ROYS ADAPTATION MODEL

BACKGROUND OF THE THEORIST

Sr. Callista Roy, a prominent nurse theorist, writer, lecturer, researcher and teacher Sr.Callistra Roy began her nursing career in 1963 after receiving her Bsc nursing degree from Mount Saint Marys College, Los Angels Completed her master's degree program in pediatric nursing at the University of California , in 1977 She also earned a masters and PhD in Sociology in 1973 and 1977 , respectively. In 1964,Roy began her model when Professor Dorothy E Johnson, challenged her to develop a conceptual model for nursing In 1976, Roy published Introduction to nursing :An Adaptation Model

DEFINITION
An individual ,family or group is viewed as an adaptive system, exposed to many internal &external stimuli in the environment interfering with optimum health.our role as nurse ,is o promote health by promoting adaptation. (Kathys) The goal of nursing is to promote adaptation for individuals &groups in each of the four adaptive modes ,thus contributing to health ,quality of life and dying with (Roy199)

INFLUENCING FACTORS

Family Education Religious Background Mentors Clinical Experience

CONCEPTUAL FRAME WORK

ELEMENTS OR CONCEPTS OF THE ROY ADAPTATION MODEL
There are five essential elements of the Roy Adaptation model.They are The person who is the recipient of nursing care The goal of nursing The concept of health The concept of environment The direction of nursing activities

The model presents concepts related to the above areas clarifying each and defining their interrelationships

1. THE PERSON The first area of concern is the identity of the recipient of nursing care. Roy states that the recipient of nursing care may be the person ,a family, a group, a community, or a society. The idea of an adaptive system combines the concept of adaptation and system. First , consider the concept of a system as applied to an individual. Roy conceptualizes the person in a holistic perspective. persons as living system ,are in constant interaction with their environments. Between the person and the environment occurs an exchange of information ,matter and energy .This characteristics of a living system is called openness. The cell is a living open system .The cell has its inner and outer worlds. System openness , therefore implies the constant exchanging of information ,matter, and energy between the system and the environment. Thes system qualities are held by the person. Within this changing world person must maintain their own integrity ie, each person continuously adapts. Hence the person is viewed as a holistic adaptive system A INPUT (Stimuli:-focal, contextual& residual stimuli) The adaptive system has input coming from the external environments as well as input coming internally from the person .Roy identifies inputs as stimuli. A stimulus is a unit of information , matter, or energy from the environment or from within the person that discus a response. The adaptation level is the range of stimuli to which the person can adaptively

respond with ordinary effort. Each persons adaptation level is influenced by coping mechanism of that person. B PROCESSES Roy has used the term coping mechanisms to describe the control processes of a person. These mechanisms are called regulator and cognator. Regulator Roy considered this as the subsystem of an adaptive system.the regulator system has the system of components of input ,internal processe, and output. The input may be internal or external to the person. The transmiters are neural ,chemical or endocrine in nature. The outut behaviors may be autonomic reflexes ,psychomotor responses or body responses.

Eg:-The regulator subsystem action.

A decrease in oxygen supply to Albert Smiths heart muscle stimulates pain receptors that transmit the message of pain along sympathetic afferent nerve fibers to his CNS. His lover brain stimulates the sympathetic efferent nerve fibers, and there is an increase in heart and respiratory rate. The result is an increase in the oxygen supply to the heart muscles.

Cognator The other control subsystem original to the Roy model is the cognator substem (cognive-emotive channels) it consist of input,internal process,and output. It regulate self concept,role function,and interdependene. The cognator subsystem controls internal process related to higher brain functions such as perception,information processing,learning from past experiences,judgment,and emotion.(eg:- a patient with diabetes who decides to increase insulin intake based on symptoms of high blood glucose.)

Eg:-The cognator subsystem action.

Mr. Albert Smith has learned from past experiences that the left chest and arm pain is related to his heart. His judgment is activated in deciding what action to take. He decides to go inside to air conditioning, to sit with his legs elevated, and to take slow, deep breaths. He also decides not to call for emergency help. He may be increasingly alert for further regulator subsystem output behaviours that might change his decision. He may design that the 900F weather causal factor to limit his activities during extreme heat. In this eg. Mr. Smith used the cognator subsystem processes of perception, learning and judgment. C THE EFFECTORS

In further delineation of the internal processes of the person as an adaptive system, Roy defines the system effectors. The four effectors or adaptive modes are

1.The physiologic function mode

It involves the bodies basic needs and ways to adapt. It is less abstract than the other three adaptive modes. The physiological function mode is as follows: Oxygenation: Describes the pattern of oxygen used related to respiration and circulation. Nutrition: Describes the pattern of nutrient use for body repair and development. Elimination: Describes the pattern of elimination of waste products. Activity and rest: Describes the pattern of exercise, activity, rest and sleep. Skin integrity: Describes the pattern of the physiological function of the skin. Senses: Describes the sensory- perceptuan functions related to obtaining visual, auditory, kinaesthetic, gustatory,tactine and olfactory information. Fluids and electrolytes: Describes the pattern of physiological use of fluids electrolytes. Neurological function: Describes the neural patterns of control regulation and intellect. Endocrine function: Describes the pattern of control and regulation including the stress response and the reproduction system.

Oxygenation:

Stable process of ventilation and stable process of gas exchange. RR= 18Bpm. Chest normal in shape. Chest expansion normal on either side. Apex beat felt on left 5th inter-costal space mid-clavicular line. Air entry equal bilaterally. No ronchi or crepitus. S1& S2 heard. No abnormal heart sounds.

Delayed capillary refill+. JVP0. Apex beat felt- normal rhythm, depth and rate. Dorsalis pedis pulsation of affected limp is not palpable. All other pulsations are normal in rate, depth, tension with regular rhythm. Cardiac dull ness heard over 3rd ICS near to sternum to left 5ht ICS mid clavicular line. S1& S2 heard. No abnormal heart sounds. BP- Normotensive. . Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.

Nutrition

He is on diabetic diet (1500kcal). Non vegetarian. Recently his Weight reduced markedly (10 kg/ 6 month). He has stable digestive process. He has complaints of anorexia and not taking adequate food. No abdominal distension. Soft on palpation. No tenderness. No visible peristaltic movements. Bowel sounds heard. Percussion revealed dullness over hepatic area. Oral mucosa is normal. No difficulty to swallow food

Elimination:

No signs of infections, no pain during micturation or defecation. Normal bladder pattern. Using urinal for micturation. Stool is hard and he complaints of constipation.

Activity and rest:

Taking adequate rest. Sleep pattern disturbed at night due unfamiliar surrounding. Not following any peculiar relaxation measure. Like movies and reading. No regular pattern of exercise. Walking from home to office during morning and evening. Now, activity reduced due to amputated wound. Mobility impaired. Walking with crutches. Pain from joints present. No paralysis. ROM is limited in the left leg due to wound. No contractures present. No swelling over the joints. Patient need assistance for doing the activities.

Protection:

Left lower fore foot is amputated. Black discoloration present over the area. No redness, discharge or other signs of infection. Nomothermic. Wound healing better now. Walking with the use of left leg is not possible. Using crutches. Pain form knee and hip joint present while walking. Dorsalis pedis pulsation, not present over the left leg. Right leg is normal in length and size. Several papules present over the foot. All peripheral pulses are present with normal rate, rhythm and depth over right leg.

Senses: No pain sensation from the wound site. Relatively, reduced touch and pain sensation in the lower periphery; because of neuropathy. Using spectacle for reading. Gustatory, olfaction, and auditory senses are normal. Fluids and electrolytes: Drinks approximately 2000ml of water. Stable intake out put ratio. Serum electrolyte values are with in normal limit. No signs of acidosis or alkalosis. Blood glucose elevated.

Neurological function:

He is conscious and oriented. He is anxious about the disease condition. Like to go home as early as possible. Showing signs of stress. Touch and pain sensation decreased in lower extremity. Thinking and memory is intact.

Endocrine function He is on insulin. No signs and symptoms of endocrine disorders, except elevated blood sugar value. No enlarged glands.

2. Self concepts
This mode identifies patterns of values, beliefs and emotions as related to ones idea of self. It comprises Physical self:- Includes sensation and body image. Eg: decrease sexual self concept, aggressive sexual behaviour, loss. Personal self:- Includes self-consistency and self-ideal Eg: anxiety,powerlessness,low self- esteem. Moral and ethical self:- Includes self-observation and selfevaluation.

3 Role function
It involves behaviour based on a persons position in society. It depends on how a person interacts with others in a given situation. It can be classified as : Primary:- Age, sex Secondary :- husband, wife Tertiary:- temporary role of a coach Eg: Role transition, role conflict, role failure. 4

Interdependence

It involves persons relationship with significant others and support systems. This mode identifies patterns of human value, affection, love etc. There is a balance between dependent behaviours (seeking help, attention and affection) and Independent behaviours (taking initiative and obtaining satisfaction from work). Eg: separation anxiety,loneliness. D OUTPUT

Output of the person as a system are the behaviours of the person . it can be both external or internal. output behaviours become feedback to the system. Roy has categorised outputs of the system as either adaptive responses or ineffective responses. Adaptive responses are those that promote the integrity of the person. Ineffective responses do not support these goals.

2 GOAL OF NURSING
Roy defines the goal of nursing as the promotion of adaptive responses in relation to the four adaptive modes. Adaptive responses are those that positively affect health. The persons adaptation level will determine whether a positive response to internal or external stimuli will be elicited. The persons adaptation level is determined by focal, contextual and residual stimuli. The stimuli immediately confronting the person are the focal stimuli. All other stimuli of the persons internal and external world and are observable, measureable or subjectively reported by the person are the contextual stimuli. Those characteristics of the person that are relevant to the situation but are difficult to measure objectively are residual stimuli Eg:- The above eg, the focus stimulus experienced by Mr.Smith is the deficit of oxygen supply to his heart muscle. The contextual stimuli include the 900 F temperature, the sensation of pain Mr.Smiths age, weight and blood sugar level. The residual stimuli include his history of cigarette smoking and work related stress. If the persons adaptation level is viewed as a line, the zone of adaptation is the distance above and below that line sets the limit of the persons adaptation capacity. When the total stimuli (focal, contextual, and residual) fail within the persons zone of adaptive response or output results. However, when the total stimuli fall outside the individuals zone of adaptation, ineffective output behaviour or responses occur .

 Nursing seeks to reduce ineffective responses and promote adaptive responces as output behaviour of the personthe person.

Eg:-In the example of Mr.Smith, the total stimulai had fallen outside his adaptation zone.The resulting deficit of oxygen to his heart, indicated by chest pain,was an ineffective response. This response become feedback to the system and a focal stimulus. A persons ability to cope varies with the state of person at different times. Roy viewed the humanistic values as the goal of nursing.

3 CONCEPT OF HEALTH
Health was originally described by Roy as a health-illness continuum, with one end of the continuum being death and the other end wellness. this is no longer used in the present model. Roy presently defines health as a state and a process of being and becoming an integrated and whole person. the nurse using Roys model viewed health as the goal of the persons behaviour and the persons ability to be an adaptive organisms.

4 ENVIRONMENT
Environment is defined by Roy as all conditions , circumstances and influences surrounding and affecting the development and behaviour of persons and groups. Environment consist of both internal and external environments which provides input in the form of stimuli. Nurses are increasing their involvement in the institutions of our nations: health, education, industry and

politics. By their involvement they are altering the environmental stimuli related to situations of health and illness in a broad and often far reaching manner at a community system level.

5 DIRECTION OF NURSING ACTIVITIES

NURSING PRACTICE WITH ROYS MODEL Nursing process is a goal oriented ,problem solving approach to guide the provision of comprehensive ,competent nursing care to a person or group of persons. according to Roy, nursing process relates directly to the view of the person as an adaptive system. Roy has conceptualised the nursing process to comprise the following six steps; Assessment of behaviour Assessment of stimuli Nursing diagnosis Goal setting Intervention Evaluation

1 Assessment of behaviour From the Roys perspective ,behaviour is an action or reaction to a stimulus. A behaviour may be observable (eg;-pulse rate) or non observable ( eg :- feeling experienced by the person and reported to the nurse.) Behaviors that need to be assessed for each adaptive modes as follows.

PHASES OF PROCESS

PHYSIOLOGICAL ADAPTIVE MODE

INTERDEPENDENCE ADAPTIVE MODE

SELF CONCEPT ADAPTIVE MODE

ROLE FUNCTION ADAPTIVE MODE

Assessmet of behavior

Oxygenation, nutrition,eliminatio n, neurological function etc

Support system, Giving,receiving etc

Body 10 role, image,self 20role, consistency, 30role self ideal etc

assessment of stimuli

Focal stimulus, Contextual stimuli ,residual stimuli

Focal stimulus, Contextual stimuli, residual stimuli Statement of behaviour with most relevant stimuli

Nursing diagnosis

Statement of behaviour with most relevant stimuli

Goal setting

Behaviour, Behaviour, Change expected, Change time frame expected, time frame

Focal stimulus, Contextual stimuli,resid ual stimuli Statement of behaviour with most relevant stimuli Behaviour, Change expected, time frame

Focal stimulus, Contextual stimuli,residu al stimuli Statement of behaviour with most relevant stimuli Behaviour, Change expected, time frame

Intervention

Management of stimuli .(ie, alter, increase,decrease ,remove,maintain)

Management of stimuli .(ie, alter, increase, decrease, remove, maintain) Observation of behaviours after intervention to see if goals have been obtained

Evaluation

Observation of behaviours after intervention to see if goals have been obtained

Manageme nt of stimuli .(ie,alter,incr ease, decrease ,remove, maintain) Observation of behaviours after intervention to see if goals have been obtained

Management of stimuli .(ie, alter,increase ,decrease, remove, maintain) Observation of behaviours after intervention to see if goals have been obtained

2 Assessment of stimuli A stimulus is any change in the internal or external environment that induces a response in the adaptive system. stimuli that arises from the environment can be classified as focal, contextual, or residual.

3 Nursing diagnosis
Nurses judgment regarding health care and adaptive needs of the client.it indicate an actual or potential problem related toadaptation.

RAM defines nursing diagnosis as a judgement process resulting in statements conveying the adaptation status of the human adaptive system 4 Goal setting The goal statement should include the behaviour to be changed ,the change expected ,and timeframe in which the change in behaviour should occur 5 Intervention

According to RAM intervention focuses the manner in which goals are attained.these are intended to promote adaptation by changing stimuli or strengthening adaptive process. 5 Evaluation In the RAM, evaluation consist of one question-has the person moved toward adaptation?. Here nurse analyse whether goal statement havebeen achieved or not by the recipient of nursing care. NURSING CARE WITH ROYS MODEL Eg:- Debbie is a 29 year old woman admitted to the oncology unit for evaluation after sensing pelvic fullness and noticing a watery ,foul smelling vaginal discharge .A papanicolaou smear revealed cervical cancer, and underwent radical hysterectomy . her past history revealed that physical examination revealed that physical examination had been infrequent. she is married and lives with her husband and her 2 children . after surgery she is unable to completely empty the bladder, and having continued post operative pain and nausea . it will be necessary for her to perform intermittent self-catheterisation at home.

NURSING CARE OF DEBBIE

Physiological adaptive mode Assessment of behaviour Postoperatively Debbie has been unable to completely empty her urinary bladder. it will be necessary for her to perform intermittent self

catheterisation at home,but it place her at more risk for urinary tract infection. Assessment of stimuli Here the nurse searches for stimuli responsible for the observed behaviour. After identification ,they are classified as focal, contextual, or residual. The focal stimulus for Debbies urinary retention is the disease process.Contexual stimuli include tissue trauma resulting from surgery and radiation therapy.Debbie identified anxiety as a residual stimulus. Nursing diagnosis Impaired elimination :urinary retention related to surgical trauma,and radiation therapy. Potential for infection related to intermittent self catheterisation, and poor understanding of aseptic principles.

Goal setting Complete urinary elimination every 4 hours as evidenced by correct demonstration of the procedure. Continued absence of signs of infection

Intervention Taught the importance of performing intermittent self catheterisation every 4 hours Taught to assess the abdomen for bladder distention Taught the procedure for intermittent self catheterisation Instructed to keep a record of the exact time and the amount of voiding and catheterisation Taught relaxation technique to facilitate voiding Stress the importance of hand washing. Evaluation Debbie performed intermittent self catheterisation berore discharge. Debbie was able to identified signs and symptoms of infection

STRENGTH 1 Research tool development

Describe responses to health and illness Evaluate interventions Measure perception of powerlessness& decision making Measure health care outcomes for cancer patients Regaining functional abilities after delivery Research variables

2 Used to identify adaptive& maladaptive behaviours to stimuli Lack of motivation to quit smoking. Assessing and planning care of surgical patients & their spouses. Obstetric, and neonatal setting. Cardiac patients. Psychiatric setting.

3 4 5 6 7

To guide nursing practice To organize nursing education Curricular frame work for various nursing colleges Provide an opportunity for consideration &understanding of multiple aspects of the human adaptive system. The importance of spiritual aspects of the human adaptive system, often omitted from nursing assessment is included in a manner that allows for incorporation of spirituality with out imposition of the nurses belief. Logically organized &draws the nurses observational & interviewing skills. WEAKNESS

1 Weaknesses have been identified in related to research and to

practice. One is the need for consistent definitions of the concepts and terms within the RAM, as well as for more research based on such consistent definitions.

2 in a practice area that is increasingly challenged with time

constraints, the amount of time required to fully implement the two areas of RAM assessment may be viewed as insurmountable.

EVIDENCE BASED STUDY D.Patton, lecturer,university college campus,Ireland conducted a stydy on An analysis of Roys adaptation model of nursing as used with in acute psychiatric nursing.

He studiesthe use of Roys Adaptation Model of Nursing within acute psychiatric nursing. The analytical framework used to analyse the framework. He believed this framework would allow for analysis of an abstract nature to occur. After examining the model under different headings it was concluded that there exists a research gap in relation to the use of Roys model within acute psychiatric nursing. It is recognized that Roys 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 researchbased evidence is required in order to fully justify the use of the model within acute psychiatric nursing.