosocial Adaptation Mode of the Roy model.

Self-concept mode: physical self and personal self

The Self-concept Mode category is related to the basic need for psychic and spiritual integrity of the elderly who undergo hemodialysis treatment, and included two subcategories: physical self and personal self.

The subcategory physical self relates to the person's assessment of the own physical condition, including the health-illness status and functionality, as well as sexuality and level of satisfaction with the appearance: body sensation and body image¹².

Body sensation is defined as the ability to feel and experience oneself as a physical being¹². In this dimension, the elderly presented behaviors such as feelings of despair, sadness and death, which represent a threat to their adaptive process. The following statements show this:

I've been in despair for days. For I have to do this treatment that causes so much suffering! I feel very bad in the machine. It's sad ! (I15)

Since the time I started doing this treatment, I lost my life. (I4)

Chronic kidney patients become discouraged, desperate and, for many reasons, give up treatment or neglect the care they should adopt. Such experience causes constant professional concern, for the non-assertive behavior and chronic low self-esteem of both the patient and the family. The difficulties of dealing with these responses result from the suffering these patients face with the onset of a chronic disease that brings about several limitations such as lack of therapeutic options, the relation of dependence on a machine on a continuous basis, three times a week ^16,17 which evokes chronic sadness in those who have to go through such experience:

It's too much sorrow! I feel like crying with such a situation. I feel sorry for everyone who lives depending on this treatment. (I9)

The person goes [for the hemodialysis] already sad, I go with a grief inside of me. (I1)

Chronic sadness is defined as experiencing a cyclical, recurrent, and potentially progressive pattern of widespread sadness¹⁸. It is worth mentioning that this feeling of sadness also stems from living with a disease that cannot be cured and that, in turn, causes desolation, leading the patient to a breakdown of his physical and psychological condition:

I'm already in the end, I have no future; the doctor told me that not even a transplant will work. I feel like I have to wait for death. (I9)

The phenomenon of grief is a normal and complex process that includes physical, spiritual, social, and intellectual responses and behaviors, through which individuals, families and communities incorporate a real, anticipated or perceived loss into their daily lives^18,19. Considering the discourses of the elderly before the experience of the CRF, like other people in the same condition, it is perceived that such responses have a negative effect on their lives¹⁹. It was observed that when they are informed about the incurable nature of the disease, they often become depressed and take death as imminent ^16,20.

The impact of this treatment reflects on the physiological, psychological and emotional realms of the elderly, generating derogatory feelings about themselves and/or denial of the disease. Changes in physical, psychological, biological, social and cultural factors will influence the quality of life of these elderly people^21-24.

As for body image, defined as the way in which the person sees himself physically and apparently¹², the elderly perceived the physical changes caused by the presence of a catheter or arteriovenous fistula to perform the therapy as a source of physical discomfort, and also shame and stigma.

My arms are thin and full of thrombi [pseudoaneurysm], it's very ugly, but it's better than the catheter. (I5)

I lost a lot of weight; my skin became ugly and sore. (I9)

It is worth noting that the representation of the body plays a significant role in the construction of self-image and consequently of individuality, which makes the person not recognize himself as before, but as a sick person. The change in body image caused by the surgical creation of the arteriovenous fistula or the insertion of the double lumen catheter is reported as one of the difficulties faced by people on hemodialysis treatment²².

This situation is closely related to chronic low self-esteem, experienced and characterized by changes in the body and by the limitations imposed by the disease^7,22. It is represented by negative and prolonged feelings about oneself or about one's own abilities¹⁸ which, in turn, affect the personal self.

The subcategory personal self, of the Self-Concept Mode of Adaptation proposed by Roy, relates to the evaluation of the person of his own characteristics, expectations and values ​​and encompasses the components: self-consistency, self-ideal, and ethical-spiritual moral self.

In self-consistency, the person resists to maintaining a consistent self-organization to avoid unbalance²³. Concomitant with other negative and therefore antagonistic feelings, some elderly people show an effective coping of the disease and therapy, and this favors a positive adaptive process. Here is the report:

When the doctor said that I was going to do this treatment, I lifted my head and said: I have to face it. If I get downhearted, it's gonna be worse [...]. (I11)

It should be noted that positive coping is favored by family support, a condition that makes the elderly feel protected, loved and significant. Such support often acts as a positive stimulus for the adaption to restraints and the confrontation of negative feelings.

With respect to the personal self, particularly the self-ideal element, defined as what the person expects to be and do¹², it was observed that when the elderly see themselves having to face a painful treatment, which can mean life and at the same time death, they seek ways to adapt positively, expressing feelings of hope of healing, dreams and desires. This assertion can be seen in the following speeches:

My greatest hope is to get well, I believe faithfully. (I4)

We hope that tomorrow we will be better... we dream that medicine advances with other discoveries for this treatment, to reduce our suffering. (I14)

The capacity of a person to build a positive life trajectory is considered a complex phenomenon. This takes a gradual process, with interactions experienced between the human being and the environment that will contribute to a positive adaptation¹⁷.

The difficulties of having to adapt to the restrictions caused by the disease lead the elderly to dream of other therapeutic modalities capable of improving their quality of life. Renal transplantations arise in this perspective, representing the possibility of a new life:

I dream with the transplant, but I'm waiting for my family to do tests. (I11)

My dream is to do the transplant, I want to stop doing this treatment and go back to living again. What will stay here [in the hospital] are the friendships that I have found and that I will take with me . (I4)

It should be pointed out that, in order to receive a renal transplantation, the elderly face several difficulties related to this type of procedure, especially with respect to organ donation, reduction of physical resistance related to the physiological process of aging and the presence of comorbidities, which often constitute obstacles to the therapeutic procedure²⁵.

The ethical-spiritual component of the subcategory personal self includes the system of ethical and the sacred beliefs and how the self is seen in relation to the person's value system²³. The speeches of the elderly express a sense of suffering, insecurity and anguish before the treatment:

I suffer to make the hemodialysis. I face the hot sun in a public transportation, and when I get here I face another suffering on this machine. It is a treatment that causes a lot of suffering for people. (I4)

It's very stressful. It's distressing. (I3)

It is also noticed that the attachment of the elderly to religiosity and to the belief in God influences their perception of the treatment. They see it as an opportunity offered by God for their survival. The belief in God and the use of spiritual resources such as faith promote an improvement in the adaptive process of the elderly. This experience is embodied empirically by the following discourses:

I try to face this situation with a much faith in God. I have faith in God that I will get well, there is nothing in the world that God does not solve. (I15)

I hope that one day God will look at me and I will stop doing this treatment [...]. (I1)

Factors such as the will to live, the support of loved ones, conformism with the inevitable, and faith in God are used as a way to move forward with life²⁵.

Real-life function mode

The behaviors of the elderly related to the function of the social role corresponding to the real-life function modes of the Roy Adaptation Model ¹² proved to be ineffective. Here is a testimonial:

[...] When I was healthy and when I was not on hemodialysis, I worked today, but now I cannot do anything. (I1)

Behaviors such as the one unveiled in the last report are determined by the sudden change in lifestyle, inability to develop a social role, and feelings of dependency.

The work and daily activities of the elderly are considered important to their lives, because they derive satisfaction and pleasure. The functional limitation can generate feelings of frustration and impotence. The inability to work causes feelings of incapacity, idleness and personal devaluation. Work is determinant in the psychological balance of the human being, since it keeps the person firmly bound to reality, with direct implications in the physiological, psychic, mental and social conditions ²⁴.

The person should be encouraged to engage in basic activities of daily life and leisure, promoting their psychosocial well-being by reducing the limitations imposed by the illness and the hemodialysis⁷. The changes in social performance and in the role of elderly people submitted to hemodialysis are the result of their continuous need for care, machines, surgical interventions, medications and diets, a fact that generates discomfort, as shown in this assertion:

[...] It is a situation that causes dependency, even though it is not a contagious disease, but it leaves us dependent on many things: of people, of medication, of the machine. It changes our whole life. (I14)

Interdependence mode

The interdependence mode refers to the close relationships between people, which involve the will and capacity to love, respect and value others and accept and respond to their love, respect and value¹². In this mode of adaptation, the needs of the person are met through social interaction and affective relationships.

Given the above, many of the elderly need the presence and the care of family and friends, especially the children and the spouse, for they assume protective functions to support them to face the health problem, as endorsed in the following reports:

I have support from everyone, especially from my family, they help me a great deal; if we are despised by the family, we would die quickly. (I11)

I have the help of my husband, children and other people in my family; this is very good to deal with this disease. (I13)

These statements express that the importance of family support, a decisive factor for the patient to create mechanisms to cope with the disease. The family occupies a prominent role in this process because it contributes to the elderly feeling protected, safe and loved²⁴.

Faced with this reality, the health institution, particularly the hemodialysis service, functions as a place where the elderly establish their sociability and relationship of help/support/friendships, as the following discourses show:

My friendships are here on hemodialysis, one gives strength to the other, and so we carry on with life. (I9)

My family is the hospital staff. (I2)

I made lots of friends here, I got another family. (I4)

The support systems are formed by people or social groups that perform the role of giving and receiving love and respect from others, and valuing them. The affective relationships between nursing professionals and patients are essential in the hemodialysis sector because they attend the service usually three times a week and need encouragement, empathy and dedication. Interaction allows the establishment of a bond between patients and the members of the nursing team, favoring positive adaptive responses ^25-27.

CONCLUSION

The study allowed us to identify that the use of the Roy Adaptation Model constituted a relevant theoretical reference for the understanding of the situation experienced by elderly patients undergoing hemodialysis. The choice of the qualitative approach for the analysis of the empirical data facilitated the interpretation of the psychosocial adaptation of these patients, revealing their behaviors/responses.

Regarding the findings, it was observed that the elderly presented ineffective behaviors related to Roy's self-concept psychosocial mode, in the subcategory physical self, evidenced by a negative perception of their body image, feelings of despair, sadness and death, which represent a threat to their adaptive process. In relation to the subcategory personal self, some elderly people showed an effective coping with the disease and the therapy, expressing feelings of hope of healing, dreams, desires and faith, favoring a positive adaptive process.

Regarding the categories of real-life function and interdependence modes of the Roy Adaptation Model, it was observed that the elderly participants showed ineffective behaviors resulting from the abrupt change in lifestyle, inability to play social roles, and feelings of dependency.

Thus, considering the above, it is emphasized that the aspects related to the psychosocial adaptation of elderly patients undergoing hemodialysis that were elucidated in the scope of this research can serve as support for the health team, especially nursing professionals, to encourage elderly patients in the coping with the disease, stimulating them to seek a re-signification of their condition of life from a perception that envisions a better quality of life.

As for the limitations of the study, although the nursing diagnoses were considered, the nursing care plans with the prediction of individual and appropriate interventions for elderly patients undergoing hemodialysis were not.

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