Adapting Beyond the Machine: A Roy Adaptation Model-Guided KTH Nursing Pathway and Real-World Outcomes in Maintenance...

Maintenance hemodialysis (HD) carries a heavy psychosocial and self-management burden that routine nursing addresses incompletely. Whether a pathway coupling the Knowledge-Treatment-Health (KTH) structure to the four adaptive modes of the Roy Adaptation Model (KTH-RAM) improves outcomes is unknown.

We analysed records of 322 adults on maintenance HD at a single centre between October 2021 and October 2025; 161 received routine nursing and 161 the KTH-RAM pathway (non-randomised). Fifteen baseline covariates (demographics, comorbidity, vascular access, laboratory values, dialysis adequacy, baseline symptom severity) were extracted. Patient-reported outcomes were assessed at four weeks, objective indicators at twelve weeks. Associations were estimated by propensity-score matching, inverse-probability weighting and multivariable regression, with E-value sensitivity analysis.

Matching yielded 122 balanced pairs (all standardized mean differences <0.10). The KTH-RAM pathway was associated with lower anxiety (Cohen's d -0.41) and depression (-0.33) and higher resilience (0.37), perceived social support (0.42), executive self-care (0.28), partnership (0.47) and emotional management (0.26); hope and problem-solving were directional but not robust. Higher dialysis compliance was more frequent with KTH-RAM across all estimators, although the difference did not reach statistical significance (adjusted OR 1.86, 95% CI 0.97-3.56; IPTW 1.79); nursing satisfaction showed the same pattern; complications were fewer (6.2% vs 13.7%). Objective indicators (albumin, phosphorus, Kt/V) favoured KTH-RAM modestly; vascular-access events and hospitalization differences were non-significant.

In this propensity-matched cohort, the KTH-RAM nursing pathway was associated with modestly better psychological, self-management and objective dialysis outcomes. For nephrology nursing, the pathway offers a structured, theory-based template that links mode-specific adaptive assessment to concrete behaviour-change actions and may help frontline teams prioritise psychological and self-management support within routine dialysis care. Given the non-randomised design and contact-time imbalance, these hypothesis-generating associations require confirmation in a prospective, attention-matched randomised trial.