CREDENTIALS AND BACKGROUND OF THE THEORIST

Sister Callista Roy, a member of the Sisters of Saint Joseph of Carondelet, was born on October 14, 1939, in Los Angeles, California. She received a bachelor’s degree in nursing in 1963 from Mount Saint Mary’s College in Los Angeles and a master’s degree in nursing from the University of California, Los Angeles, in 1966. After earning her nursing degrees, Roy began her education in sociology, receiving both a master’s degree in sociology in 1973 and a doctorate in sociology in 1977 from the University of California.

While working toward her master’s degree, Roy was challenged in a seminar with Dorothy E. Johnson to develop a conceptual model for nursing. While working as a pediatric staff nurse, Roy had noticed the great resiliency of children and their ability to adapt in response to major physical and psychological changes. Roy was impressed by adaptation as an appropriate conceptual framework for nursing. Roy developed the basic concepts of the model while she was a graduate student at the University of California, Los Angeles, from 1964 to 1966. Roy began operationalizing her model in 1968 when Mount Saint Mary’s College adopted the adaptation framework as the philosophical foundation of the nursing curriculum. The Roy Adaptation Model was first presented in the literature in an article published in Nursing Outlook in 1970 entitled “Adaptation: A Conceptual Framework for Nursing” (Roy, 1970).

Roy was an associate professor and chairperson of the Department of Nursing at Mount Saint Mary’s College until 1982. She was promoted to the rank of professor in 1983 at both Mount Saint Mary’s College and the University of Portland. She helped initiate and taught in a summer master’s program at the University of Portland. From 1983 to 1985, she was a Robert Wood Johnson postdoctoral fellow at the University of California, San Francisco, as a clinical nurse scholar in neuroscience. During this time, she conducted research on nursing interventions for cognitive recovery in head injuries and on the influence of nursing models on clinical decision making. In 1987, Roy began the newly created position of nurse theorist at Boston College School of Nursing.

Roy has published many books, chapters, and periodical articles and has presented numerous lectures and workshops focusing on her nursing adaptation theory (Roy & Andrews, 1991). The refinement and restatement of the Roy Adaptation Model is published in her 1999 book, The Roy Adaptation Model (Roy & Andrews, 1999).

Roy is a member of Sigma Theta Tau, and she received the National Founder’s Award for Excellence in Fostering Professional Nursing Standards in 1981. Her achievements include an Honorary Doctorate of Humane Letters by Alverno College (1984), honorary doctorates from Eastern Michigan University (1985) and St. Joseph’s College in Maine (1999), and an American Journal of Nursing Book of the Year Award for Essentials of the Roy Adaptation Model (Andrews & Roy, 1986). Roy has been recognized in the World Who’s Who of Women (1979), Personalities of America (1978); as a fellow of the American Academy of Nursing (1978); recipient of a Fulbright Senior Scholar Award from the Australian-American Educational Foundation (1989), and the Martha Rogers Award for Advancing Nursing Science from the National League for Nurses (1991). Roy received the Outstanding Alumna award and the prestigious Carondelet Medal from her alma mater, Mount Saint Mary’s. The American Academy of Nursing honored Roy for her extraordinary life achievements by recognizing her as a Living Legend (2007).

THEORETICAL SOURCES

Derivation of the Roy Adaptation Model for nursing included a citation of Harry Helson’s work in psychophysics that extended to social and behavioral sciences (Roy, 1984). In Helson’s adaptation theory, adaptive responses are a function of the incoming stimulus and the adaptive level (Roy, 1984). A stimulus is any factor that provokes a response. Stimuli may arise from the internal or the external environment (Roy, 1984). The adaptation level is made up of the pooled effect of the following three classes of stimuli:

Helson’s work developed the concept of the adaptation level zone, which determines whether a stimulus will elicit a positive or a negative response. According to Helson’s theory, adaptation is the process of responding positively to environmental changes (Roy & Roberts, 1981).

Roy (Roy & Roberts, 1981) combined Helson’s work with Rapoport’s definition of system to view the person as an adaptive system. With Helson’s adaptation theory as a foundation, Roy (1970) developed and further refined the model with concepts and theory from Dohrenwend, Lazarus, Mechanic, and Selye. Roy gave special credit to co-authors Driever, for outlining subdivisions of self-integrity, and Martinez and Sato, for identifying common and primary stimuli affecting the modes. Other co-workers also elaborated the concepts. Poush-Tedrow and Van Landingham made contributions to the interdependence mode, and Randell made contributions to the role function mode.

After the development of her model, Roy presented it as a framework for nursing practice, research, and education. Roy (1971) acknowledged that more than 1500 faculty and students contributed to the theoretical development of the adaptation model. She presented the model as a curriculum framework to a large audience at the 1977 Nurse Educator Conference in Chicago (Roy, 1979). And, by 1987, it was estimated that more than 100,000 nurses in the United States and Canada had been prepared to practice using the Roy model.

In Introduction to Nursing: An Adaptation Model, Roy (1976a) discussed self-concept and group identity mode. She and her collaborators cited the work of Coombs and Snygg regarding self-consistency and major influencing factors of self-concept (Roy, 1984). Social interaction theories are cited to provide a theoretical basis. For example, Roy (1984) notes that Cooley (1902) theorizes that self-perception is influenced by perceptions of others’ responses, termed the “looking glass self.” She points out that Mead expands the idea by hypothesizing that self-appraisal uses the generalized other. Roy builds on Sullivan’s suggestion that self arises from social interaction (Roy, 1984). Gardner and Erickson support Roy’s developmental approaches (Roy, 1984). The other modes—physiologicalphysical, role function, and interdependence—were drawn similarly from biological and behavioral sciences for an understanding of the person.

Additional development of the model occurred during the later 1900s and into the twenty-first century. These developments included updated scientific and philosophical assumptions; a redefinition of adaptation and adaptation levels; extension of the adaptive modes to group level knowledge development; and analysis, critique, and synthesis of the first 25 years of research based on the Roy Adaptation Model. Roy agrees with other theorists who believe that changes in the person-environment systems of the earth are so extensive that a major epoch is ending (Davies, 1988; De Chardin, 1966). During the 67 million years of the Cenozoic era, the Age of Mammals and an era of great creativity, human life appeared on Earth. During this era, humankind has had little or no influence on the universe (Roy, 1997). “As the era closes, humankind has taken extensive control of the life systems of the earth. Roy claims that we are now in the position of deciding what kind of universe we will inhabit” (Roy, 1997, p. 42). Roy “has made the foci of assumptions of the twenty-first century mutual complex person and environment self-organization and a meaningful destiny of convergence of the universe, persons, and environment in what can be considered a supreme being or God” (Roy & Andrews, 1999, p. 395). According to Roy (1997), “persons are coextensive with their physical and social environments” (p. 34), and they “share a destiny with the universe and are responsible for mutual transformations” (Roy & Andrews, 1999, p. 395). Developments of the model that were related to the integral relationship between person and environment have been influenced by Pierre Teilhard De Chardin’s law of progressive complexity and increasing consciousness (De Chardin, 1959, 1965, 1966, 1969) and the work of Swimme and Berry (1992).

USE OF EMPIRICAL EVIDENCE

From this beginning, the Roy Adaptation Model has been supported through research in practice and in education (Brower & Baker, 1976; Farkas, 1981; Mastal & Hammond, 1980; Meleis, 1985, 2007; Roy, 1980; Roy & Obloy, 1978; Wagner, 1976). In 1999 (Roy & Andrews, 1999), a group of seven scholars working with Roy conducted a meta-analysis, critique, and synthesis of 163 studies based on the Roy Adaptation Model that had been published in 44 English language journals on five continents and dissertations and theses from the United States. Of these 163 studies, 116 met the criteria established for testing propositions from the model. Twelve generic propositions based on Roy’s earlier work were derived. To synthesize the research, findings of each study were used to state ancillary and practice propositions, and support for the propositions was examined. Of 265 propositions tested, 216 (82%) were supported.

MAJOR ASSUMPTIONS

Assumptions from systems theory and assumptions from adaptation level theory have been combined into a single set of scientific assumptions. From systems theory, human adaptive systems are viewed as interactive parts that act in unity for some purpose. Human adaptive systems are complex and multifaceted and respond to a myriad of environmental stimuli to achieve adaptation. With their ability to adapt to environmental stimuli, humans have the capacity to create changes in the environment (Roy & Andrews, 1999). Drawing on characteristics of creation spirituality by Swimme and Berry (1992), Roy combined the assumptions of humanism and veritivity into a single set of philosophical assumptions. Humanism asserts that the person and human experiences are essential to knowing and valuing, and that they share in creative power. Veritivity affirms the belief in the purpose, value, and meaning of all human life. These scientific and philosophical assumptions have been refined for use of the model in the twenty-first century (Box 17-1).

THEORETICAL ASSERTIONS

Roy’s model focuses on the concept of adaptation of the person. Her concepts of nursing, person, health, and environment are all interrelated to this central concept. The person continually experiences environmental stimuli. Ultimately, a response is made and adaptation occurs. That response may be either an adaptive or an ineffective response. Adaptive responses promote integrity and help the person to achieve the goals of adaptation, that is, they achieve survival, growth, reproduction, mastery, and person and environmental transformations. Ineffective responses fail to achieve or threaten the goals of adaptation. Nursing has a unique goal to assist the person’s adaptation effort by managing the environment. The result is attainment of an optimal level of wellness by the person (Andrews & Roy, 1986; Randell, Tedrow, & Van Landingham, 1982; Roy, 1970, 1971, 1980, 1984; Roy & Roberts, 1981).

As an open living system, the person receives inputs or stimuli from both the environment and the self. The adaptation level is determined by the combined effect of focal, contextual, and residual stimuli. Adaptation occurs when the person responds positively to environmental changes. This adaptive response promotes the integrity of the person, which leads to health. Ineffective responses to stimuli lead to disruption of the integrity of the person (Andrews & Roy, 1986; Randell et al., 1982; Roy, 1970, 1971, 1980; Roy & McLeod, 1981).

There are two interrelated subsystems in Roy’s model (Figure 17-1). The primary, functional, or control processes subsystem consists of the regulator and the cognator. The secondary, effector subsystem consists of the following four adaptive modes: (1) physiological needs, (2) self-concept, (3) role function, and (4) interdependence (Andrews & Roy, 1986; Limandri, 1986; Mastal, Hammond, & Roberts, 1982; Meleis, 1985, 2007; Riehl & Roy, 1980; Roy, 1971, 1975).

Roy views the regulator and the cognator as methods of coping. The regulator coping subsystem, by way of the physiological adaptive mode, “responds automatically through neural, chemical, and endocrine coping processes” (Andrews & Roy, 1991, p. 14). The cognator coping subsystem, by way of the self-concept, interdependence, and role function adaptive modes, “responds through four cognitive-emotive channels: perceptual information processing, learning, judgment, and emotion” (Andrews & Roy, 1991, p. 14). Perception is the interpretation of a stimulus, and perception links the regulator with the cognator in that “input into the regulator is transformed into perceptions. Perception is a process of the cognator. The responses following perception are feedback into both the cognator and the regulator” (Galligan, 1979, p. 67).

The four adaptive modes of the two subsystems in Roy’s model provide form or manifestations of cognator and regulator activity. Responses to stimuli are carried out through four adaptive modes. The physiological-physical adaptive mode is concerned with the way humans interact with the environment through physiological processes to meet the basic needs of oxygenation, nutrition, elimination, activity and rest, and protection. The self-concept group identity adaptive mode is concerned with the need to know who one is and how to act in society. An individual’s self-concept is defined by Roy as “the composite of beliefs or feelings that an individual holds about him- or herself at any given time” (Roy & Andrews, 1999, p. 49). An individual’s self-concept is comprised of the physical self (body sensation and body image) and the personal self (self-consistency, self-ideal, and moral-ethical-spiritual self). The role function adaptive mode describes the primary, secondary, and tertiary roles that an individual performs in society. A role describes the expectations about how one person behaves toward another person. The interdependence adaptive mode describes the interactions of people in society. The major task of the interdependence adaptive mode is for persons to give and receive love, respect, and value. The most important components of the interdependence adaptive mode are a person’s significant other (spouse, child, friend, or God) and his or her social support system. The purpose of the four adaptive modes is to achieve physiological, psychological, and social integrity. The four adaptive modes are interrelated through perception (Roy & Andrews, 1999) (Figure 17-2).

The person as a whole is made up of six subsystems. These subsystems (the regulator, the cognator, and the four adaptive modes) are interrelated to form a complex system for the purpose of adaptation. Relationships among the four adaptive modes occur when internal and external stimuli affect more than one mode, when disruptive behavior occurs in more than one mode, or when one mode becomes the focal, contextual, or residual stimulus for another mode (Brower & Baker, 1976; Chinn & Kramer, 2008; Mastal & Hammond, 1980).

With regard to human social systems, Roy broadly categorizes the control processes into the stabilizer and innovator subsystems. The stabilizer subsystem is analogous to the regulator subsystem of the individual and is concerned with stability. To maintain the system, the stabilizer subsystem involves organizational structure, cultural values, and regulation of daily activities of the system. The innovator subsystem is associated with the cognator subsystem of the individual and is concerned with creativity, change, and growth (Roy & Andrews, 1999).

LOGICAL FORM

The Roy Adaptation Model of nursing is both deductive and inductive. It is deductive in that much of Roy’s theory is derived from Helson’s psychophysics theory. Helson developed the concepts of focal, contextual, and residual stimuli, which Roy (1971) redefined within nursing to form a typology of factors related to adaptation levels of persons. Roy also uses other concepts and theory outside the discipline of nursing and synthesizes these within her adaptation theory.

Roy’s adaptation theory is inductive in that she developed the four adaptive modes from research and nursing practice experiences of herself, her colleagues, and her students. Roy built on the conceptual framework of adaptation and developed a step-by-step model by which nurses use the nursing process to administer nursing care to promote adaptation in situations of health and illness (Roy, 1976a, 1980, 1984).

The Roy Adaptation Model is deeply rooted in nursing practice, and this, in part, contributes to its continued success (Fawcett, 2002). It remains one of the most frequently used conceptual frameworks to guide nursing practice, and it is used nationally and internationally (Roy & Andrews, 1999; Fawcett, 2005).

Roy’s model is useful for nursing practice, because it outlines the features of the discipline and provides direction for practice, education, and research. The model considers goals, values, the patient, and practitioner interventions. Roy’s nursing process is well developed. The two-level assessment assists in identification of nursing goals and diagnoses (Brower & Baker, 1976).

Early on, it was recognized as a valuable theory for nursing practice because of the goal that specified its aim for activity and a prescription for activities to realize the goal (Dickoff, James, & Wiedenbach, 1968a, 1968b). The goal of nursing and of the model is adaptation in four adaptive modes in a person’s health and illness. The prescriptive interventions are when the nurse manages stimuli by removing, increasing, decreasing, or altering them. These prescriptions may be found in the list of practice-related hypotheses generated by the model (Roy, 1984).

When using Roy’s six-step nursing process, the nurse performs the following six functions:

By manipulating the stimuli and not the patient, the nurse enhances “the interaction of the person with their environment, thereby promoting health” (Andrews & Roy, 1986, p. 51). The nursing process is well suited for use in a practice setting. The two-level assessment is unique to this model and leads to the identification of adaptation problems or nursing diagnoses.

Roy and colleagues have developed a typology of nursing diagnoses from the perspective of the Roy Adaptation Model (Roy, 1984; Roy & Roberts, 1981). In this typology, commonly recurring problems have been related to the basic needs of the four adaptive modes (Andrews & Roy, 1991).

Intervention is based specifically on the model, but there is a need to develop an organization of categories of nursing interventions (Roy & Roberts, 1981). Nurses provide interventions that alter, increase, decrease, remove, or maintain stimuli (Roy & Andrews, 1999). The nursing judgment model outlined by McDonald and Harms (1966) is recommended by Roy to guide selection of the best intervention for modifying a particular stimulus. According to this model, a number of alternative interventions are generated that may be appropriate for modifying the stimulus. Each possible intervention is judged for the expected consequences of modifying a stimulus, the probability that a consequence will occur (high, moderate, or low), and the value of the change (desirable or undesirable).

Senesac (2003) reviewed the literature for evidence that the Roy Adaptation Model is being implemented in nursing practice. She reported that the Roy Adaptation Model has been used to the greatest extent by individual nurses to understand, plan, and direct nursing practice in the care of individual patients. Although fewer examples of implementation of the adaptation model are found in institutional practice settings, such examples do exist. She concluded that if the model is to be implemented successfully as a practice philosophy, it should be reflected in the mission and vision statements of the institution, recruitment tools, assessment tools, nursing care plans, and other documents related to patient care.

The Roy Adaptation Model is useful in guiding nursing practice in institutional settings. It has been implemented in a neonatal intensive care unit, an acute surgical ward, a rehabilitation unit, two general hospital units, an orthopedic hospital, a neurosurgical unit, and a 145-bed hospital, among others (Roy & Andrews, 1999).

DeVillers (1998) demonstrated the way in which clinical nurse specialists could use the Roy Adaptation Model to help delineate their roles as expert practitioners in the obstetrical and gynecological setting. She applied Roy’s steps of the nursing process and gave specific examples of expert care from each of the adaptive modes.

The Roy Adaptation Model has been applied to the nursing care of individual groups of patients. Examples of the wide range of applications of the Roy Adaptation Model are found in the literature. Villareal (2003) applied the Roy Adaptation Model to the care of young women who were contemplating smoking cessation. The author provides a comprehensive discussion of the use of Roy’s six-step nursing process to guide nursing care for young women in their mid-20s who smoked and were members of a closed support group. The researcher performed a two-level assessment. In the first level, stimuli were identified for each of the four adaptive modes. In the second level, the nurse made a judgment about the focal (nicotine addiction), contextual (belief that smoking is enjoyable, makes them feel good, relaxes them, brings them a sense of comfort, and is part of their routine), and residual stimuli (beliefs and attitudes about their body image and that smoking cessation causes weight gain). The nurse made the nursing diagnosis that for this group, a lack of motivation to quit smoking was related to dependency. The women in the support group and the nurse mutually established short-term goals to change behaviors, rather than the long-term goal of smoking cessation. The intervention focused on discussion of the effects of smoking on the body, reasons and beliefs about smoking and smoking cessation, stress management, nutrition, physical activity, and self-esteem. During the evaluation phase, it was determined that the women had moved from pre-contemplation to the contemplation phase of smoking cessation. The author concluded that the Roy Adaptation Model provided a useful framework for providing care to women who smoke.

Samarel, Tulman, and Fawcett (2002) examined the effects of two types of social support (telephone and group social support) and education on adaptation to early-stage breast cancer in a sample of 125 women. Women in the experimental group received both types of social support and education (n = 34), while women in the first control group received only telephone support and education, and women in the second control group received only education. Mood disturbance and loneliness were reduced significantly for the experimental group and for the first control group but were not reduced for the second control group. No differences were observed among the groups in terms of cancer-related worry or well-being. This study provides an excellent example of how the Roy Adaptation Model can be used to guide the conceptualization, literature review, theory construction, and development of an intervention.

Samarel and colleagues (1999) developed a resource kit for women with breast cancer. The contents of this kit were derived from the Roy Adaptation Model. The kit contains The Resource Manual for Women with Breast Cancer, which collects pertinent information into one source. The manual is divided into eight chapters that are theoretically based on the four adaptive modes. It contains a variety of practice activities to reinforce the information contained in the chapters. The kit contains pamphlets, audiotapes, and videotapes that supplement the narrative in the manual.

Newman (1997a) applied the Roy Adaptation Model to caregivers of chronically ill family members. With a thorough review of the literature, Newman demonstrated how the Roy Adaptation Model was used to provide care for this population. Newman views the chronically ill family member as the focal stimulus. Contextual stimuli include the caregiver’s age, gender, and relationship to the chronically ill family member. The caregiver’s physical health status is a manifestation of the physiological adaptive mode. The caregiver’s emotional responses to caregiving (shock, fear, anger, guilt, increased anxiety) are effective or ineffective responses of the self-concept mode. Relationships with significant others and support indicate adaptive responses in the interdependence mode. Caregivers’ primary, secondary, and tertiary roles are strained by the addition of the caregiving role. Practice and research implications illuminate the applicability of the Roy Adaptation Model for providing care to caregivers of chronically ill family members.

The Roy Adaptation Model has been applied to the care of persons with chronic renal failure who require hemodialysis (Keen et al., 1998), women in menopause (Cunningham, 2002), and to the assessment of an elderly man undergoing a right, below-the-knee amputation. The Roy Adaptation Model has been applied to the care of adolescents with asthma (Hennessy-Harstad, 1999) and inflammatory bowel disease (Decker, 2000) and a 10-month-old child with tracheomalacia (Lankester & Sheldon, 1999). Cook (1999) delineates nursing assessment related to the self-concept of patients with cancer and provides specific interventions to promote adaptation in this group of patients.

Araich (2001) uses a case study to illustrate how theory can be integrated into a cardiac care unit. In this effort, Araich conducts a two-level assessment and describes possible nursing interventions to promote adaptation of persons in cardiac care. Dixon (1999) demonstrates how the Roy Adaptation Model guides community health nursing practice.

Education

The Roy Adaptation Model defines the distinct purpose of nursing for students, which is to promote the adaptation of persons in each of the adaptive modes in situations of health and illness. This model distinguishes nursing science from medical science by having the content of these areas taught in separate courses. She stresses collaboration but delineates separate goals for nurses and physicians. According to Roy (1971), it is the nurse’s goal to help the patient put his or her energy into getting well, whereas the medical student focuses on the patient’s position on the health-illness continuum with the goal of causing movement along the continuum. She views the model as a valuable tool for analyzing the distinctions between the two professions of nursing and medicine. Roy (1979) believes that curricula based on this model support understanding of theory development by students as they learn about testing theories and experience theoretical insights. Roy (1971, 1979) noted early on that the model clarified objectives, identified content, and specified patterns for teaching and learning.

The adaptation model has been useful in the educational setting and has guided nursing education at Mount Saint Mary’s College Department of Nursing in Los Angeles since 1970. As early as 1987, more than 100,000 student nurses had been educated in nursing programs based on the Roy Adaptation Model in the United States and abroad. The Roy Adaptation Model provides educators with a systematic way of teaching students to assess and care for patients within the context of their lives rather than just as victims of illness.

Dobratz (2003) evaluated the learning outcomes of a nursing research course designed from the perspective of the Roy Adaptation Model and described in detail how to teach the theoretical content to students in a senior nursing research course. The evaluation tool was a Likert-type scale that contained seven statements. Students were asked to disagree, agree, or strongly agree with seven statements. Four open-ended questions were included to elicit information from students about the most helpful learning activity, the least helpful learning activity, methods used by the instructor that enhanced learning and grasp of research, and what the instructor could have done to increase learning. The researcher concluded that a research course based on the Roy Adaptation Model helped students put the pieces of the research puzzle together.

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