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e eBook Collection Conceptual Models Chapter08 This is a Protected PDF document. Please enter your user name and password to unlock the text. 4 Remember my user name and password. If you are experiencing problems unlocking this document or you have questions regarding Protectedpdf files please contact a Technical Support representative: In the United States: 1-877-832-4867 In Canada: 1-800-859-3682 Outside the U. S. and Canada: 1-602-387-2222 Email: [email protected] edu. 1000-0001-62C2-00019A9E 8 Roy’s Adaptation Model Mary E. Tiedeman

Sister Callista Roy received a bachelor’s degree in nursing in 1963 from Mount Saint Mary’s College. She received a master’s degree in pediatric nursing in 1966, a master’s degree in sociology in 1975, and a doctorate in sociology in 1977, all from the University of California, Los Angeles. In 1985, she completed a 2-year postdoctoral fellowship in neuroscience nursing at the University of California, San Francisco, and she spent an additional 2 years doing clinical research with patients who had neurological deficits. Roy’s professional career has included positions in both clinical and educational settings.

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Her major professional positions have been in educational settings; she is currently a professor at the School of Nursing, Boston College. She also is an active member of the Sisters of Saint Joseph of Carondolet and a Fellow of the American Academy of Nursing (Roy, personal communication, March 6, 1986; Roy, 1983; 1997; Roy & Andrews, 1991, 1999). According to Roy (personal communication, March 6, 1986), her major professional interest is the development of nursing as a scientific and humanistic discipline with an articulated and tested theory base that directs nursing practice and nursing education.

Her clinical and research interests focus on neuroscience nursing and are aimed at understanding basic human cognitive processes, particularly cognitive recovery in persons with head injury. The development of the adaptation model for nursing has been influenced by Roy’s personal and professional background. She is committed to 146 Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 hilosophical assumptions characterized by the general principles of humanism, veritivity, and cosmic unity, espousing a belief in holism and in the innate capabilities, purpose, and worth of human beings. Her pediatric clinical experience has fostered a belief in the resiliency of the human body and spirit. It was from her clinical experience in nursing and a review of the literature that she derived her concepts of person, environment, health, and nursing (Andrews & Roy, 1991a, 1986; Roy, 1991a, 1987a; Roy & Andrews, 1999).

Roy began her work on the adaptation model in the 1960s, when she was a graduate student at the University of California, Los Angeles. Drawing upon the works of experts in the areas of systems theory (von Bertalanffy, 1968) and adaptation (Dohrenwend, 1961; Helson, 1964; Lazarus, 1966; Mechanic, 1970; Selye, 1978), she formulated a beginning conceptualization and has continued developing the model. During the last 30 years, the model has been developed as a framework for nursing education, research, and practice using a variety of strategies, including model construction, theory development, philosophical explication, and research.

During this time nurses in the United States and around the world have helped to clarify, refine, and extend the model. Use of the model in practice and research has provided data to help validate the model (Andrews & Roy, 1991a; Roy, 1991a; Roy & Andrews, 1991, 1999; Roy & McLeod, 1981). BASIC CONSIDERATIONS IN THE MODEL Definitions of Person, Nursing, Health, and Environment Person. Within the model, person (human) is described as a holistic adaptive system, which is in constant interaction with the environment (Andrews & Roy, 1991a).

More specifically, the person is defined as “an adaptive system, with regulator and cognator acting to maintain adaptation in the four adaptive modes; physiologic function, self-concept, role function, and interdependence” (Roy, 1984, p. 12). The definition of person has evolved as the model has been developed. Although Roy has always described the person in terms of systems and adaptation, initial definitions and descriptions focused on the person as a biopsychosocial being in constant interaction with a changing environment (Roy, 1976a).

Although Roy no longer specifically defines person as a biopsychosocial being, the biopsychosocial nature of the person as an adaptive system is reflected in the four adaptive modes: physiological (biologic), self-concept (psychological), role function (social), and interdependence (social). ROY’S ADAPTATION MODEL 147 Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 148 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION

Nursing. Roy has described nursing as a scientific discipline with a practice orientation. The science of nursing is interested in understanding life processes, which promote adaptation and health, how persons cope with health and illness, and nursing interventions to promote or enhance adaptive coping and health. As a practice discipline nursing uses this scientific knowledge to provide a service to people. More specifically, Roy has defined nursing as the science and practice of promoting adaptation for the purpose of affecting health positively.

Thus, the adaptation model provides guidelines for the development of nursing knowledge (science) and the practice of nursing based on that knowledge. The theoretical and scientific domains of nursing and the nursing process distinguish it from other health disciplines (Andrews & Roy, 1991b; Roy, 1984, 1986, 1988, 1991a, 1991b; Roy & Andrews, 1999). Within the model nursing consists of both the goal of nursing and nursing activities. Roy (Roy & Andrews, 1999) has defined the goal of nursing as “the promotion of adaptation in each of the four modes, thereby contributing to the person’s health, quality of life, and dying with dignity” (p. 5). The nurse’s role is to promote health by promoting adaptation and enhancing interaction of the human system with the environment through acceptance, protection, and fostering of interdependence, thereby promoting personal and environmental transformations. Nursing activities specified by the model are referred to as the nursing process (Andrews & Roy, 1991b; Roy & Andrews, 1999). Although Roy has continued to refine her definition and description of nursing, there have been no major changes in this area of the model.

The goals of nursing and nursing activities have been consistently identified as aspects of the concept of nursing and the fundamental description of these aspects of nursing has remained the same. Her more recent writings have put increased emphasis on describing the science of nursing and its relationship to nursing practice and have more clearly delineated how the adaptation model guides the development of the science of nursing. More recent writings also reflect the new assumptions for the 21st century (Andrews & Roy 1991a, 1991b; Roy, 1991a, 1991b, 1997; Roy &Andrews, 1999).

Health. An understanding of the concepts of the human adaptive system and environment and an appreciation of the scientific and philosophic assumptions of the model are essential to an understanding of health as explicated within the model (Roy & Andrews, 1999). According to Roy (Roy & Andrews, 1999), health is defined as “a state and a process of being and becoming an integrated and whole person” (p. 54). Health can be viewed as a reflection of the interaction or adaptation of human adaptive systems within a changing environment.

Being integrated is a state that reflects the adaptation process and can be described at any given point in time as it is Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 149 manifested in the wholeness and integration of the four adaptive modes. Becoming integrated is a continuous process consisting of a systematic series of actions directed toward the human goals or survival, growth, reproduction, mastery, and person and environment transformations and the urposefulness of human existence (Andrews & Roy, 1991a; Roy, 1990; Roy & Andrews, 1999). Being integrated implies a soundness or unimpaired condition leading to wholeness. Integration and wholeness can lead to completeness or unity and the highest possible fulfillment of human potential. Thus, integration is health, whereas the absence of integration is a lack of health. Health is defined without reference to illness and includes emphasis on states of wellbeing (Andrews & Roy, 1991a; Roy, 1984,1990; Roy &Andrews, 1999). Environment.

Environment is defined as “all conditions, circumstances, and influences that surround and affect the development and behavior of human adaptive systems with particular consideration of person and earth resources” (Roy & Andrews, 1999, p. 52). As the world around and within human adaptive systems, the environment is viewed as input for the human adaptive system and may be described as internal and external stimuli. These stimuli may be further classified as focal, contextual, and residual (Andrews & Roy, 1991a, Roy & Andrews, 1999). Additional Understanding of Nursing Nursing science.

Roy’s (1988) perspective of the discipline of nursing is “that of an integrated metaparadigm that has the dynamics of life processes at its heart and the functional life patterns emanating from that center and being manifested in human responses to actual or potential health problems” (p. 28). This perspective includes both the basic and the clinical science of nursing. The basic science of nursing focuses on human life processes and patterns that promote health; that is, understanding persons as adaptive systems. Life processes include regulating, thinking, becoming, valuing, relating, feeling, and acting.

Functional life patterns emerge from the development and use of these life processes, and the person’s response to health problems arises from these patterns (Roy, 1988, 1990, 1991a, 1991b; Roy & Andrews, 1999). The clinical science of nursing focuses on the diagnosis of effective and ineffective adaptation and on intervention strategies to enhance adaptation in situations of health and illness (Roy, 1988, 1990, 1991a, 1991b; Roy & Andrews, 1999). Roy (1988) has described the clinical science of nursing as the “diagnosis and treatment of the patterning of life processes” (p. 8), or the “diagnosis and treatment of human responses within the functional health patterns” (p. 29). Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 150 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION Nursing activities. The recipient of nursing is a holistic, adaptive system, which may be an individual, family, group, community, or society (Andrews & Roy, 1991a; Roy & Andrews, 1999).

Although the discussion in most of Roy’s writings has focused on the individual, the principles can be applied to families, groups, communities, and society. The focus on collectives has become more evident as the model has been developed (Roy, 1983; Roy & Andrews, 1999; Roy & Anway, 1989). Nursing is concerned with the human-environment interaction, where input and internal and external stimuli from the environment activate coping processes that act to maintain adaptation.

Situations of particular concern to nursing are those in which the environmental changes strain the person’s coping mechanisms; that is, situations in which unusual stressors (focal stimuli) or weakened coping mechanisms make a person’s usual attempts to cope ineffective. This should not be interpreted to mean that nursing activities are needed or occur only when the person is ill or not coping effectively. According to Roy, nursing’s holistic approach looks at processes for maintaining well-being and high-level functioning.

This focus on positive adaptation is particularly evidenced by the recent development of typologies of indicators of positive adaptation (Andrews & Roy, 1991a, 1991b; Roy & Andrews, 1999; Roy & Roberts, 1981). The goal of nursing—promoting adaptation by enhancing the interaction of human systems with the environment—is fostered by nursing activities; that is, the use of the nursing process: assessment, nursing diagnosis, goal-setting, intervention, and evaluation. The adaptation model provides specific guidelines for use of the nursing process (Andrews & Roy, 1991a, 1991b; Roy & Andrews, 1999).

Roy has consistently described a six-step nursing process. Although each step is described separately, Roy (Andrews & Roy, 1991b; Roy & Andrews, 1999) emphasizes that the process is ongoing and simultaneous. The units of analysis for the two-level assessment (steps 1 and 2) are the person in interaction with his or her environment. The first level of assessment is the collection of data about the person’s behavior (observable and nonobservable) in each of the four adaptive modes. The primary concern is with behaviors that are ineffective; however, identification of adaptive behaviors is also important.

The second level of assessment is the collection of data regarding the focal, contextual, and residual stimuli. It is particularly important to determine factors that influence the behavior of concern (ineffective behavior), although it is also important to identify factors influencing adaptive behaviors (Andrews & Roy, 1991b; Roy &Andrews, 1999). The third step of the nursing process, nursing diagnosis, involves interpretation of the assessment data. This step involves “a judgment process resulting in statements conveying the adaptation status of the human adap- Conceptual Models of Nursing: Analysis and Application, by Joyce J.

Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 151 tive system” (Roy & Andrews, 1999, p. 77). Goal-setting, step 4 of the nursing process, involves establishing a clear statement of the behavioral outcomes for the person as a result of nursing care. This goal statement has three parts: behavior, expected change, and time frame (Andrews & Roy, 1991b; Roy & Andrews, 1999). Nursing intervention, step 5, focuses on stimuli influencing behavior and the ability to cope (i. . , the coping processes). Management of stimuli (internal and external) involves removing, increasing, decreasing, maintaining, or altering stimuli. Focal or contextual stimuli may be the focus of nursing intervention; however, when possible the focus should be the focal stimulus. Managing stimuli promotes adaptive behavior by bringing the stimuli within the ability of the coping processes of the human system. Interventions also may be designed specific to the coping processes of regulator-stabilizer and cognator-innovator systems (e. . , providing knowledge to alter perception, thus influencing the cognator). In step 6, behavioral outcomes are evaluated and approaches modified as needed (Andrews & Roy, 1991b; Roy & Andrews, 1999). Within the model the person is viewed as an active participant in personal care. There is emphasis on the importance of collaboration with the person throughout the steps of the nursing process and manipulation of stimuli is not seen as manipulation of the person (Andrews & Roy, 1991b; Roy & Andrews, 1999; Roy & Roberts, 1981).

Understanding of Person To gain a clearer understanding of humans (person), as conceptualized within the model, it is necessary to examine in more detail the description of humans as holistic adaptive systems The term holistic comes from the philosophic assumptions of the model and conveys the idea that human systems function as wholes in one unified expression of meaningful behavior. As a system, humans can be described as a set of interrelated parts with inputs, control and feedback processes, and outputs functioning as a whole for some purpose.

As adaptive systems, humans not only have the capacity to adjust effectively to environmental changes, but also can affect the environment (Andrews & Roy, 1986, 1991a; Roy & Andrews, 1999). Input for the system is stimuli, which are received externally from the environment (external stimuli) and from the internal environment (internal stimuli). A specific input to the system is the human’s adaptation level, which results from the pooling of certain relevant stimuli—focal, contextual, and residual. It represents the condition of life processes and may be described in three levels: integrated, compensatory, and compromised.

This constantly changing adaptation level affects the ability of the human Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 152 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION system to respond positively (Andrews & Roy, 1991a, 1991b; Roy, 1984; Roy & Andrews, 1999). The control processes of the system are two coping mechanisms for adapting or coping with a changing environment.

These control processes are the regulator and cognator subsystems for individuals and the stabilizer and innovator subsystems for groups. In the individual these mechanisms are viewed as biological, psychological, and social in origin and are both innate and acquired. The regulator is viewed as responding automatically through neural, chemical, and endocrine channels. The cognator is viewed as responding through cognitive-emotive channels that include perceptualinformation processing, learning, judgment, and emotion. The stabilizer nd innovator subsystems of groups parallel those of the regulator and cognator subsystems of the individual and are related to goals of stability and change. The responses of the regulator-cognator and stabilizer-innovator are manifested or carried out through four adaptive or effector modes (Andrews & Roy, 1991a; Roy, 1976a; Roy &Andrews, 1999). Four adaptive modes were initially developed for individual human systems based on the analysis and categorization of samples of patient behavior and have been expanded to include groups.

These four modes— physiological-physical, self-concept-group identity, role function, and interdependence—are seen as providing the particular form or manifestation of regulator-cognator or stabilizer-innovator activity. Beneath each of the adaptive modes is a basic need for integrity that includes physiological, psychic, and social integrity (Andrews & Roy, 1991a; Roy &Andrews, 1999). Relationships among the regulator and cognator and the four adaptive modes are complex. Processes of the regulator and cognator, defined in a series of propositions, link together the regulator and cognator with the four adaptive modes.

The regulator is viewed as related predominantly to the physiological mode. The propositions of the regulator are applied to each of the physiological functions and are related to adaptive and ineffective responses. The cognator is viewed as related to each adaptive mode in at least three ways: (a) each mode provides specific, relevant input for the cognator; (b) the adaptive mode under consideration will specify the relevant pathways and apparatus; and (c) within each mode it is possible to view specific cognator processes (Roy & McLeod, 1981; Roy & Roberts, 1981).

The process of perception is found in both the regulator and cognator and is viewed as the process linking these two subsystems. “Inputs to the regulator are transformed into perception. Perception is a process of the cognator. The responses following perception are feedback into both the cognator and the regulator” (Roy & McLeod, 1981, p. 67). Thus, the relationship between the regulator and cognator is a hierarchical relationship (Roy & McLeod, 1981). Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall.

Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 153 Three relationships can be observed among the four modes. These relationships are that (a) internal and external stimuli may affect more than one adaptive mode simultaneously, (b) one behavior may be a manifestation of disruption in more than one mode, and (c) each adaptive mode may act as a focal, contextual, or residual stimulus for each of the other modes. The complex relationships among the adaptive modes and the regulator and cognator subsystems reflect the integrated, holistic nature of the person.

Examples of the various relationships may be found in the writings of Roy and others (Andrews & Roy, 1991a; Roy & McLeod, 1981; Roy & Roberts, 1981; Tiedeman, 1989). The same complexity exists between the stabilizer and innovator and the four adaptive modes of a group (Roy & Andrews, 1999). Outputs of the system are responses called behavior. Behavior is viewed as “internal and external actions and reactions under specified circumstances” (Roy & Andrews, 1999, p. 43). Behaviors result from the control processes; are manifested in the four adaptive modes; and can be observed, measured, or subjectively reported.

In collaboration with the person, behaviors can be judged as adaptive or ineffective. Adaptive responses maintain or promote integrity, whereas ineffective responses disrupt integrity. Through feedback processes behaviors (responses) provide further input for the person as a system (Andrews & Roy, 1991a; Roy & Andrews, 1999). A schematic representation of the person as an adaptive system is shown in Figure 8–1 of the model. Understanding of Environment In defining environment, three classes of stimuli are described: focal, contextual, and residual.

These stimuli may be either internal or external. The stimulus most immediately confronting the person is called the focal stimulus. The focal stimulus is the focus of the person’s attention, and the person expends energy to deal with it. All other stimuli present in the situation that are contributing to the effect of the focal stimulus are called contextual stimuli. Although not the center of the person’s attention and energy, contextual stimuli influence how the person is able to deal with the focal stimulus. Stimuli whose effects on the given situation are unclear are called residual stimuli.

This category is useful for considering possible influencing stimuli based on general knowledge and/or intuitive impressions (Andrews & Roy, 1991a). As the environment changes, the significance of any one stimulus changes. In a rapidly changing environment stimuli may readily switch from one category of stimuli to another. The identification and classification of relevant stimuli is important for providing nursing care within the framework of the model (Andrews & Roy, 1991a). Conceptual Models of Nursing: Analysis and Application, by Joyce J.

Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 154 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION Outputs (Behavior) Inputs (Stimuli) Adaptive Responses Ineffective Responses External stimuli from environment Internal stimuli from self Adaptation level (focal, contextual, residual stimuli) Perception Cognator Control Processes (Coping Mechanisms) Regulator Feedback Role Function Self- Concept Physiological Interdependence FIGURE 8–1 The person as an adaptive system. Adaptation

The definition of adaptation, the core concept of the adaptation model, has been expanded recently to reflect the mission of nursing in a new epoch and the scientific and philosophic assumptions of the 21st century (Roy, 1997). Adaptation is defined 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” (Roy & Andrews, 1999, p. 30). The concept of adaptation is closely linked to the concept of health. The person, as an adaptive system, is in constant interaction with a changing environment.

Health is a reflection of this interaction. Adaptive responses promote integrity relative to the goals of the human system—survival, growth, reproduction, mastery, and person environment transformations—thereby promoting health. Ineffective responses do not promote integrity or contribute to the goals of adaptation. In addition, adaptive responses free energy from ineffective coping and allow the person to respond to other stimuli. This freeing of energy can promote healing and enhance health. It is the freeing of energy that links the concepts of adaptation and health (Andrews & Roy, 1991a; Roy, 1984, 1990; Roy & Andrews, 1999).

Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 155 Within the model adaptation is viewed as both a process and an outcome. As a process, it involves a systematic series of actions directed toward the goals of adaptation, thus promoting integrity and affecting health positively. The process of adaptation includes all of the person’s interactions with the environment.

It is a two-part process, which is a function of the focal stimulus and the person’s adaptation level. The first part of the process is initiated by changes in the internal or external environment (focal stimuli) that demand a response. The impact of these focal stimuli is mediated by contextual and residual factors. The second part of the process is coping mechanisms that are triggered to produce adaptive or ineffective responses. Although this process is described in terms of responding to stimuli, Roy indicates that it is not a passive process, but is always positive, active, and creative.

The emphasis is on purposefulness of human existence in a universe that is creative and views persons as coextensive with their physical and social environments (Andrews & Roy, 1991a; Roy, 1990; Roy & Andrews, 1999; Roy & McLeod, 1981). Adaptation also is considered an outcome in that the condition of the person with respect to the environment may be viewed at any given point in time. It is a state of dynamic equilibrium, which is the result of the cumulative effect of the ongoing process of adaptation and can be described in terms of conditions, which promotes the goals of the human system and the individualized goals of the person.

Each new adaptive state affects the adaptation level of the person, resulting in the dynamic equilibrium of the person being at an even higher level and allowing greater ranges of stimuli to be dealt with successfully by the person as an adaptive system. Thus, promoting adaptation leads to higher level of well-being or health (Andrews & Roy, 1991a; Roy, 1990; Roy & McLeod, 1981; Roy & Roberts, 1981). Interrelationships Among the Concepts Adaptation is the central and unifying concept within the model.

The recipient of nursing care is the person (or group) as an adaptive system in constant interaction with a changing environment. Stimuli from the external and internal environment activate the coping processes of regulatorcognator (or stabilizer-innovator), which produce behavior observed in the four adaptive modes. This behavior is a function of input (stimuli) and the individual or group adaptation level. When adaptive responses occur, energy is freed for response to other stimuli, thus promoting integrity or health.

Nursing enhances adaptation through the use of the nursing process, thereby promoting health through the management of stimuli (environment) or the strengthening of coping processes (Andrews & Roy, Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 156 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION Output Adaptive Responses Integrity Nursing Uses the Nursing Process to Promote Ineffective Responses Input Person Interaction (Adaptation) Environment

FIGURE 8–2 Relationships among the basic components of the adaptation model of nursing. 1991a, 1991b; Roy, 1984, 1990; Roy & Andrews, 1999). The relationships among the basic concepts of the model are shown in Figure 8–2. INTERNAL ANALYSIS AND EVALUATION Underlying Assumptions The assumptions of the adaptation model include both scientific and philosophical assumptions. The scientific assumptions are associated with systems theory and adaptation-level theory; the philosophical assumptions are associated with humanism and veritivity (Andrews & Roy, 1991a; Roy, 1986; Roy & Andrews, 1999).

Underlying assumptions associated with systems theory include holism, interdependence, control processes, information feedback, and complexity of living systems. Underlying assumptions associated with adaptation-level theory include behavior as adaptive; adaptation as a function of stimuli and adaptation level; individual, dynamic adaptation levels; and positive and active processes of responding. These notions have been expanded to include views of the universe progressing in structure, organization, and complexity, and the purposefulness of human existence (Roy, 1997; Roy &

Andrews, 1999). Scientific assumptions for the 21st century are more explicitly identified in Table 8–1. Underlying assumptions associated with humanism include creativity, purposefulness, holism, and interpersonal process, whereas those associated with veritivity include purposefulness of human existence; unity of purpose; activity and creativity; and value and meaning of life. Philosophic concepts also have been expanded. Philosophic assumptions for the Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall.

Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 157 TABLE 8–1 Scientific Assumptions of the Roy Adaptation Model for the 21st Century 1. Systems of matter and energy progress to higher levels of complex self-organization. 2. Consciousness and meaning are constitutive of person and environment integration. 3. Awareness of self and environment is rooted in thinking and feeling. 4. Human decisions are accountable for the integration of human processes. 5. Thinking and feeling mediate human action. 6.

System relationships include acceptance, protection, and fostering of interdependence. 7. Persons and earth have common patterns and integral relations. 8. Person and environment transformations are created in human consciousness. 9. Identification of human and environment meanings results in adaptation. Roy (1997, p. 44); Roy & Andrews (1999, p. 35). TABLE 8–2 Philosophic Assumptions of the Roy Adaptation Model for the 21st Century 1. Persons have mutual relationships with the world and with a God—figure. 2. Human meaning is rooted in an omega point convergence of the universe. . God is intimately revealed in the diversity of creation and in the common destiny of creation. 4. Persons use human creative abilities of awareness, enlightenment, and faith. 5. Persons are accountable for the processes of deriving, sustaining, and transforming the universe. Roy (1997, p. 45); Roy & Andrews (1999, p. 35). 21st century are more explicitly identified in Table 8–2 (Andrews & Roy, 1991a; Roy, 1986, 1988). According to Barnum (1998), identification of the underlying assumptions is necessary to both the internal and external evaluation of the theory.

Internal criticism deals with logic and consistency of the theory given the underlying assumptions. External criticism involves the congruence of the assumptions with the “real world. ” Internal and external criticisms will be addressed later. The philosophical orientation most compatible with the adaptation model appears to be that of logical positivism. Within this philosophical orientation concepts are used in describing phenomena, statements or propositions are developed to propose how concepts are related, and propositions are related to each other in a systematic way (Barnum, 1998; Jacox, 1974).

A clearer understanding of the philosophical orientation of the model can be obtained by examining it in terms of principle, interpretation, and method (Barnum, 1998). The key principle in the adaptation model is adaptation. Adaptation is the process and outcome of coping with a changing environment and, thus, it is located in the person-environment interaction. The outcome of adaptation is viewed as a state of dynamic equilibrium. Therefore, the nature of the principle of adaptation as explicated within the model is reflexive; that is, the principle is located in the interaction of the person and circumstances (changing environment).

The principle of adaptation also may be classified as a simple principle—one Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 158 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION that explains the principle in terms of component parts; for example, the inputs (stimuli), control and feedback processes (coping mechanisms), and outputs (responses) characterizing the process of adaptation (Andrews &

Roy, 1991a; Barnum, 1998; Roy, 1990; Roy & Andrews, 1999). In examining the interpretation of the model, one needs to consider how the author views the reality of the phenomenon under consideration. The phenomena of Roy’s model fall within the human experience (as distinct from phenomena beyond it) and would be termed phenomenal. When the essence of the subject matter is phenomenal, the model may be interpreted as existential or essential. An essential interpretation is one in which the phenomenon is explained by reference to the circumstances in which it occurs (Barnum, 1998).

Within the adaptation model, the person’s adaptation occurs in response to a changing environment or by affecting the environment (Andrews & Roy, 1991a; Roy & Andrews, 1999). Therefore, the adaptation model is an essential model. The method of the adaptation model is less easily identified. The logistic method is evident in the earlier scientific assumptions of the model, particularly the assumptions related to systems theory. The logistics method is one in which parts are used to organize the whole so that “a system, event, or entity is organized by reference to its parts and their interrelationships” (Barnum, 1998, p. 33). This method is less clear in the scientific assumptions for the 21st century, which appear to be moving toward the dialectic method by describing person and earth as having common patterns and integral relationships. The philosophical assumptions are more in keeping with the dialectic method. Within the dialectic method all components are parts of a larger whole, “a whole that is different from and greater than a mere summation of those parts” (Barnum, 1998, p. 132). Relative Importance of the Basic Components

The components of the adaptation model that receive the most emphasis are the concepts of person as an adaptive system and adaptation. Roy has discussed these concepts in detail and depth and they have received much attention as she has clarified and refined the model. Adaptation is viewed as the central and unifying concept of the model. It is the concept of adaptation that links the concepts of person, environment, health, and nursing. The nursing process has been delineated clearly within the model and has undergone little change as the model has been clarified and refined.

In her more recent writings, Roy has placed more emphasis on the science of nursing, describing both the basic and clinical science of nursing. The concepts of health and environment have received more attention as the model has developed. Although environment is defined in terms of stimuli, there is more emphasis on the discussion of stimuli as related to Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2

ROY’S ADAPTATION MODEL 159 the person as an adaptive system rather than as related to the environment. The concept of health, as explicated within the model, is viewed by Roy as being in the developing stages, and according to Roy, an understanding of the concept of health is contingent upon an understanding of the concepts of person and environment. The concept of health is closely related to the concept of adaptation and has been explicitly defined within the model since 1983 (Andrews & Roy, 1991a; Roy, 1983; Roy & Andrews, 1999). Analysis of Consistency

It is important to examine the clarity and consistency (congruence) of a model (Barnum, 1998; Meleis, 1991). To assess clarity and consistency, one needs to determine if the concepts are clearly and consistently defined, if the relationships between the concepts are clear and consistent, and if the assumptions are consistent with the concepts and the relationships between the concepts. The concepts of person, adaptation, health, environment, and nursing are clearly defined and can be readily understood; however, there are some inconsistencies.

Within the adaptation model, person is described as an adaptive system, a whole made up of parts that adapts to changes in the environment and also affects the environment (Andrews & Roy, 1991a; Roy & Andrews, 1999). A mechanistic view of person is inconsistent with the holistic view espoused by Roy. However, Roy has stated that the focus on parts is only for descriptive purposes and that the model is based on a holistic view of person. The philosophic assumptions of the model support the holistic view espoused by Roy that behavior is purposeful and not a chain of cause and effect.

Thus, to explicate relationships, the person’s behavior is described as both purposeful and as cause and effect or response to stimulus. Although Roy has stated that the person affects the environment, she has placed much greater emphasis on the person’s response to the environment (Andrews & Roy, 1991a; Roy, 1986, 1988; Roy &Andrews, 1999). Roy (1988) provided further support for the holistic view of person by stating that “the complexities and subtleties of the process whereby the person takes in and responds to the environment precludes . . a behavioristic interpretation” (p. 32). In the model, environment is defined as internal and external stimuli, and the person is described as receiving inputs from the external and internal environments (Andrews & Roy, 1991a; Roy & Andrews, 1999). In her earlier writings, Roy (Roy & Roberts, 1981) stated that further work was needed to clarify environment as distinct from internal stimuli. It would seem that internal stimuli are now viewed as part of the environment.

This raises the following question: If internal stimuli are part of the environment, how is this internal environment differentiated from the person as an adaptive system; that is, how does one determine what is part of Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 160 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION the internal environment and what is part of the person?

This is a particularly important question because within the model, nursing intervention is viewed as the management of stimuli, and Roy (Roy & Roberts, 1981) has clearly indicated that the manipulation of stimuli is not manipulation of the person. It also is not clear how environment is distinguished from the person’s adaptation level, given that both are defined and described in terms of focal, contextual, and residual stimuli (Andrews & Roy, 1991a; Roy & Andrews, 1999).

The relationships among the concepts vary in clarity but there are no discrepancies or contradictions within the relationships. The relationships among person, adaptation, and nursing are clear. The person adapts and nursing promotes this adaptation. The relationship between adaptation and health also is fairly clear. Adaptation promotes integrity and integrity is health. Thus, adaptation leads to health. Because nursing promotes adaptation, the relationship between nursing and health also is clear; that is, nursing promotes health (Andrews & Roy, 1991a; Roy & Andrews, 1999).

The relationship between person and health is less clear but appears to be an indirect relationship linked by the concept of adaptation. There is a question with regard to the concept of adaptation, especially as it is related to the other concepts in the model. Adaptation refers to the person-environment interaction. In this interaction the person may respond adaptively or ineffectively; however, Roy (Andrews & Roy, 1991a; Roy & Andrews, 1999) has indicated that the person adapts and that nursing promotes this adaptation for the purpose of enhancing health.

It seems that nursing is actually promoting successful adaptation or adaptive responses rather than adaptation per se. The relationships between the regulator and cognator and the four adaptive modes are not always specified. This is particularly true of the relationship between the regulator and the physiological mode. The propositions of the regulator and the physiological mode need additional distinction (Limandri, 1986). The definitions of the concepts within the model and the relationships among them are consistent with the model’s scientific assumptions.

The definitions of the concepts and the relationships among them are not always clearly consistent with the philosophical assumptions that emphasize holism. Integration of these assumptions within the model would help clarify the congruence of the more part-focused systems theory and adaptation-level theory with the more whole-focused philosophical assumptions (Whall, 1992). With the new definition of adaptation and the scientific assumptions for the 21st century, the model is moving in that direction.

Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 161 Analysis of Adequacy According to Barnum (1998), “a theory is adequate if it accounts for the subject matter with which it purports to deal” (p. 174) and “if its prescriptions are extensive enough to cover the scope claimed by its author” (p. 174). Using this definition, the adaptation model meets the criterion of adequacy.

The model views nursing as promoting adaptation in situations related to health, and it deals with the concept of adaptation in a careful and detailed manner. The model is viewed as broad in scope and the identification of interventions as the management of stimuli or the strengthening of coping processes would support the broad scope inferred by the author of the model (Andrews & Roy, 1991a; Roy, 1984; Roy & Andrews, 1999). Hardy (1974) described two criteria for assessing the adequacy of a model—meaning and logical adequacy, and operational-empirical adequacy.

In assessing meaning and logical adequacy, one needs to examine the validity of the assumptions and the validity of the meaning attributed to the concepts; that is, are the concepts defined in a manner similar to that used by other scientists in the area? In addition, one needs to examine the logic of the theoretical system. Person, adaptation, health, and nursing are clearly defined and explained in detail within the model. Although each of the concepts has aspects unique to the model, each has aspects similar to those used by other scientists in the area.

The cognator and regulator as coping mechanisms are unique to the model, although there is support for the concept of coping mechanisms in the conceptions of person as specified by other scientists. The idea of persons having four adaptive modes also is unique to the model. Some have stated that they found it difficult to separate the self-concept, role function, and interdependence modes (Gerrish, 1989; Limandri, 1986; Nyqvist & Sjoden, 1993; Wagner, 1976). These modes were identified based on the analysis and categorization of patient behaviors (Roy, 1991a).

Therefore, there is a question that if a person’s behavior cannot be absolutely categorized, are these modes mutually exclusive? Two aspects of nursing are unique to the model: the two-level assessment in the nursing process and intervention as management of stimuli. The two-level assessment provides for evaluation of patient behavior (responses) and the stimuli to which the person is responding. This is appropriate to a model that focuses on persons responding to stimuli. The specification within the model of nursing intervention as management of focal and contextual stimuli, both internal and external, raises a question.

Can internal stimuli be manipulated without manipulating the person? It is clearly stated that the manipulation of stimuli is different from the Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 162 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION manipulation of people (Roy & Roberts, 1981). An example would serve to clarify this point. This question still remains, although internal stimuli have now been conceptualized as part of the environment (Andrews & Roy, 1991a; Roy & Andrews, 1999).

The concept of adaptation as process and outcome draws upon the definitions of other theorists, such as Dohrenwend (1961). Lazarus (1966), Mechanic (1970), and Selye (1978), who defined adaptation as a process, and Helson (1964), who defined it as a product (outcome). The model combines the various aspects of the definitions in a logical manner and has developed the concept further in a manner that is consistent with the definitions of these theorists. The logical adequacy of the model also can be assessed by examining the relationships among the concepts.

Roy has described most of the relationships clearly. There are no apparent discrepancies or contradictions. In assessing operational and empirical adequacy, one asks the following questions. Can the concepts be measured? Do operational definitions reflect theoretical concepts? Does the evidence support the model or the theories derived from it; that is, do the empirical data conform to hypothesized expectations (Calvillo & Flaskerud, 1993; Hardy, 1974)? Because this is a broad model for nursing, the adaptation model does not define the major concepts operationally.

However, general propositions have been developed in the model and from these propositions it is possible to deduce testable hypotheses. Thus, concepts contained in these hypotheses could be defined in a manner that would be theoretically consistent with the concepts and would be measurable. Testable hypotheses have been derived from the model and have provided evidence (empirical data) that supports portions of the model (Fawcett & Tulman, 1990; Frederickson, Jackson, Strauman, & Strauman, 1991; Hill & Roberts, 1981; Smith, 1988; Thornbury & King, 1992).

Another aspect of adequacy is pragmatic adequacy; that is, the usefulness of the model, including its usefulness in generating innovative actions from the research, which could be used in practice (Calvillo & Flaskerud, 1993). A number of studies have used the model to derive interventions and then tested these interventions in practice. These studies supported the usefulness of interventions derived from the model (Smith, 1988; Thornbury & King, 1992). EXTERNAL ANALYSIS Relationship to Nursing Research The usefulness of a model for research depends on its ability to guide all phases of a study.

It should provide a perspective for research by suggesting the subject matter or phenomena to be studied, identifying the nature Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 163 of the problems to be studied or the research questions to be asked, and identifying appropriate methods of inquiry (Barnum, 1998; Fawcett&Tulman, 1990; Roy, 1991a). The elements and assumptions of the adaptation model provide such a perspective for research in both the basic nd clinical science of nursing. The phenomena of study, as identified by the model, are persons (both individuals and groups). The distinctive nature of the problems to be studied or the research questions to be asked are related to basic life processes and patterns, coping with health and illness, and enhancing adaptive coping (positive life processes and patterns) (Roy, 1987b, 1988, 1990, 1991a). According to Roy (1991a), multiple methods are appropriate and desirable when conducting research based on the model.

The concepts Roy (1970) articulated provide a model for the long-term process of observation and clarification of facts leading to postulates regarding (a) the occurrence of adaptation problems; (b) coping mechanisms; and (c) interventions based on laws derived from factors composing the response potential; that is, focal, contextual, and residual stimuli. Using this framework, typologies of adaptation problems or nursing diagnoses have been developed as well as typologies of indicators of positive adaptation (Andrews & Roy, 1991b; Roy & Andrews, 1991).

In 1981, Roy and Roberts noted the need to develop an organization of categories of interventions that would fit within the model. Some research has been done in this area. Data on cognitive deficits have been used to design intervention protocols for cognitive recovery from head injury (Roy, 1991a). Others have used the framework to develop and test interventions to help promote adaptation based on managing stimuli (Fawcett, 1990; Kuhns, 1997; Samarel et al. , 1998; Smith, 1988; Thornbury & King, 1992).

Within the tradition of logical empiricism, to be useful for research, a model must be able to generate testable hypotheses (Silva & Rothbart, 1984). This is consistent with the verificationist perspective of logical positivism, in which the meanings of propositions depend on their method of verification. A number of general propositions have been developed from the adaptation model (Roy & McLeod, 1981; Roy & Roberts, 1981). From these general propositions, specific propositions or testable hypotheses can be developed.

Roy (Roy & Roberts, 1981) has cited examples of such testable hypotheses, which she has stated are relevant for specifying prescriptions for practice. Others also have demonstrated the development of testable hypotheses from the model. Testing of these hypotheses has provided data to validate or support the model (Frederickson et al. , 1991; Hill & Roberts, 1981; Smith, 1988; Thornbury & King, 1992; Zhan, 2000). The model has been used as a framework for research by Roy and others.

During the last 30 years it has been used in more than 200 quantitative research studies (Frederickson, 2000; Roy & Andrews, 1999). (See Table 8–3 for a partial list of studies using the model. ) Roy (1991a) has provided Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 164 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION TABLE 8–3 Use of the Adaptation Model in Research Focus of research Researcher

Cross-cultural pain Cavillo & Flaskerud (1993) Caesarean birth Fawcett (1990) Child-bearing women Fawcett & Tulman (1990), Tulman et al. (1998) Cancer patients Frederickson et al. (1991), Samarel et al. (1998) Spinal cord injury patients Harding-Okimoto (1997) Abused women Limandri (1986) Well adolescents Modrcin et al. (1998) Breast-feeding women Nyqvist & Sjoden (1993) Spouses of surgical patients Silva (1987) Elderly persons Smith (1988), Zhan (2000) Person with Alzheimer’s disease Thornbury & King (1992) research examples from both basic and clinical nursing science.

In basic nursing science the model has been used as a framework for exploring how the cognator coping mechanism acts to promote adaptation and its relationship to the four adaptive modes, and for examining the relationship of adaptation to health. In clinical nursing science the model has been used in a program of research related to cognitive recovery of patients with head injury. Specifically, this research focused on gaining an understanding of basic human cognitive processes and how nurses can assist persons to positively affect their health by use of these processes.

Scholars who have used the adaptation model as the conceptual basis for their research have found it to be useful in identifying the concepts and variables to study and in selecting instruments to measure or operationalize these variables (Calvillo & Flaskerud, 1993; Fawcett, 1990; Fawcett & Tulman, 1990; Harding-Okimoto, 1997; Limandri, 1986; Modrcin- Talbott, Pullen, Ehrenberger, Zandstra, & Muenchen, 1998; Tulman, Morin, & Fawcett, 1998; Vicenzi & Thiel, 1992).

In addition, it has been found to be useful in suggesting the design or methodology for research studies (Fawcett & Tulman, 1990; Roy, personal communication, March 6, 1986) and in structuring and organizing data into themes and categories (Nyqvist & Sjoden, 1993; Silva, 1987). The model also is useful for deriving testable hypotheses and propositions. The model clearly has demonstrated its usefulness in research to date. As the model continues to develop it will serve as a framework for both quantitative and qualitative research. Relationship to Nursing Education The adaptation model has demonstrated its usefulness in education.

As a theoretical framework for nursing education, it is one the most widely used models in the United States and is being used increasingly in other countries (Roy, 1982; Roy&Andrews, 1991). Acombination of nursing process Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 165 and adaptation problems provide the framework for nursing curricula based on the model, and form the units and strands of knowledge and practice that are developed throughout the educational program (Roy, 1973).

The model is currently the basis for the nursing curricula at Mount Saint Mary’s College, Los Angeles, and the Royal Alexandra Hospitals School of Nursing, Edmonton, Alberta, Canada (Roy & Andrews, 1991). The model also has been used in a geriatric nurse-practitioner program (Brower & Baker, 1976), and in the first-year nursing course of a generic baccalaureate program at the University of Ottawa School of Nursing, Ottawa, Ontario, Canada (Morales-Mann & Logan, 1990). According to Roy (1973, 1976b, 1979), the curriculum at Mount Saint Mary’s has clearly demonstrated the relationship of nursing theory to nursing education.

The model allows for increasing knowledge in the areas of both theory and practice, and it helps students test theory and develop new theoretical insights. In addition, the model distinguishes between nursing science and medical science. Brower and Baker (1976) stated that the adaptation model for nursing integrated nursing theory, thereby decreasing students’ anxiety. They also stated that the model provided some distinction between nursing and medicine, although there was some overlap.

Although the model has demonstrated its usefulness in education, challenges faced by educators when implementing the model have been identified. These challenges include (a) developing or adapting courses to be congruent with the model; (b) developing teaching tools that are consistent with the model and suitable for student learning; (c) sequencing content to facilitate student learning about the model, course content, and the relationship between them; and (d) obtaining competent role models in the application of the model (Morales-Mann & Logan, 1990). Relationship to Professional Nursing Practice

The clinical application of an explicit model improves nursing practice by integrating theory into everyday processes of patient care and nursing administration, providing a distinctive focus for nursing practice, helping to define nursing roles and goals, facilitating communication among nurses, and fostering development of common goals for patient care. Amodel provides structure to guide practice by providing direction for the nursing process (Connerly, Ristau, Lindberg, & McFarland, 1999; Keen et al. , 1998). The adaptation model provides this direction based on its welldeveloped guidelines for the use of the nursing process.

The two-level assessment process focuses on the assessment of behaviors and stimuli and leads to the identification of nursing diagnoses (behaviors related to stimuli) and the establishment of goals (behavioral outcomes). The model provides the framework for intervention, which is focused on the management Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 166 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION

TABLE 8–4 Use of the Roy Adaptation Model in Practice Focus of research Researcher Cancer patients Cook (1999), Gerrish (1989) Patients undergoing amputation Dawson (1998) Occupational health, work environment Doyle & Rejacich (1991) Patients with anxiety Frederickson (1993) Hospitalized children Galligan (1979), Starn & Niederhauser (1990) Coronary care unit Hamner (1989) Adolescents with asthma Hennessy-Harstad (1999) Adult hemodialysis patients Keen et al. (1998) Home care Lankester & Sheldon (1999), Schmitz (1980) Abused women Limandri (1986) Patients with Kawasaki disease Nash (1987)

Adolescents with bulimia nervosa Pilote (1998a, 1998b) Elderly in apartment complexes Smith (1988) Patients with Alzheimer’s disease Thornbury & King (1992) of stimuli or strengthening the adaptive processes. Evaluation assesses the effectiveness of the intervention by examining behavior relative to the goals. As the model has been developed, there has been a refinement of the approaches to nursing diagnosis, an identification of major stimuli for each mode, and development of intervention protocols based on the model (Andrews & Roy, 1991b; Gray, 1991; Roy & Andrews, 1991, 1999).

The usefulness of the adaptation model in practice has been demonstrated in a variety of clinical settings with various populations (see Table 8–4). In addition, the model has been adopted by a number of healthcare agencies in the United States and abroad, where it serves as a basis for practice (Connerly et al. , 1999; Frederickson, 1991; Frederickson & Williams, 1997; Nyqvist & Sjoden, 1993; Roy, 1986; Weiss, Hastings, Holly, & Craig, 1994). Use of this comprehensive, holistic model in practice has advantages and disadvantages.

The model has been found to facilitate thorough and holistic assessments by providing a comprehensive framework, which includes psychosocial aspects as well as physiological aspects (Dawson, 1998; Doyle & Rajacich, 1991; Galligan, 1979; Gerrish, 1989; Hamner, 1989; Smith, 1988; Thornbury & King, 1992). This holistic approach may foster earlier identification of problems (Frederickson, 1993). In addition, as the model has developed, coping processes and adaptive modes have been defined for groups that parallel those of the individual human adaptive system.

This expansion of the model offers a framework for systematic healthcare delivery to aggregates, making it more amenable to community health nursing applications (Dixon, 1999). The adaptation model has been used in practice to design nursing interventions based on the management or manipulation of stimuli or the strengthening of adaptive processes that were identified during assessment Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall. Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 ROY’S ADAPTATION MODEL 167 nd formulation of nursing diagnoses. This approach to intervention, which is specific to the individual and the diagnosis, helps individualize care and may be more effective than more general, standardized approaches to care (Cook, 1999; Frederickson, 1993; Hennessy-Harstad, 1999; Lankester & Sheldon, 1999; Smith, 1988; Starn & Niederhauser, 1990; Thornberry & King, 1992). A number of additional advantages have been identified by nurses who have used the model in practice. The holistic approach of the model helps prevent putting too much emphasis on aspects of illness and allows for the inclusion of health promotion.

In addition, it is easy to apply as a family-centered model (Lankester & Sheldon, 1999). Other advantages are a perceived improvement in efficiency and effectiveness of the nursing process and quality of patient outcomes, and improved patient and/or family satisfaction (Frederickson & Williams, 1997; Weiss et al. , 1994). Despite its usefulness in facilitating thorough and holistic assessments, application of the nursing process based on the model can be lengthy, repetitious, and time consuming, especially during the assessment phase.

In addition, the process may include elements not considered necessary or relevant to the actual care of the patient. These concerns have been found to be most problematic in intensive care units, where there are rapid changes in patient’s conditions, and least problematic in outpatient and long-term care settings (Gerrish, 1989; McIver, 1987;Wagner, 1976;Weiss et al. , 1994). Some difficulty in using the model in practice arises from some apparent overlap in modes, which can make it difficult to structure the assessment to cover one mode at a time and/or to decide which mode is ppropriate for a given behavior (Gerrish, 1989; Limandri, 1986; Nyqvist & Sjoden, 1993; Wagner, 1976). Because of the possible overlap in modes, Nyqvist and Sjoden (1993) expressed doubt about the appropriateness of the model for daily patient assessment. Others expressed difficulty in using the model for identification and classification of stimuli as focal, contextual, or residual (Gerrish, 1989; Lankester & Sheldon, 1999). Despite some difficulties in using the model in practice, the advantages in using the model clearly outweigh the disadvantages. Nursing Classification Systems and the Model

Nursing practice is conducted through the nursing process (Roy & Andrews, 1999). Three American Nurses Association (ANA)-approved classification systems focus on components of the nursing process. These classification systems include the North American Nursing Diagnosis Association (NANDA) classification of nursing diagnoses, the Nursing Outcomes Classification (NOC), and the Nursing Interventions Classification (NIC). These classification systems have been linked to one another given Conceptual Models of Nursing: Analysis and Application, by Joyce J. Fitzpatrick and Ann Whall. Published by Prentice-Hall.

Copyright © 2005 by Pearson Education, Inc. ISBN: 0-536-26229-2 168 CONCEPTUAL MODELS OF NURSING: ANALYSIS & APPLICATION that they all suggest specific interventions and outcomes for specific diagnoses (Wilkinson, 2000). Roy (Roy & Andrews, 1999) defines nursing diagnosis as “a judgment process resulting in a statement conveying the person’s adaptation status” (p. 77). Although this definition reflects both process and outcome, the emphasis is on the outcome or product. This outcome has been described as a summary statement or conclusion about the person based on the interpretation of assessment data.

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