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Correspondence: PATTON D. (2004) Journal of Psychiatric and Mental Health Nursing 11, 221–228
D. Patton An analysis of Roy’s Adaptation Model of Nursing as used within acute psychiatric
School of Nursing and Midwifery nursing
University College Dublin
Ballsbridge Campus This article examines the use of Roy’s Adaptation Model of Nursing within acute psychi-
Ballsbridge
atric nursing. The analytical framework used to analyse the model was that of McKenna’s
Dublin
(1997) framework. The author believed this framework would allow for analysis of an
Ireland
abstract nature to occur. After examining the model under different headings it was con-
E-mail: Declan.Patton@ucd.ie
cluded that there exists a research gap in relation to the use of Roy’s model within acute psy-
chiatric nursing. It is recognized that Roy’s model is well developed and therefore has the
potential to positively effect nurse practice and patient outcomes within acute psychiatric
nursing. However, it is also acknowledged that a greater level of research-based evidence is
required in order to fully justify the use of the model within acute psychiatric nursing.
222 © 2004 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 11, 221–228
Roy’s Adaptation Model of Nursing
Only after extensive reading upon the model did he come way to colleagues within the MDT. At a more ideal level,
to a greater understanding of its content and how it may be using Roy’s model may allow nurses to talk about patients
applied to psychiatric nursing practice. Some nurses may be in a more positive light with MDT colleagues.
resistive towards using the model if they perceive it as com- A nursing model must address four key concepts, which,
plex. Also, by not being knowledgeable about the model combined, are known as the metaparadigm. As can be seen
nurses may become passive in its deliverance. Patients may in Appendix 1, these four concepts are those of health, the
also find the model difficult to understand. This may inhibit person, the nurse and the environment (McKenna 1994).
their willingness to partake within formulating their care All four concepts are addressed in Roy’s theory. Roy views
plan and subsequent nursing interventions. The patient’s the person in a holistic way. A person’s functioning may be
role within the nursing process may then be negatively enhanced or mitigated against by internal or environmental
affected (Rodwell 1996, Cahill 1998). However, it could be stressors. These stressors when presenting may have three
questioned if it is always prudent for nurses to try to ori- types of stimuli. Focal stimuli represent an immediate and
entate patients to the complexities of this model whilst they apparent cause of the problem; contextual stimuli are
are experiencing an acute form of mental illness. Doing so other causative factors whilst residual stimuli relate to the
may lead to a deterioration in the patient’s mental state. A patient’s past experiences with the illness and how these
further issue is that of nurses maintaining control over experiences may impact upon the patient’s current plight.
patients by using this model in a complex way. It has been Regulator and cognator activities are manifested through
identified in a phenomenologically based study that a patient’s illness. Regulator activities are physiological in
patients perceive nurses as having power through knowl- nature whilst cognator activities may range from a physical
edge (Nordgren & Fridlund 2001). This may occur if attribute to a psychological or social attribute. In relation
nurses do not engage with patients in informing them to the three stimuli, it may only be possible to identify the
about the model. Some psychiatric nurses may find it easier focal stimulus in some cases (Roy 1984). This is applicable
to practise if they maintain some control over those for to acute psychiatry for three reasons. First, within the acute
whom they are caring. Nurses who do talk to patients psychiatric environment it may not always be possible to
about the model may use diagrammatic representations to carry out an in-depth initial assessment with patients. For
help those patients understand how the model works. On example, a patient experiencing an episode of psychosis
a more positive note, by being so well defined, the strict may find it difficult to communicate what has caused their
application of the model to any practice area may lead to current problem. Second, some patients’ stay within an
the deliverance of a high standard of systematically con- acute setting may be quite short. For example once an acute
structed nursing care. episode has subsided, a patient may be transferred to a
It could be argued that structured care could be pro- step-down acute unit. Not being an inpatient within an
vided without using Roy’s model, for example, by nurses acute unit for a lengthy period of time may not afford a
implementing the nursing process without guidance from nurse time to carry out a comprehensive assessment of a
any nursing model. The medicalized nature of the nursing patient. Third, some patients within acute settings may not
process does not imply that nurses either involve patients in want to be in hospital, therefore, they may not take part in,
their care or focus on adaptive health patterns. However, or sabotage any nursing assessment.
Roy’s model makes it clear that patients are involved in the The goal of nursing within the model is to promote, and
assessment of their care needs and in the planning of appro- if possible, maintain patient adaptation within a current
priate nursing interventions. Roy’s model is also quite difficulty. This goal may be achieved by the nurse and
unique in that it explicitly states that the nurse should focus patient partaking in a six-stage nursing process. These six
on positive patient health patterns as well as health pat- stages are: the assessment of patient behaviour, assessment
terns, which are maladaptive in nature. Within the Repub- of stimuli, nursing diagnosis, goal setting, intervening and
lic of Ireland (ROI), psychiatric patient care is structured evaluating. Assessing a patient may prove time consuming,
by multidisciplinary teams (MDT), which are teams made time that may not always be available within an acute set-
up of various heath care professionals employed by indi- ting. However, using Roy’s assessment process will lead to
vidual service areas. Using a nursing model may lead to a detailed holistic overview of the patient’s current situa-
fragmentation in patient care in that the model is nursing tion. However, nurses must be aware that acutely ill
specific. An assessment tool and problem intervention patients may not always be able to partake within a thor-
strategy open to use by all within the MDT may lead to ough assessment immediately after their admission. In such
more all encompassing patient care. In defence of Roy’s cases it is the role of the nurse to assess and plan interven-
model, the author is of the opinion that Roy’s model will tions, which he/she thinks will best meet identified patient
allows nurses to present patient progression in a structured needs. Such care planning may be called maintenance care
© 2004 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 11, 221–228 223
D. Patton et al.
planning. When the patient becomes more receptive to par- in practice. Instead of being critical of the model perhaps
taking in their care, they should be immediately involved in nursing should be looking towards such well-defined the-
their care. This type of care planning is called contractual ories such as Roy’s in guiding nurse practice.
care planning.
As regards nursing interventions, Roy & Andrews
How the theory is used
(1999) stipulate that stimuli may be manipulated so that
the patient will be able to adapt to their current difficulty. How the model is used and guides nursing practice, the
This consideration could be called into question on ethical quality of care given and the nursing process will be
grounds. The term ‘manipulation’ may lead some nurses addressed in this section. Some general issues relating to the
to believe that they ultimately decide what care a patient model’s use within acute psychiatric care have been pre-
should receive. This would be in keeping with former sented. These issues, along with some other practice issues,
paternalistic trends within psychiatric nursing. Perhaps will now be further demonstrated in a short case presenta-
more appropriate terminology would be that of being a tion. Goals and interventions negotiated will be outlined
companion to the patient during his/her illness. with reference to concepts deemed important within Roy’s
With regards to the concept of health, a healthy person model.
is one who can adapt to current difficulties. In her earlier David Kelly was a 22 years old male admitted on an
model Roy does not give a definite definition of what health involuntary basis with symptoms of depression. After
entails (Fawcett 1987). This lack of a clear definition of being assessed by the medical registrar David was
health may be viewed as a positive attribute of the model. accompanied to the acute unit by his parents and the
By no definition being given nurses may conclude with author. Prior to fulfilling a nursing assessment using
patients what health means to them. Although not stated Roy’s model the author read what the medical registrar
explicitly, Roy may be implying the uniqueness of how peo- had written in David’s medical notes and recorded some
ple and their perceptions of health interact. In the most collateral information from David’s family. The author
recent edition of her model Roy states that illness and completed this to give him a basis to work on whilst
health can co-exist (Roy & Andrews 1999). In practice this assessing David. The Interdependence Mode of Roy’s
recognition of how health and illness can co-exist occurs model identifies the importance of significant others and
when adaptive and maladaptive health patterns are identi- support systems, recognizing the significant other may
fied at assessment. This has a positive implication for psy- be enacted through collecting collateral information
chiatric nursing in that a proportion of people function in from them. The author initially assessed David for 1 h.
life with an enduring mental health difficulty. For example, During this time David was more talkative than the
those people living in sheltered community dwellings. In author had envisaged. An array of information relating
relation to acute psychiatric care, Roy’s model will allow to the four modes was collected. Some of this informa-
nurses to engage with patients in a way that allows patients tion had not been collected as collateral information.
to have optimum input into their care and that allows them This point highlights the importance of the four modes
to define what ‘being healthy’ means to them. By engaging in allowing the nurse to perform a thorough initial
with the patient within a health-oriented context as assessment. This array of information helped build a
opposed to an illness one, the nurse may improve the holistic picture of David’s predicament, as opposed to a
chances of recovery for the patient. Roy’s model implies purely medical picture. The fulfilment of a first and sec-
that nurses engage in a nursing process that does not cor- ond level assessment and the formulation of interven-
relate closely with the medical approach to mental illness. tions and goals occurred over the following 2 days.
Such a non-medical, non-problem-based approach to Roy’s model gives scope to the initial patient assessment
patient care may serve to improve patient outcomes. By to be carried out over an extended period of time. Using
being ‘health’-oriented, Roy’s model may militate against Roy’s model allows for the nurse to spend time with the
the development of ‘sick role’ behaviour patterns, and may patient in trying to seek solutions to the patients pre-
assist the wider community to recognize that those with senting life and health difficulties. Appendix 2 provides
mental health problems can exist as functional persons. a brief summary of some of the problems and interven-
In conclusion, Roy’s model possesses many underlying tions that the author and David concluded upon. The
concepts. This may portray the model as complex and author found that David related in an increasingly open
therefore difficult to use in practice. In defence of the fashion, the longer the author spent in his company.
model, the concepts, which underpin the model, are well Much of this time was spent by the author helping
defined, therefore increasing the validity of the model. This David to recognize his adaptive and maladaptive health
enhanced level of validity makes Roy’s model ideal for use patterns and subsequent interventions. By being jointly
224 © 2004 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 11, 221–228
Roy’s Adaptation Model of Nursing
formulated, the author found David to be more recep- 1996). As alluded to earlier Roy supports the development
tive to receiving help. Also, the identification of positive of nursing science and the use of science in practice. How-
health patterns helped David develop an overall more ever, in the more recent editions of her model, Roy has
positive schema, which the author believes helped him placed a greater emphasis on the correlation between nurs-
in gaining strength to overcome the problems, which ing science and nursing practice. Adopting the philosophy
had led to his depression. At times the author and David that nursing science and practice are closely related may
did not agree with the evaluation of certain interven- help bridge the nursing theory–practice gap.
tions. However, the fact that David could disagree with According to Roy (1979), her model defines for student
the author within a mutual relationship must be appre- nurses the distinct purpose of nursing. She also states that
ciated. The author believes that using Roy’s model led her model will allow students to develop new practice-
to this. On discharge, David responded positively to a based theories (Roy 1979). Because of the complexity of
patient satisfaction questionnaire. The author believes the model this may not be possible for students in the ear-
that using Roy’s model helped him provide care for lier part of their training. The author would suggest the
David in a way, which allowed David to feel satisfied teaching of the model in a spiralled way. This way, students
with the help he had received. may be better able to correlate their practice experiences
The only true way to measure the effectiveness of any with the theoretical content of the model and therefore help
model is to perform a concurrent or retrospective audit them bridge the theory–practice gap.
upon its usefulness. No research exists detailing how useful It appears that the model has the potential to be gener-
Roy’s model is within acute psychiatric care, although it alized within the areas of nurse practice, education and
has been evaluated within a forensic care setting (Miller research. Roy’s adaptation theory in itself has generated a
1991). The research gap that is evident in relation to the general theory of the person as a holistic system and theo-
model should be addressed both qualitatively and quanti- ries relating to the four adaptive modes. The model has the
tatively in order for the more intangible aspects of using the potential to generate specific practice theories pertaining to
model to be explored effectively. Patients should also be one or all of the four modes. These defined practice theories
involved in evaluating the model, although this may prove may lead to the enhancement of psychiatric nursing care.
problematic within acute psychiatry, as some patients may For example, more specific theories into how a high level of
not want to be involved in an evaluation process. This may psychosocial care may be delivered to patients. Such theo-
result from the fact that they do not want to be in hospital ries may have value for psychiatric care as virtually all psy-
or result from the nature of their illness. In order to over- chiatric disorders have psychological and social elements.
come this, patients should be asked to evaluate their care This aspect of the model makes it somewhat implicit that
on discharge. the theory has the potential to benefit psychiatric nursing.
The question of how generalizable the theory is may be Other ideas that underpin the model and which have rele-
answered by an exploration of its possible use within nurse vance for psychiatric nursing are those of a person being a
practice, education and research. It is evident that Roy’s holistic entity, possessing a unique adaptation zone and
model is used within psychiatric nurse practice, and more that patients should be involved in the formulation of their
specifically within acute psychiatric nursing practice. How- care plans.
ever, there is a severe shortage of research-based literature
into the use of the model within psychiatric nursing. The
When compared to other models
theory has been studied within the context of general, pae-
diatric and community nursing. Findings within these envi- Within the context of acute psychiatric nursing in the ROI
ronments have been mixed. At a broader level, in order for the author is familiar with three other models/theories.
models to be researchable they must be able to generate First, Orem’s Self-Care Deficit Theory focuses upon the
testable hypotheses. Roy’s model has the ability to do this nurse helping the patient become more independent in
because of the well-defined theoretical structure of the meeting their health needs (Orem 1995). Although not
model. made explicit in Roy’s model, it is implied that the nurse
Evidence-based practice is very much to the fore within strives to help the patient become more self-sufficient in
contemporary nursing (Cranston 2002). Employing evi- their care. Roper, Logan and Tierney developed their
dence-based nursing interventions usually means the use of model around how nurses assist patients achieve their
research findings into what is best practice within a partic- activities of daily living (Roper et al. 2000). In relation to
ular area (McClarey & Duff 1997). Such research findings psychiatric nursing, the main criticism of this model is
may come from quantitative or qualitative studies, both of that it is slightly more medical in nature than Roy’s
which aim to contribute to nursing knowledge (Begley model. The final model is Barker’s Tidal Model (Barker
© 2004 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 11, 221–228 225
D. Patton et al.
226 © 2004 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 11, 221–228
Roy’s Adaptation Model of Nursing
Roy C. (1997) Future of the Roy model: challenge to redefine Smith L. (1996) Issues raised by the use of nursing models in psy-
adaptation. Nursing Science Quarterly 10, 42–48. chiatry. Nurse Education Today 6, 69–75.
Roy C. & Andrews H.A. (1991) The Roy Adaptation Stevenson C., Barker P. & Fletcher E. (2002) Judgement days:
Model: The Definitive Statement. Appleton and Chalmers, developing an evaluation for an innovative nursing model.
CT. Journal of Psychiatric and Mental Health Nursing 9, 271–276.
Roy C. & Andrews H. (1999) The Roy Adaptation Model, 2nd Walsh M. (1991) Models in Clinical Nursing: The Way Forward.
edn. Appleton & Lange, Stamford. Bailliere Tindall, London.
Schon D.A. (1983) The Reflective Practitioner. Basic Books, New
York.
Appendix 1
The metaparadigm
Person Nursing
Through
Focus of nursing
Environment
Appendix 2
Problems identified and interventions planned within the four adaptive modes
Self-Concept Mode
Problem: David had a negative perception of his existence and wanted to perceive himself more positively.
Intervention: It was agreed that I would spend dedicated daily time talking to David about how his day was progressing and how he felt about
himself. We agreed that the focus of our interaction during this dedicated time would be on David being positive about himself and his
existence.
Outcome: Over time David began to talk more positively about himself and the life he was living/going to live.
© 2004 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 11, 221–228 227
D. Patton et al.
Problem: David was worried about how his family may perceive him whilst in his current state.
Intervention: I informed David’s family of the importance of providing positive reinforcement to David when they visited him. I also spent time
with David after family visits talking about what the visit represented for him.
Outcome: David’s family were very supportive of him whilst he was hospitalized. Just after his admission David did not talk at length with any
family member when they visited. This altered over time.
Interdependence Mode
Problem: David was concerned that he may be left alone whilst in hospital.
Intervention: I asked David’s family to ensure that one or more of them attended each evening at visiting time. I also asked them if it would be
possible for some of David’s friends to visit him.
Outcome: One or more of David’s family visited each evening. A number of David’s friends also visited regularly.
Physiological Mode
Problem: David thought he was going mad in the sense that something was wrong with his brain.
Intervention: I talked to David about his illness and assured him that his brain was not distorted.
Outcome: David’s thought processes in relation to how he perceived that anatomy of his brain altered as his admission progressed.
Problem: David was slightly constipated in the days immediately after his admission.
Intervention: I informed David of the importance of remaining hydrated. I also encouraged David to walk as much as he could around the unit
and within the enclosed garden.
Outcome: David’s slight constipation did not become anything more than a passing problem in the initial period after his admission.
228 © 2004 Blackwell Publishing Ltd, Journal of Psychiatric and Mental Health Nursing 11, 221–228