Self-Regulation Theory: Applying Theory to Your Practice
The learner objectives for this chapter are to be able to:
- Explain the origin of the book.
- Describe the stressors related to receiving radiation therapy.
- Explain assumptions in self-regulation theory about patients' roles or responsibilities when receiving health care.
- Explain providers' attitudes toward patients participating in their care that are a part of self-regulation theory.
- Describe activities that help in learning the approach to preparing patients for radiation therapy
- that is presented in this book. Describe how the book is organized.
The Basis of the Book
The impetus for this book was a clinical research project designed to test the feasibility of staff nurses using self-regulation theory as a guide for preparing patients to receive radiation therapy (RT) and to evaluate the impact of that care on patients. The results showed (a) that it is possible to translate a complex theory about how people cope with stressful events into actual nursing practice within a radiation therapy department and (b) that nursing care based on that scientific knowledge affected patient outcomes that are relevant to patients' quality of life. The study was the most recent in a series of studies on how to help people cope with stressful experiences, including studies of patients receiving RT (Johnson, 1996; Johnson, Nail, Lauver, King, & Keys, 1988).
More than 25 years of research influenced the development of the self-regulation theory, which is a theory about coping with healthcare experiences. The theory has guided research on the effects of preparatory information on patients' coping. In the early studies,patients were prepared for healthcare procedures of short duration (e.g., orthopedic cast removal [Johnson, Kirchhoff, & Endress, 1975], gastroendoscopy [Johnson, Morrissey, & Leventhal, 1973]) and the intervention was labeled "sensory information" (McHugh, Christman, & Johnson, 1982). When the research focused on preparation of patients for complex events that extended over days and weeks, the intervention expanded. In addition to descriptions of physical sensations, other components of patients' experiences were included.
The recommendation for nurses to prepare patients for the physical sensations experienced during a procedure has appeared in nursing text books and has become usual practice in many settings. Rarely have nurses or other providers been informed about the research and theory that are the bases for that practice. An in-depth understanding of self-regulation theory allows nurses to use it when caring for patients in many situations. The use of the self-regulation theory in nursing practice could benefit many patients.
The Stress of Receiving Radiation Therapy
RT was the clinical situation used to demonstrate the effects on patients of staff nurses using the self-regulation theory in nursing practice. RT was selected for the demonstration because of its complexity. The value of the theory for nursing practice would be increased if it was shown to be a useful guide for staff nurse-delivered care in a complex clinical situation. The following description of RT will introduce readers to what is generally involved when patients receive this therapy.
RT frequently is used to treat cancer. The experience can be stressful to patients for several reasons. Patients must deal with the stress of the cancer diagnosis, the stress provoked by starting a therapy that they know little about, and the stress associated with demands on time and other resources during treatment.
Patients may begin RT with only vague ideas about the treatment or with misconceptions about what to expect. Misconceptions can include beliefs such as the radiation will burn or side effects such as hair loss or nausea will occur, which is true in only some patients. Those patients who have had or who know someone who has had RT may not have accurate information about what the experience will be like. The information could be outdated or based on experiences about RT delivered to a different part of the body.
The experience of receiving RT taxes patients' resources. Radiation treatments usually are administered daily, Monday through Friday, for four to seven weeks. The exact number of treatments varies by patient and tumor location. Commuting to the treatment facility five days a week for several weeks can be disruptive and burdensome. The therapy may cause side effects that result in discomfort and a disruption in patients' usual activities of daily living. Patients may attribute some side effects to the cancer and become unduly concerned.
The stressful events that patients receiving RT must deal with are different for each phase of the experience. The first event for patients who have decided to receive RT is a one-to-two-hour treatment planning session called a simulation. Patients are in an environment unusual to them and have to lie on a narrow hard treatment table, which can be uncomfortable. Following the simulation, a session during which the treatment plans are checked using beam films may be held, and then the first treatment is delivered. Receiving a radiation treatment can be frightening and produce anxiety. There is little variation in what happens to patients while they are in the treatment room. However, two to three weeks into treatment, most patients begin to experience side effects. The side effects experienced depend on the site being treated. Most side effects continue for weeks to months following RT, and occasionally long-term side effects occur that continue or are exhibited years following RT. Following the completion of therapy, patients may feel stressed because they no longer have daily contact with staff and other patients. Although patients rarely experience extremely high levels of stress from RT, most find the experience to be stressful to some degree.
Summary of the Findings
The application of the theory was reflected in four structured interventions provided during nurse-patient interactions. Interventions were provided (1) before the simulation procedure, (2) during the first week of RT, (3) during the last week of RT, and (4) one month following RT.
The demonstration of a direct link between staff nurses using self-regulation theory as the basis for patient preparation for RT and patient outcomes provided support for the recommendation that other healthcare providers use the approach in their practice. The purpose of this book is to present information needed by nurses to provide the type of patient care that was demonstrated to be effective.
How to Learn to Use Self-Regulation Theory
Self-regulation theory is based on assumptions about patients and their role in healthcare. Patients are responsible for coping with the experience, including making decisions about the type of treatment, complying with treatment regimes, providing self-care, and dealing with all aspects of the experience. This responsibility contrasts with that of care providers, which is to provide the care. Patients' and providers' responsibilities require different knowledge and skills. Technical information that care providers need may not be useful to patients. For example, to deliver effective care, nurses working in a radiation department need to know how to position patients, how to insert tubes or needles, how radiation affects cancer cells and normal cells, and what information is most effective for helping patients fulfill their responsibilities. A way to select information that may be beneficial to patients is to ask the question "Will the information help patients do what they have to do?"
Self-regulation theory is based on the assumption that care providers accept patients as active participants in the healthcare process. This includes the acknowledgment that patients make decisions and control much of what happens to them. It can be argued that patients are in control even if they make the decision to accept prescriptions of care providers. Effective use of self-regulation theory in practice requires that providers value patients' participation and practice in a way that fosters the participation in a beneficial manner. In the case of preparing patients for RT, the effective use of self-regulation theory requires nurses to recognize and accept the importance of providing patients with the type of information needed to make decisions about self-care. The nurse must also realize that instructions about self-care activities without information to assist the patient in making a decision about the use of these activities may not be the most effective information to enhance patients' ability to cope and care for themselves. Because self-care instructions have comprised the majority of the information nurses have provided to patients, it may be difficult for some to change. This point is detailed in Chapter III.
This book contains the information needed to learn self-regulation theory and to apply it to the practice of nursing. Learning activities that nurses can use to become proficient in applying self-regulation theory in their practice are included. RT patients are the focus of the learning activities demonstrated in this book because the study demonstrating the positive effect of self regulation theory nursing was conducted in a radiation therapy facility. Nurses practicing in other settings can adapt the learning activities discussed. When patients' experiences are less complex than those of RT, nurses may find they can learn to apply self-regulation theory to the individual practice without the use of extensive learning activities.
Because learning how to apply the theory to practice by merely reading the book would be difficult for nurses, the use of these activities to enhance learning is highly recommended. Nurses are encouraged to actively participate in the suggested learning activities because they provide an understanding of self-regulation theory and the characteristics of interventions based on the theory. That understanding will allow them to deliver the structured interventions in a way that meets patients' unique situations and also to use the approach in unplanned interactions with patients. Objectives that can help nurses evaluate their understanding of the material are presented for each chapter.
Nurses can benefit from working in groups to learn this new method of preparing patients. Group discussions about each section of the book can increase the depth of understanding of the content. Group discussions about how the information can be used in practice will allow nurses to identify aspects of their practice that will require change and how to bring the change about. Nurses can use the interventions developed for our treatment facility as a beginning point for developing content appropriate for individual practice settings. Discussions can build a consensus about the content to include in interventions so that patients receive the same information from all their nurses. This is discussed in more detail in Chapter VI. When a consensus exists among nurses about what to include in each intervention, the same nurse does not have to provide all interventions to any one patient. When a nurse documents that a particular intervention was provided to a patient, all nurses know what information the patient has received.
Nurses should discuss attempts to provide the interventions in the group meetings. Questions about what to include and problems encountered when delivering the interventions are examples of topics for discussion. The discussions allow group members to help each other find effective strategies for overcoming difficulties.
Tape recording meetings with patients when an intervention is delivered is another way to increase skill in applying the theory in practice. A nurse can listen to or read a transcription of a tape-recorded interaction and evaluate it. Recordings are useful for identifying parts of the interaction that are consistent with the theory and parts that are not consistent and need to be changed. An outline of the content to be included in each intervention is useful for determining how consistent the content is with that suggested by self-regulation theory. Chapter VII contains outlines of content for the prototype interventions for patients with prostate, breast, head and neck, or lung cancer. The recordings can be shared with a colleague who can help identify omissions of information and confirm that the information provided is consistent with self-regulation theory. This can increase nurses' confidence about their ability to use the theory.
The nurses in our setting found that tape recording interactions with patients was anxiety provoking. The nurses knew that the researchers would evaluate the interactions. Evaluations of one's behavior causes most people to become anxious. However, the nurses also found that the tape recordings helped them break old habits. Recordings allowed the nurses to identify when they were delivering the interventions according to the agreed standards. This positive feedback allowed the nurses to be confident that they had acquired the skill to deliver interventions consistent with self-regulation theory.
Before a nurse-patient interaction is recorded, the patient and the nurse must give permission for the recording. We found that patients were not concerned about the interaction being recorded. The patients were told that the interactions were being recorded to improve patient care and not to evaluate their behavior. We recommend that patients be informed about the reason for the recording before obtaining their permission to tape record an interaction. Nurses should explain to the patient that the tape recordings will not be used to evaluate them.
Planning is necessary because the interventions require that nurses meet with patients before each of four phases of the RT experience. Routines of care should be examined, and plans should be made for how to incorporate the interventions into those routines. The group should discuss changes that need to be made and how to find the time and a location to deliver the interventions. In their discussions, nurses might look for activities that can be omitted because the new approach to care addresses them in a more efficient manner, review how they deliver care to find more efficient ways, and look for activities that can be delegated to other people in the work setting. The group should especially look for overlap of activities by nurses and others. Eliminating the duplication of effort could save time that can be allocated to delivering the interventions.
Organization of the Book
The content of the book is organized into chapters. Each chapter builds on the prior one. The most efficient approach to mastering the material and applying it to clinical practice is to follow each chapter in numerical order. Each chapter begins with a brief explanation of the content included and its relevance to using self-regulation theory in preparing patients for RT.
Chapter II explains the nature of professional nursing practice. This explanation is included because the interventions are most effectively implemented when nurses practice within a professional nursing practice model. Content that will help nurses to understand the difference between the self-regulation approach to providing information and other approaches, such as patient teaching, also is included in Chapter II.
Chapter III presents an explanation of self-regulation theory. An understanding of the theory and explanations of why the interventions are effective allow nurses to be confident about the care they are providing. Nurses can be confident about the effectiveness of the care they provide when that care is based on scientific research that has shown patient benefits. Nurses can rely on their understanding of the theory to answer questions about why they use a particular focus and particular information in the preparation of patients.
The usefulness of a theory to practice is greatly enhanced when it has been tested on clinical populations. A summary of selected research based in self-regulation theory, including the study that demonstrated that patients benefit from the use of self-regulation theory by staff nurses as the basis for interventions, is described in Chapter IV. That study is discussed in more detail than the others because it was the basis for the prototype interventions and learning activities included in this book.
Chapter V further details how self-regulation theory and its principles relate to practice, focusing on how patients, nursing, and information is represented in self-regulationtheory. That discussion will help the learner to gain more insight into applying self-regulation theory to practice.
Chapter VI includes a brief description of the content of each of the four interventions that the staff nurses provided to patients during the study and suggestions for how to fit the interventions into clinical routines. The specific information included in each intervention is introduced in the chapter. The suggestions given for delivery of the interventions demonstrate how they can be individualized for patients and altered in response to pressures in the clinical setting.
Prototypes of the specific content included in each of the four interventions by diagnostic group are in Chapter VII. These prototypes can be used as a template for interventions that are appropriate for other radiation therapy clinics. An outline of the content covered in each of the interventions is included. Outlines can be used by nurses as reminders of the information to include in patient interactions and to analyze tape-recorded interactions with patients.
Chapter VIII discusses problems or concerns that patients might present to nurses and suggestions for responses that are consistent with self-regulation theory and research. Once nurses learn to apply the theory, they will want to apply it to other aspects of care. Chapter VIII is designed to help nurses transfer the information.
The last chapter, Chapter IX, explains the process for implementation of the change in practice in a RT facility. Changes in care will be necessary to accommodate the time required for nurses to provide the interventions. This content will be of special interest to nurse managers and supervisors. Included in the chapter are suggestions for applying the theory to other patient-care situations and extensions of the theory to research in other settings.
- Johnson, J.E. (1996). Coping with radiation therapy: Optimism and the effects of preparatory interventions. Research in Nursing and Health, 19, 312.
- Johnson, J.E., Fieler, V.K., Wlasowicz, G.S., Mitchell, M.L., & Jones, L. (in press). The effects of self-regulation theory guided nursing care on coping with radiation therapy. Oncology Nursing Forum.
- Johnson, J.E., Kirchhoff, K., & Endress, M.P. (1975). Altering children's distress behavior during orthopedic case removal. Nursing Research, 24, 404-410.
- Johnson, J.E., Morrissey, J.F., & Leventhal, H. (1973). Psychological preparation for an endoscopic examination. Gastrointestinal Endoscopy, 19, 180-182.
- Johnson, J.E., Nail, L.M., Lauver, D., King, K.B., & Keys, H. (1988). Reducing the negative impact of radiation therapy on functional status. Cancer, 61, 46-51.
- McHugh, N.G., Christman, N.J., & Johnson, J.E. (1982). Preparatory information: What helps and why. American Journal of Nursing, 82, 780-782.