INTRODUCTION

Osteoarthritis (OA) is a primary indication for total knee replacement (TKR) surgery. OA can develop in different joints, but it is most commonly seen in the knee joints as an outcome of the increase in the number of overweight individuals and decreases in people’s social activities.^1-3 Worldwide, OA is the joint most commonly affected by with an estimated prevalence of 15% in persons aged 56 to 84 years.⁴

In the United States, OA was the justification for 95% of TKA procedures performed.⁵ OA in the knees leads to limitations in movement, deformities, and a disruption of the knee structure, which in turn become barriers to daily living and social activities, resulting in both physical and psychosocial disability.^1,6 TKR surgery is a successful treatment for eliminating pain and allowing recovery of movement in the joints.^7-9 However, patients undergoing TKR surgery experience various circumstances that affect their quality of life before and after surgery. While patients hope to be relieved of their pain on the one hand, they also become fearful of becoming dependent on others. Pain, weakness, activities of daily living (ADL) limitations, becoming dependent, and a change in customary roles may result in social isolation, anxiety, and depression, especially in the early postoperative period.^2,10-13 Successful recovery and adaptation to the prosthesis depends on the adaptation of patients to the care and rehabilitation provided, successful management of additional illnesses, and the presence of sufficient psychological and social support.^12,14 The recent decrease in hospital stay duration has made continuous care a requirement.¹¹ Continuous care refers to the establishment of a continuous and consistent interaction between patient and caregiver.^12,15-18 This process encompasses the period before hospitalization and after discharge and requires a multidisciplinary team equipped to handle issues arising in different areas of specialization.^12,17 Nurses play key roles in helping patients adapt to daily life by determining patients’ levels of knowledge, care, and needs and by interacting with other health professionals.^16,19 This study used the Roy Adaptation Model (RAM) in patients undergoing TKR to enhance nurses’ understanding of caregiving theories and their skills at incorporating these theories into the care they provide. Using continuous care based on RAM may provide insight into evaluating the adaptation process that patients undergo and relevant factors, and may be a useful example of providing integrated care.

Continuous Care

The concept of continuous care in healthcare services was introduced in 1960 in the United States.¹⁸ Continuous care is specifically planned for the individual patient and relates to a specific time. This period can cover as short a time as the hospitalization period of a patient or it can apply to long-term care that starts with the individual’s first-line healthcare. Continuous care has three components: informational continuity, relational continuity, and management continuity.¹⁶ Various methods may be used in the implementation of continuous care. These methods encompass discharge instructions, periodic patient follow-ups, case conferences among team members in which patients and their families are also included, and telephone follow-ups.¹⁸ In the continuous care of TKR patients, emphasis is placed on the importance of a multidisciplinary team that includes a case management nurse, nurse anesthetist, occupational therapist, orthopedist, physiotherapist, dietician, and a psychiatrist when necessary. While the case management nurse is in charge of managing care, support from other healthcare disciplines is enlisted when needed.^12,15,18,20 In this study, the researcher performed the duties of a case management nurse.

Roy Adaptation Model

Sister Callista Roy defined the model as a “continuously growing and developing adaptive system of conditions, circumstances, and influences that surround and affect the development and behavior of a person”.¹⁹ Various focal, contextual, and residual stimuli change the environment and affect the open system of the human being. Focal stimuli are those that are extrinsic to which the individual immediately responds with the reflex of adjustment. Contexual stimuli are all those that are not directly caused by behavior but have an effect on behavior and arise from the individual’s internal and external worlds. Residual stimuli are internal or external factors that have a continuous effect on the individual but whose impact cannot be fully explained. The model describes two coping subsystems of individuals-the regulator and cognator systems-that are present at birth or later acquired. If environmental impacts are greater than what the individual can cope with, the system cannot function and a deviation from health is the result. The observable behaviors of individuals comprise the RAM’s physiological, self-concept, role function, and interdependence adaptive modes. Behaviors in the physiological domain consist of functions that maintain physical integrity. Roy classified behavioral responses in the domain of adaptation as adaptive or non-adaptive. The objective of nursing is to develop adaptive responses.¹⁹

Aim

The aim of this study sough to evaluate the effects of RAM-based continuous care given to post-operative TKR patients. The hypotheses of the study were (primary outcomes): (1) The intervention group’s pain, anxiety, and depression levels will be lower than the control group levels. (2) The intervention group’s functional state will be higher than in the control group. (3) There is a difference between the mean scores of pain, anxiety, and functional status between the intervention and control groups, and between group x time (Baseline, Pre-discharge, 3^rd month) interactions.

MATERIALS AND METHODS

Design: This study had a quasi-experimental design.

Sample: The study was completed with TKR patients treated from October 2012 to July 2014 at the orthopedic and traumatology unit of a university hospital situated in western Türkiye. A convenience sample was selected from patients admitted to the orthopedic unit for TKR surgery. The inclusion criteria were being a first-time TKR patient, age 18 or older, oriented, and able to speak and understand Turkish. The exclusion criteria included a confirmed neurological or psychiatric medical diagnosis. Eighty-three patients participated, and seven patients were excluded from the study (Figure 1). The first 44 patients were designated as the control group, and the next 39 patients were recruited into the intervention group (n=76). After the study data were collected, the data were applied to the G^*power package program for power analysis. The sample size for each group was taken as an average of 36, and the two-way analysis of variance was used in the power analysis on repeated measures. The power analysis employed the mean scores for anxiety and depression, the study’s dependent variables, and it was found that the power was above 80%.²¹ At the end of the study, the power was 0.86, and when the effect size was 0.37, the p values were 0.05.

Procedure: Informational booklets and telephone follow-ups provided during this period were part of the continuous care intervention. The patients were provided with education “preoperatively,” “postoperatively” and “pre-discharge” based on the informational booklet drawn up by the researcher. In the follow-ups after discharge, the information was repeated according to the patients’ needs (Figure 2). The educational booklet contained updated information considering evidence-based applications on: preoperative preparation with the TKR patient, difficulties that the patient may encounter postoperatively, relevant pre-discharge and post-discharge information, and guidance for caretakers post-discharge.^{3,7,13,20,22,23} The opinions of four academic nurses, a physician, an academic physiotherapist, two orthopedic nurses, and three patients who had undergone TKR were included in the booklet. Over the study period, the patients were allowed to call the researcher whenever they wanted to ask a question and receive advice on any topic they wanted. In addition, the patients’ recovery processes were assessed, and patients who needed more follow-ups were called once a week.

The control group was provided with routine care at the clinic during the study period. When TKR was planned for a patient, the physician provided the patient with information about “the diagnosis, risks of the surgery, and surgical procedure.” Before discharge, patients were given informational brochures about the period after discharge. Any question that patients had throughout the process, from admittance until discharge, were answered during nursing interventions. The data for the intervention group were collected after the completion of data collection for the control group. Following the collection of initial information from the patients, the researcher implemented continuous care based on RAM (Figure 3). Data were collected from the patients “preoperatively,” “pre-discharge,” and in “the 3^rd month.” The application of instruments was completed in 20-30 min for each measurement. Phone calls lasted 20-40 minutes on average. A researcher collected the data (A.S.).

Instruments: The research data were collected using (1) a Patient Identification Form, (2) the Western Ontario and McMaster Universities Osteoarthritis Index, and reliable scale for the evaluation of pain, stiffness, and functional state in patients with OA.^24,25 Scores are based on a scale of 20 points for pain, 8 points for stiffness, and 68 points for functional state; the higher the points, the worse the individual’s condition.²⁴ The Cronbach’s alpha coefficients (baseline, 1^st follow-up and 2^nd follow-up) were: 0.77, 0.78, 0.82, respectively for pain; 0.82, 0.96, 0.90, respectively for stiffness, and 0.93, 0.91, 0.93, respectively, for functionality. The Cronbach’s alpha coefficient indicates whether items measure the same characteristics and whether the items are related to what is being measured. Cronbach’s alpha coefficients less than 0.40 indicate that the instrument is not reliable; coefficients between 0.40≤ α <0.60 indicate low reliability, 0.60≤ α <0.80 good reliability, and 0.80≤ α 21

The Hospital Anxiety and Depression Scale developed by Zigmond and Snaith²⁶ consists of subscales for anxiety and depression. This is a commonly used, valid, and reliable scale.²⁷ The scale is made up of 14 items: 7 symptoms of depression and 7 symptoms of anxiety. The results of the receiver operating characteristic analysis determined that the cut-off points on the Turkish questionnaire were 10 for the anxiety subscale and 7 for the depression subscale. Individuals scoring above these points are identified as a risk group.²⁷ The Cronbach’s alpha coefficients (baseline, 1^st follow-up, 2^nd follow-up) for this study were 0.83, 0.74, 0.87 for anxiety and 0.59, 0.59, 0.70 for depression.

Ethics

Written informed consent was approved by the Dokuz Eylül University Hospital Ethical Committee (approval number: 30-GOA2011/13-09-2011). In addition, written permission was obtained from the University Hospital. The researcher obtained the patients’ written and verbal consents after explaining to them the purpose of the research, the process of data collection, and the study’s implementation, informing them that they may withdraw from the study at any time and that their names would be kept confidential. The studies comply with the Declaration of Helsinki.

Statistical Analysis

The Statistical Package for the Social Services SPSS version 15.0 (SPSS^®, IBM^® Corp., Armonk, NY, USA) program was used in the data analysis in the second stage of the study. Data analysis included descriptive statistics of numbers (i.e. percentages, means, standard deviation), χ², t-tests, a 2-factor repeated-measures analysis of variance, and a paired t-test with Bonferroni correction.

RESULTS

Sociodemographic Characteristics

Of all patients participating in the study, 89.5% (68) were women, 84.2% were married, 64.5% were housewives, 30.1% were retired, 71.1% lived with their spouses, and 15.8% lived at their children’s homes. Of the patients, 69.7% had a chronic illness, 51.3% had tried physical therapy, 76.3% underwent surgery because of pain and loss of function, 31.3% had been suffering from knee pain for more than 4 years, 50.0% had bilateral surgery, and 41.8% required the support of a cane, crutches, or someone’s assistance before the surgery. Of the patients, 58.2% could walk without a helping vehicle. The mean age of the intervention group was 66.77±8.3, mean body mass index (BMI) was 32.6±7.03, the average stay at the hospital was 9.5±2.9 days; in the control group, the mean age was 65.57±6.5, mean BMI was 30.5±4.71, and the average stay at the hospital was 9.2±3.2 days. The distribution of the features of the intervention and control groups is shown in Table 1.

Effects of RAM-Based Continuous Care on Pain, Stiffness and Functional State

No significant difference was found in the intervention group in pain, stiffness, and functional state scores in terms of the group time interaction (Baseline, pre-discharge, 3^rd month) (Table 2). Except for the pain score, no statistically significant difference in the pre-discharge and 3^rd month was found for the patients in the intervention and control groups. It was determined that the pain scores of patients in the intervention group in the pre-discharge period were lower than those in the control group (t=2.343 p=0.022). No statistically significant difference in the pre-discharge and 3^rd month was found for stiffness scores for the patients in the intervention and control groups (pre-test t=0.633, p=0.528; post-test t, time 1=0.933, p=0.354; post-test t, time 2=0.102; p=0.919). No statistically significant difference in the pre-discharge and 3^rd month was found between functional state scores for the patients in the intervention and control groups (pre-test t=1.836, p=0.071; post-test t, time 1=1.533, p=0.130; post-test t, time 2=0.178; p=0.859) (Table 2).

Effects of RAM-Based Continuous Care on Anxiety and Depression

A significant difference was found between the anxiety score averages in time in the intervention group in terms of the group x time interaction (Baseline, pre-discharge, 3^rd month) (F=4.892) (p=0.009) (Table 3). Because of further analysis, a statistically significant difference was determined that the anxiety scores of patients in the intervention group in the 3^rd month were lower than those in the control group (t=2.201; p=0.032). No statistically significant difference was determined between pre-test (t=1.355; p=0.259) and post-test t, time 1 (t=1.532; p=0.130). A significant difference was found between the depression score averages in time in the intervention group in terms of the group time interaction (Baseline, Pre-discharge, 3^rd month). (F=3.359) (p=0.037). As a result of further analysis, no statistically significant difference in the pre-discharge and 3^rd month depression scores was found between the patients in the intervention and control groups (pre-test t=0.815, p=0.418; post-test t, time 1=0.047, p=0.963; post-test t, time 2=1.322, p=0.191) (Table 3).

DISCUSSION

Total knee surgery is a choice that leads to a welcomed increased quality of life. The improvement in the postoperative pain-stiffness-functionality variables of all patients was consistent with the literature. Reduced pain, decreased stiffness, improved functioning, and an increased quality of life are the most fundamental outcomes of TKR surgery.^9,22,28 Another study with female patients undergoing TKR surgery reported reduced pain along with improved functioning.²⁹ In long-term studies that followed up on patients, pain and functionality were reported to be good.^8,9,30 However, orthopedic surgery can cause serious pain in the early postoperative period.^31,32 One study determined that among patients undergoing TKR surgery, 12% experienced severe pain in the early postoperative period.³ In this study, it was determined that the pain scores of patients in the intervention group in the pre-discharge period were lower than those in the control group. This result was related to effective pain control in the intervention group. The results of this study may be considered effective adaptive behaviors in the physiological adaptation domain. In particular, the fact that the pain scores were better in the intervention group may be associated with how the patients in the intervention group developed effective adaptive behavior to cope with pain, which was included in the self-concept adaptation domain.

The tendency toward anxiety and depression decreased with time in the intervention group compared with the control group. At the same time, the anxiety scores in the intervention group in the 3^rd month were significantly lower than those in the control group. All of these findings are consistent with the literature. Before the operation, the pain associated with the condition generally leads to increasing restrictions in movement as well as to deformities and instabilities, which impede ADL, make adaptation to home and work life difficult, and cause the patient to feel handicapped.^2,6 Because surgical prosthesis is an elective procedure, these interventions are postponed because of patients’ experience with severe pain. This causes fear and avoidance of chronic pain and leads to patients adopting negative thought patterns. With fear comes hypervigilance or avoidance.¹⁰ On the other hand, while patients undergoing TKR surgery hope that they will be relieved of their pain and will be able to prevent their immobility, they also live in fear that their problems will increase.^28,33 In the early postoperative period, patients are faced with pain and other adverse effects of the surgery, additional illnesses, anesthesia, narcotic analgesics, fear (i.e. falling, becoming handicapped, becoming a burden), and other factors.¹³ Following discharge from the hospital, patients face pain, restricted movement, and fears (i.e. of falling, of hurting the prosthesis, of dependency, of being discharged before being fully prepared, of a lack of information, and of being a burden). Throughout the process, patients have to cope with social isolation, weakness, anxiety, an inability to cope, an inability to fulfill one’s role, and a loss of self-respect, among other negative factors.^2,11 In a study, 41.5% of patients undergoing orthopedic surgery experienced psychological changes in the post-operative period. These changes were feeling discouraged, feeling ill and handicapped, crying, feeling low, apathy, changes in sleep patterns, fatigue, irritability, nervousness and despair, and helplessness.¹⁷ In another study, 20% of patients undergoing TKR were found to experience a sizable amount of post-operative stress in the first and third months.¹⁰ However, postoperatively, patients may be confronted with symptoms such as a lack of energy, a loss of balance, and a fear of falling.²⁸ In our study, patients said that they felt crippled in the early period and were anxious that they would never walk again. At the same time, the patients experienced a fear of falling and perceived themselves as dependents that were a burden on their families. A study reported that 21% of their patients felt the need for some sort of social or psychological support.¹⁷ In another study, also reported that telephone follow-ups were effective because this method provided the opportunity to evaluate the patient’s environmental factors and support systems.³⁴ The low anxiety and depression scores in the patients in our intervention group indicated that individuals were able to display effective adaptive behavior in the self-concept, interdependency, and role function adaptation domains.

Patients are faced with many problems after TKR surgery. Education and follow-up protocols have been devised to improve TKR surgery outcomes and to help patients adapt to life with prostheses.^35,36 Education and subsequent follow-ups are of great importance because patients have to spend more time recovering at home due to shortened hospital stays.¹⁴ Follow-ups are particularly important for evaluating the condition of patients who do not come in for routine visits.³⁷ In our study, it was found that patients, especially those living in other provinces, had difficulty coming in for their check-ups and were happy with telephone follow-ups. On the other hand, it is recommended that the topics covered in the education of patients are repeated because patients may be sleepy, irritated, in pain, stressed, and may not be able to concentrate on the information given to them pre-discharge.^8,37 A study discovered that patients and their families who were provided with a brief education did not learn much. Therefore, patients encountered problems at home because of gaps in their knowledge and had no opportunity to ask questions.³⁸ In another study where 207 patients with total joint prostheses were followed over the course of a year, it was found that patients were able to feel free to ask any questions they might have.¹⁴

Study Limitations

The lack of randomization in the study was one of its limitations. In addition, because a large majority of the patients lived in different cities, their coming in for a checkup and being examined by the same healthcare professionals was problematic. This was a limitation because maintaining continuity in caregivers is an important factor in continuous care. Another limitation was that the patients’ health insurance did not cover their additional rehabilitation needs.

Moreover, the system of working on a multidisciplinary platform is a structure that has not yet become well established in the Turkish healthcare system. The researcher acted as a bridge between disciplines to facilitate continuous care interventions. The study’s foundation on a nursing model is a strength of the research. The use of a nursing model not only helped to generate new knowledge for nursing researchbut also facilitated a holistic approach to the patient/individual/group and provided the means to determine realistic goals that were tailored to consider individual differences and ensure the maintenance of continuous care. The model acts as a bridge between theory and practice in the nursing profession and contributes to the evaluation of care.

CONCLUSION

Evaluation in RAM depends on the question, “Did the individual adapt?” This requires analyzing and deciding whether the targeted behavioral change was achieved. When the nurse evaluates the adaptation of patients with TKR, the change processes must be assessed, and it must be determined whether there has been effective adaptation. Changes in pain, stiffness, and functional status of patients affect their physiological, self-concept, and role function adaptive modes according to RAM. Anxiety and depression situations affect their self-concept, role function, and interdependence adaptive modes according to RAM. Moreover, all these adaptive modes affect each other. The lower levels of pain, anxiety, and depression in the patients in the intervention group indicated that they were better at showing more effective adaptive behavior. The outcome revealed that RAM-based continuous care prepared patients for better adaptation to living life with their prosthesis.

Relevance to Clinical Practice

In our study, as in the literature, the patients experienced stress for many reasons preoperatively, postoperatively, at pre-discharge, and at home, and for this reason sought support. RAM-based continuous care prepared patients for the process with education, advice, and telephone follow-ups; offered them the chance to become familiar with and adapt to their prosthesis, express their distress, identify problems at an early stage, and be encouraged to participate in social activities. Continuous care enables early identification and prevention of possible complications, thereby increasing the success of TKR surgery and easing the economic burden caused by revision surgery and other costs. Continuous care based on a model may provide integrated care that will serve as a guide for nursing interventions. Continuous care structured around RAM, which will be used in orthopedic nursing in TKR patients for the first time, will serve as a guide for nursing regarding patient care, carrying the dimensions of care to another level and enabling a more humanistic and holistic approach.

MAIN POINTS

• This study used the Roy Adaptation Model in patients undergoing total knee replacement surgery to enhance nurses’ understanding of caregiving theories and their skills at incorporating these theories into the care they provide.

• Basing the continuous care provided to patients undergoing knee replacement surgery on the RAM may provide insight into evaluating the adaptation process patients go through and influencing factors, and it may be a useful example of integrated care.

• The use of a nursing model in this study contributed to strengthening the philosophy of nursing science.

Acknowledgments: The authors wish to thank the participants who voluntarily participated in the study.

ETHICS

Ethics Committee Approval: Written informed consent was approved by the Dokuz Eylül Hospital Ethical Committee (approval number: 30-GOA2011/13-09-2011).

Informed Consent: The researcher obtained the patients’ written and verbal consents after explaining to them the purpose of the research, the process of data collection, and the study’s implementation, informing them that they may withdraw from the study at any time and that their names would be kept confidential.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: A.S., Ö.B., Design: A.S., Ö.B., Supervision: Ö.B., Resources: A.S., Materials: A.S., Ö.B., Data Collection and/or Processing: A.S., Analysis and/or Interpretation: A.S., Ö.B., Literature Search: A.S., Writing: A.S., Critical Review: Ö.B.

DISCLOSURES

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study had received no financial support.