Roy’s Adaptation Model in Nursing Practice
Kenneth D. Phillips and Robin Harris
Adaptation is viewed as the process and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration.
Human beings incessantly respond to myriad internal and external environmental stimuli. A stimulus is any entity that provokes a response (Andrews & Roy, 1991a) and that serves as the point of interaction between the person and the environment (Roy & Andrews, 1999). Environmental stimuli either threaten or enhance an individual’s ability to adapt. As an example, loving, supportive behaviors from a parent enhance a child’s ability to successfully adapt, whereas a hostile, abusive parent poses a threat to a child’s adaptation.
Nursing plays a vital role in assisting individuals who are sick or well to respond to a variety of new stressors, move toward optimal well-being, and improve the quality of their lives through adaptation. The Roy Adaptation Model (Roy & Andrews, 1991) provides an effective framework for addressing the adaptive needs of individuals, families, and groups.
As noted in Chapter 1, nursing’s most pressing question is the following: “What is the nature of the knowledge that is needed for the practice of nursing?” Nurses practicing within the Roy Adaptation Model seek the following:
• Greater knowledge of factors that either promote or hinder adaptation
• Better methods and tools for assessing adaptation level
• Specific nursing interventions that either promote or hinder adaptation
• Effective methods for evaluating adaptation as an outcome of nursing care
History and Background
Sister Callista Roy, a Sister of Saint Joseph of Carondelet, developed the Roy Adaptation Model (RAM) in 1964 in response to a challenge by her professor, Dorothy E. Johnson. Since that time, the RAM has been reconceptualized for use in the twenty-first century. The development of the model has been a dynamic process. The preliminary ideas of this conceptual framework were first published in an article titled Adaptation: A Conceptual Framework for Nursing (Roy, 1970). The RAM continues to be refined. The RAM is presented in its most complete and recent form in The Roy Adaptation Model (Roy & Andrews, 1999). Nurses in the United States, in Canada, and around the world practice nursing from the perspective of RAM. The RAM has stimulated other scholars to publish books of their own about adaptation nursing (Rambo, 1984; Randell, Poush Tedrow, & Van Landingham, 1982; Welsh & Clochesy, 1990), has been implemented in numerous hospitals and other health care settings, and has been applied to diverse populations, adaptive needs, and developmental stages (Fawcett, 2005; Phillips, 2006).
Overview of Roy’s Adaptation Model
The RAM provides a useful framework for providing nursing care for persons in health and in acute, chronic, and terminal illness. The RAM views the person as an adaptive system in constant interaction with an internal and external environment. The environment is the source of a variety of stimuli that either threaten or promote the person’s unique wholeness. The person’s major task is to maintain integrity in the face of these environmental stimuli. Integrity is “the degree of wholeness achieved by adapting to changes in needs” (Roy & Andrews, 1999, p. 102). Roy, drawing on the work of Helson (1964), categorizes these types of stimuli as focal, contextual, or residual. The first type of stimulus, focal, is defined as the internal or external stimulus most immediately challenging the person’s adaptation. The focal stimulus is the phenomenon that attracts the most of one’s attention. Contextual stimuli are all other stimuli existing in a situation that strengthen the effect of the focal stimulus. Residual stimuli are any other phenomena arising from a person’s internal or external environment that may affect the focal stimulus but whose effects are unclear (Roy & Andrews, 1999). The three types of stimuli act together and influence the adaptation level, which is a person’s “ability to respond positively in a situation” (Andrews & Roy, 1991a, p. 10). A person’s adaptation level may be described as integrated, compensatory, or compromised (Roy & Andrews, 1999).
A person does not respond passively to environmental stimuli; the adaptation level is modulated by a person’s coping mechanisms and control processes. Roy categorizes the coping mechanisms into either the regulator or the cognator subsystem. The coping mechanisms of the regulator subsystem occur through neural, chemical, and endocrine processes. The coping mechanisms of the cognator subsystem occur through cognitive-emotive processes. Roy has identified two control processes that coincide with the regulator and cognator subsystems when a personresponds to a stimulus. The control processes identified by Roy are the stabilizer subsystem and the innovator subsystem. The stabilizer subsystem refers to “the established structures, values, and daily activities whereby participants accomplish the primary purpose of the group and contribute to common purposes of society” (Roy & Andrews, 1999, p. 47). The innovator subsystem refers to cognitive and emotional strategies that allow a person to change to higher levels of potential (Roy & Andrews, 1999).
Although direct observation of the processes of the regulator and cognator subsystems is not possible, Roy proposes that the behavioral responses of these two subsystems can be observed in any of the four adaptive modes: physiological, self-concept, role function, and interdependence adaptive modes. Roy and her associates describe the function of the adaptive modes in the Theory of the Person as an Adaptive System (Andrews & Roy, 1991a).
Roy’s Theory of the Person as an Adaptive System postulates that the four adaptive modes are interrelated through perception. Either an adaptive response or an ineffective response in one mode influences adaptation in the other modes.
The physiological adaptive mode refers to the “way a person responds as a physical being to stimuli from the environment” (Andrews & Roy, 1991a, p. 15). The five physiological needs of this mode are oxygenation, nutrition, elimination, activity and rest, and protection. Four complex processes that mediate the regulatory activity of this mode are senses, fluids and electrolytes, neurological function, and endocrine function. Physiological integrity is the adaptive response of this adaptive mode (Andrews & Roy, 1991a, 1991c).
The self-concept adaptive mode refers to psychological and spiritual characteristics of the person (Andrews, 1991b; Andrews & Roy, 1991a; Roy & Andrews, 1999). A person’s self-concept consists of all the beliefs and feelings that one has formed about oneself. The self-concept is formed both from internal perceptions and from the perceptions of others. The self-concept changes over time and guides one’s actions. The self-concept incorporates two components: the physical self and the personal self. The physical self incorporates body sensation and body image (Buck, 1991b). The personal self incorporates self-consistency, self-ideal, and moral-ethical-spiritual self (Buck, 1991a). Psychic integrity is the goal of the self-concept mode (Andrews, 1991b; Andrews & Roy, 1991a).
The interdependence adaptive mode refers to coping mechanisms arising from close relationships that result in “the giving and receiving of love, respect, and value” (Andrews & Roy, 1991a, p. 17). In general, these contributive and receptive behaviors occur between the person and the most significant other or between the person and his or her support system. Affectional adequacy is the goal of the interdependence adaptive mode (Roy & Andrews, 1999; Tedrow, 1991).
The role function adaptive mode refers to the primary, secondary, or tertiary roles the person performs in society. According to Andrews and Roy (1991a), “A role, as the functioning unit of society, is defined as a set of expectations about how a person occupying one position behaves toward a person occupying another position” (p. 16). Social integrity is the goal of the role function mode (Andrews, 1991a; Nuwayhid, 1991; Roy & Andrews, 1999).
Adaptive or ineffective responses result from these coping mechanisms. Adaptive responses promote the integrity of the person and the goals of adaptation. The major task of a person is to adapt to environmental stimuli to achieve survival, growth, development, and mastery. Ineffective responses neither promote integrity nor contribute to the goals of adaptation (Andrews & Roy, 1991a).
As described earlier, adaptation is accomplished through two main coping subsystems: regulator and cognator. The mechanisms of regulator and cognator have not been explicated by Roy because these mechanisms cannot be directly observed and remain largely unknown. However, the behaviors of regulator and cognator are manifested indirectly and can be observed and measured in the four adaptive modes (Roy, 1981).
Roy and Andrews (1999) define health as “a state and a process of being and becoming an integrated and whole person” (p. 31). Health is a reflection of how successfully an individual has adapted to environmental stimuli. The goal of nursing therefore is to help a person achieve adaptation by helping the person survive, grow, reproduce, and master. Adaptation leads to optimum health and well-being, to the highest quality of life possible, and to death with dignity (Andrews & Roy, 1991a). Adaptation enables the person to find meaning and purpose in life and to become an integrated whole.
Critical Thinking in Nursing Practice with Roy’s Model
The nursing process is a goal-oriented, problem-solving approach to guide the provision of comprehensive, competent nursing care to a person or groups of persons. According to Andrews and Roy (1991b), the nursing process “relates directly to the view of the person as an adaptive system” (p. 27). Roy has conceptualized the nursing process to comprise the following six simultaneous, ongoing, and dynamic steps (Roy & Andrews, 1999):
Each of these phases of the nursing process is discussed within the RAM. The goal of nursing in the RAM is to promote adaptation in each of the four adaptive modes (Roy & Andrews, 1999).
The nursing process alone is limited in promoting critical thinking; however, nursing theory serves as a guide for nursing care. Nursing theory directs the practitioner toward important aspects of assessing, planning, goal setting, implementation, and evaluation. Furthermore, practice within a model allows the practitioner to ignore irrelevant considerations and to selectively choose among a variety of nursing strategies. Another way of saying this is that nursing theory promotes critical thinking. Table 14-1 illustrates how the RAM guides the nurse through the critical thinking process.
TABLE 14-1
Critical Thinking in the Roy Adaptation Model
| Phases of Process | Physiological Adaptive Mode | Interdependence Adaptive Mode | Self-Concept Adaptive Mode | Role Function Adaptive Mode |
| Assessment of behavior | Oxygenation Nutrition Elimination Activity and rest Protection Senses Fluids and electrolytes Neurological function Endocrine function | Significant other Giving Receiving Support system Giving Receiving | Physical self Body sensation Body image Personal self Self-consistency Self-ideal Moral-ethical-spiritual self | Instrumental Primary role Secondary roles Tertiary roles Expressive Primary role Secondary roles Tertiary roles |
| Assessment of stimuli | Focal stimulus Contextual stimuli Residual stimuli | Focal stimulus Contextual stimuli Residual stimuli | Focal stimulus Contextual stimuli Residual stimuli | Focal stimulus Contextual stimuli Residual stimuli |
| Nursing diagnosis | Statement of behaviors with most relevant stimuli | Statement of behaviors with most relevant stimuli | Statement of behaviors with most relevant stimuli | Statement of behaviors with most relevant stimuli |
| Goal setting | Behavior Change expected Time frame | Behavior Change expected Time frame | Behavior Change expected Time frame | Behavior Change expected Time frame |
| Intervention | Management of stimuli Alter Increase Decrease Remove Maintain | Management of stimuli Alter Increase Decrease Remove Maintain | Management of stimuli Alter Increase Decrease Remove Maintain | Management of stimuli Alter Increase Decrease Remove Maintain |
| Evaluation | Observation of behaviors after interventions have been completed to see if goals have been obtained | Observation of behaviors after interventions have been completed to see if goals have been obtained | Observation of behaviors after interventions have been completed to see if goals have been obtained | Observation of behaviors after interventions have been completed to see if goals have been obtained |
Assessment of Behavior
From Roy’s perspective, behavior is an action or a reaction to a stimulus. A behavior may be observable or nonobservable. An example of an observable behavior is pulse rate; a nonobservable behavior is a feeling experienced by the person and reported to the nurse. Exploration of behaviors manifested in the four adaptive modes allows the nurse to achieve an understanding of the current adaptation level and to plan interventions that will promote adaptation. At the beginning of thenurse-client relationship, a thorough assessment of behavior must be performed (Roy & Andrews, 1999) and the assessment must be ongoing. Table 14-1 presents categories of behaviors that are assessed in each of the adaptive modes.
Assessment of Stimuli
A stimulus is any change in the internal or external environment that induces a response in the adaptive system. Stimuli that arise from the environment can be classified as focal, contextual, or residual. In this level of assessment, the nurse analyzes subjective and objective behaviors and looks more deeply for possible causes of a particular set of behaviors (Roy & Andrews, 1999).
Nursing Diagnosis
A nurse’s education and experience enable him or her to make an expert judgment regarding health care and adaptive needs of the client. This judgment is expressed in a diagnostic statement that indicates an actual or a potential problem related to adaptation. The diagnostic statement specifies the behaviors that led to the diagnosis and a judgment regarding stimuli that threaten or promote adaptation (Roy & Andrews, 1999). The RAM defines nursing diagnosis “as a judgment process resulting in statements conveying the adaptation status of the human adaptive system” (Roy & Andrews, 1999, p. 77).
Goal Setting
Goal setting focuses on promoting adaptive behaviors. Together the nurse and the client agree on clear statements about desired behavioral outcomes of nursing care. The outcome statement should reflect a single adaptive behavior, be realistic, and be measurable. The goal statement should include the behavior to be changed, the change expected, and the time frame in which the change in behavior should occur (Roy & Andrews, 1999).
Intervention
According to Andrews and Roy (1991b), “Intervention focuses on the manner in which goals are attained” (p. 44). A nursing intervention is any action taken by a professional nurse that he or she believes will promote adaptive behavior by a client. Nursing interventions arise from a solid knowledge base and are aimed at the focal stimulus whenever possible (Andrews & Roy, 1991b). Intervention is any nursing approach that is intended “to promote adaptation by changing stimuli or strengthening adaptive processes” (Roy & Andrews, 1999, p. 86).
Evaluation
In the RAM, evaluation consists of one question: “Has the person moved toward adaptation?” Evaluation requires that analysis and judgment be made to determine whether those behavioral changes stated in the goal statement have, or have not, been achieved by the recipient of nursing care (Andrews & Roy, 1991b). In the evaluation phase, the nurse judges the effectiveness of the nursing interventions that have been implemented and determines to what degree the mutually agreed upon goals have been achieved (Roy & Andrews, 1999).
Nursing Care of Debbie with Roy’s Model
Physiological Adaptive Mode
Debbie’s health problems are complex. It is impossible to develop interventions for all of her health problems within the space of this chapter; therefore, representative examples are presented.
Assessment of Behavior
Postoperatively, Debbie has been unable to completely empty her urinary bladder. She states that she is numb and unable to tell when she needs to void. Catheterization for residual urine revealed that she was retaining 300 ml of urine after voiding. It will be necessary for her to perform intermittent self-catheterization at home. Unsanitary conditions at Debbie’s home place her at high risk for developing a urinary tract infection. She states that she is scared about performing self-catheterization.
Assessment of Stimuli
In this phase of the nursing process, the nurse searches for stimuli responsible for the observed behavior. After stimuli have been identified, they are classified as focal, contextual, or residual.
The focal stimulus for Debbie’s urinary retention is the disease process. Contextual stimuli include tissue trauma resulting from surgery and radiation therapy. Debbie verified anxiety as a residual stimulus.
Infection is a potential problem. The focal stimulus is the need for intermittent self-catheterization. Contextual stimuli include altered skin integrity related to surgical incision, poor understanding of aseptic principles, and unsanitary conditions at Debbie’s home.
Nursing Diagnosis
From the assessment of behaviors and the assessment of stimuli, the following nursing diagnoses were made:
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