Sister Callista Roy theory on adaptation

1. Presented by: Dave Jay S. Manriquez RN.
Roy's model of nursing sees an individual as a set of interrelated systems,
biological, psychological, and social. The individual tries to maintain a balance
between each of these systems and the outside world. However, there is no
absolute level of balance. According to Roy we all strive to live within a band
where we can cope adequately. This band will be unique to an individual. The
adaptation level is the range of adaptability within which the individual can deal
effectively with new experiences.
Callista Roy maintains there are four main adaptation systems which she calls
modes of adaptation. She calls these the physiological system, the self concept
system, the role mastery system, and the interdependency system.
ASSUMPTIONS
Scientific
· Systems of matter and energy progress to higher levels of complex self-
organization
· Consciousness and meaning are constitutive of person and environment
integration
· Awareness of self and environment is rooted in thinking and feeling
· Humans by their decisions are accountable for the integration of creative
processes
· Thinking and feeling mediate human action
· System relationships include acceptance, protection, and fostering of
interdependence
· Persons and the earth have common patterns and integral relationships
· Persons and environment transformations are crated in human consciousness
· Integration of human and environment meanings results in adaptation
Philosophical
· Persons have mutual relationships with the world and God
· Human meaning is rooted in an omega point convergence of the universe
· God is intimately revealed in the diversity of creation and is the common destiny
of creation
· Persons use human creative abilities of awareness, enlightenment, and faith
· Persons are accountable for the processes of deriving, sustaining, and
transforming the universe

2. PERSONS AND RELATING PERSONS
· An adaptive system with coping processes
· Described as a whole comprised of parts
· Functions as a unity for some purpose
· Includes people as individuals or in groups (families, organizations,
communities, nations, and society as a whole)
· An adaptive system with cognator and regulator subsystems acting to maintain
adaptation in the four adaptive modes: physiologic-physical, self-concept-group
identity, role function, and interdependence
Adaptive Modes Individual Group
Five needs-oxygenation,
nutrition, elimination,
activity and rest,
Operating resources:
protection
Physiologic- participants, capacities,
Four complex processes-
physical physical facilities, and
senses; fluid, electrolyte,
fiscal resources
and acid-base balance;
neurologic function;
endocrine function
Need is group identity
integrity through shared
Need is psychic and
relations, goals, values,
spiritual integrity so that
and coresponsibility for
Self-concept- one can be or exist with a
goal achievement; implies
group identity sense of unity, meaning,
honest, soundness, and
and purposefulness in the
completeness of
universe
identifications with the
group
Need is role clarity,
Need is social integrity;
understanding and
knowing who one is in
committing to fulfill
relation to others so one
expected tasks so group
can acct; role set is the
can achieve common
complex of positions
Role function goals; process of
individual holds; involves
integrating roles in
role development,
managing different roles
instrumental and
and their expectations;
expressive behaviors,
complementary roles are
and role taking process
regulated

3. Need is to achieve
relational integrity using
Need is to achieve
processes of
relational integrity using
developmental and
process of affectional
resource adequacy, i.e.,
adequacy, i.e., the giving
Interdependence learning and maturing in
and receiving of love,
relationships and
respect, and value
achieving needs for food,
through effective relations
shelter, health, and
and communication
security through
independence with others
ENVIRONMENT
· All conditions, circumstances, and influences surrounding and affecting the
development and behavior of persons and groups with particular consideration of
mutuality of person and earth resources
· Three kinds of stimuli: focal, contextual, and residual
· Significant stimuli in all human adaptation include stage of development, family,
and culture
HEALTH AND ADAPTATION
· Health: a state and process of being and becoming integrated and whole that
reflects person and environmental mutuality
· Adaptation: the process and outcome whereby thinking and feeling persons, as
individuals and in groups, use conscious awareness and choice to create human
and environmental integration
· Adaptive Responses: responses that promotes integrity in terms of the goals of
the human system, that is, survival, growth, reproduction, mastery, and personal
and environmental transformation
· Ineffective Responses: responses that do not contribute to integrity in terms of
the goals of the human system
· Adaptation levels represent the condition of the life processes described on
three different levels: integrated, compensatory, and compromised

4. NURSING
· Nursing is the science and practice that expands adaptive abilities and
enhances person and environment transformation
· Nursing goals are to promote adaptation for individuals and groups in the four
adaptive modes, thus contributing to health, quality of life, and dying with dignity
· This is done by assessing behavior and factors that influence adaptive abilities
and by intervening to expand those abilities and to enhance environmental
interactions
NURSING PROCESS
· A problem solving approach for gathering data, identifying the capacities and
needs of the human adaptive system, selecting and implementing approaches for
nursing care, and evaluation the outcome of care provided
1. Assessment of Behavior: the first step of the nursing process which involves
gathering data about the behavior of the person as an adaptive system in each of
the adaptive modes
2. Assessment of Stimuli: the second step of the nursing process which involves
the identification of internal and external stimuli that are influencing the person’s
adaptive behaviors. Stimuli are classified as: 1) Focal- those most immediately
confronting the person; 2) Contextual-all other stimuli present that are affecting
the situation and 3) Residual- those stimuli whose effect on the situation are
unclear.
3. Nursing Diagnosis:step three of the nursing process which involves the
formulation of statements that interpret data about the adaptation status of the
person, including the behavior and most relevant stimuli
4. Goal Setting: the forth step of the nursing process which involves the
establishment of clear statements of the behavioral outcomes for nursing care.
5. Intervention: the fifth step of the nursing process which involves the
determination of how best to assist the person in attaining the established goals
6. Evaluation: the sixth and final step of the nursing process which involves
judging the effectiveness of the nursing intervention in relation to the behavior
after the nursing intervention in comparison with the goal established.
The nursing philosophy or model of Sister Calista Roy focuses on the individual
(person) as a biopsychosocial adaptive system. According to Roy (1997) nursing
is a discipline that emphasizes strengthening, expanding, and improving upon
the person's coping abilities for the purpose of enhancing the patient's wellness
or health. The model was chosen for review because her work is studied and
utilized frequently in nursing education (Roy & Andrews, 1999).

5. Roy’s Adaptation Model: Demonstration of Theory
Integration into Process of Care in Coronary Care
Unit
Abstract: This article describes a case study involving a process of theory
integration into nursing care in a cardiac care setting. This approach was guided
by Roy’s adaptation model from the totality paradigm. Following a brief overview
of practice methodology of Roy’s Adaptation Model, a two-level assessment is
conducted for a cardiac patient. Based on the two-level assessment nursing
diagnosis is established and nursing interventions are planned which aim to
promote adaptation.
Various nursing strategies are described which help the patient to move towards
the direction of adaptation. The research support of the theory and proposed
research to support the theory is also
mentioned.
INTRODUCTION
Theory-based nursing practice is entrenched in the concept that the work of any
discipline is directed by its knowledge base. The practice then is guided by the
distinctive theories of that particular discipline. A practitioner using process of
theory-based nursing practice develops a practice proposition and a plan for
schematic application of this nursing process in the relevant area of nursing. This
article will present an example of this process using Roy’s Adaptation Model
(RAM). The purpose of this article is to demonstrate theory integration into the
process of care for a CVAS patient.
I. Overview of the Theory
RAM assumes that the basis of nursing knowledge is founded upon an
understanding of people adapting within their given life situations. Roy identifies
three elements in her model of nursing: the recipient of nursing, the goal of
nursing, and nursing intervention.
Each of these essential elements includes the concepts of nursing, person,
health-illness, environment, and adaptation. The concept of adaptation assumes
that people are open systems who respond to stimuli from both outside and
inside of the person (Roy & Andrew,
1991).
The use of RAM in a patient with CVA will illustrate how a nurse can
promote a client’s adjustment to challenges related to health and illness. In this
theory, adjustment refers to adaptation, and challenges refer to stimuli. This
theoretical model incorporates information from many fields into nursing.
RAM includes a detailed nursing process, which involves assessing client
behaviors and their influencing factors, identifying problems, setting goals,
selecting interventions, and evaluating outcomes in order to provide
comprehensive nursing. The nurse’s role while caring for a patient involves
manipulating the stimuli that comes from the environment so that they fall within
the client’s field of positive coping resulting in adaptation. The adaptation is

6. considered as the positive response to a stimulus, whereas a negative response
is described as mal-adaptation (Tolson & McIntosh, 1996).
Adaptation is considered to take place in one biological and three psychosocial
modes (Fig. 1). The biological mode of adaptation, referred to as the
physiological mode, is concerned with basic needs to maintain the anatomical
and physiological integrity of an individual. The psychosocial mode of adaptation
includes self-concept, role function, and interdependence mode. The four modes
of adaptation are interrelated. Responses in any one mode may have an effect
on or act as a stimulus on one or all of the four modes.
Environmental stimuli are categorized as focal, contextual, and residual stimuli
(Fig. 1). The goal of nursing is to promote adaptation by managing the
environmental stimuli. Nursing management while caring for a CVA patient will
include: increasing, decreasing, maintaining, removing, or otherwise altering or
changing relevant focal and/or contextual stimuli.
Figure 1. Three different kinds of stimuli affecting adaptation modes
stimuli
II. Demonstration of Theory Integration into Care Process in CVA patient
According to Roy, the goal of nursing is to promote adaptation, thus contributing
to health, quality of life, and, if appropriate death with dignity. The practice
methodology in
RAM is the nursing process, which is a problem-solving method for identifying
stimuli and assessing functions in the adaptive modes. The nursing process
according to RAM involves a two level assessment: assessment of a patient’s
behavior and assessment of stimuli affecting a patient’s behavior. As result of
these two level assessments, planning, nursing intervention,
and evaluation of care provided will emerge
Figure 2. Diagrammatic description of nursing process according to RAM
The first step of the nursing process is the assessment of behavior. The behavior
is assessed in four adaptation modes: physiological, Self-concept, role function,
and interdependence mode. The second level assessment involves analysis of
three types of stimuli influencing ineffective behavior: focal stimuli (changes or
situations which immediately affect the individual, such as stress, injury, or
illness); contextual stimuli (all other stimuli which may influence a response to a
focal stimuli, for example, family environment); residual stimuli (characteristics,
values, and attitudes of the individual which have developed from the past
experiences, such as beliefs, experiences, and traits) (Tolson and McIntosh,
1996).
Two-level assessment
Assessment of
behavior Assessment of
stimuli
Planning
Nursing diagnosis
Goal setting
Nursing interventions

7. Mr. B.E.., a 60-year-old man, was diagnosed to have post-infarct seizure, status
post Cerebrovascular Accident. This patient had several hospital admissions
over the last few months. He was also an insulin dependent diabetic for the last
20 years.
Physical examination revealed blood pressure of 200/130 mm of Hg, a regular
pulse of 100-110 beats per minute, and respirations of 28 per minute.
Two Two-level Assessment
In this case study, the approach to Mrs. T. using Roy’s model began with the two
level assessment. In first level assessment, adaptive responses in all four modes
were examined. In physiological mode the patient’s ineffective adaptation i.e.,
unstable vital signs, was the first priority for nursing care. The patient was alert,
oriented, and was able to speak
indicating that her central neurological functioning was intact. Adaptation
problems that
were observed during assessment included: hemodynamic instability, sleep
deprivation,
activity intolerance, and elimination.
Assessment of the self-concept mode revealed, grieving over loss of regular
physical
activity. Mrs. T. cried frequently and seemed depressed. While assessing the role
functioning
mode, it was noticed that Mrs. T. was having difficulty accepting her role as a
patient. She
did not understand the importance of the intravenous medication infusions. In
addition, She
was upset with the MD who inserted central line as she thought she did not need
it.
Moreover, she felt that all these treatments were making her sicker. She also
refused
assistance with personal hygiene, but was unable to do it unaided. During
assessment of
interdependence mode, no ineffective adaptive responses were noted as patient
had good
family support.
In second level assessment, the level of focal, contextual, and residual stimuli
influencing Mrs. T’s ineffective behavior were examined. The focal stimulus
identified was:
poor left ventricular function causing congestive heart failure and resultant impact
on
maintaining optimum cardiac output, vital signs, and tolerance to regular physical
activities.
Contextual stimuli included: anxiety due to illness and fear of the unknown.
Residual stimuli
influencing Mrs. T’s ineffective behavior were identified as: personality traits, her
valuing of

8. independence, possible residual effects from her previous hospitalization,
memories of past
experiences, and past patterns of relating and coping.
Nursing Diagnosis and Intervention Interventions
Based on two level assessment of Mrs. B., the nursing diagnosis for
physiological
mode was decreased cardiac output related to poor ventricular function resulting
from
previous myocardial injuries. In view of this nursing diagnosis, planned
interventions were
aimed at promoting patient adaptation by managing focal stimuli. Short-term
nursing goals
included improving cardiac output, and maintaining optimum vital signs by
titrating
hemodynamic drugs to get desired response. In order to achieve these goals,
appropriate
nursing interventions were planned and implemented. The Dopamine drip was
titrated up
to maintain systolic blood pressure of 90 mm of Hg or greater, Dobutamine and
Milrinone
infusions helped to improve cardiac output, and lasix drip improved diuresis,
which
consequently helped in resolving the congestive heart failure.
The nursing diagnosis for self-concept mode was depression and anxiety related
to
physical inability and loss of self-esteem. The nursing goal related to this
diagnosis was, to
resolve her depression over physical dysfunction and expression of satisfaction
with her
present self. The nursing diagnosis in the role function mode was dysfunctional
independence, and the nursing goal related to this diagnosis was, that client will
realize the
importance of medical and nursing treatment, and will accept her role as a
patient by
accepting assistance with personal care when needed. Planned interventions in
the selfconcept
and role function mode focused on helping Mrs. T. adjust to her limitations and
begin to reestablish some independence in terms of improving tolerance to
activities of daily
life, such as personal hygiene, and elimination (Mitchell and Pilkington, 1990).
Evaluation of Care Process
Evaluation is the last step in the nursing process according to Roy’s Adaptation
Model to judge effectiveness of nursing interventions used to promote adaptation
in each
four modes. Evaluation of outcomes in the physiological mode revealed adaptive
behavior,

9. which was achieved by manipulating the focal stimulus, by means of titrating
intravenous
infusions of drugs affecting hemodynamic status as per physician’s order. As a
result,
optimum blood pressure was maintained, and heart failure was resolved. The
physician’s
orders were primarily aimed at managing focal stimulus.
In the self-concept and role function mode, progress towards goal
accomplishment
was relatively slow, as patient’s medical illness was a chronic condition. Some of
the expected
outcomes were achieved, such as, decreased anxiety level, and better ability to
verbalize her
understanding about her illness, and the need for treatment. The patient was also
able to
realize that it was her physical necessity to get help from others during the acute
phase of her
illness, so she appropriately accepted some assistance from nurses for the
ambulation, and for
the personal hygiene.
III. Strategies Utilized to Carry out the Care Process
The practice methodology in Roy’s Adaptation Model is the nursing process, a
six step problem-solving method. Four nursing strategies summarize the critical
care nurse’s use
of the nursing process to help the patient move towards desired direction of
adaptation:
1. The nurse functioned as a direct care provider. The approach to Mrs. T’s care
began with
two-level assessment, which included assessment of behavior and assessment
of stimuli.
Client’s behavior was examined in all four adaptive modes: physiological, self-
concept, role
function, and interdependence.
2. The nurse functioned as problem solver. When the two-level assessment was
completed,
problem areas were identified and stated as nursing diagnoses. Based on the
nursing
diagnosis and desired outcomes, specific goals and interventions were
determined that guided
the process of manipulation of stimuli to move the patient in the desired direction
of change
towards adaptation. Nursing interventions were evaluated as the patient’s
behavior changed,
and were modified accordingly to promote adaptation in all four modes.

10. 3. The nurse functioned as a resource-linker. The evaluation phase was on-going
and
involved analysis of stimuli and estimation of patient’s progress towards goal
attainment. As
the nurse assisted the patient and the family to identify problems, strengths, and
resources in
each area of assessment, appropriate information was shared about resources
that were not
known to the patient and the family, such as cardiac rehabilitation programs.
Roy’s
Adaptation Model provided a suitable framework for assessing Mrs. T. according
to
physiologic, psychological, and social criteria and to identify the effect of internal
and
external stresses on adaptation.
4. The nurse functioned as an advanced practice nurse. Using advanced practice
skills, the
nurse interpreted disease and treatment information to patient and family, and
created an
opportunity for them to ask questions. This holistic viewpoint allowed nurse to
relate to the
patient, which in turn helped in improving patient outcome.
IV. Research Support of Theory
The elements and assumptions of the adaptation model provide a perspective for
research in both the basic and clinical science of nursing. In basic nursing
science the model
has been used as a framework for exploring how the cognator coping
mechanisms act 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
(Tiedman, 1996).
The phenomenon of study, as identified by the model, is a person, both
individuals
and groups. The distinctive nature of the problems to be studied is related to
basic life
processes and patterns, coping with health and illness, and enhancing adaptive
coping. The

11. model also is useful for deriving testable hypotheses and propositions (Tiedman,
1996). The
model has clearly demonstrated its usefulness in research by means of
stimulating reflective
practice and appeared to help nurses to identify problems and implement
changes in their
practice (Tolson & McIntosh, 1996).
V. Proposed Research to Support the Theory
. It has been shown that the adaptation model for nursing is a complex model
that
deals with multiple concepts and relationships. The individual concepts are also
complex.
Although this model is broad in scope and can be applied in many clinical
situations, there
are still some limitations of the model, which need further research for
clarification of the
concepts. The limitations, which need further research and clarification, include:
- The adaptive modes overlap, especially in the modes of self-concept, role
function,
and interdependence.
- The judgment of behavior as adaptive or maladaptive will be influenced by the
value
system of the nurse assessing the client.
- The term “adaptation” generally does not convey a meaning of growth as
intended in
the model (Lancaster, 1992).
The need for longitudinal studies, for refinement and replication, and for
programs of
research is noted. Further research should be encouraged to describe the
process of
integration of conceptual models into practice, to compare utility of different
models, and to
determine nurse and patient outcome associated with the use of nursing
conceptual models
as frameworks for the practice. The philosophical and scientific assumptions, the
essential
elements of the model, and initial research efforts can guide further research to
support this
theory (Roy, 1991).

12. VI. Conclusion
The use of Roy Adaptation Model of Nursing enhances nursing care on a
CVA patient. Implementing this model in practice is perceived as having a
positive impact on personal sense of nurses as well as on the image of nursing
profession as a whole. The model is found effective in providing direction towards
achieving patient outcomes. According to the writer, the introduction of the model
on a CVA patient made a positive difference in quality of patient care, primarily
due to the comprehensive approach to assessment and planning. In the clinical
care setting, the model concepts were more easily incorporated in to practice
than the actual language of the model. A several stimuli which are affecting the
person from the internal and external environment in four different modes of
adaptation are being managed by nursing interventions. The stimuli are shown
as aiming to affect person’s equilibrium, but with appropriate nursing
interventions, they are diverted away from the patient, and effective adaptation is
achieved. Overall, this model provides a structure for focusing, organizing, and
directing thoughts and actions related to patient care and for achieving, desired
patient outcomes efficiently and effectively.
Reference
Lancaster, J. (1992). Conceptual Models of Nursing. MO: Mosby-Year Book.
Mitchell, J. and Pilkington, B. (1990). Theoretical Approaches in Nursing
Practice: A comparison of Roy and Parse. Nursing science quarterly, (5)1, 81-87.
Roy, C. (1991). An explication of the philosophical assumptions of Roy’s
adaptation mode. Nursing Science Quarterly, 1(1), 26-34.
Roy, C. and Andrew, A. (1991). The Roy Adaptation Model: The definitive
statement. Norwalk, Conn: Appleton-Century-Crofts.
Tiedman, M.(1996). Roy’s Adaptation Model. Conceptual models of nursing,
analysis and application (Third edition). Norwalk, Conn: Appleton-Century-Crofts.
Tolson, D. and McIntosh, J. (1996). The Roy Adaptation Model: A consideration
of its properties as a conceptual framework for an intervention study. Journal of
Advanced Nursing, 24(5), 981-987.