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Science Quarterly

Research Based on the Roy Adaptation Model : Last 25 Years

Callista Roy
Nurs Sci Q 2011 24: 312
DOI: 10.1177/0894318411419218
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419218
zak / Research IssuesNursing Science Quarterly

NSQXXX10.1177/0894318411419218Florc

Research Issues

Research Based on the Roy Adaptation

Model: Last 25 Years

Nursing Science Quarterly

24(4) 312320
The Author(s) 2011
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0894318411419218
http://nsq.sagepub.com

Callista Roy, PhD; RN; FAAN1

Abstract
Two key events lead to the prominence of links among Roys grand theory, derived middle-range theories and the design
of research. The author in this column describes this work in two formats. Essential details of two areas of research are
presented in episodic formthe first is work on secondary analysis of Roy model-based research over 40 years and the
authors study of persons cognitive recovery from mild head injury.The second is a project on re-conceptualizing coping and
adaptation processing in sequential detail within the context of work in the field and the significance of on-going work for
nursing practice.
Keywords
adaptation, coping, middle-range theory, research, Roy adaptation model

The story of research based on the Roy adaptation model

(RAM) can be told in many ways. When asked to write about
research based on the RAM in the past 25 years I considered
the major events of those years and also how to organize a
description of the resulting research. First, I considered that
it was 20 years ago that the first group presented a synthesis
and critique of studies based on the RAM by five different
investigators (Pollock et al., 1991). This was the beginning
of the Roy Adaptation Association (RAA) currently with five
international chapters. It was the beginning of an on-going
project to analyze, critique, and synthesize all published
studies in English based on the RAM. Secondly, doing 4
years of full-time clinical research in neuroscience nursing,
beginning with post doctoral work as a Robert Wood Johnson Clinical Nurse Scholar in 1983 at the University of California at San Francisco, provided the opportunity to focus
my research on the cognator as a major element of the RAM.
In this column I present an overview of the major RAMbased research derived from these key events. Two different
styles were selected to present the significant research of this
timeframe.

Synopsis of 25 Years of Roy ModelBased Research

The overall view of RAM-based research in Figure 1 depicts
how major theoretical concepts (in rectangles) from a grand
theory, guide middle-range theory development (in ovals)
from which research projects (in squares) are designed. The
theory of the cognator initially was described as part of the
theory of the person as an adaptive system (Roy & McLeod,

1981). In explicating the cognator subsystem I had identified

pathways for perceptual/information processing, learning,
judgment, and emotion. This work was significantly refined
by post doctoral studies in neuroscience nursing (Roy, 1988,
2001). The middle-range theory of cognitive processing
(Figure 2) was developed to show the major processes
involved in the input, central, and output phases of cognitive
processing. These processes were embedded in another
major concept of the model, the environment. The environment includes focal stimuli as immediate sensory experience
and contextual and residual stimuli involving education and
experience.
Early work on the RAM (Roy, 1976) also identified the
major theoretical concept of coping in four adaptive modes.
These modes represent the categories whereby the nurse
assesses behaviors that persons use to deal with their internal
and external environments. The behaviors are viewed as
stemming from the central processes of persons, the cognator and regulator. The modes were named from a content
analysis of 500 samples of patient behavior collected by student nurses. The categories physiologic, self concept, role
function, and interdependence have remained useful through
the years for education, practice, and research (Roy, 2009).
The theory of coping in the adaptive modes was combined
1

Professor and Nurse Theorist, Boston College

Contributing Editor:
Kristine L. Florczak, RN, PhD, Associate Professor, Saint Xavier University,
7807 Janes Avenue, Woodridge, Illinois, 60517
Email: Florczak@sxu.edu

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Roy

Theory of Cognator of Roy Adaptation Model

Middle-Range
Theory of Cognitive
Processing

Integrated Review
of RAA Research
and Testing of
Propositions
(BBARNS, 1999; Roy
et al.,2005)

Theory of Coping in the Four Adaptive Modes

Middle-Range Theory Coping

and Adaptation Processing

Cognitive
Recovery from
Mild Head Injury
(Roy, 2011)

Coping and
Adaptation
Processing
Instrument
Development

The Coping and

Adaptation Processing
Scale (CAPS):
Exploring Issues of State
and Trait (Chayaput &
Roy, 2007)

The relationship between

coping strategies and the
impaired ADL in elderly
stroke patients : The first
report of CAPS in Japanese
(Toriya & Tsuhako,2008)

Effectiveness of an
educational program focus
on cognitive processing to
modify the capacity of
coping and adaptation
processing(Gonzalez, 2007)

Coping capacity and

adaptations in
older adults
(Gutierrez, 2009)

Figure 1. Roy adaptation model research synthesis.

Note. RAA = Roy Adaptation Association, BBARNS = Boston-Based Adaptation Research in Nursing Society

with the middle-range theory of cognitive processing and

empirical work, as described below, resulting in a middlerange theory of coping and adaptation processing.
This theoretical work was used to derive the major
research projects reported here and named in Figure 1 within
the squares. To handle the challenge of presenting this array
of work in one column I turned to an image of two kinds of
clocks (Carroll, 2011). The analogue clock has a numerically
defined face and pointed hands that mark seconds, minutes,
and hours by an endless succession of circles in motion with
a context and a dynamic sequence. The digital clock, however generally shows only hours and minutes with the numbers remaining static until a shift occurs. The kind of time on
this clock is episodic rather than continuous. Based on this
image of time, I decided to present an episodic digital picture
of two major research projects. Firstly, a secondary analysis
research project used the 360 studies in an integrated review
of Roy model-based research to test propositions derived

directly from the major theoretical concepts of the model. The

rationale for this approach to this project is that it is the work
of teams, the executive board of the RAA, all the investigators
who published their research, and the student research fellows
who have assisted us. Still, it provides clear and rich information on research based on the model from 1970 to the present
and how the review has been used to develop knowledge for
nursing. Secondly, one of the major foci of the middle-range
theory of cognitive processing involved the design and testing
of interventions for cognitive recovery of people with mild
head injuries (Roy, 2010, 2011). This work calls for the essentials episodic approach because it is a recently completed
comparative intervention study that was presented nationally
as a paper (Roy, 2010) and locally (Roy, 2011) with two publications in preparation.
Another major focus of my research over these years
lends itself to a presentation more like the analogue clock,
that is, the dynamic process and context of the sequential

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Nursing Science Quarterly 24(4)

Background: General Literature

on Coping

Figure 2. Middle-range theory of cognitive processing.

stages. This involved a re-conceptualization of coping to

develop a measurement tool based on the concept of coping
and adaptation processing and to derive additional research
projects.

Coping and Adaptation Processing

Theory and Research Development
in General Literature
Coping is recognized as the crucial variable in understanding the effect of stress on physical and mental health
(Aldwin, 2007). Based on the significant function of coping,
healthcare clinicians often aim to promote coping abilities of
patients and their families. Yet in spite of significant theoretical and research literature in many fields, knowledge
effective in practice has remained elusive. Two approaches
identified as showing the greatest promise were multidimensional (Frydenberg, 2002) and transactional processes
(Aldwin, 2007). The Roy adaptive modes and an in-depth
understanding of cognator processing, representing both
cognition and emotion, provided a basis for studying coping
as a multidimensional and transactional process to add
to knowledge for nursing practice. The revised conceptualization of coping, derived theory development, and inductive and deductive empirical strategies were the basis for
developing, a middle-range theory, a new instrument, and
intervention.

Early work on coping tended to look at psychopathology.

Further cognitive and physiologic concepts and variables
were used with little attention given to emotion. Through the
decades of the 1980s and 1990s scholars continued to refine
conceptualizations and measurement of stress and coping. In
the 1990s there was a shift toward positive psychology and
the positive role of emotions, crystallized by Seligman as
president of the American Psychological Association (Snyder,
1999). Lazarus is credited with the shift from coping, viewed
as a response to emotion, to coping and emotion understood
in a dynamic relationship (Lazarus, 1991,1999). In the 1990s,
issues in the field were identified as measurement styles versus processes (Aldwin, 1994); trying not entirely successfully
to examine both the person and environment (Schwarzer &
Schwarzer, 1996); the need to balance deductive and inductive approaches to provide a theoretical base for scale items,
and to have a closer match between concept and measurement
(Schwarzer & Schwarzer, 1996).
In 2007 Aldwin updated an earlier review to handle the
burgeoning general literature that added 186,000 articles on
stress and 37,000 articles on coping in the intervening years.
Aldwin addressed the on-going issues of conceptualizations
and measurements. She divided the theoretical approaches
that are person-based into three schools, that is, psychoanalytic, personality trait, and perceptual styles. Those who
focused on situational determinants of coping noted that the
types of strategies that individuals use in coping with problems depend on environmental demands, or the pull for different types of solutions. Aldwin further noted that cognitive
approaches assumed: that individual coping is largely dependent upon appraisal of the situation; that individuals are flexible and coping strategies have some degree of situational
specificity; that both problem-solving and emotion-focused
strategies are used in coping efforts; and, that there is not
necessarily a hierarchy of adaptation. The authors analysis
showed that a majority of coping researchers have adopted at
least some aspects of the cognitive approach. However,
many continued to regard the use of coping strategies primarily as a function of personality. Aldwin (2007) concluded
that the extent to which coping strategies are a function of
both the person and the environment is a matter of some
debate and that coping affects adaptation in extremely complicated ways (p. 126). The issue of state versus trait was
not yet settled.
In dealing with measurement, Aldwin (2007) stated that
this is still the most controversial issue in the field.
Laboratory, paper and pencil tests, and qualitative research
are all used. The person versus environment conceptualizations may be at odds or creative strategies are used to combine both. One way that researchers have addressed this
problem is to develop coping scales that are specialized by

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Roy
situations or the strategies measured. Aldwin reported that in
1987 she identified over 20 coping scales; in 1994 the list
was updated to 70; and in 2007 there were 200 references to
coping scales. She identified increases in scales in languages
other than English, those for children and adolescents, and
those with highly specialized strategies. In a list of coping
scales for clinical health situations, Aldwin included, for
example, coping with asthma in everyday life.
Nursing research on coping has drawn extensively from
the literature in psychology, notably Johnson's (1972) seminal work used in the conceptualization developed by Lazarus
and associates (Lazarus & Folkman, 1984). Johnson and her
colleagues studied individuals' levels of distress when they
were given sensory information before threatening events in
both clinical and laboratory situations. Later intervention
studies (Johnson, Rice, Fuller, & Endress, 1978) made use of
Lazarus' distinction between problem-solving coping and
emotion-focused stress related coping. Even this early work
began to call this dichotomy into question. Johnson and colleagues found that teaching problem-solving coping was not
more effective for recovery from surgery. They suggested
that the most useful nursing intervention might be to support
and teach effective use of the patient's own coping strategies,
and that these strategies might incorporate elements of both
the problem-solving and emotion-focused approaches.
Later Jalowiec (1993) reviewed a decade of stress and coping research in nursing and reported that 70 percent of nursing
studies used Lazarus model. She specifically questioned
whether or not nurse researchers were losing discrimination in
measurement and in differentiation of outcomes by relying on
the distinction between problem or emotion coping and not
tapping into the rich cognitive and behavioral domains of coping. The persistent wide use of Lazarus conceptualization and
instrument is reflected in a review of the Cumulative Index to
Nursing and Allied Health Literature (1998 to 2004) databases
that showed 151 studies reported use of the questionnaire during those years. When the same search was repeated by this
author the number of studies reported using Lazarus from
2005 to 2010 was 25. In some of these studies the instrument
did not perform as predicted, for example, only one coping
subscale was found to partially mediate the relationship
between levels of stress and well-being in mothers of preschool children with asthma (Sangsuwan, 2006). The lack of
evidence of cumulative knowledge in the nursing literature is
notable. The Ways of Coping Questionnaire by Lazarus and
associates has been referred to as the standard in the field.
However, a number of authors, as reported by Aldwin (2007)
noted the construct validity of the instrument was not strong,
given an unstable factor structure.
Later Folkman and Moskowitz (2004) reviewed 35 years
of coping research across social and behavioral science,
medicine, public health, and nursing and concluded that we
seem only to have scratched the surface of understanding the
ways in which coping actually affects psychological, physiological, and behavioral outcomes both in the short-and the

longer-term (p. 748). Further, these authors identified three

issues they found reflected in the literature, that is, measurement, nomenclature, and the determination of effectiveness.
The authors highlighted that continuing interest in coping
research is not only that it is an explanatory concept related
to how people differ in response to stress, but it is also has
potential as a basis for interventions.
Based on this state of the knowledge on coping and the
identified issues, it was proposed that efforts to improve on
conceptualization and measurement can focus on deriving a
new multidimensional and transactional conceptualization.
The revised conceptualization and resulting research was
based on the theory of coping in four adaptive modes and the
middle-range theory of cognator processes of adaptation,
using inductive and deductive approaches, within the situational context of health and illness. The purpose of this work
was to contribute to the efforts of other disciplines to understand and measure this significant phenomenon. The aims
were to develop knowledge needed to advance coping
assessment, interventions, and outcomes in nursing research
and practice.

Methods for Concept and Scale

Development
A sequential approach to inductive and deductive theoretical
work was used to derive the middle-range theory of coping
and adaptation processing that addressed the multidimensional and transactional nature of the construct of coping.
Observations and interviews in a number of clinical settings
were used to develop categories within the theory. The principles of coding for parsimony, completeness, consistency in
the level of abstraction and language, and authenticity relative
to the middle-range nursing theory were used to organize the
clinical data. The resulting items were arranged in a scaled
instrument that was subjected to initial psychometric testing.

Theoretical Basis for Revised

Conceptualization of Coping
As noted in Figure 1 The theory of coping in four modes was
synthesized with the middle-range theory of cognitive processing to derive a middle-range theory of coping and adaptation processing that reflects both multidimensionality and
transaction (see Figure 3). The left side of the figure provides multidimensionality of the four adaptive modes and
the right side depicts the three types of cognitive processing
in transaction with the environment.

Scale Development based on Coping and

Adaptation Processing Conceptualization
The inadequate fit of current measurement tools for some
clinical situations that nurses deal with has been noted. The
next step was inductive and deductive empirical work based

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Nursing Science Quarterly 24(4)

COGNATOR

Manifested in

Subsystem of the
Roy Adaptation
Model

ADAPTIVE
MODES
Physiologic
Self Concept

Uses
INFORMATION
PROCESSING

Inferred
ObservedCoping
CognitiveStrategies
Behaviors

Role Function

Input
Central
Output

Interdependence
Synthesized
Coping and
Adaptation Processing

Figure 3. Middle-range theory of coping and adaptation

processing.

on the middle-range theory to generate items for the Coping

and Adaptation Processing Scale (CAPS) instrument and to
do initial refinement and testing of the scale. The samples
for each step of the project are summarized in Table 1. Since
the cognator subsystem of the RAM is manifested by behavior in each of four adaptive modes, in an earlier project Roy
(1975) aimed to identify coping strategies of hospitalized
patients. She conducted 10 patient interviews (step 1) and
collected 36 recorded nursing care plans based on the RAM
(step 2). Content analysis was used on both data sets to
inductively infer coping strategies within the adaptive
modes. Forty-five discrete coping strategies were identified
by the principle investigator using the principles for coding.
For example, an inferred coping strategy within the self
concept mode was: differential focus on the good. The data
from which this was derived was a patient who was asked
how he was handling facing a diagnostic test and stated, I
felt it was necessary. I want to get it done. I want to find out
whats wrong.
The inferred strategies were reviewed by two volunteer
experts who were recruited because of their extensive work
in both nursing theory and coping research. The review identified a) differing levels of generality of the items, and b) the
need for another approach to organize the implied multidimensionality, as well as to emphasize the process of transaction with the environment. As a result, the nursing model of
cognitive processing was used to deductively identify 26
categories within the three types of transaction with the environment (input, central, and output cognitive processing).
Roy (1988, 2001) has discussed the deductive categories and
provided examples of behaviors in each category observed in
clinical experience in neuroscience nursing practice. For
example, the broad dimension of input processes included
the conceptual strategies of arousal and attention. These
strategies further had a subcategory of selective attention

that is useful for behavioral observations such as whether a

person has focused attention or is distracted.
The categories derived inductively from the patient interviews and nursing care plans were compared with those from
deductive categories and patient observations. It was noted
that the inferred coping strategies and the behavioral observations within cognitive processing categories were related.
For example, differential focus on the good, inferred from a
patient statement, was seen as a form of selective attention
within the input level of the cognitive processing transaction
with the patient environment. The original items from the
inductive classification system were combined with the
deductively derived categories of cognitive processing and
their behavioral examples. The result was 73 statements in
an item pool. Four experts were recruited to review the items,
two with expertise in coping and adaptation theory and two
with expertise in cognitive processes. Through independent
judgments followed by discussion, 100% agreement on the
relevance of the items to the proposed alternative coping and
adaptation processing construct was reached.

Definition of Terms
Key terms based on the theoretical and empirical work by Roy
(1976, 1988, 2001) were defined as follows. Adaptation is the
process and outcome whereby thinking and feeling persons
use conscious awareness and choice to create human and
environmental integration. Coping strategies are behaviors
whereby adaptation processing is carried out in daily situations and in critical periods; the categories are synthesized
from behaviors in four adaptive modes, physiologic, self
concept, role, and interdependence. Adaptation processing is
patterning of coping behaviors that take in, handle, and
respond to stressors and are directed toward survival, growth,
reproduction, mastery, and transcendence. Coping and adaptation processing is the patterning of innate and acquired ways
of taking in, handling, and responding to a changing environment in daily situations and in critical periods that direct
behavior toward survival, growth, reproduction, mastery, and
transcendence. Capacity of coping and adaptation processing
is the ability of persons based to respond to changes in the
environment that use their coping styles and strategies to
adapt effectively to challenges (Gonzalez, 2007).
The revised conceptual and behavioral understanding of
coping and adaptation processing is both person and environment based; includes process, multidimensionality, and
transaction. Further, it can be relevant for designing and testing interventions related to the study of people and their
health.

Scale Development and Testing

The middle-range theory and the related empirical work
provided a pool of items for development of a coping
and adaptation processing scale. A scaled instrument is most

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Roy
Table 1. Description of Samples Used in Scale Development and Testing
Step
1
2
3
4

Description (n)

Men

Women

Mean Age (Range)

in Years

Patients hospitalized on medical unit, half scheduled for diagnostic testing,

half hospitalized more than one day (N = 10)
Nursing care plans of adult medical surgical patients recorded by student
nurses using the Roy adaptation model, from 10 schools in United States
and Canada (N = 36)
National mailing list of Spinal Cord Injury Association (N = 243)
National mailing list of Acoustic Neuroma Association (N = 104)

54 (33-78)

16

20

58 (23-83)

161
35

82
69

42 (18-80)
56 (27-77)

useful for research on interventions and outcomes of nursing

practice. In his classic work, Likert (1932) recommended
preparing and selecting more statements than are likely to be
used in the final instrument. He noted that it is not important
what the extremes of the continuum are called. The important fact is that persons do differ in the attribute under consideration, some being more toward one extreme and some
more toward the other. However, later investigators found
that instructions to the respondents on coping questionnaires
are crucial and consistent context is important (Aldwin,
1994). In the development of the Coping and Adaptation
Processing Scale (CAPS), the instructions were carefully
worded to evoke responses to the experience of a crisis, or
extremely difficult event. Although perceptions and interpretations of respondents will vary, the instructions place
some boundary on the possibilities of stimulus events. It was
anticipated that such measurement would capture individual
variability in coping that may be amenable to intervention
and could change over time.
The multidimensional and transactional construct of coping and adaptation processing was identified within a middle-range theory. Because of the theoretical approach used to
develop the items, there was reason to believe that the 73
items relate to the revised construct. In early testing of the
instrument, 26 items were dropped by removing redundant
items, that is, those that seemed to be saying the same thing.
Also, after exploratory factor analysis some items were
dropped as described below.
The CAPS is a 47-item Likert scale with response choices
ranging from 4 (always) to 1 (never). Each item of the CAPS
is a short statement about how an individual responds to
experiencing a crisis or extremely difficult event. Twelve
items are reversed scored. The possible range of scores is
from 47 to 188 with a high score indicating a more consistent
use of the identified strategies of coping.
The psychometric analysis was conducted using a pooled
sample from two groups who responded to the CAPS scale
(see Table 1, steps 3 and 4). These were nonprobability purposive samples from patient support groups obtained from
two national mailing lists using proportional representation
by region. Approval for each survey was obtained from the

university human research review committee. In the step 3

group, the CAPS tool was part of a mailed survey questionnaire to 1,000 members of the Spinal Cord Injury Association,
living with the effects of spinal cord injury. The response rate
was 29% (N = 243). The step 4 group had a 52% response
rate obtained from 200 questionnaires mailed to members of
the Acoustic Neuroma Association (N = 104). These were
persons who had treatment for benign tumors at the base of
the skull and were living with the effects of damage to one or
more cranial nerves and/or the cerebellum.
The socioeconomic status of the subjects varied widely,
with occupations ranging from administrator to unemployed
and years of education ranging from 8 to 21 years. Fiftythree subjects (11%) had finished eighth grade, 186 (39%)
finished high school and the remaining 50% had at least
some college education. Racial variation was more limited
with White being the predominant identifier. The total number of valid cases was 349. This number was considered
adequate since the common rule used is to have 5 to 10 times
the number of items. T-tests were run to confirm that the
groups did not differ and the scores could be combined for
further analysis.
Psychometric evaluation of the CAPS involved addressing issues of validity and reliability. The content validity of
this instrument is based on the procedure used for the development of the scale. The theorist of the RAM has been the
principle investigator of the work since its inception and
experts were used at two stages to validate coding, thus
including both expert and face validity. The exploratory factor analysis reflected the construct validity of the CAPS.
An exploratory factor analysis was necessary because
theoretically the major dimensions had not been identified
and because of the special issues related to multidimensionality and transaction. The Statistical Package for the Social
Sciences (SPSS) Version 11 (Norusis, 2002) was used to
extract the factors of the CAPS using principle component
(PC) analysis with varimax rotation. Eigenvalues of 1 or
greater and factor loadings equal to or larger than .30 were
considered to have conceptual interpretability. Five factors
emerged with factor loadings ranging from a high of .71 to a
low of .31. Cronbach alpha coefficients ranged from .86 on

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Nursing Science Quarterly 24(4)

Factor 2 to .78 on Factor 4. Each factor contained a set of

items that lent themselves to conceptual interpretation
according to the middle-range theory of coping and adaptation processing. The items were labeled with the adaptive
modes involved and the type of cognitive processing represented. This was a way of linking the theory to the measurement and was helpful in interpreting factors.
The five factors were extracted in five iterations and identified on the scree plot where a sharp decline in the explained
variance occurred (Polit & Beck, 2010). Factor 1, resourceful and focused, contains 10 items with factor loadings ranging from .71 to .49 and explained 26.6% of the variance.
Factor 2, physical and fixed, with 14 items having factor
loadings from .72 to .43 explained 8.4 % of the variance.
Factor 3, alert processing, has 9 items with loadings from .61
to .49 explaining 3.8 % of the variance. Factor 4, named systematic processing, contains 6 items with loadings from .71
to .31 and explained 3.3% of the variance. Finally, Factor 5,
knowing and relating, had 8 items whose loadings ranged
from .63 to .31 and explained 3.2% of the variance.
Predictive validity was demonstrated in a study of elders
with hearing impairment living in the community when the
total scores on the CAPS scale explained 42% of the variance
of self- consistency (Zhan, 2000). Convergent validity is a special case in the testing of this new instrument. The aim of this
work was to re-conceptualize coping within a multidimensional and transactional framework and to develop a tool to
measure the concept that addressed previous issues in the
field. Thus, it is not anticipated that convergent validity would
be demonstrated by a high correlation of the CAPS with any
existing measurement scale. However, it was assumed that
there would be some degree of shared conceptual space
between the new instrument and tools in the field. To demonstrate this assumption, the Ways of Coping Questionnaire
(WCQ) (Folkman & Lazarus, 1988) was administered to both
groups in the samples 3 and 4 (N = 347) along with the CAPS.
Pearsons correlation with a 2-tailed test of significance
between the WCQ and the CAPS was performed, as well as
with each subscale of both instruments.
Findings indicated that there was only a low correlation
between the total scale scores on the two measures with this
sample. However, in looking at the correlations among the
subscales, some statistically significant correlations of interest were identified. The CAPS subscale of resourceful and
focused correlated negatively with the WCQ escapeavoidance scale, and positively with the positive reappraisal
and planful problem solving scales. The CAPS subscale
of physical and fixed, which is scored negatively in its
contribution to overall coping and adaptation processing,
correlated negatively with five scales from the WCQ
(escape-avoidance, seeking social support, confrontive coping, self controlling, and accepting responsibility). The third
CAPS subscale, alert processing, correlated negatively with
the WCQ escape-avoidance scale and positively with planful problem solving. The systematic processing subscale

from the CAPS, as with the first subscale, correlated negatively with the WCQ escape-avoidance scale and positively
with the positive reappraisal and planful problem solving
scales. Likewise, the CAPS subscale of knowing and relating correlated negatively with the WCQ escape-avoidance
scale and positively with the positive reappraisal and planful
problem solving scales.
Two approaches to reliability lent credence to the ability
of the CAPS to consistently measure the construct of interest. The Cronbachs alpha coefficient for the total CAPS was
calculated at .94. This indicated the desired internal consistency of the items, yet reflected that fine discriminations in
levels of the construct could be made (Burns & Grove, 2009).
Further the Spearman-Brown split-half reliability scores for
the five subscales were: .84 for factor 1, .84 for factor 2, .80
for factor 3; .72 for factor 4, and .78 for subscale 5. Spit-half
reliability is considered less rigorous than test-retest reliability, but was deemed an appropriate indicator at this stage of
development of the instrument.

Discussion and Recommendations

The CAPS was developed to address some of the unresolved
issues in understanding and measuring the complex multidimensional and transactional construct of coping as an important variable for establishing research-based nursing practice.
The five factors identified provide major dimensions to
understand the construct. Items in Factor 1, resourceful and
focused, form a subscale that reflects behaviors using self
and resources that concentrate on expanding input, being
inventive, and seeking outcomes. Conversely the items in
Factor 2, physical and fixed highlight physical reactions
and the input phase of handling situations. For Factor 3,
alert processing, the behaviors represent both the personal
and physical self and focus on all three levels of processing, input, central, and output. Factor 4, systematic processing, describes personal and physical strategies to take
in situations and methodically handle them. Finally,
in Factor 5, knowing and relating, there are items that
describe strategies that use self and others, memory and
imagination.
The scale is easy to administer and to score and it reflects
adequate psychometric properties in initial testing. The scale
seems to provide conceptual clarity that can be useful in
planning nursing care. To increase, maintain or enhance coping abilities the nurse will assess what adaptive modes are
most prominent, for example, whether self concept or interdependence is most prominent. Further, one can assess what
cognitive processes are being used or could be strengthened,
such as input or central processing. The nurse can help
patients to enhance their selected strategies in a given situation and provide opportunities and support for developing
new strategies and flexibility in using them. In further testing
in other clinical situations the tool can be assessed for usefulness in intervention nursing research.

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Roy
The development of this instrument was derived from a
multidimensional and transactional conceptualization to
answer the difficulties identified in the measurement of coping. The conceptualization based on understanding the process of adaptation provided an integrated view of the persons
coping and used inductive and deductive approaches rooted
in nursing practice. The psychometric analysis is promising
as is its clinical usefulness. Recommendations for further
testing include: a) Confirm the stability of both the construct
and the instrument through confirmatory factor analysis; b)
test usefulness in intervention nursing research; and c)
explore cross-cultural use of the CAPS in other populations.

Summary
The link of middle-range theory development derived from a
nursing grand theory to design research has been particularly
prominent in the last 25 years of research based on the RAM.
The key events of the founding of the RAA and Roys postdoctoral studies and research in neuroscience nursing, sparked
several decades of significant work by Roy, colleagues, and
scholars in general. As a final example presented here, even as
clarification and publication of the CAPS progresses, Figure
1 illustrates some examples of research stemming from this
work. Because the scale development has been reported at
meetings of the RAA, it has been translated into other languages (under the supervision of the principal investigator)
and used by investigators globally. The tool was translated
into Thai (Chayput & Roy, 2007) by one of Roys students
and the tool has been in use for research in that country. The
first use by members of the RAA, Japan Chapter (Toriya &
Tsuhako, 2008), is identified along with an on-going work of
scholars of RAA, Colombia Chapter (Guiterrez, 2009). The
intervention study by Gonzalez (2007), RAA, Panama
Chapter, was an important contribution to theory, methods,
and practice. Roy continues to explore issues such as state and
trait with colleagues as well.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

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