ROY ADAPTATION MODEL

INTRODUCTION

Sister callista Roy, a member of the Sisters of Saint Joseph of Carondler, was born October 14th 1939,in los angels , California. She received a bachelor of arts in nursing in 1963 from mount saint Mary’s college in los angels and a master of science in nursing from the University of California at los angels in 1966. After earning her nursing degrees, Roy began her education in sociology, receiving both an M.A, in sociology in 1973 and a PhD in sociology in 1977 from the university of California.

EVOLUTION OF THEORY
The Roy Adaptation Model has evoked much interest and respect since its 1964 inception by Sister Roy as part of her graduate work under the guidance of Dorothy E Johnson at the University of California, los angels. In 1970, the faculty of mount saint Mary’s college in los angels adopted the Roy adaptation model as the conceptual framework of the undergraduate nursing curriculum. That same year Roy first published her ideas about adaptation.

THE ROY ADAPTATION MODEL
Roy credits the works of von bertalanffy’s (1968) general system theory and Helson’s (1964) adaptation theory as forming the original basis of the scientific assumptions underlying the Roy model. Table 15-1 identifies the assumptions following from the initial philosophical and scientific perspectives. The philosophic assumptions flow, according to Roy, from humanism and veritivity. The term vertivity was coined by Roy to identify the common purposefulness of human existence.(roy,1988)
Table 15-1 Assumptions underlying the Roy adaptation model
Scientific
System theory
Adaptation-level theory
Holism

Interdependence

Control processes

Information feedback

Complexity of living systems
Behaviour as adaptive

Adaptation as a function of stimuli
And adaptation level


Individual ,dynamic adaptation levels

Positive and active processes of responding.



Philosophic
humanism
vertivity
Creativity

Purposefulness

Holism

Interpersonal process

Purposefulness

Unity of purpose

Activity, Creativity

Value and meaning of life

In response to the 25th anniversary of the model’s publication, Roy restated the assumptions that form the basis of the model and redefined adaptation. Adaptation is defined as” the process and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration
Table 15- 2 vision basic to concepts for the 21st century
Scientific assumptions
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 created in human
Consciousness.

Integration of human and environment meanings results in adaptation




CONCEPTS OF THEORY
The four major concepts of the Roy Adaptation Model (RAM) are the following:
1. humans as adaptive systems as both individuals and groups
2. the environment
3. health
4. the goal of nursing
5. the direction of nursing activities

1. THE PERSON:
The first area of concern is the identity of the recipient of nursing care. it may be a person, family, a group, a community or a society. Each is considered by the nurse as a holistic system. The living systems are in constant interaction with the environment. There are both internal and external changes. Within this changing world persons must maintain their own integrity that is each person continuously adapts. Hence the person is viewed as a holistic adaptive system.

The person as an adaptive system
INPUT PROCESS EFFECTOR OUTPUT
External Focal regular - adaptive modes adaptive
Coping - physiologic response
Or stimulus Contextual mechanism functions or
Cognator - self concept ineffective
-role functions response
Internal Residual -interdependence

The input
Roy identifies inputs as stimulus. Roy categorises these stimuli as focal, contextual or external stimulus most immediately challenging the person’s adaptation. It attracts ones attention contextual stimuli are all other stimuli existing in a situation that strengthen the effect of focal stimuli. Residual stimuli are any other phenomena arising from a person’s internal or external environment that may affect the local stimuli but the effects are unknown. These 3 stimuli act together and influence the adaptive level which is a person’s ability to respond positively in a situation.

The process
Roy has used the term coping mechanisms to describe the control process of the person as an adaptive system. Roy presents a unique nursing science concept of control mechanism. These mechanisms are called as regulator and cognator. The transmitters of the regulatory systems are chemical neural or endocrine in nature. The other control subsystem is the cognator subsystem. Cognator control processes are related to the bigger brain functions of perception, information processing, judgement and emotion. Maximum use of coping mechanism broadens the adaptation level of an individual and increases the range of stimuli to which a person can positively respond.

The effector
Roy postulates 4 adaptive modes refers to the way a person responds as a physical being to stimuli from the environment. These needs are oxygen, nutrition, elimination, activity, rest and protection. The self concept adaptive mode refers to physiologic and physical characteristics of the person. This includes self concept, beliefs and feelings that one has formed about one self. The interdependent adaptive mode refers to coping mechanisms that result in the giving and receiving of love, respect and value. The role function adaptation mode refers to primary, secondary, or tertiary roles the person the person prefers in the society, the role as a functioning unit of the society.

The output
Output of the person as a system is the behaviours of the person. It can be external or internal behaviour; hence it can be observed and measured or subjectively reported.

Goals of nursing
Roy defines the goal of nursing as the promotion of adaptive responses in relation to the adaptive modes. Adaptive responses are those that positively affect health humanistic values of the ray adaptation model are linked to its definition of the specific purpose or goal of nursing. Human existence is viewed as a goal setting. Goals are the end point behaviour that the person is to achieve. Long term goals would reflect resolution of adaptive problem and the availability of energy to meet other goals (survival, growth, reproduction and mastery). Short term goals identify expected client behaviour after manipulation of focal, contextual or residual stimuli, as well as state client behaviour that indicate cognator or regulator coping.

plans for implementation: nursing implementation are planned with the purpose of altering or manipulating the stimuli .implementation may also focus on broadening the persons coping ability or adaptation zone, so that the total stimuli fall with in that person ability to adapt.

Evaluation: the nursing process is completed by evaluation. Goal behaviour are compared to the persons output behaviours and movement toward or away from goal achievement is determined .readjustment to goals and interventions are made based on evaluation data.




Internal neural spinal cord→ effectors → autonomic
↑ Brainstem and reflex
Stimuli autonomic reflects response
Chemical
↓
intact intact → responsiveness hormonal responsiveness body
Circulation pathways of endocrine→ output →of target organs → response
To from glands organs or tissues
↑ CNS

Chemical
External
Stimuli ↓
Neural perception → short term→ psychomotor → effectors
Memory choice of
Response



long term
(The regulator) TABLE 15-3

Internal
Stimuli

Intact pathways
And apparatus for → processes for
Perceptual processing selective attention, coding
And memory

Learning → imitation, reinforcement,
And insight → psycho → effects → response
Motor
Judgement → problem-solving and choice of
Decision making response

Emotion defences to seek relief
→ and affective appraisal
And attachment
External stimuli (The cognator) TABLE 15-4



ADAPTIVE MODELS
The coping processes, cognator-regulator and stabilizer promote adaptation in human adaptive systems. However, the coping process is not directly observable. Only the responses of the person or group can be observed, measured, or subjectively reported. Roy has identified four adaptive modes as categories for assessment of behaviour resulting from regulator cognator coping mechanism in persons or stabilizer –innovator coping processes in groups. These adaptive modes the nurse can identify adaptive or ineffective responses in situations of health and illness.
a) physiological-physical model
The physiological mode represents the human system’s physical responses and interactions with the environment (Roy and Andrews,1999).for the individual ,the underlying need of this mode is physiologic integrity, which is composed of the basic needs associated with oxygenation, nutrition, elimination, activity and rest and protection. The complex processes of this mode are associated with oxygenation, nutrition, elimination, activity, and rest and protection. The complex processes of this mode are associated with the senses; fluid, electrolyte, and acid base balance, neurological function; and endocrine function. These needs are processes may be defined as follows:
oxygenation
The processes (ventilation, gas exchange, and transport of
gases) by which cellular oxygen supply is maintained by the body
Nutrition
The series of processes by which a person takes in nutrients,
then assimilates and uses then to maintain body tissue, promote growth, and provide energy
elimination
Expulsion from the body of undigested substances, fluid wastes and excess ions
Activity and rest
Body movements that serves various purposes and changes in such movement so energy requirements are minimal
Protection
Non-specific (surface membrane barriers and chemical and cellular defences) and specific (immune systems) defence processes to protect the body from foreign substance.
Senses
The processes by which energy(light, sound,heat,mechanical vibration, and pressure) changes to neural activity and becomes perception
Fluid, Electrolyte
And , acid-base balance
The complex process of maintaining a stable internal environment of the body
Neurological function
Key neural processes and the complex relationship of neural function to regulator and cognator coping mechanisms
Endocrine
function
Patterns of endocrine control and autonomic nervous systems to maintain control of all physiologic processes

The physical is the focus of assessment in the first adaptive mode for a family, group or collective human adaptive system. The need underlying this mode is resource adequacy or wholeness. For groups, the mode relates to basic operating resources such as participants, physical facilities, and fiscal resources.

b) Self concept-group identity mode:
For individuals, the self concept mode relates to the basic need for psychic and spiritual integrity or a need to know the self with a sense of unity. Self concept has the component of physical self and personal self. The physical self includes body sensation and body image is how the person views the physical self. Self consistency represents the person’s efforts to maintain self organization and avoid disequilibrium; self ideal represent the person’s belief system and self evaluator. The need underlying the group identity mode for a family, group, or a collective is identity integrity. In collectives “the mode consist of interpersonal relationships, group self image, social milieu, and culture.

c) Role function model:
Role function mode is category of behaviour for both individuals and groups. A role consist of a set of expectations how a person in a particular position will behave in relation to a person who holds another position. The need underlying this mode is social integrity. More specifically, Roy states the social integrity knows who one is in relation to a person who holds another position. The need underlying this mode is social integrity. More specifically, Roy states the social integrity knows who one is in relation to others so that one can act appropriately. For the individual this focuses on the roles of the individual in society, Role behaviour in group’s means through which the social system achieves goals and functions. The need underlying the role function mode in groups is termed role clarity. The mode includes functions of members of the administration and staff, information management, decision making systems, systems to maintain order, or the need for group members to understand and commit to fulfilling expected responsibilities.

d) Interdependence mode:
The interdependence mode applies to adaptive behaviour for both individuals and groups. Behaviour is assessed as it relates to interdependence relationships of individuals and groups. For individuals, the underlying need of this mode is relational integrity or security in nurturing relationships. The mode focuses on the giving and receiving love, respect, and value with significant others and support systems. Significant others are those persons who are of greatest importance to the person. Support systems are identified as those who help the person meet the needs for love, respect, and value. For groups, interdependence relates to social context, including both public and private contacts within and outside the group. The components are context, infrastructure, and resources.




METAPARDIGM – RAM

Human being
Person is a bio psychosocial being in constant interaction with a changing environment and recipient of nursing care as living system.
Environment
Roy has broadly defined environment as “all conditioning circumstances and influences that surround and effect the development and behaviour of the persons or group.” Thus all stimuli, whether internal or external are part of the persons environment. Within her model, Roy specifically categorizes stimuli as focal, contextual, and residual. Changes in the environment act as catalysts, stimulating person to make adaptive responses. Thus stimuli from within the person represent the element of environment. To quote an example, elderly person admitted to hospital all the conditions of influence on him.
Health
Health is been defined as “a state and process of being and becoming an integrated and whole person. “ Holism and integrated functioning are not only basic premises of system theory, but are also congruent with the philosophical assumptions of Roy’s Adaptation Model. The integrity of the person is expressed as the ability to meet the goals of survival, growth, reproduction and mastery. The aim of nurse practicing under the Roy model is to promote the health of the person by promoting adaptive responses.
Nursing
Roy defines the goal of nursing “as the e promotion of adaptive responses in relation to the four adaptive modes. Adaptive responses are those that positively affect the health. Stimuli and persons adaptation level are inputs to the person as any adaptive system. The person’s adaptive level determines whether a positive response to internal or external stimuli will be elicited. Nursing seeks to reduce ineffective responses and promote adaptive responses as output behaviour of the person. The nurse therefore promotes health in all life process, including dying with dignity. A person’s ability to cope varies with the state of the person at different times.
Nursing activities or interventions are delineated by the model on those that promote adaptive responses in situations of health and illness. As a rule these approaches are identified as action taken by the nurse to manage the focal, contextual, or residual stimuli on the person. By making these adjustments, the total stimuli fall within the adaptive level of the person, whenever possible the focal stimulus- that which represents the greatest degree of changes in the focus of nursing activity. For a person with chest pain, the focal stimulus is the imbalance between the demand for oxygen by the body and the supply of oxygen that the heart can provide. To alter the focal stimuli, the nurse manages the stimuli of demand so that an adaptive response can be made. In turn, when focal stimuli can not be altered, the nurse promotes an adaptive response by altering contextual stimuli.
In addition, the nurse may anticipate that the person has a potential for in effective response secondary to stimuli, likely to be present in a particular situation. The nurse acts to prepare the person for anticipated changes through strengthening regulator and cognator coping mechanism. Plans that broaden the person’s adaptation levels correlate with the ideas of health promotion currently found in the literature. Finally nursing actions suggested by the model include approaches aimed at maintaining adaptive responses that support the person’s effort to creativity use his or her coping mechanisms.

THE NURSING PROCESS

The nursing process is a vehicle or decision making method compatible with the practice of nursing using the RAM. After making a behavioural assessment and a nursing judgement, nurses assess stimuli affecting responses, make a nursing diagnosis, set goals, and implement interventions to promote adaptation. Roy offers the following broad aims for nursing in response to the assumptions written for the 21st century: “nurses aim to enhance system relationships through acceptance, protection and fostering of interdependence and to promote personal and environmental transformations”.
The RAM offers guidelines to the nurse in application of the nursing process. The elements of the Roy nursing process include assessment of behaviour, assessment of stimuli, nursing diagnosis, goal setting, intervention, and evaluation
Assessment of behaviour
Assessment of behaviour is considered to be the gathering of responses or output behaviours of the human system as an adaptive system in relation to each of the four adaptive modes: physiological-physical, self –concept- group identity, role function, and interdependence. Roy defines behaviour as “actions or reactions under specified circumstances, it can be observable or non observable”. The nurse, through the process of observation, careful measurement, and skilled interview techniques, gathers the specific data. Assessment of the client in each of the four adaptive modes enhances a systematic and holistic approach.
Assessment of stimuli
After gathering behavioural assessment data, the nurse analyzes the emerging themes and patterns of client behaviour to identify responses or adaptive responses requiring nurse support with continual involvement of the human system receiving care. Behaviour that varies from expectation, norms, and guidelines frequently represents ineffective responses. Roy has identified frequently occurring signs of pronounced regulator activity and cognator ineffectiveness. The presence of these behaviours also suggests ineffective response. When ineffective behaviours or adaptive behaviours requiring nurse support with continual involvement of the human system receiving care. Behaviour that varies from expectations, norms, and guidelines frequently represents ineffective responses, Roy has identified frequently
occurring signs of pronounced regulator activity and cognator ineffectiveness, The presence of these behaviours also suggests ineffective responses. When ineffective behaviours or adaptive behaviours requiring support are present, the nurse assesses the internal and external stimuli that may be affecting behaviour. In this phase of assessment, the nurse collects data about the focal, contextual, and residual stimuli challenging the person’s coping. For groups, ineffective responses may be indicated by increased stabilizer activity associated with innovator effectiveness. For example, the death of the wage earner in a family could result in frenzied housecleaning by the rest of the family in preparation for the return of the member to the house (increased stabilizer activity) along with refusal to arrange the funeral (innovator effectiveness). Adaptive responses requiring nursing support include behaviours related to promoting, maintaining, or improving adaptive responses that will not continue to be effective with the occurrence of anticipated future changes. They may also include behaviours that are adaptive but that could be strengthened through education or anticipatory guidance.
The assessment of stimuli uses the same skills as assessment of behaviour and clarifies the nature of the focal stimulus, it should be remembered that behaviour in one mode can serve as a focal stimulus for another mode, and that a given focal stimulus may influence more that one mode. The first priority is given to behaviours that indicate a threat to the integrity of the system (ineffective response). The nurse identifies significant contextual and residual stimuli. Common influencing stimuli have been identified by Roy and her colleagues.
TABLE 15-3 INDICATIONS OF ADAPTATION DIFFICULTY
Signs of pronounce regulator activity:
1. Increase in heart rate or blood pressure
2. Tension
3. Excitement
4. Loss of appetite
5. Increase in serum cortisol
Signs of cognator ineffectiveness include:
1. Faculty perception and information processing
2. Ineffeective learning
3. Poor judgement
4. Inappropriate affect
TABLE 15-4 COMMON STIMULI AFFECTING ADAPTATION
Culture: Socioeconomic status, ethinicity, belief system
Family/ aggregate participants; structure and tasks
Developmental stage: age, sex, tasks, genetic factors, longevity of aggregate, vision.
Integrity of adaptive modes: physiologic (including disease pathology):- physical (including basic operating resources):-self concept group identity; role function; interdependence modes.
Cognator- innovator effectiveness: Perception, Knowledge, Skill.
Environmental considerations: Change in internal or external environment, medical management: use of drugs, alcohol, tobacco; political or economic stability
Nursing diagnosis
A nursing diagnosis is an interpretative statement that represents a judgement that the nurse makes in relation to the adaptation status of the human adaptive system (Roy and Andrews 1999) . The method suggested by Roy is stating the observed behaviour along with the most influential stimuli. Using this method, a diagnosis for Mr. Smith could be stated as: “chest pain caused by a deficit of oxygen to the heart muscle associated with an overexposure to hot weather.” A nursing diagnosis can also be a statement of adaptive responses that the nurse wishes to support. For e.g.: if Mr. Smith is keeping help through vocational counselling to adapt to his physical limitation, the nurse may diagnose a need to support this behaviour. In this case, an appropriate diagnosis would be: “adaptation to role failure by seeking an alternative career.” Roy and others also have developed a typology of indicators of positive adaptation.
Goal setting
The goal of nursing intervention is to maintain and enhance adaptation, and to change ineffective behaviour to adaptive behaviour. Goal setting involves making clear statements of the desired behavioural outcomes of nursing care. These outcomes will reflect adaptation. Roy suggests that goal statements be in terms of the desired behaviour of the desired behaviour of the human system. A complete statement is as one that includes the behaviour of the human system. A complete statement is described as one that includes the behaviour desired, the change expected, and a time frame. Goals may be long term or short term relative to the situation.
In the case of Mr. smith the short term goal would read: Mr. smith will proceed with daily activities( behaviour) with no chest pain (change) after 30 minutes of rest( time frame). The long term goal statement would read: Mr.Smith will be able to resume work (behaviour) in a new field (change) in six months (time frame).
Intervention
Nursing interventions are planned with the purpose of altering stimuli or strengthening adaptive process. The nurse plans specific activities to alter the selected stimuli appropriately. Nursing activities manage stimuli by “altering, increasing, decreasing, removing or maintaining them” as most appropriate to the situation. By using these strategies, the nurse adjusts stimuli so that the total stimuli fall within that person’s ability to cope. The coping processes of the person are the usual means of adaptation for the human adaptive system. It is when the coping processes are unable to respond effectively that the integrity of the person is compromised.
Consider Mr. Smith, previously discussed, who has chest pain. The nurse might identify a need for information related to heart disease, a need for low fat diet information, a need for cooking classes as well as for programme of cardiac
rehabilitation exercise to increase cardiac strength and endurance. These plans of care alter the contextual stimuli and assist the patient in reaching the long term goal of resuming productive work.
Evaluation
Evaluation occurs to establish the effectiveness of the actions taken. The nurse and the involved individuals look collaboratively at the behaviours to see if the behavioural goals have been reached. Goal behaviours are compared to the client’s output responses and movement toward or away from goal achievement is determined. If the goals have not been achieved, the nursing process begins again with additional questions relating to the accuracy and completeness of the assessment data, the match between identified goals and the client systems wishes, and the ways in which interventions were carried out. Readjustments to goals and interventions are made on the basis of evaluation data.

THE ROY NURSING PROCESS APPLIED TO NURSING PRACTICE

Individual situation
In a recovery room, the RAM can be applied to nursing assessment and interventions in various clinical situations. In the following case study, the Roy model is applied to a person during the period of immediate recovery from surgery and anaesthesia.
Assessment of behaviour focuses on the physiologic mode responses during the first hour of recovery time after a person experiences surgery and general anaesthesia. By applying the RAM, significant behaviours can be conceptualised as regulator output responses. Increased sympathetic or parasympathetic system activity can signal regulator system activity. Regulator output responses that vary from baseline values determined for the person’s presurgery measures of heart rate, blood pressure, and respiratory rate. Immediately up on observation of changes from the baseline, assessment of stimuli is done. Goals are set with the basic survival of the person as a priority. Interventions are taken so that focal and contextual stimuli are altered and adaptation is promoted. The evaluation of goal achievement is made, and further actions are taken as necessary.
Mrs. Reed is received from surgery after a major abdominal operation. Before surgery, her baseline vital signs were; HR-80bts/mt, BP-120/80mm Hg, RR-16/mt. After 45 minutes in recovery, her vital signs are: HR-150bts/mt, BP-90/60 mmof Hg, RR-32/mt.Increased regulator output response is signalled by sympathetic nervous system stimulation of the heart in response to decreased blood pressure. The nurse decides that Mrs. Reed is showing an ineffective response. Therefore, assessment of stimuli is done. The focal stimulus is a decrease in arterial blood pressure secondary to an unknown underlying cause. The contextual stimuli are: age 45 yrs, cool extremities, poor nail blanching, no food or drink for 12 hrs, and intra venous infusion of dextrose 5% in water with lactated ringers solution at 100 cc /hr. also, contextual stimuli include 200 cc of IV fluids infused during surgery, 10 cc of urine excreted during the first 45 mts in recovery, 1.5 hrs of general anaesthesia, estimated blood loss of 500cc during surgery, no operative site bleeding, and level of consciousness slow to respond to tactile stimuli after 45 mts in recovery. The residual stimuli include history of renal infections.
The nursing diagnosis of a decreased arterial blood pressure secondary to fluid volume deficit is made. A fluid volume loss is suggested both by the contextual data and both by the changes in the baseline heart rate, blood pressure, and urine output. The nurse then intervenes by altering contextual stimuli so that an adaptive response is promoted. The goal of a circulatory volume adequate to maintain a blood pressure of +/- 20 mm hg of baseline levels within 15 minutes is set. The nurse plans and then takes the following interventions steps. The IV rate is increased to 300cc per hr. the foot of the bed is elevated to increase venous return. 40% oxygen is given by mask. Mrs. Reed is verbally and tactilely stimulated and told to take slow deep breaths. The nurse prepares vasopressor medications for immediate use and applies an external continues blood pressure cuff for constant blood pressure monitoring. The nurse also consults with other team members as to Mrs. Reed’s clinical presentation.
A constant evaluation of the effectiveness of the nursing actions is made. The nurse holds Mrs. Reed in recovery until the goal of adequate circulation volume is met. Evaluation criteria include urine output greater than 30cc per hour, mental alertness, rapid nail bed blanching, blood pressure plus or minus 20 beats per minutes of baseline, and respirations =/- 5 / mts of presurgery levels.
Group situation
A school nurse surveys the members of the tenth grade in her school about personal substance use and finds that 30% of the teens are smoking more than 2 cigarettes per day. The students states that the smoking is cool, gives them a buzz, is a way to ‘break away from control by parents’, and that the health risk is ‘almost none’. Stimuli are assessed as; lack of adaptive coping by students to control developmental anxieties, lack of involvement by parent’s teen communication, and lack of knowledge related to the health risk of self-worth and esteem, ineffective use of substance to developmental anxieties, ineffective use of substance in separation issues with the family, and inadequate knowledge of health risks of smoking. The nurse sets the following goals; within three months, the students will state the myths related to the image of smoking created by advertising. Within four months, the tenth grade students will state the health risk of cigarette smoking. Within six months, the rate of cigarette used by tenth graders will decrease by 50% . Within one year, students will identify positive coping strategies to deal with developmental anxieties, and parents will increase involvement in teen activities. The nurse will create a core group of concerned teens, parents and teachers to plan strategies. The team decides to alter stimuli related to lack of positive role modelling in advertising that presents smoking as cool. Plans include use of posters that show a different image of the smoker, and talks by non-smoking college nursing students about setting life goals and building self esteem without use of substance. The group members secure resources including funding, space, and scheduling assistance. The team that the nurse has assembled develops many other strategies. One year later, smoking has decreased to 17% of the teens.

STRENGTH AND WEAKNESS OF THE ROY ADAPTATION MODEL

The RAM offers a variety of strengths for all areas of nursing. First, is the focus on, the whole person or group? The four modes provide an opportunity for consideration of multiple aspects of the human adaptive system and support gaining an understanding of the whole system. The importance of the spiritual aspects of the human adaptive system, often omitted from nursing assessment, is included in a manner that allows for incorporation of spiritually without imposition of the nurses beliefs. It is evident from the amount of research using the RAM reported in the literature and through the formation of BBARNS, that research is supported. Due to this research connection, the RAM is evolving rather than static. It is logically organised and draws on the nurses observational and interviewing skills.
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. Also, 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. This is particularly true/ as one begins to use the RAM; a nurse more experienced in the use of the RAM may find the time constraints less compelling.
CONCLUSION
The Roy adaptation model identifies the essential concepts relevant to nursing as the human adaptive system is viewed as constantly interacting with internal and external environmental stimuli. The human adaptive system is active and reactive to these stimuli. Stimuli are defined as focal, contextual and residual. The internal coping processes of regulator and cognator for the individual and stabilizer and innovation for collective human adaptive systems are phenomena of concern to nursing. Support of coping processes may be the focus of nursing intervention. The four adaptive modes may be the first aspect of the model that the student or nurse is able to assimilate.