alligood 8th edition_Neat

282 UNIT III Nursing Conceptual Models

(Neuman, Deloughery, & Gebbie, 1971). Neuman de- within the organism. When the stabilizing process fails
signed a nursing conceptual model for students at to some degree, or when the organism remains in a state
UCLA in 1970 to expand their understanding of client of disharmony for too long, illness may develop. If the
variables beyond the medical model (Neuman & Young, organism is unable to compensate through illness, death
1972). Neuman first published her model during the may result (Neuman & Young, 1972).
early 1970s (Neuman & Young, 1972; Neuman, 1974). The model is also derived from the philosophical
The first edition of The Neuman Systems Model: Applica- views of de Chardin and Marx (Neuman, 1982). Marxist
tion to Nursing Education and Practice was published in philosophy suggests that the properties of parts are
1982; further development and revisions of the model determined partly by the larger wholes within dynami-
are illustrated in subsequent editions (Neuman, 1989, cally organized systems. With this view, Neuman (1982)
1995, 2002b, 2011b). confirms that the patterns of the whole influence aware-
Since developing the Neuman Systems Model, ness of the part, which is drawn from de Chardin’s
Neuman has been involved in numerous publications, philosophy of the wholeness of life.
paper presentations, consultations, lectures, and confer- Neuman used Selye’s definition of stress, which is
ences on application and use of the model. She is a the nonspecific response of the body to any demand
Fellow of the American Association of Marriage and made on it. Stress increases the demand for readjust-
Family Therapy and of the American Academy of Nurs- ment. This demand is nonspecific; it requires adapta-
ing. She taught nurse continuing education at UCLA tion to a problem, irrespective of the nature of the
and in community agencies for 14 years and was in problem. Therefore, the essence of stress is the non-
private practice as a licensed clinical marriage and fam- specific demand for activity (Selye, 1974). Stressors
ily therapist, with an emphasis on pastoral counseling. are the tension-producing stimuli that result in stress;
Although retired, Neuman continues to do occasional they may be positive or negative.
pastoral and nutritional counseling. Neuman lives in Neuman adapts the concept of levels of prevention
Ohio and maintains a leadership role in the Neuman from Caplan’s conceptual model (1964) and relates
Systems Model Trustees Group. She serves as a consul- these prevention levels to nursing. Primary preven-
tant nationally and internationally regarding imple- tion is used to protect the organism before it encoun-
mentation of the model for nursing education programs ters a harmful stressor. Primary prevention involves
and for clinical practice agencies. reducing the possibility of encountering the stressor
or strengthening the client’s normal line of defense to
decrease the reaction to the stressor. Secondary and
Theoretical Sources tertiary prevention are used after the client’s encoun-
The Neuman Systems Model is based on general sys- ter with a harmful stressor. Secondary prevention
tem theory and reflects the nature of living organisms attempts to reduce the effect or possible effect of
as open systems (Bertalanffy, 1968) in interaction stressors through early diagnosis and effective treat-
with each other and with the environment (Neuman, ment of illness symptoms; Neuman describes this as
1982). Within this model, Neuman synthesizes strengthening the internal lines of resistance. Tertiary
knowledge from several disciplines and incorporates prevention attempts to reduce the residual stressor
her own philosophical beliefs and clinical nursing effects and return the client to wellness after treat-
expertise, particularly in mental health nursing. ment (Capers, 1996; Neuman, 2002b).
The model draws from Gestalt theory (Perls, 1973),
which describes homeostasis as the process by which an
organism maintains its equilibrium, and consequently Use of Empirical Evidence
its health, under varying conditions. Neuman describes Neuman conceptualized the model from sound theo-
adjustment as the process by which the organism satis- ries before nursing research was begun on the model.
fies its needs. Many needs exist, and each may disrupt She initially evaluated the utility of the model by sub-
client balance or stability; therefore, the adjustment mitting a tool to her graduate nursing students at UCLA
process is dynamic and continuous. All life is character- and published the outcome data in Nursing Research
ized by this ongoing interplay of balance and imbalance (Neuman & Young, 1972). Subsequent nursing research

CHAPTER 16 Betty Neuman 283

MAJOR CONCEPTS & DEFINITIONS

Betty Neuman (2011b) describes the Neuman sys- reaction to stress are basic components of an open
tems model by stating the following: system (Neuman, 2011c, p. 328; see also Neuman,
1982, 1989, 1995, 2002b).
The Neuman Systems Model is a unique, open-
systems-based perspective that provides a unifying Function or Process
focus for approaching a wide range of concerns.
A system acts as a boundary for a single client, The client as a system exchanges energy, informa-
a group, or even a number of groups; it can also tion, and matter with the environment as well as
be defined as a social issue. A client system in other parts and subparts of the system as it uses
interaction with the environment delineates the available energy resources to move toward stability
domain of nursing concerns (p. 3). and wholeness.(Neuman, 2011c, p. 328; see also
Neuman, 1982, 1989, 1995, 2002b).
Major concepts identified in the model (see Figure
16–1) are wholistic approach, open system (includ- Input and Output
ing function, input and output, feedback, negent- For the client as a system, input and output are the
ropy, and stability), environment (including created matter, energy, and information that are exchanged
environment), client system (including five client between the client and the environment (Neuman,
variables, basic structure, lines of resistance, normal 2011c, p. 328).
line of defense, and flexible line of defense), health
(wellness to illness), stressors, degree of reaction, Feedback
prevention as intervention (three levels), and recon- System output in the form of matter, energy, and
stitution (Neuman, 2011c, pp 327–329; see also information serves as feedback for future input for
Neuman, 1982, 1989, 1995, 2002b).
corrective action to change, enhance, or stabilize the
Wholistic Approach system (Neuman, 2011c, p. 327).
The Neuman Systems Model is a dynamic, open, Negentropy
systems approach to client care originally developed
to provide a unifying focus for defining nursing The process of energy conservation that assists system
problems and for understanding the client in inter- in the progression toward stability or wellness is
action with the environment. The client as a system negentropy (Neuman, 2011c, p. 328; see also Neuman,
may be defined as a person, family, group, commu- 1982, 1989, 1995, 2002b).
nity, or social issue (Neuman, 2011c).
Clients are viewed as wholes whose parts are in Stability
dynamic interaction. The model considers all vari- Stability is a dynamic and desirable state of bal-
ables simultaneously affecting the client system: ance in which energy exchanges can take place
physiological, psychological, sociocultural, develop- without disruption of the character of the system,
mental, and spiritual. Neuman included the spiritual which points toward optimal health and integrity
variable in the second edition (1989). She changed (Neuman, 2011c, p. 328; see also Neuman, 1982,
the spelling of the term holistic to wholistic in the 1989, 1995, 2002b).
second edition to enhance understanding of the
term as referring to the whole person (B. Neuman, Environment
personal communication, June 20, 1988). As defined by Neuman, “ . . . internal and external
forces surrounding the client, influencing and be-
Open System ing influenced by the client, at any point in time”
A system is open when there is a continuous flow of (Neuman, 2011c, p. 327; see also Neuman, 1982,
input and processes, output, and feedback. Stress and 1989, 1995, 2002b).
Continued

284 UNIT III Nursing Conceptual Models

MAJOR CONCEPTS & DEFINITIONS—cont’d

Created Environment time and serves as the standard by which to measure
The created environment is developed uncon- wellness deviation. (Neuman, 2011c, p. 328; see also
sciously by the client to express system wholeness Neuman, 1982, 1989, 1995). Expansion of the nor-
symbolically. Its purpose is to provide protection for mal line of defense reflects an enhanced wellness
client system functioning and to insulate the client state, and contraction indicates a diminished well-
from stressors (Neuman, 2011c, p. 327; see also ness state (Neuman, 2001, p. 322).
Neuman, 1982, 1989, 1995, 2002a).
Flexible Line of Defense
Client System The model’s outer broken ring is called the flexible
The client system is a composite of five variables (phys- line of defense (see Figure 16–1). It is perceived as
iological, psychological, sociocultural, developmental, serving as a protective buffer for preventing stress-
and spiritual) in interaction with the environment. ors from breaking through the usual wellness state
The physiological variable refers to body structure and as represented by the normal line of defense. Situa-
function. The psychological variable refers to mental tional factors can affect the degree of protection
processes in interaction with the environment. The afforded by the flexible line of defense, both posi-
sociocultural variable refers to the effects and influences tively and negatively (Neuman, 2011c, p. 327; see
of social and cultural conditions. The developmental also Neuman, 1982, 1989, 1995, 2002a).
variable refers to age-related processes and activities. Neuman describes the flexible line of defense
The spiritual variable refers to spiritual beliefs and influ- as the client system’s first protective mechanism.
ences (Neuman, 2011c, p. 327; see also Neuman, 1982, “When the flexible line of defense expands, it pro-
1989, 1995, 2002a). vides greater short-term protection against stressor
invasion; when it contracts, it provides less protec-
Basic Structure tion” (Neuman, 2011, p. 322).
The client as a system is composed of a central core
surrounded by concentric rings. The inner circle of Health
the diagram (see Figure 16–1) represents the basic Health is a continuum of wellness to illness that is
survival factors or energy resources of the client. dynamic in nature. Optimal wellness exists when
This core structure “ . . . consists of basic survival the total system needs are being completely met
factors common to human beings,” such as innate or (Neuman, 2011c, p. 328).
genetic features (Neuman, 2011c, p. 327; see also
Neuman, 1982, 1989, 1995, 2002a). Wellness
Wellness exists when all system subparts interact in
Lines of Resistance harmony with the whole system and all system
A series of broken rings surrounding the basic core needs are being met (Neuman, 2011c, p. 329; see
structure are called the lines of resistance. These also Neuman, 1982, 1989, 1995, 2002b).
rings represent resource factors that help the client
defend against a stressor (see Figure 16–1). Lines of Illness
resistance serve as protection factors that are acti- Illness exists at the opposite end of the continuum
vated by stressors penetrating the normal line of from wellness and represents a state of instability
defense (Neuman, 2011c, p. 328). and energy depletion (Neuman, 2011c, p. 329; see
also Neuman, 1982, 1989, 1995, 2002b).
Normal Line of Defense
The normal line of defense is the model’s outer solid Stressors
circle (see Figure 16–1). It represents the adapta- Stressors are tension-producing stimuli that have
tional level of health developed over the course of the potential to disrupt system stability, leading to

CHAPTER 16 Betty Neuman 285

MAJOR CONCEPTS & DEFINITIONS—cont’d
an outcome that may be positive or negative. They but the degree of risk is known. The purpose is to
may arise from the following: reduce the possibility of encounter with the stressor
n Intrapersonal forces occurring within the indi- or to decrease the possibility of a reaction (Neuman,
vidual, such as conditioned responses 1982, p. 15; 2011c, p. 328)
n Interpersonal forces occurring between one or
more individuals, such as role expectations Secondary Prevention
n Extrapersonal forces occurring outside the indi- Secondary prevention involves interventions or
vidual, such as financial circumstances (Neuman, treatment initiated after symptoms from stress have
2002b, p. 324; see also Neuman, 1982, 1989, 1995). occurred. The client’s internal and external resources
are used to strengthen internal lines of resistance,
Degree of Reaction reduce the reaction, and increase resistance factors
The degree of reaction represents system instability (Neuman, 1982, p. 15; see also Neuman, 2011c,
that occurs when stressors invade the normal line of p. 328).
defense (Neuman, 2011c, p. 327; see also Neuman,
1982, 1989, 1995, 2002a). Tertiary Prevention
Tertiary prevention occurs after the active treat-
Prevention As Intervention ment or secondary prevention stage. It focuses on
Interventions are purposeful actions to help the cli- readjustment toward optimal client system stabil-
ent retain, attain, or maintain system stability. They ity. The goal is to maintain optimal wellness by
can occur before or after protective lines of defense preventing recurrence of reaction or regression.
and resistance are penetrated. Neuman supports Tertiary prevention leads back in a circular fash-
beginning intervention when a stressor is suspected ion toward primary prevention (Neuman, 2011c,
or identified. Interventions are based on possible or p. 328; see also Neuman, 1982).
actual degree of reaction, resources, goals, and an-
ticipated outcomes. Neuman identifies three levels Reconstitution
of intervention: (1) primary, (2) secondary, and (3) Reconstitution occurs after treatment for stressor
tertiary (Neuman, 2011, p. 328; see also Neuman, reactions. It represents return of the system to sta-
1982, 1989, 1995). bility, which may be at a higher or lower level of
wellness than before stressor invasion (Neuman,
Primary Prevention 2011c, p. 328).
Primary prevention is used when a stressor is sus-
pected or identified. A reaction has not yet occurred,




has produced sound empirical evidence in support of Neuman (1995) states that the perceptual field of the
the Neuman Systems Model (Figure 16–1). caregiver and the client must be assessed.
Person
Major Assumptions
Neuman presents the concept of person as an open
Nursing client system in reciprocal interaction with the envi-
Neuman (1982) believes that nursing is concerned with ronment. The client may be an individual, family,
the whole person. She views nursing as a “unique pro- group, community, or social issue. The client system is
fession in that it is concerned with all of the variables a dynamic composite of interrelationships among
affecting an individual’s response to stress” (p. 14). The physiological, psychological, sociocultural, develop-
nurse’s perception influences the care given; therefore, mental, and spiritual factors (Neuman, 2011b, p. 15).

286 UNIT III Nursing Conceptual Models













Basic structure • Basic factors common to all organisms: • Normal temperature range • Genetic structure • Response pattern • Organ strength • Weakness • Ego structure • Knowns or commonalities Stressors • More than one stressor could occur simultaneously* • Same stressors could vary as to impact or reaction • Normal defense line varies with age and development Note: * Phys






Stressor



Flexible line of defense Normal line of defense Lines of resistance Basic structure energy resources Reconstitution Reconstitution • Could begin at any degree or level of reaction • Range of possibility may extend beyond normal line of defense Intra Personal Inter factors Extra The Neuman Systems Model. (Original copyright 1970 by Betty Neuman. Used with











Stressor Degree of reaction Reaction Personal factors








Stressors • Identified • Classified as to knowns or possibilities • Loss • Pain • Sensory deprivation • Cultural change Intra Personal Inter factors Extra Reaction • Individual intervening variables: • Basic structure idiosyncrasies • Natural and learned resistance • Time of encounter with stressor Intra Inter Extra Intervention







FIGURE permission.)
Primary prevention • Reduce possibility of encounter with stressors • Strengthen flexible line of defense Secondary prevention • Early case-finding • Treatment of symptoms Tertiary prevention • Readaption • Reeducation to prevent future occurrences • Maintenance of stability

CHAPTER 16 Betty Neuman 287

Neuman links the four essential concepts of person,
Health environment, health, and nursing in her statements
Neuman considers her work a wellness model. She regarding primary, secondary, and tertiary prevention.
views health as a continuum of wellness to illness Neuman’s earlier publications stated basic assump-
that is dynamic in nature and is constantly changing. tions that linked essential concepts of the model.
Neuman states that “Optimal wellness or stability These statements have been recognized as proposi-
indicates that total system needs are being met. A tions and serve to define, describe, and link the con-
reduced state of wellness is the result of unmet sys- cepts of the model. Numerous theoretical assertions
temic needs” (2011c, p. 328). have been proposed, tested, and published, as noted
throughout Neuman and Fawcett (2011).
Environment
Neuman defines environment as all the internal and
external factors that surround and influence the client Logical Form
system. Stressors (intrapersonal, interpersonal, and Neuman used deductive and inductive logic in devel-
extrapersonal) are significant to the concept of envi- oping her model. As previously discussed, Neuman
ronment and are described as environmental forces derived her model from other theories and disci-
that interact with and potentially alter system stability plines. The model is also a product of her philosophy
(2011c, p. 327). and of observations made in teaching mental health
Neuman (1995) identifies three relevant environ- nursing and clinical counseling (Fawcett, Carpenito,
ments: (1) internal, (2) external, and (3) created. The Efinger, et al., 1982).
internal environment is intrapersonal, with all interac-
tion contained within the client. The external environ- Applications by the Nursing
ment is interpersonal or extrapersonal, with all factors
arising from outside the client. The created environment Community
is unconsciously developed and is used by the client to Alligood (2010) clarifies that a conceptual model pro-
support protective coping. It is primarily intrapersonal. vides a frame of reference, while a grand theory pro-
The created environment is dynamic in nature and poses direction or action that is testable. The Neuman
mobilizes all system variables to create an insulating Systems Model is both a model and a grand nursing
effect that helps the client cope with the threat of envi- theory. As a model, it provides a conceptual frame-
ronmental stressors by changing the self or the situation. work for nursing practice, research, and education
Examples are the use of denial (psychological variable) (Freese, Russell, Neuman, & Fawcett, 2011; Louis,
and life cycle continuation of survival patterns (develop- Neuman, Gigliotti, et al., 2011; Newman, Lowry, &
mental variable). The created environment perpetually Fawcett, 2011). As a grand theory, it proposes ways of
influences and is influenced by changes in the client’s viewing nursing phenomena and nursing actions that
perceived state of wellness (Neuman, 1995, 2011b). are assumed to be true but may form propositions for
testing (Neuman, 2002a).
The model serves equally well for all levels of
Theoretical Assertions nursing education and for a wide variety of practice
Theoretical assertions are the relationships among the areas. It adapts well transculturally and is used fre-
essential concepts of a model (Torres, 1986). The quently for public health nursing in other countries.
Neuman model depicts the nurse as an active partici- The model is used extensively in the United States,
pant with the client and as “concerned with all the Canada, and Holland. It has been used throughout
variables affecting an individual’s response to stress- the world (Australia, Brazil, Costa Rica, Denmark,
ors” (Neuman, 1982, p. 14). The client is in a recipro- Egypt, England, Finland, Ghana, Holland, Hong
cal relationship with the environment in that “he Kong, Iceland, Japan, Korea, Kuwait, New Zealand,
interacts with this environment by adjusting himself Portugal, Puerto Rico, the Republic of China, Spain,
to it or adjusting it to himself” (Neuman, 1982, p. 14). Sweden, Taiwan, Wales, and Yugoslavia).

288 UNIT III Nursing Conceptual Models

The ongoing development and universal appeal of the three prevention-as-intervention modes. Eval-
of the model are reflected in the international uation then is used to confirm that the desired out-
Biennial Neuman Systems Model Symposia, which comes have been achieved or to reformulate the goals
provide a forum across cultures for practitioners, or outcomes. Neuman (2011a) outlines her nursing
educators, researchers, and students to share informa- process format, clarifying the steps in the process
tion about their use of the model. The first sympo- for use of her model in Appendix C (pp. 338–350).
sium was held in 1986 at Neumann College in Aston, Russell (2002) provides a review of clinical tools using
Pennsylvania. Subsequent symposia have been held in the model to guide nursing practice with individuals,
Kansas City, Missouri (1988); Dayton, Ohio (1990); families, communities, and organizations.
Rochester, New York (1993); Orlando, Florida (1995); The breadth of the Neuman model has resulted in
Boston, Massachusetts (1997); Vancouver, British its application and adaptation in a variety of nursing
Columbia (1999); Salt Lake City, Utah (2001); Willow practice settings, including hospitals, nursing homes,
Grove, Pennsylvania (2003); Akron, Ohio (2005); rehabilitation centers, hospices, mental health units,
Ft. Lauderdale, Florida (2007); Las Vegas, NV (2009); childbirth centers, and community-based services
and Allentown, PA (2011). Each symposium has such as congregational nurse practices. Numerous
attracted participation from countries throughout examples are cited in Neuman’s books (1982, 1989,
the world and from disciplines beyond nursing. 1995, 2002b, 2011). The model’s wholistic approach
makes it particularly applicable for clients who are
Practice experiencing complex stressors that affect multiple
Use of the Neuman Systems Model for nursing client variables such as terminal liver cancer (Hsuan,
practice facilitates goal-directed, unified, wholistic 2009).The model has been used to guide nursing
approaches to client care, yet the model is also ap- practice in countries throughout the world. As an
propriate for multidisciplinary use to prevent frag- example, it is used in Holland to guide Emergis,
mentation of client care. The model delineates a a comprehensive program of mental health that
client system and classification of stressors that can provides psychiatric care for children, adolescents,
be understood and used by all members of the adults, and elderly, and addiction care and social ser-
health care team (Mirenda, 1986). Guidelines have vices (Merks, van Tilburg, & Lowry, 2011; Munck &
been published for use of the model in clinical nurs- Merks, 2002).
ing practice (Freese, Russell, Neuman, & Fawcett, Neuman’s model provides a systems perspective for
2011) and for the administration of health care ser- use with individuals and families, for community-
vices (Shambaugh, Neuman, & Fawcett, 2011). based practice with groups, and in public health nurs-
Several instruments have been published to facilitate ing, as its wholistic principles assist nurses to achieve
use of the model. These instruments include an assess- high-quality care through evidence-based practices
ment and intervention tool to assist nurses in collecting (Ume-Nwagbo, Dewan, & Lowry, 2006). Anderson,
and synthesizing client data, a format for prevention as McFarland, and Helton (1986) used the model for a
intervention, and a format for application of the nursing community health needs assessment in which they
process within the framework of the Neuman Systems identified violence toward women as a major commu-
Model (Neuman 2011a; Russell, 2002). nity health concern. This model has been used to guide
The Neuman Nursing Process Format consists of pediatric nursing practice (Spurr, Bally, Ogenchuk,
three steps: (1) nursing diagnosis, (2) nursing goals, et al., 2011) and as a framework for advanced psychiat-
and (3) nursing outcomes. (When used by other dis- ric nursing practice (Groesbeck, 2011).
ciplines, the term nursing is changed accordingly.) Likewise, the model is functional in the acute care
Diagnosis involves obtaining a broad, comprehensive setting. For example, Allegiance Health in Michigan
data base from which variances from wellness can adopted the Neuman Systems Model to be imple-
be determined. Goals are established by negotiation mented as the nursing conceptual model at their
between client and caregiver for desired prescriptive institution. As part of the implementation process,
changes to correct variances from wellness. Outcomes various documents were revised or created to reflect
are established in relation to the goal for one or more nursing care using concepts of the model, such as the

CHAPTER 16 Betty Neuman 289

use of the “six Neuman Systems Model questions” continues to serve as the conceptual framework for
that were incorporated into the admission assessment over 25 nursing education programs both in the United
(Burnett & Crisanti, 2011). States and abroad including Loma Linda University
The model works well for multidisciplinary use. As (Burns, 2011), Anna Maria College (Cammuso,
an example, it is used to guide a team approach to Audrey Silveri, & Remijan, 2011), Indiana University/
holistic care for older adults after hip fracture (Kain, Purdue University Fort Wayne (Beckman, Lowry, &
2000). It also has proved useful in hospital-based case Boxley-Harges, 2011), and Douglas College (Tarko &
management in several Kansas hospitals, with the Helewka, 2011).
development of case management teams involving The model works equally well to guide clinical learn-
social workers and nursing staff (Wetta-Hall, Berry, ing. For example, it is used with nursing students at a
Ablah, et al., 2004). Further research continues to community nursing center (Newman, 2005), and to
validate its applicability in and beyond nursing. teach nursing students to promote the health of com-
munities (Falk-Rafael, Ward-Griffin, Laforet-Fliesser,
Education et al., 2004). It is used as a comprehensive framework
The model is well accepted in academe and is used to organize data collected from maternity patients
widely as a curriculum guide. It has been used through- by undergraduate nursing students at the University
out the United States and in other countries, including of South Florida (Lowry, 2002). Bruick-Sorge (2007)
Australia, Canada, Denmark, England, Holland, Japan, reported using the model in the clinical simulation set-
Korea, Kuwait, Portugal, and Taiwan (Beckman, ting to improve critical thinking skills by using model
Boxley-Harges, Bruick-Sorge, et al., 1994; Lowry, concepts.
2002). In an integrative review of use of the model The Neuman Systems Model is used to guide
in educational programs at all levels, Lowry (2002) learning in classroom and clinical settings for multi-
reports that “although the trend is toward eclecticism ple levels of nursing and health-related curricula
in nursing education today, the Neuman Systems around the world. Acceptance by the nursing educa-
Model has served many programs well . . .” and fre- tion community is clearly evident. As online nursing
quently is selected in other countries to facilitate stu- education increases, it will be imperative that nurse
dent learning (p. 231). Guidelines have been published educators find novel approaches for presenting this
for use of the model in education for the health profes- information to all levels of students.
sions (Newman, Lowry, & Fawcett, 2011).
The model’s wholistic perspective provides an Research
effective framework for nursing education at all levels. A significant amount of research has been conducted
Lowry and Newsome (1995) reported on a study of over the past decade on the components of the model
12 associate degree programs that used the model as to generate nursing theory and use of the model as a
a conceptual framework for curriculum development. conceptual framework to advance nursing as a scien-
Results indicate that graduates use the model most tific discipline. Rules for Neuman Systems Model–
often in the roles of teacher and care provider, and Based Nursing Research as specified by Fawcett, a
that they tend to continue practice from a Neuman Neuman model trustee, are based on the content of
Systems Model–based perspective following gradua- the model and related literature (Fawcett & Gigliotti,
tion. Neuman’s model has been selected for baccalau- 2001). Other guidelines have been published to guide
reate programs on the basis of its theoretical and use of the model for nursing research (Louis, Gigliotti,
comprehensive perspectives for a wholistic curricu- Neuman, et al., 2011).
lum, and because of its potential for use with indi- In the fourth edition of The Neuman Systems Model,
viduals, families, small groups, and the community. Fawcett and Giangrande (2002) present an integrated
Neumann College Division of Nursing was the first review of 200 research reports of model use that were
school to select the Neuman Systems Model as its published through 1997. Skalski, DiGerolamo, and
conceptual base for its curriculum and approach Gigliotti (2006) reported a literature review of 87
to client care in 1976. Neuman, Lowry, and Fawcett Neuman Systems Model–based studies to identify and
(2011) report that the Neuman Systems Model categorize client system stressors. The Neuman Systems

290 UNIT III Nursing Conceptual Models

Model is used frequently by nurse researchers as a con- adolescent depression (Sinsiri, 2009). Research pre-
ceptual framework, as it lends itself to both quantitative sented at the thirteenth symposium included studies
and qualitative methods. Recent examples of qualitative on the exploration of spirituality and spiritual care in
studies include studies of post-traumatic stress disorder a baccalaureate nursing program in South Carolina
symptoms in emergency nurses (Lavoie, Talbot, & (South, 2011), role stress and eating behaviors among
Mathieu, 2011) and experiences of patients following clergy (Kavanagh-Mannister, 2011), the relationship
mastectomy (Alves, Mourão, Galvão, et al, 2010). between shift work, sleep quality, and body mass
Examples of quantitative studies include investigations index in nurses (Huth, 2011), and colon cancer aware-
on the effect of back massage on relaxation (Walton, ness (Boxer 2011).
2009), the effects of nurse facilitated family participa- Research projects that were reported at previous
tion in the psychological care of critically ill patients symposia (1993 through 2007) are cited in previous
(Black, Boore, & Parahoo, 2011), perceived wellness editions of this chapter.
and stress in early adolescents (Yarcheski, Mahon, The Neuman Systems Model is used extensively to
Yarcheski, et al., 2010), and the effects of coping and provide the conceptual framework for research projects
support groups for reduction of burnout among nurses in the United States and in other countries. Acceptance
(Günüşen & ūstün, 2010). by the nursing research community is clearly evident.
Graduate students frequently use the model for
dissertations and theses. Recent examples include
studies on created environment of registered nursing Further Development
students in Nevada (Elmore, 2010), acculturation and When published initially, the Neuman Systems Model
birth outcomes in Mexican and Mexican-American was described as being at a very early stage of theory
women (Chaponniere, 2010), the relationship be- development (Walker & Avant, 1983). Although the
tween nursing student stress and the perception of diagram itself has remained unchanged, the model has
clinical nurse educator caring (Roe, 2009), neonatal been refined based on its use and further developed
sepsis from peripherally inserted central catheters in subsequent publications (Fawcett, 2001). At least
(Clem, 2010), and the association of various factors of two components have been supported and further
persons undergoing methadone maintenance therapy developed since 2000. Major developments include
(Paicentine, 2010). spirituality (Beckman, Boxley-Harges, Bruick-Sorge,
Earlier research studies using the Neuman Systems et al., 2007; DiJoseph & Cavendish, 2005; Lee, 2005;
Model are reported in previous editions of this chapter. Lowry, 2002) and the concept of created environment
Additional studies using this model are listed in the (Hemphill, 2006).
bibliography at the end of this chapter. Establishing full credibility of the model depends
The Biennial Neuman Systems Model Symposium on extending the development and testing of middle-
provides a rich forum for presentation of research range theory from it. Neuman and Koertvelyessy
(completed and in progress). At the twelfth (2009) identified two theories generated from the model:
and thirteenth (2011) symposia, nurses from the (1) the theory of optimal client system stability, and
United States, Canada, Holland, Thailand, and China (2) the theory of prevention as intervention (Fawcett,
reported on numerous studies that used the model. 1995b). Gigliotti (2011) reports that additional middle-
Research presented at the twelfth symposium in- range theories continue to be derived from the
cluded studies on participation in online support Neuman Systems Model, including the Theory of Ado-
groups by women with peripartum cardiomyopathy lescent Vulnerability to Risk Behaviors, Theory of
(Weinland & Hess, 2009), stressors and coping strate- Well-being, Theory of Maternal Role Stress, and the
gies in adolescents with scoliosis prior to and follow- Theory of Dialysis Decision Making. Further research
ing surgical correction (Zhou, Ye, Zhang, et al., 2009), based on the Neuman Systems Model is needed to
the utility of the Neuman Systems Model as a guide validate the relationship between model concepts and
for psychiatric nursing practice in Holland (Merks, research outcomes (Fawcett & Giangrande, 2002;
van Tilburg, & Lowry, 2009), and factors influencing Gigliotti, 2011).

CHAPTER 16 Betty Neuman 291

The Neuman Systems Model Trustee Group was states that the concepts can be separated for analysis,
established in 1988 to preserve, protect, and perpetu- specific goal setting, and interventions (B. Neuman,
ate the integrity of the model for the future of nursing personal communication, June 21, 1992). This model
(Neuman, 2011d). Its international members, person- can be used to explain the client’s dynamic state of equi-
ally selected by Neuman, are dedicated professionals. librium and the reaction or possible reaction to stress-
The Neuman Systems Model Research Institute has ors. The concept of prevention as intervention can
been organized to generate and test middle-range be used to describe or predict nursing phenomena.
theories derived from the model. Preliminary work The model is complex; therefore, it cannot be described
that has been completed includes assembling as being simple, yet nurses using the model describe it
resources, identifying concepts and the relationships as easy to understand and it is used across cultures and
among them, and synthesizing existing research in a wide variety of practice settings.
based on Neuman Systems Model concepts (Gigliotti,
2003). The Research Institute offers grants and fellow- Generality
ships to deserving researchers in an effort to promote The Neuman Systems Model has been used in a wide
the use of the model and work in generating middle- variety of nursing situations; it is both comprehensive
range theories from the model, and also offers consul- and adaptable. Some concepts are broad and represent
tation services regarding the use of the model in the phenomenon of “client,” which may be one person
nursing research (Gigliotti, 2011). or a larger system. Other concepts are more definitive
and identify specific modes of action, such as primary
prevention. The model’s systematic broad scope allows
Critique it to be useful to nurses and to other health care pro-
Neuman developed a comprehensive conceptual model fessionals in working with individuals, families,
that operationalizes systems concepts that are relevant groups, or communities in all health care settings.
to the breadth of nursing phenomena. The model’s Health professionals beyond nursing use the model
wholistic perspective allows for a wide range of creativ- as a framework for care because its wholistic perspec-
ity in its use. It remains relevant for use by nursing and tive accommodates varied approaches to client assess-
by other health care professions in the future. ment and care. Its systems approach and its emphasis
on involving the client as an active participant fit well
Clarity with contemporary health care values such as preven-
Neuman presents abstract concepts that are familiar tion and interdisciplinary care management.
to nurses. The model’s essential concepts of client,
environment, health, and nursing are congruent with Accessibility
traditional understanding of the nursing metapara- The model has been tested and is used extensively to
digm. Concepts defined by Neuman and those bor- guide nursing research. Early work (Hoffman, 1982;
rowed from other disciplines are used consistently Louis and Koertvelyessy, 1989) provided initial docu-
throughout the model. However, the model’s clarity mentation of empirical support. Continued testing
has been criticized in that concepts need to be defined and refinement through the work of the Research
more completely (August-Brady, 2000; Heyman & Institute and independent nurse researchers increase
Wolfe, 2000). the model’s empirical precision as research continues
and findings from multiple studies are synthesized
Simplicity (Gigliotti, 1999, 2003, 2011; Skalski, DiGerolamo, &
The model concepts are organized in a complex yet Gigliotti, 2006).
systematically logical manner. Multiple interrelation-
ships exist among concepts, and variables overlap to Importance
some degree. Distinctions between concepts tend to Neuman’s conceptual model includes guidelines for the
blur at several points, but loss of theoretical meaning professional nurse for assessment of the client system,
would occur if they were separated completely. Neuman utilization of the nursing process, and implementation

292 UNIT III Nursing Conceptual Models

of preventive interventions, which are all important This model has been well accepted by the nursing
to delivery of care. The focus on primary prevention community and is used in administration, practice,
and interdisciplinary care is futuristic and serves education, and research. The Neuman Systems Model
to improve quality of care. The Neuman nursing pro- Trustees Group is actively involved in protecting the
cess fulfills current health mandates by involving the integrity of the model and advancing its development.
client actively in negotiating the goals of nursing care The Neuman Systems Model Research Institute has
(Neuman, 2011b). been established and is working to generate and test
A major feature of the model is its potential middle-range theories based on the model.
to generate nursing theory, for example, the theories
of optimal client stability and prevention as interven- CASE STUDY
tion (Fawcett, 1995a). The model concepts are highly
relevant for use by health professionals in the twenty- Individuals and a Family as a Client
first century. Through continued theory development Elizabeth Jefferies is a divorced 46-year-old mother
and research with the model, the nursing discipline of two children and the daughter of two aging
can expand its scientific knowledge base. According parents in the southeastern United States. She and
to Fawcett (1989, 1995b), the model meets social con- her children have recently relocated from an urban
siderations of congruence, significance, and utility. neighborhood to a rural town to care for her parents,
The model is broad and systems based. It lends itself Robert and Susan. The move involved a job change
well to a comprehensive approach for nurses to evalu- for Elizabeth, a change in schools for the children,
ate evidence and respond to the world’s rapidly chang- and an increased distance from the children’s father.
ing health care needs.
Robert is a 72-year-old Methodist minister who
recently suffered a stroke, leaving him with dimin-
SUMMARY ished motor function on his left side and difficulty
The Neuman Systems Model is derived from general swallowing. Susan is 68 years old and suffers from
fibromyalgia, limiting her ability to assist with the
system theory. Its focus is on the client as a system daily care of her husband. She has experienced an
(which may be an individual, family, group, or com- increase in generalized pain, difficulty sleeping, and
munity) and on the client’s responses to stressors. The worsening fatigue since her husband’s stroke.
client system includes five variables (physiological, Use the Neuman Systems Model as a conceptual
psychological, sociocultural, developmental, and framework to respond to the following:
spiritual) and is conceptualized as an inner core n Describe the Jefferies family as a client system
(basic energy resources) surrounded by concentric using each of the five variables.
circles that include lines of resistance, a normal line of n What are the actual and potential stressors that
defense, and a flexible line of defense. Each of the five threaten the family? Which of these stressors are
variables is considered in each of the concentric positive, and which are negative? What actual
circles. Stressors are tension-producing stimuli that and potential stressors threaten the individual
may be intrapersonal, interpersonal, or extrapersonal members of the family? Which of these stressors
in nature. are positive, and which are negative?
The model proposes three levels of nursing inter- n What additional nursing assessment data are
vention (primary prevention, secondary prevention, needed considering Robert’s medical diagnoses?
tertiary prevention) based on Caplan’s concept of lev- What additional data would be helpful for
els of prevention (1964). The purpose of prevention as Susan’s medical diagnoses?
intervention is to achieve the maximum possible level n What levels of prevention intervention(s) are
of client system stability. Neuman suggests a nursing appropriate for the Jefferies family? What levels
process format in which the client, as a recipient of of prevention intervention(s) are appropriate
care, participates actively with the nurse as caregiver for each individual member of the family?
to set goals and select interventions.

CHAPTER 16 Betty Neuman 293

CRITICAL THINKING ACTIVITIES
Community as Client What factors in the lines of defense support
Select one organization with which you are familiar healthy organizational functioning?
that would be considered a community, based on it 2. What stressors, actual or potential, may disrupt
having face-to-face interaction and a shared set of the organization as a system and result in change?
interests or values. This could be a church, an 3. If the perceptions of goals by the members and
employing organization, or a civic group. Use the the leaders differ, how can the differences be
Neuman Systems Model as a framework to analyze resolved for mutual goal setting that will be
the organization as a community-client and to beneficial for the organization?
support organizational planning, as follows: 4. What prevention as intervention strategies would
1. What is the basic structure (core)? What factors support the organization in making changes
in the lines of resistance support the status quo? successful?

POINTS FOR FURTHER STUDY

n Geib, K. (2010). Neuman System’s Model in nurs- n Lists of Neuman research publications at: www.
ing practice. In M. R. Alligood, (Ed.), Nursing neumann.edu/academics/undergrad/nursing/
theory: Utilization and application (4th ed., model
pp. 235–260). Maryland Heights, (MO): Mosby- n The Neuman Archives that preserve and protect
Elsevier at: www.neumansystemsmodel.org works related to the model are housed in the
n Neuman, B., & Fawcett, J. (2011). The Neuman Neumann College Library in Aston, (PA).
systems model (5th ed.). Upper Saddle River, (NJ):
Pearson.
n Neuman, B., & Reed, K. S. (2007). A Neuman
systems model perspective on nursing in 2050.
Nursing Science Quarterly, 20(2), 111–113.


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17

CHAP TER



















Sister Callista Roy
1939 to present


Adaptation Model


Kenneth D. Phillips and Robin Harris



“God is intimately revealed in the diversity of creation and is the common destiny of creation;
persons use human creative abilities of awareness, enlightenment, and faith; and persons
are accountable for the process of deriving, sustaining, and transforming the universe”
(Roy, 2000, p. 127).




While working toward her master’s degree, Roy
Credentials and Background was challenged in a seminar with Dorothy E. Johnson
of the Theorist to develop a conceptual model for nursing. While
Sister Callista Roy, a member of the Sisters of Saint working as a pediatric staff nurse, Roy had noticed
Joseph of Carondelet, was born on October 14, 1939, the great resiliency of children and their ability to
in Los Angeles, California. She received a bachelor’s adapt in response to major physical and psychological
degree in nursing in 1963 from Mount Saint Mary’s changes. Roy was impressed by adaptation as an
College in Los Angeles and a master’s degree in nurs- appropriate conceptual framework for nursing. Roy
ing from the University of California, Los Angeles, in developed the basic concepts of the model while she
1966. After earning her nursing degrees, Roy began was a graduate student at the University of California,
her education in sociology, receiving both a master’s Los Angeles, from 1964 to 1966. Roy began opera-
degree in sociology in 1973 and a doctorate degree in tionalizing her model in 1968 when Mount Saint
sociology in 1977 from the University of California. Mary’s College adopted the adaptation framework as



Previous authors: Kenneth D. Phillips, Carolyn L. Blue, Karen M. Brubaker, Julia M. B. Fine, Martha J. Kirsch, Katherine R.
Papazian, Cynthia M. Riester, and Mary Ann Sobiech. The author wishes to express appreciation to Sister Callista Roy for
critiquing the chapter.

303

304 UNIT III Nursing Conceptual Models

the philosophical foundation of the nursing curricu-
lum. The Roy Adaptation Model was first presented Theoretical Sources
in the literature in an article published in Nursing Derivation of the Roy Adaptation Model for nursing
Outlook in 1970 entitled “Adaptation: A Conceptual included a citation of Harry Helson’s work in psycho-
Framework for Nursing” (Roy, 1970). physics that extended to social and behavioral sciences
Roy was an associate professor and chairperson of (Roy, 1984). In Helson’s adaptation theory, adaptive
the Department of Nursing at Mount Saint Mary’s responses are a function of the incoming stimulus and
College until 1982. She was promoted to the rank of the adaptive level (Roy, 1984). A stimulus is any factor
professor in 1983 at both Mount Saint Mary’s College that provokes a response. Stimuli may arise from the
and the University of Portland. She helped initiate and internal or the external environment (Roy, 1984).
taught in a summer master’s program at the University The adaptation level is made up of the pooled effect of
of Portland. From 1983 to 1985, she was a Robert the following three classes of stimuli:
Wood Johnson postdoctoral fellow at the University of 1. Focal stimuli immediately confront the individual.
California, San Francisco, as a clinical nurse scholar 2. Contextual stimuli are all other stimuli present that
in neuroscience. During this time, she conducted contribute to the effect of the focal stimulus.
research on nursing interventions for cognitive recov- 3. Residual stimuli are environmental factors of which
ery in head injuries and on the influence of nursing the effects are unclear in a given situation.
models on clinical decision making. In 1987, Roy Helson’s work developed the concept of the adapta-
began the newly created position of nurse theorist at tion level zone, which determines whether a stimulus
Boston College School of Nursing. will elicit a positive or negative response. According
Roy has published many books, chapters, and peri- to Helson’s theory, adaptation is the process of
odical articles and has presented numerous lectures and responding positively to environmental changes (Roy
workshops focusing on her nursing adaptation theory & Roberts, 1981).
(Roy & Andrews, 1991). The refinement and restatement Roy (Roy & Roberts, 1981) combined Helson’s
of the Roy Adaptation Model is published in her 1999 work with Rapoport’s definition of system to view
book, The Roy Adaptation Model (Roy & Andrews, 1999). the person as an adaptive system. With Helson’s
Roy is a member of Sigma Theta Tau, and she adaptation theory as a foundation, Roy (1970) devel-
received the National Founder’s Award for Excellence oped and further refined the model with concepts
in Fostering Professional Nursing Standards in 1981. and theory from Dohrenwend, Lazarus, Mechanic,
Her achievements include an Honorary Doctorate and Selye. Roy gave special credit to co-authors
of Humane Letters from Alverno College (1984), hon- Driever, for outlining subdivisions of self-integrity,
orary doctorates from Eastern Michigan University and Martinez and Sato, for identifying common and
(1985) and St. Joseph’s College in Maine (1999), and an primary stimuli affecting the modes. Other co-
American Journal of Nursing Book of the Year Award for workers also elaborated the concepts. Poush-Tedrow
Essentials of the Roy Adaptation Model (Andrews & Roy, and Van Landingham made contributions to the
1986). Roy has been recognized as the World Who’s interdependence mode, and Randell made contribu-
Who of Women (1979); Personalities of America tions to the role function mode.
(1978); fellow of the American Academy of Nursing After the development of her model, Roy presented
(1978); recipient of a Fulbright Senior Scholar Award it as a framework for nursing practice, research, and
from the Australian-American Educational Foundation education. Roy (1971) acknowledged that more than
(1989), ) and received the Martha Rogers Award for 1500 faculty and students contributed to the theoreti-
Advancing Nursing Science from the National League cal development of the adaptation model. She pre-
for Nursing (1991). Roy received the Outstanding sented the model as a curriculum framework to a large
Alumna award and the prestigious Carondelet Medal audience at the 1977 Nurse Educator Conference in
from her alma mater, Mount Saint Mary’s. The American Chicago (Roy, 1979). And, by 1987, it was estimated
Academy of Nursing honored Roy for her extraordi- that more than 100,000 nurses in the United States and
nary life achievements by recognizing her as a Living Canada had been prepared to practice using the Roy
Legend (2007). model.

CHAPTER 17 Sister Callista Roy 305

In Introduction to Nursing: An Adaptation Model, person-environment systems of the earth are so exten-
Roy (1976a) discussed self-concept and group identity sive that a major epoch is ending (Davies, 1988;
mode. She and her collaborators cited the work of De Chardin, 1966). During the 67 million years of the
Coombs and Snygg regarding self-consistency and Cenozoic era, the Age of Mammals and an era of great
major influencing factors of self-concept (Roy, 1984). creativity, human life appeared on Earth. During this
Social interaction theories are cited to provide a theo- era, humankind has had little or no influence on the
retical basis. For example, Roy (1984) notes that Cooley universe (Roy, 1997). “As the era closes, humankind
(1902) theorizes that self-perception is influenced by has taken extensive control of the life systems of the
perceptions of others’ responses, termed the “looking earth. Roy claims that we are now in the position
glass self.” She points out that Mead expands the idea of deciding what kind of universe we will inhabit”
by hypothesizing that self-appraisal uses the general- (Roy, 1997, p. 42). Roy “has made the foci of assump-
ized other. Roy builds on Sullivan’s suggestion that self tions of the twenty-first century mutual complex
arises from social interaction (Roy, 1984). Gardner and person and environment self-organization and a mean-
Erickson support Roy’s developmental approaches ingful destiny of convergence of the universe, persons,
(Roy, 1984). The other modes—physiological-physical, and environment in what can be considered a supreme
role function, and interdependence—were drawn sim- being or God” (Roy & Andrews, 1999, p. 395). Accord-
ilarly from biological and behavioral sciences for an ing to Roy (1997), “persons are coextensive with their
understanding of the person. physical and social environments” (p. 43) and they
Additional development of the model occurred “share a destiny with the universe and are responsible
during the later 1900s and into the twenty-first century. for mutual transformations” (Roy & Andrews, 1999,
These developments included updated scientific and p. 395). Developments of the model that were related
philosophical assumptions; a redefinition of adaptation to the integral relationship between person and
and adaptation levels; extension of the adaptive modes environment have been influenced by Pierre Teilhard
to group-level knowledge development; and analysis, De Chardin’s law of progressive complexity and
critique, and synthesis of the first 25 years of research increasing consciousness (De Chardin, 1959, 1965,
based on the Roy Adaptation Model. Roy agrees 1966, 1969) and the work of Swimme and Berry
with other theorists who believe that changes in the (1992).


MAJOR CONCEPTS & DEFINITIONS

System can respond with ordinary adaptive responses”
A system is “a set of parts connected to function as a (Roy, 1984, pp. 27–28).
whole for some purpose and that does so by virtue of Adaptation Problems
the interdependence of its parts” (Roy & Andrews,
1999, p. 32). In addition to having wholeness and Adaptation problems are “broad areas of concern
related parts, “systems also have inputs, outputs, and related to adaptation. These describe the difficulties
control and feedback processes” (Andrews & Roy, related to the indicators of positive adaptation”
1991, p. 7). (Roy & Andrews, 1999, p. 65). Roy (1984) states the
following:
Adaptation Level It can be noted at this point that the distinction
“Adaptation level represents the condition of the being made between adaptation problems and
life processes described on three levels as integrated, nursing diagnoses is based on the developing
compensatory, and compromised” (Roy & Andrews, work in both of these fields. At this point, adapta-
1999, p. 30). A person’s adaptation level is “a con- tion problems are seen not as nursing diagnoses,
stantly changing point, made up of focal, contextual, but as areas of concern for the nurse related to
and residual stimuli, which represent the person’s adapting person or group (within each adaptive
own standard of the range of stimuli to which one mode) (pp. 89–90).
Continued

306 UNIT III Nursing Conceptual Models

MAJOR CONCEPTS & DEFINITIONS—cont’d

Focal Stimulus Adaptive Responses
The focal stimulus is “the internal or external stimulus Adaptive responsesare those “that promote integrity
most immediately confronting the human system” in terms of the goals of human systems” (Roy &
(Roy & Andrews, 1999, p. 31). Andrews, 1999, p. 31).
Contextual Stimuli Ineffective Responses
Contextual stimuli “are all other stimuli present in Ineffective responses are those “that do not contribute
the situation that contribute to the effect of the focal to integrity in terms of the goals of the human system”
stimulus” (Roy & Andrews, 1999, p. 31), that is, (Roy & Andrews, 1999, p. 31).
“contextual stimuli are all the environmental factors
that present to the person from within or without Integrated Life Process
but which are not the center of the person’s attention Integrated life process refers to the “adaptation level
and/or energy” (Andrews & Roy, 1991, p. 9). at which the structures and functions of a life pro-
cess are working as a whole to meet human needs”
Residual Stimuli (Roy & Andrews, 1999, p. 31).
Residual stimuli “are environmental factors within
or without the human system with effects in the cur- Physiological-Physical Mode
rent situation that are unclear” (Roy & Andrews, The physiological mode “is associated with the physi-
1999, p. 32). cal and chemical processes involved in the function
and activities of living organisms” (Roy & Andrews,
Coping Processes 1999, p. 102). Five needs are identified in the physio-
Coping processes “are innate or acquired ways of logical-physical mode relative to the basic need of
interacting with the changing environment” (Roy & physiological integrity as follows: (1) oxygenation,
Andrews, 1999, p. 31). (2) nutrition, (3) elimination, (4) activity and rest,
and (5) protection. Complex processes that include
Innate Coping Mechanisms the senses; fluid, electrolyte, and acid-base balance;
Innate coping mechanisms “are genetically deter- neurological function; and endocrine function con-
mined or common to the species and are generally tribute to physiological adaptation. The basic need of
viewed as automatic processes; humans do not have the physiological mode is physiological integrity
to think about them” (Roy & Andrews, 1999, p. 46). (Roy & Andrews, 1999). The physical mode is “the
manner in which the collective human adaptive sys-
Acquired Coping Mechanisms tem manifests adaptation relative to basic operating
Acquired coping mechanisms “are developed through resources, participants, physical facilities, and fiscal
strategies such as learning. The experiences encoun- resources” (Roy & Andrews, 1999, p. 104). The basic
tered throughout life contribute to customary responses need of the physical mode is operating integrity.
to particular stimuli” (Roy & Andrews, 1999, p. 46).
Self-Concept-Group Identity Mode
Regulator Subsystem The self-concept-group identity mode is one of the
Regulator is “a major coping process involving the three psychosocial modes; “it focuses specifically on
neural, chemical, and endocrine systems” (Roy & the psychological and spiritual aspects of the human
Andrews, 1999, p. 32). system. The basic need underlying the individual
self-concept mode has been identified as psychic
Cognator Subsystem and spiritual integrity, or the need to know who one
Cognator is “a major coping process involving four is so that one can be or exist with a sense of unity,
cognitive-emotive channels: perceptual and informa- meaning, and purposefulness in the universe” (Roy
tion processing, learning, judgment, and emotion” & Andrews, 1999, p. 107). “Self-concept is defined
(Roy & Andrews, 1999, p. 31). as the composite of beliefs and feelings about oneself

CHAPTER 17 Sister Callista Roy 307

MAJOR CONCEPTS & DEFINITIONS—cont’d

at a given time and is formed from internal percep- activities such as clubs or hobbies (Andrews,
tions and perceptions of others’ reactions” (Roy & 1991, p. 349).
Andrews, 1999, p. 107). Its components include the The major roles that one plays can be analyzed by
following: (1) the physical self, which involves sen- imagining a tree formation. The trunk of the tree is
sation and body image, and (2) the personal self, one’s primary role, or developmental level, such as a
which is made up of self-consistency, self-ideal or generative adult female. Secondary roles branch off
expectancy, and the moral-ethical-spiritual self. The from this—for example, wife, mother, and teacher.
group identity mode “reflects how people in groups Finally, tertiary roles branch off from secondary
perceive themselves based on environmental feed- roles—for example, the mother role might involve
back. The group identity mode [is composed] of the role of parent-teacher association president for a
interpersonal relationships, group self-image, social given period. Each of these roles is seen as occurring
milieu, and culture” (Roy & Andrews, 1999, p. 108). in a dyadic relationship, that is, with a reciprocal
The basic need of the group identity mode is identity role (Roy & Andrews, 1999).
integrity (Roy & Andrews, 1999).
Interdependence Mode
Role Function Mode
The role function mode “is one of two social modes “The interdependence mode focuses on close rela-
and focuses on the roles the person occupies in tionships of people (individually and collectively)
society. A role, as the functioning unit of society, is and their purpose, structure, and develop-
defined as a set of expectations about how a person ment . . . Interdependent relationships involve the
occupying one position behaves toward a person willingness and ability to give to others and accept
occupying another position. The basic need under- from them aspects of all that one has to offer such
lying the role function mode has been identified as love, respect, value, nurturing, knowledge,
as social integrity—the need to know who one is skills, commitments, material possessions, time,
in relation to others so that one can act” (Hill & and talents” (Roy & Andrews, 1999, p. 111).
Roberts, 1981, pp. 109–110). Persons perform pri- The basic need of this mode is termed rela-
mary, secondary, and tertiary roles. These roles are tional integrity (Roy & Andrews, 1999).
carried out with both instrumental and expressive be- Two specific relationships are the focus of the
haviors. Instrumental behavior is “the actual physical interdependence mode as it applies to individu-
performance of a behavior” (Andrews, 1991, p. 348). als. The first is with significant others, persons
Expressive behaviors are “the feelings, attitudes, likes who are the most important to the individual.
or dislikes that a person has about a role or about the The second is with support systems, that is, oth-
performance of a role” (Andrews, 1991, p. 348). ers contributing to meeting interdependence
needs (Roy & Andrews, 1999, p. 112).
The primary role determines the majority of
behavior engaged in by the person during a par- Two major areas of interdependence behaviors have
ticular period of life. It is determined by age, sex, been identified: receptive behavior and contributive
and developmental stage (Andrews, 1991, p. 349). behavior. These behaviors apply respectively to the
Secondary roles are those that a person “receiving and giving of love, respect and value in
assumes to complete the task associated with a interdependent relationships” (Roy & Andrews,
developmental stage and primary role (Andrews, 1999, p. 112).
1991, p. 349).
Tertiary roles are related primarily to second- Perception
ary roles and represent ways in which individuals “Perception is the interpretation of a stimulus and the
meet their role associated obligations . . . Tertiary conscious appreciation of it” (Pollock, 1993, p. 169).
roles are normally temporary in nature, freely Perception links the regulator with the cognator and
chosen by the individual, and may include connects the adaptive modes (Rambo, 1983).

308 UNIT III Nursing Conceptual Models

Use of Empirical Evidence Major Assumptions

From this beginning, the Roy Adaptation Model has Assumptions from systems theory and assumptions
been supported through research in practice and in from adaptation level theory have been combined
education (Brower & Baker, 1976; Farkas, 1981; Mastal into a single set of scientific assumptions. From
& Hammond, 1980; Meleis, 1985, 2007; Roy, 1980; Roy systems theory, human adaptive systems are viewed
& Obloy, 1978; Wagner, 1976). In 1999 (Roy & as interactive parts that act in unity for some pur-
Andrews, 1999), a group of seven scholars working with pose. Human adaptive systems are complex and
Roy conducted a meta-analysis, critique, and synthesis multifaceted and respond to a myriad of environ-
of 163 studies based on the Roy Adaptation Model that mental stimuli to achieve adaptation. With their
had been published in 44 English language journals on ability to adapt to environmental stimuli, humans
five continents and dissertations and theses from the have the capacity to create changes in the environ-
United States. Of these 163 studies, 116 met the criteria ment (Roy & Andrews, 1999). Drawing on charac-
established for testing propositions from the model. teristics of creation spirituality by Swimme and
Twelve generic propositions based on Roy’s earlier work Berry (1992), Roy combined the assumptions of
were derived. To synthesize the research, findings of humanism and veritivity into a single set of philo-
each study were used to state ancillary and practice sophical assumptions. Humanism asserts that the
propositions, and support for the propositions was person and human experiences are essential to
examined. Of 265 propositions tested, 216 (82%) were knowing and valuing, and that they share in creative
supported. Roy (2011a) presented a comprehensive power. Veritivity affirms the belief in the purpose,
review of research based on the adaptation model for value, and meaning of all human life. These scientific
the last 25 years in Nursing Science Quarterly, volume and philosophical assumptions have been refined
24, number 4. The complete issue is dedicated to honor- for use of the model in the twenty-first century
ing Callista Roy and her life work. (Box 17–1).




BOX 17-1 Vision Basic to Concepts for the Twenty-First Century
Scientific Assumptions
n Systems of matter and energy progress to higher levels of complex self-organization.
n Consciousness and meaning are constitutive of person and environment integration.
n Awareness of self and environment is rooted in thinking and feeling.
n Humans, by their decisions, are accountable for the integration of creative processes.
n Thinking and feeling mediate human action.
n System relationships include acceptance, protection, and fostering of interdependence.
n Persons and the earth have common patterns and integral relationships.
n Persons and environment transformations are created in human consciousness.
n Integration of human and environment meanings results in adaptation.

Philosophical Assumptions
n Persons have mutual relationships with the world and God.
n Human meaning is rooted in an omega point convergence of the universe.
n God is ultimately revealed in the diversity of creation and is the common destiny of creation.
n Persons use human creative abilities of awareness, enlightenment, and faith.
n Persons are accountable for the processes of deriving, sustaining, and transforming the universe.

From Roy, C., & Andrews, H. (1999). The Roy adaptation model (2nd ed., p. 35). Upper Saddle River, NJ: Pearson.

CHAPTER 17 Sister Callista Roy 309

and by intervening to promote adaptive abilities
Adaptation and to enhance environment interactions (Roy &
Roy has further defined adaptation for use in the Andrews, 1999).
twenty-first century (Roy & Andrews, 1999). According
to Roy, adaptation refers to “the process and outcome Person
whereby thinking and feeling persons, as individuals or According to Roy, humans are holistic, adaptive sys-
in groups, use conscious awareness and choice to create tems. “As an adaptive system, the human system is
human and environmental integration” (Roy & described as a whole with parts that function as unity
Andrews, 1999, p. 30). Rather than being a human sys- for some purpose. Human systems include people as
tem that simply strives to respond to environmental individuals or in groups, including families, organiza-
stimuli to maintain integrity, every human life is pur- tions, communities, and society as a whole” (Roy &
poseful in a universe that is creative, and persons are Andrews, 1999, p. 31). Despite their great diversity,
inseparable from their environment. all persons are united in a common destiny (Roy &
Andrews, 1999). “Human systems have thinking and
feeling capacities, rooted in consciousness and mean-
Nursing ing, by which they adjust effectively to changes in the
Roy defines nursing broadly as a “health care profession environment and, in turn, affect the environment”
that focuses on human life processes and patterns and (Roy & Andrews, 1999, p. 36). Persons and the earth
emphasizes promotion of health for individuals, fami- have common patterns and mutuality of relations and
lies, groups, and society as a whole” (Roy & Andrews, meaning (Roy & Andrews, 1999). Roy (Roy &
1999, p. 4). Specifically, Roy defines nursing according Andrews, 1999) defined the person as the main focus
to her model as the science and practice that expands of nursing, the recipient of nursing care, a living,
adaptive abilities and enhances person and environ- complex, adaptive system with internal processes
mental transformation. She identifies nursing activities (cognator and regulator) acting to maintain adapta-
as the assessment of behavior and the stimuli that influ- tion in the four adaptive modes (physiological, self-
ence adaptation. Nursing judgments are based on this concept, role function, and interdependence).
assessment, and interventions are planned to manage
the stimuli (Roy & Andrews, 1999). Roy differentiates Health
nursing as a science from nursing as a practice disci- “Health is a state and a process of being and becoming
pline. Nursing science is… “a developing system of integrated and a whole person. It is a reflection of
knowledge about persons that observes, classifies, and adaptation, that is, the interaction of the person and
relates the processes by which persons positively affect the environment” (Andrews & Roy, 1991, p. 21). Roy
their health status” (Roy, 1984, pp. 3–4). Nursing as a (1984) derived this definition from the thought that
practice discipline is “nursing’s scientific body adaptation is a process of promoting physiological,
of knowledge used for the purpose of providing an psychological, and social integrity, and that integrity
essential service to people, that is, promoting ability to implies an unimpaired condition leading to com-
affect health positively” (Roy, 1984, pp. 3–4). “Nursing pleteness or unity. In her earlier work, Roy viewed
acts to enhance the interaction of the person with the health along a continuum flowing from death and
environment—to promote adaptation” (Andrews & extreme poor health to high-level and peak wellness
Roy, 1991, p. 20). (Brower & Baker, 1976). During the late 1990s, Roy’s
Roy’s goal of nursing is “the promotion of adapta- writings focused more on health as a process in which
tion for individuals and groups in each of the four health and illness can coexist (Roy & Andrews, 1999).
adaptive modes, thus contributing to health, quality Drawing on the writings of Illich (1974, 1976), Roy
of life, and dying with dignity” (Roy & Andrews, 1999, wrote, “health is not freedom from the inevitability of
p. 19). Nursing fills a unique role as a facilitator of death, disease, unhappiness, and stress, but the ability
adaptation by assessing behavior in each of these four to cope with them in a competent way” (Roy &
adaptive modes and factors influencing adaptation Andrews, 1999, p. 52).

310 UNIT III Nursing Conceptual Models

Health and illness is one inevitable, coexistent ineffective response. Adaptive responses promote integ-
dimension of the person’s total life experience (Riehl rity and help the person to achieve the goals of adapta-
& Roy, 1980). Nursing is concerned with this dimen- tion, that is, they achieve survival, growth, reproduction,
sion. When mechanisms for coping are ineffective, mastery, and person and environmental transforma-
illness is the result. Health ensues when humans con- tions. Ineffective responses fail to achieve or threaten the
tinually adapt. As people adapt to stimuli, they are goals of adaptation. Nursing has a unique goal to assist
free to respond to other stimuli. The freeing of energy the person’s adaptation effort by managing the environ-
from ineffective coping attempts can promote healing ment. The result is attainment of an optimal level of
and enhance health (Roy, 1984). wellness by the person (Andrews & Roy, 1986; Randell,
Tedrow, & Van Landingham, 1982; Roy, 1970, 1971,
Environment 1980, 1984; Roy & Roberts, 1981).
According to Roy, environment is “all the conditions, As an open living system, the person receives
circumstances, and influences surrounding and affect- inputs or stimuli from both the environment and
ing the development and behavior of persons or groups, the self. The adaptation level is determined by the
with particular consideration of the mutuality of person combined effect of focal, contextual, and residual
and earth resources that includes focal, contextual, and stimuli. Adaptation occurs when the person responds
residual stimuli” (Roy & Andrews, 1999, p. 81). “It is the positively to environmental changes. This adaptive
changing environment [that] stimulates the person to response promotes the integrity of the person, which
make adaptive responses” (Andrews & Roy, 1991, p. 18). leads to health. Ineffective responses to stimuli lead to
Environment is the input into the person as an adaptive disruption of the integrity of the person (Andrews &
system involving both internal and external factors. Roy, 1986; Randell, Tedrow, & Van Landingham,
These factors may be slight or large, negative or posi- 1982; Roy, 1970, 1971, 1980; Roy & McLeod, 1981).
tive. However, any environmental change demands There are two interrelated subsystems in Roy’s model
increasing energy to adapt to the situation. Factors in (Figure 17–1). The primary, functional, or control pro-
the environment that affect the person are categorized cesses subsystem consists of the regulator and the cog-
as focal, contextual, and residual stimuli. nator. The secondary, effector subsystem consists of the
following four adaptive modes: (1) physiological needs,
(2) self-concept, (3) role function, and (4) interdepen-
Theoretical Assertions dence (Andrews & Roy, 1986; Limandri, 1986; Mastal,
Roy’s model focuses on the concept of adaptation of the Hammond, & Roberts, 1982; Meleis, 1985, 2007; Riehl
person. Her concepts of nursing, person, health, and & Roy, 1980; Roy, 1971, 1975).
environment are all interrelated to this central concept. Roy views the regulator and the cognator as meth-
The person continually experiences environmental ods of coping. The regulator coping subsystem, by way
stimuli. Ultimately, a response is made and adaptation of the physiological adaptive mode, “responds auto-
occurs. This response may be either an adaptive or an matically through neural, chemical, and endocrine


Input Control Effectors Output
processes

Coping Physiological function Adaptive
Stimuli mechanisms Self-concept and
Adaptation Regulator Role function ineffective
level
Cognator Interdependence responses


Feedback
FIGURE 17-1 Person as an adaptive system. (From Roy, C.. [1984]. Introduction to nursing: An adaptation
model [2nd ed., p. 30]. Englewood Cliffs, NJ: Prentice Hall.)

CHAPTER 17 Sister Callista Roy 311

coping processes” (Andrews & Roy, 1991, p. 14). The
cognator coping subsystem, by way of the self-concept, HUMAN SYSTEMS
interdependence, and role function adaptive modes,
“responds through four cognitive-emotive channels: PHYSIOLOGICAL- SELF-
perceptual information processing, learning, judgment, STIMULI PHYSICAL CONCEPT–
and emotion” (Andrews & Roy, 1991, p. 14). Perception GROUP
is the interpretation of a stimulus, and perception links IDENTITY
the regulator with the cognator in that “input into the COPING
regulator is transformed into perceptions. Perception PROCESSES
is a process of the cognator. The responses following BEHAVIOR
perception are feedback into both the cognator and the INTERDEPENDENCE
regulator” (Galligan, 1979, p. 67). ROLE
The four adaptive modes of the two subsystems in FUNCTION
Roy’s model provide form or manifestations of cognator
BEHAVIOR
and regulator activity. Responses to stimuli are carried ADAPTATION
out through four adaptive modes. The physiological- FIGURE 17-2 Diagrammatic representation of human adap-
physical adaptive mode is concerned with the way tive systems. (From Roy, C., & Andrews, H. [1999]. The Roy
humans interact with the environment through physi- adaptation model [2nd ed.]. Upper Saddle River, NJ: Pearson.)
ological processes to meet the basic needs of oxygen-
ation, nutrition, elimination, activity and rest, and
protection. The self-concept group identity adaptive
mode is concerned with the need to know who one is Relationships among the four adaptive modes occur
and how to act in society. An individual’s self-concept is when internal and external stimuli affect more than
defined by Roy as “the composite of beliefs or feelings one mode, when disruptive behavior occurs in more
that an individual holds about him- or herself at any than one mode, or when one mode becomes the
given time” (Roy & Andrews, 1999, p. 49). An individ- focal, contextual, or residual stimulus for another
ual’s self-concept is composed of the physical self (body mode (Brower & Baker, 1976; Chinn & Kramer,
sensation and body image) and the personal self (self- 2008; Mastal & Hammond, 1980).
consistency, self-ideal, and moral-ethical-spiritual self). With regard to human social systems, Roy broadly
The role function adaptive mode describes the primary, categorizes the control processes into the stabilizer
secondary, and tertiary roles that an individual per- and innovator subsystems. The stabilizer subsystem is
forms in society. A role describes the expectations about analogous to the regulator subsystem of the individ-
how one person behaves toward another person. The ual and is concerned with stability. To maintain the
interdependence adaptive mode describes the interac- system, the stabilizer subsystem involves organiza-
tions of people in society. The major task of the interde- tional structure, cultural values, and regulation of
pendence adaptive mode is for persons to give and daily activities of the system. The innovator subsys-
receive love, respect, and value. The most important tem is associated with the cognator subsystem of the
components of the interdependence adaptive mode are individual and is concerned with creativity, change,
a person’s significant other (spouse, child, friend, or and growth (Roy & Andrews, 1999).
God) and his or her social support system. The purpose
of the four adaptive modes is to achieve physiological,
psychological, and social integrity. The four adaptive Logical Form
modes are interrelated through perception (Roy & The Roy Adaptation Model of nursing is both deduc-
Andrews, 1999) (Figure 17–2). tive and inductive. It is deductive in that much
The person as a whole is made up of six subsys- of Roy’s theory is derived from Helson’s psychophys-
tems. These subsystems (the regulator, the cognator, ics theory. Helson developed the concepts of focal,
and the four adaptive modes) are interrelated to form contextual, and residual stimuli, which Roy (1971)
a complex system for the purpose of adaptation. redefined within nursing to form a typology of factors

312 UNIT III Nursing Conceptual Models

related to adaptation levels of persons. Roy also uses 3. Makes a statement or nursing diagnosis of the
other concepts and theory outside the discipline of person’s adaptive state
nursing and synthesizes these within her adaptation 4. Sets goals to promote adaptation
theory. 5. Implements interventions aimed at managing the
Roy’s adaptation theory is inductive in that she stimuli to promote adaptation
developed the four adaptive modes from research and 6. Evaluates whether the adaptive goals have been met
nursing practice experiences of herself, her colleagues, By manipulating the stimuli and not the patient, the
and her students. Roy built on the conceptual frame- nurse enhances “the interaction of the person with their
work of adaptation and developed a step-by-step environment, thereby promoting health” (Andrews &
model by which nurses use the nursing process Roy, 1986, p. 51). The nursing process is well suited for
to administer nursing care to promote adaptation use in a practice setting. The two-level assessment is
in situations of health and illness (Roy, 1976a, 1980, unique to this model and leads to the identification of
1984). adaptation problems or nursing diagnoses.
Roy and colleagues have developed a typology of
Acceptance by the Nursing Community nursing diagnoses from the perspective of the Roy
Adaptation Model (Roy, 1984; Roy & Roberts, 1981).
Practice In this typology, commonly recurring problems have
The Roy Adaptation Model is deeply rooted in nursing been related to the basic needs of the four adaptive
practice, and this, in part, contributes to its continued modes (Andrews & Roy, 1991).
success (Fawcett, 2002). It remains one of the most fre- Intervention is based specifically on the model, but
quently used conceptual frameworks to guide nursing there is a need to develop an organization of categories
practice, and it is used nationally and internationally of nursing interventions (Roy & Roberts, 1981). Nurses
(Roy & Andrews, 1999; Fawcett, 2005). provide interventions that alter, increase, decrease,
Roy’s model is useful for nursing practice, because remove, or maintain stimuli (Roy & Andrews, 1999).
it outlines the features of the discipline and provides The nursing judgment model outlined by McDonald
direction for practice, education, and research. The and Harms (1966) is recommended by Roy to guide
model considers goals, values, the patient, and practi- selection of the best intervention for modifying a par-
tioner interventions. Roy’s nursing process is well ticular stimulus. According to this model, a number
developed. The two-level assessment assists in identi- of alternative interventions are generated that may be
fication of nursing goals and diagnoses (Brower & appropriate for modifying the stimulus. Each possible
Baker, 1976). intervention is judged for the expected consequences
Early on, it was recognized as a valuable theory of modifying a stimulus, the probability that a conse-
for nursing practice because of the goal that specified quence will occur (high, moderate, or low), and the
its aim for activity and a prescription for activities value of the change (desirable or undesirable).
to realize the goal (Dickoff, James, & Wiedenbach, Senesac (2003) reviewed the literature for evidence
1968a, 1968b). The goal of nursing and of the model that the Roy Adaptation Model is being implemented
is adaptation in four adaptive modes in a person’s in nursing practice. She reported that the Roy Adap-
health and illness. The prescriptive interventions are tation Model has been used to the greatest extent by
when the nurse manages stimuli by removing, individual nurses to understand, plan, and direct
increasing, decreasing, or altering them. These pre- nursing practice in the care of individual patients.
scriptions may be found in the list of practice-related Although fewer examples of implementation of the
hypotheses generated by the model (Roy, 1984). adaptation model are found in institutional practice
When using Roy’s six-step nursing process, the settings, such examples do exist. She concluded that if
nurse performs the following six functions: the model is to be implemented successfully as a prac-
1. Assesses the behaviors manifested from the four tice philosophy, it should be reflected in the mission
adaptive modes and vision statements of the institution, recruitment
2. Assesses the stimuli for those behaviors and catego- tools, assessment tools, nursing care plans, and other
rizes them as focal, contextual, or residual stimuli documents related to patient care.

CHAPTER 17 Sister Callista Roy 313

The Roy Adaptation Model is useful in guiding Samarel, Tulman, and Fawcett (2002) examined
nursing practice in institutional settings. It has been the effects of two types of social support (telephone
implemented in a neonatal intensive care unit, an and group social support) and education on adapta-
acute surgical ward, a rehabilitation unit, two general tion to early-stage breast cancer in a sample of 125
hospital units, an orthopedic hospital, a neurosurgical women. Women in the experimental group received
unit, and a 145-bed hospital, among others (Roy & both types of social support and education (n 5 34);
Andrews, 1999). women in the first control group received only tele-
Weiland (2010) described use of the Roy Adapta- phone support and education, and women in the
tion Model in the critical care setting by advanced second control group received only education. Mood
practice nurses to incorporate spiritual care into nurs- disturbance and loneliness were reduced significantly
ing care of patients and families. Spiritual care is an for the experimental group and for the first control
important, but often overlooked, aspect of nursing group but were not reduced for the second control
care for patients in the critical care setting. group. No differences were observed among the groups
The Roy Adaptation Model has been applied to in terms of cancer-related worry or well-being. This
the nursing care of individual groups of patients. study provides an excellent example of how the Roy
Examples of the wide range of applications of the Roy Adaptation Model can be used to guide the conceptu-
Adaptation Model are found in the literature. Villar- alization, literature review, theory construction, and
eal (2003) applied the Roy Adaptation Model to the development of an intervention.
care of young women who were contemplating smok- Zeigler, Smith, and Fawcett (2004) described the use
ing cessation. The author provides a comprehensive of the Roy Adaptation Model to develop a community-
discussion of the use of Roy’s six-step nursing pro- based breast cancer support group, the Common Jour-
cess to guide nursing care for women in their mid- ney Breast Cancer Support Group. A qualitative study
twenties who smoked and were members of a closed design was used to evaluate the program from both
support group. The researcher performed a two-level participant and facilitator perspectives. Responses
assessment. In the first level, stimuli were identified from participants were categorized using the Roy
for each of the four adaptive modes. In the second Adaptation Model. Findings from this study showed
level, the nurse made a judgment about the focal that the program was effective in providing support for
(nicotine addiction), contextual (belief that smoking women with various stages of breast cancer.
is enjoyable, makes them feel good, relaxes them, Newman (1997a) applied the Roy Adaptation Model
brings them a sense of comfort, and is part of their to caregivers of chronically ill family members. With a
routine), and residual stimuli (beliefs and attitudes thorough review of the literature, Newman demon-
about their body image and that smoking cessation strated how the Roy Adaptation Model was used to
causes weight gain). The nurse made the nursing provide care for this population. Newman views the
diagnosis that for this group, a lack of motivation to chronically ill family member as the focal stimulus. Con-
quit smoking was related to dependency. The women textual stimuli include the caregiver’s age, gender, and
in the support group and the nurse mutually estab- relationship to the chronically ill family member. The
lished short-term goals to change behaviors, rather caregiver’s physical health status is a manifestation of the
than the long-term goal of smoking cessation. The physiological adaptive mode. The caregiver’s emotional
intervention focused on discussion of the effects of responses to caregiving (i.e., shock, fear, anger, guilt,
smoking on the body, reasons and beliefs about increased anxiety) are effective or ineffective responses
smoking and smoking cessation, stress management, of the self-concept mode. Relationships with significant
nutrition, physical activity, and self-esteem. During others and support indicate adaptive responses in the
the evaluation phase, it was determined that the interdependence mode. Caregivers’ primary, secondary,
women had moved from pre-contemplation to the and tertiary roles are strained by the addition of the
contemplation phase of smoking cessation. The author caregiving role. Practice and research implications illu-
concluded that the Roy Adaptation Model provided a minate the applicability of the Roy Adaptation Model for
useful framework for providing care to women who providing care to caregivers of chronically ill family
smoke. members.

314 UNIT III Nursing Conceptual Models

The Roy Adaptation Model has been applied than 100,000 student nurses had been educated
to adult patients with various medical conditions, in nursing programs based on the Roy Adaptation
including post-traumatic stress disorder (Nayback, Model in the United States and abroad. The Roy
2009), to women in menopause (Cunningham, 2002), Adaptation Model provides educators with a system-
and to the assessment of an elderly man undergoing atic way of teaching students to assess and care for
a right, below-the-knee amputation. The Roy Adapta- patients within the context of their lives rather than
tion Model has been used to evaluate the care just as victims of illness.
of needs of adolescents with cancer (Ramini, Brown, Dobratz (2003) evaluated the learning outcomes of
& Buckner, 2008), asthma (Buckner, Simmons, Brake- a nursing research course designed from the perspec-
field, et al., 2007), high-normal or hypertensive blood tive of the Roy Adaptation Model and described in
pressure readings (Starnes & Peters, 2004), and death detail how to teach the theoretical content to students
and dying (Dobratz, 2011). in a senior nursing research course. The evaluation
Kan (2009) used the Roy Adaptation Model tool was a Likert-type scale that contained seven
to study perceptions of recovery following coronary statements. Students were asked to disagree, agree,
artery bypass surgery for patients who had undergone or strongly agree with seven statements. Four open-
this surgery for the first time. Findings revealed a ended questions were included to elicit information
positive relationship between perception of recovery from students about the most helpful learning activ-
and role function. Knowledge of adaptive responses ity, the least helpful learning activity, methods used by
following cardiac surgery has important implications the instructor that enhanced learning and grasp of
for discharge planning and discharge teaching. research, and what the instructor could have done to
increase learning. The researcher concluded that a
Education research course based on the Roy Adaptation Model
The Roy Adaptation Model defines the distinct pur- helped students put the pieces of the research puzzle
pose of nursing for students, which is to promote the together.
adaptation of persons in each of the adaptive modes
in situations of health and illness. This model distin- Research
guishes nursing science from medical science by If research is to affect practitioners’ behaviors, it must
having the content of these areas taught in separate be directed toward testing and retesting theories
courses. She stresses collaboration but delineates derived from conceptual models for nursing prac-
separate goals for nurses and physicians. According tice. Roy (1984) has stated that theory development
to Roy (1971), it is the nurse’s goal to help the patient and the testing of developed theories are the highest
put his or her energy into getting well, whereas the priorities for nursing. The model continues to gener-
medical student focuses on the patient’s position on ate many testable hypotheses to be researched.
the health-illness continuum with the goal of causing Roy’s theory has generated a number of general
movement along the continuum. She views the model propositions. From these general propositions, spe-
as a valuable tool for analyzing the distinctions cific hypotheses can be developed and tested. Hill and
between the two professions of nursing and medi- Roberts (1981) have demonstrated the development
cine. Roy (1979) believes that curricula based on this of testable hypotheses from the model, as has Roy.
model support students’ understanding of theory Data to validate or support the model are created by
development as they learn about testing theories and the testing of such hypotheses; the model continues to
experience theoretical insights. Roy (1971, 1979) generate more of this type of research. The Roy Adap-
noted early on that the model clarified objectives, tation Model has been used extensively to guide
identified content, and specified patterns for teaching knowledge development through nursing research
and learning. (Frederickson, 2000).
The Roy Adaptation Model has been used in the Roy (1970) has identified a set of concepts that
educational setting and has guided nursing education form a model from which the process of observation
at Mount Saint Mary’s College Department of Nurs- and classification of facts would lead to postulates.
ing in Los Angeles since 1970. As early as 1987, more These postulates concern the occurrence of adaptation

CHAPTER 17 Sister Callista Roy 315

problems, coping mechanisms, and interventions an excellent fit with stage of illness, laboratory values
based on laws derived from factors that make up the (white blood cell count, hemoglobin, platelets, abso-
response potential of focal, contextual, and residual lute neutrophil count), and total number of hospital-
stimuli. Roy and colleagues have outlined a typology izations. Although it is not altogether clear how the
of adaptation problems or nursing diagnoses (Roy, focal and contextual stimuli were defined, this study
1973, 1975, 1976b). Research and testing continue in showed that environmental stimuli (severity of
the areas of typology and categories of interventions illness, age, gender, understanding of illness, and
that have been derived from the model. General prop- communication with others) influence the biopsy-
ositions also have been developed and tested (Roy & chosocial adaptive responses of children to cancer.
McLeod, 1981). Finally, this study demonstrated the interrelatedness
of the physiological (physical HRQOL), self-concept
Practice-Based Research (disease and symptoms HRQOL), interdependence
DiMattio and Tulman (2003) described changes (social HRQOL), and role function (cognitive
in functional status and correlates of functional status HRQOL) adaptive modes.
of 61 women during the 6-week postoperative period Woods and Isenberg (2001) provide an example of
following a coronary artery bypass graft. Functional theory synthesis. In their study of intimate abuse and
status was measured at 2, 4, and 6 weeks after surgery, traumatic stress in battered women, they developed a
using the Inventory of Functional Status in the Elderly middle-range theory by synthesizing the Roy Adapta-
and the Sickness Impact Profile. Significant increases tion Model with the current literature reporting on
were found in all dimensions of functional status except intimate abuse and post-traumatic stress disorder.
personal at the three measurement points. The greatest A predictive correlational model was used to examine
increases in functional status occurred at between 2 and adaptation as a mediator of intimate abuse and post-
4 weeks after surgery. However, none of the dimensions traumatic stress disorder. The focal stimulus of this
of functional status had returned to baseline values at study was the severity of intimate abuse, emotional
the 6-week point. This information will help women abuse, and risk of homicide by an intimate partner.
who have undergone coronary artery bypass graft sur- Adaptation was operationalized within the four adap-
gery to better understand the recovery period and to set tive modes and was tested as a mediator between
more realistic goals. intimate abuse and post-traumatic stress disorder.
Young-McCaughan and colleagues (2003) studied Direct relationships were reported between the focal
the effects of a structured aerobic exercise program on stimulus and intimate abuse, and adaptation in each
exercise tolerance, sleep patterns, and quality of life in of the four modes mediated relationships between the
patients with cancer from the perspective of the Roy focal stimulus and traumatic stress.
Adaptation Model. Subjects exercised for 20 minutes, Chiou (2000) conducted a meta-analysis of the
twice a week, for 12 weeks. Significant improvements interrelationships among Roy’s four adaptive modes.
in exercise tolerance, subjective sleep quality, and Using well-defined inclusion and exclusion criteria, a
psychological and physiological quality of life were literature search of the Cumulative Index to Nursing
demonstrated. and Allied Health Literature yielded eight research
Yeh (2002) tested the Roy Adaptation Model in reports with diverse samples. One in-press report was
a sample of 116 Taiwanese boys and girls with cancer included. Convenience samples for the nine studies
(7 to 18 years of age at the time of diagnosis). Two included only adults, and some were elderly. The
Roy propositions were tested. The first proposition is meta-analysis revealed small to medium correlations
that environmental stimuli (severity of illness, age, between each two mode set and a nonsignificant
gender, understanding of illness, and communication association between the interdependence and physi-
with others) influence biopsychosocial responses ological modes. Zhan (2000) found support for
(health-related quality of life [HRQOL]). The second Roy’s proposition about cognitive adaptive processes
proposition is that the four adaptive modes are inter- in relation to maintaining self-consistency. Using
related. Using structural equation modeling, the Roy’s Cognitive Adaptation Processing Scale (Roy &
researcher found that severity of illness provided Zhan, 2001) to measure cognitive adaptation and the

316 UNIT III Nursing Conceptual Models

Self-Consistency Scale (Zhan & Shen, 1994), Zhan negative relationships were found between self-esteem
found that cognitive adaptation plays an important and depression, state anger, trait anger, anger-in, anger-
role in helping older adults maintain self-consistency out, anger control, and anger expression. In the second
in the face of hearing loss. Self-consistency was higher study, adolescents were sampled from participants of
for hearing-impaired men than for hearing-impaired regularly scheduled group sessions as part of an outpa-
women, but it did not vary for age, educational level, tient psychiatric treatment program. Self-esteem sig-
race, marital status, or income. nificantly differed by age group, with older adolescents
Nuamah, Cooley, Fawcett, and McCorkle (1999) scoring lowest on self-esteem. Self-esteem did not dif-
studied quality of life in 515 patients with cancer. fer by gender or whether or not they smoked tobacco.
These researchers clearly established theoretical link- A significant negative relationship was observed
ages among the concepts of the Roy Adaptation between self-esteem and depression. Unlike their study
Model, middle-range theory concepts, and empirical in well adolescents, no statistically significant relation-
indicators. Focal and contextual stimuli were identi- ship was found between self-esteem and the dimen-
fied. Variables in each of the adaptive modes were sions of anger. Self-esteem was not significantly related
operationalized. Using structural equation modeling, to parental alcohol use in either group.
the researchers found that two of the environmental Modrcin-Talbott, Harrison, Groer, and Younger
stimuli (adjuvant cancer treatment and severity of the (2003) tested the effects of gentle human touch on the
disease) explained 59% of the variance in biopsycho- biobehavioral adaptation of preterm infants based on
social indicators of the latent variable health-related the Roy Adaptation Model. According to Roy, infants
quality of life. Their findings supported the proposi- are born with two adaptive modes: the physiological
tion of the Roy Adaptation Model that environmental and interdependence modes. Premature infants often
stimuli influence biopsychosocial responses. are deprived of human touch, and an environment
Samarel and colleagues (1998, 1999) used the Roy filled with machines, noxious stimuli, and invasive
Adaptation Model to study women’s perceptions of procedures surrounds them. These researchers found
adaptation to breast cancer in a sample of 70 women that gentle human touch (focal stimulus) promotes
who were participating in an experimental support physiological adaptation for premature infants. Heart
and education group. The experimental group re- rate, oxygen saturation stability, increased quiet sleep,
ceived coaching; the control group received no coach- less active sleep and drowsiness, decreased motor
ing. Using quantitative content analysis of structured activity, increased time not moving, and decreased
telephone interviews, the researchers found that 51 behavioral distress cues were identified as effective
of 70 women (72.9%) experienced a positive change responses in the physiological adaptive mode. This
toward their breast cancer over the study period, study supports Roy’s conceptualization of adaptation
which was indicative of adaptation to the breast can- in infants.
cer. The researchers report qualitative indicators of Weiss, Fawcett, and Aber (2009) used the Roy
adaptation for each of Roy’s four adaptive modes. Adaptation Model to study adaptation in postpartum
Modrcin-Talbott and colleagues studied self-esteem women following caesarean delivery. Findings showed
from the perspective of the Roy Adaptation Model fewer adaptive responses in women with unplanned
in 140 well adolescents (Modrcin-Talbott, Pullen, caesarean delivery. Cultural differences in adaptive
Ehrenberger, et al., 1998) and 77 adolescents in an responses were found among African-American and
outpatient mental health setting (Modrcin-Talbott, Hispanic women compared to Caucasian women.
Pullen, Zandstra, et al., 1998). Well adolescents were Implications for nursing practice include early assess-
grouped in terms of early (12 to 14 years), middle (15 ment of adaptive responses and learning needs for
to 16 years), or late adolescence (17 to 19 years). Well patients who have had caesarean delivery to develop
adolescents were recruited conveniently from a large, a discharge teaching plan to facilitate adaptive
southeastern church. Self-esteem in well adolescents responses postdischarge.
did not differ by age group, gender, or whether or not The University of Montreal Research Team in
they smoked tobacco. Well adolescents who exercised Nursing Science (Ducharme, Ricard, Duquette, et al.,
regularly did score higher on self-esteem. Significant 1998; Levesque, Ricard, Ducharme, et al., 1998) is

CHAPTER 17 Sister Callista Roy 317

studying adaptation to a variety of environmental Development of Middle-Range Theories
stimuli. Four groups of individuals were included in of Adaptation
their studies as follows: (1) informal family caregivers Silva (1986) pointed out early on that merely using a
of a demented relative at home, (2) informal family conceptual framework to structure a research study is
caregivers of a psychiatrically ill relative at home, not theory testing. Many researchers have used Roy’s
(3) nurses as professional caregivers in geriatric insti- model but did not actually test propositions or
tutions, and (4) aged spouses in the community. hypotheses of her model. They have provided face
Using linear structural relations (LISREL), perceived validity of its usefulness as a framework to guide their
stress (focal stimulus), social support (contextual studies. How theory derives from a conceptual frame-
stimulus), and passive and avoidance coping (coping work must be made explicit; therefore, development
mechanism) were directly or indirectly linked to psy- and testing of middle-range theories derived from the
chological distress. This finding supports Roy’s prop- Roy Adaptation Model are needed. Some research of
osition that coping promotes adaptation. this nature has been conducted with the model, but
DeSanto-Madeya (2009) studied adaptation in more is needed for further validation and develop-
individuals with spinal cord injury and their family ment of new areas. The model does generate many
members using the Roy Adaptation Model. In this testable hypotheses related to both practice and nurs-
study, fifteen patient and family member dyads were ing theory. The success of a conceptual framework
included. Of the fifteen dyads, seven dyads were is evaluated, in part, by the number and quality
1 year postinjury, and eight dyads were 3 years postin- of middle-range theories it generates. The Roy Adap-
jury. Telephone interviews using the Adaptation to tation Model has been the theoretical source of
Spinal Cord Injury Interview Schedule (ASCIIS) were a number of middle-range theories (Roy, 2011a). The
conducted. Findings showed that both individuals utility of those theories in practice sustains the life of
and families had moderate adaptation scores at both the model.
1 year and 3 years. Study findings have important Dunn (2004) reports the use of theoretical sub-
implications for nurses who must care for spinal cord struction to derive a middle-range theory of adapta-
injury patients in both acute and outpatient care tion for chronic pain from the Roy Adaptation Model.
settings. In Dunn’s model of adaptation to chronic pain, pain
intensity is specified as the focal stimulus. Contextual
Development of Adaptation Research stimuli include age, race, and gender. Religious and
Instruments nonreligious coping are functions of the cognator
The Roy Adaptation Model has provided the theoreti- subsystem. Manifestations of adaptation to chronic
cal basis for the development of a number of research pain are its effects on functional ability and psycho-
instruments. Newman (1997b) developed the Inven- logical and spiritual well-being.
tory of Functional Status–Caregiver of a Child in a Frame, Kelly, and Bayley (2003) developed the
Body Cast to measure the extent to which parental Frame theory of adolescent empowerment by synthe-
caregivers continue their usual activities while a child sizing the Roy Adaptation Model, Murrell-Armstrong’s
is in a body cast. Reliability testing indicates that the empowerment matrix, and Harter’s developmental
subscales for household, social, and community child perspective. The theory of adolescent empowerment
care of the child in a body cast, child care of other was tested using a quasi-experimental design in which
children, and personal care (rather than the total children diagnosed with attention-deficit/hyperactivity
score) are reliable measures of these constructs. disorder (ADHD) were randomly assigned to a treat-
Modrcin-McCarthy, McCue, and Walker (1997) used ment or a control group. Ninety-two fifth and sixth
the Roy Adaptation Model to develop a clinical tool grade students were assigned to the treatment or the
that may be used to identify actual and potential control group. Children in the treatment group
stressors of fragile premature infants and to imple- attended an eight-session, school nurse–led support
ment care for them. This tool measures signs of stress, group intervention (twice weekly for 4 weeks). The treat-
touch interventions, reduction of pain, environmen- ment was designed to teach the children about ADHD;
tal considerations, state, and stability (STRESS). the gifts of having ADHD, powerlessness versus

318 UNIT III Nursing Conceptual Models

empowerment; empowerment with one’s feelings, caregiving and for the Roy Adaptation Model
teachers, family, and classmates; and how to learn to (Ducharme, Ricard, Duquette, et al., 1998; Levesque,
relax. Children in the control group received no inter- Ricard, Ducharme, et al., 1998).
vention. Using analysis of covariance, children in the Tsai, Tak, Moore, and Palencia (2003) derived a
treatment group reported significantly higher per- middle-range theory of pain from the Roy Adaptation
ceived social acceptance, perceived athletic compe- Model. In the theory of chronic pain, chronic pain is
tence, perceived physical appearance, and perceived the focal stimulus, disability and social support are
global self-worth. contextual stimuli, and age and gender are residual
Jirovec, Jenkins, Isenberg, and Baiardi (1999) have stimuli. Perceived daily stress is a coping process.
proposed a middle-range urine control theory Depression is an outcome variable manifested in
derived from the Roy Adaptation Model, intended all four adaptive modes. Path analysis provided par-
to explicate the phenomenon of urine control and tial support for the theory of chronic pain. Greater
to decrease urinary incontinence. According to the chronic pain and disability were associated with more
theory of urine control, the focal stimulus for urine daily stress, and greater social support was associated
control is bladder distention. Contextual stimuli with less daily stress. These three variables accounted
include accessible facilities and mobility skills. A re- for 35% of the variance in daily stress. Greater daily
sidual stimulus is the intense socialization about blad- stress explained 35% of the variance in depression.
der and sanitary habits that begin in childhood. This Other middle-range theories derived from the Roy
theory takes into account physiological coping mech- Adaptation Model have been proposed, but research
anisms, regulator (spinal reflex mediated by S2 to reports testing these theories were not found at the
S4, and coordinated detrusor muscle contraction time of this literature review. Tsai (2003) has pro-
and sphincter relaxation) and cognator (perception, posed a middle-range theory of caregiver stress.
learning judgment, and awareness of urgency or drib- Whittemore and Roy (2002) developed a middle-
bling). Adaptive responses to prevent urinary incon- range theory of adapting to diabetes mellitus using
tinence are described for the four adaptive modes. theory synthesis. Based on an analysis of Pollock’s
Effective adaptation is defined as continence, and (1993) middle-range theory of chronic illness and a
ineffective adaptation is defined as incontinence. The thorough review of the literature, reconceptualization
authors provide limited support for the theory of of the chronic illness model and the addition of con-
urine control through case studies. The theory of cepts such as self-management, integration, and
urine control illuminates the complexity, multidi- health-within-illness more specifically extend the Roy
mensionality, and holistic nature of adaptation. Adaptation Model to adapting to diabetes mellitus.
Researchers at the University of Montreal have Pollock’s (1993) research on adaptation to chronic ill-
proposed a middle-range theory of adaptation to ness theory included patients with insulin-dependent
caregiving that is based on the Roy Adaptation Model. diabetes, multiple sclerosis, hypertension, and rheu-
This middle-range theory has been tested in a num- matoid arthritis.
ber of published studies of informal caregivers of
demented relatives at home, informal caregivers of
psychiatrically ill relatives at home, professional care- Further Development
givers of elderly institutionalized patients, and aged The Roy Adaptation Model is an approach to nursing
spouses in the community. Perceived stress is concep- that has made and continues to make a significant
tualized as the focal stimulus. Contextual stimuli contribution to the body of nursing knowledge; how-
include gender, conflicts, and social support. Coping ever, areas remain for future development as health
mechanisms include active, passive, and avoidant care progresses. A thoroughly defined typology of
coping strategies. In this middle-range theory, the nursing diagnoses and an organization of categories
adaptive (nonadaptive) response (psychological dis- of interventions would facilitate its use in nursing
tress) is manifested in the self-concept mode. LISREL practice. Scientists who do research from the perspec-
analyses have provided support for many of the prop- tive of the Roy Adaptation Model continue to note
ositions of this middle-range theory of adaptation to overlap in the psychosocial categories of self-concept,

CHAPTER 17 Sister Callista Roy 319

role function, and interdependence. Roy recently has Rather than a system acting to maintain itself, the em-
redefined health, deemphasizing the concept of phasis shifts to the purposefulness of human existence in
a health-illness continuum and conceptualizing health a universe that is creative” (Roy & Andrews, 1999, p. 35).
as integration and wholeness of the person. This Roy has written that other disciplines focus on an
approach more clearly incorporates the adaptive aspect of the person, and that nursing views the person
mechanisms of the comatose patient in response to as a whole (Roy & Andrews, 1999). “Based on the
tactile and verbal stimuli. However, because health philosophic assumptions of the nursing model, persons
was not conceptualized in this manner in the earlier are seen as coextensive with their physical and social
work, this opens up a new area for research. Based on environments. The nurse takes a values-based stance,
her integrative review of the literature, Frederickson focusing on awareness, enlightenment and faith” (Roy
(2000) concluded that there is good empirical support & Andrews, 1999, p. 539). Roy contends that persons
for Roy’s conceptualization of person and health. She have mutual, integral, and simultaneous relationships
made the following recommendations for future with the universe and God, and that as humans they
research. First, there is a need to design studies to test “use their creative abilities of awareness, enlightenment,
propositions related to environment and nursing. Sec- and faith in the processes of deriving, sustaining, and
ond, interventions based on previously supported transforming the universe” (Roy & Andrews, 1999,
concepts and propositions have been tested, while p. 35). Using these creative abilities, persons (sick or
others remain for testing to document evidence. well) are active participants in their care and are able to
achieve a higher level of adaptation (health).
Critique Mastal and Hammond (1980) discussed difficul-
ties with Roy’s model in classifying certain behaviors
Clarity because concept definitions overlapped. The prob-
The metaparadigm concepts of the Roy Adaptation lem dealt with theory conceptualization and the
Model (person, environment, nursing, and health) are need for mutually exclusive categories to classify
clearly defined and consistent. Roy clearly defines the human behavior. Conceptualizing a person’s posi-
four adaptive modes (physiological, self-concept, tion on the health-illness continuum is no longer a
interdependence, and role function). A challenge of problem because Roy redefined health as personal
the model that was identified is Roy’s espousal of a integration. Other researchers have referred to diffi-
holistic view of the person and environment, while culty in classifying behavior exclusively in one adap-
the model views adaptation as occurring in four tive mode (Bradley & Williams, 1990; Limandri,
adaptive modes, and person and environment are 1986; Nyqvist & Sjoden, 1993; Silva, 1987). However,
conceptualized as two separate entities, with one this observation supports Roy’s proposition that
affecting the other (Malinski, 2000). An answer to this behavior in one adaptive mode affects and is affected
challenge is that Roy’s adaptation model is holistic, by the other modes.
since change in the internal or external environment
(stimulus) leads to response (adapts) as a whole. Simplicity
In fact, Roy’s perspective is consistent with other The Roy model includes the concepts of nursing, per-
holistic theories, such as psychoneuroimmunology son, health-illness, environment, adaptation, and
and psychoneuroendocrinology. As one example, nursing activities. It also includes two subconcepts
psychoneuroimmunology is a theory that proposes (regulator and cognator) and four modes (physiologi-
a bidirectional relationship between the mind and cal, self-concept, role function, and interdependence).
the immune system. Roy’s model is broader than psy- This model has several major concepts and subcon-
choneuroimmunology and provides a theoretical cepts, so the relational statements are complex until
foundation for research about, and nursing care of, the model is learned.
the person as a whole.
In more recent writings, Roy has acknowledged the Generality
holistic nature of persons who live in a universe that is The Roy Adaptation Model’s broad scope is an advan-
“progressing in structure, organization, and complexity. tage because it may be used for theory building and

320 UNIT III Nursing Conceptual Models

for deriving middle-range theories for testing in stud- nursing care that addresses the holistic needs of the
ies of smaller ranges of phenomena (Reynolds, 1971). patient. The model is also capable of generating new
Roy’s model (Roy & Corliss, 1993) is generalizable to information through the testing of hypotheses that have
all settings in nursing practice but is limited in scope, been derived from it (Roy, 2011a; Roy & Corliss, 1993;
as it primarily addresses the person-environment Smith, Garvis, & Martinson, 1983).
adaptation of the patient, and information about the
nurse is implied.
SUMMARY
Accessibility The Roy Adaptation Model has greatly influenced the
Roy’s broad concepts stem from theory in physiological profession of nursing. It is one of the most frequently
psychology, psychology, sociology, and nursing; empiri- used models to guide nursing research, education,
cal data indicate that this general theory base has sub- and practice. The model is taught as part of the cur-
stance. Roy’s model offers direction for researchers who riculum of most baccalaureate, master’s, and doctoral
want to incorporate physiological phenomena in their programs of nursing. The influence of the Roy Adap-
studies. Roy (1980) studied and analyzed 500 samples of tation Model on nursing research is evidenced by the
patient behaviors collected by nursing students. From vast number of qualitative and quantitative research
this analysis, Roy proposed her four adaptive modes in studies it has guided. The Roy Adaptation Model
humans. has inspired the development of many middle-range
Roy (Roy & McLeod, 1981; Roy & Roberts, 1981) nursing theories and of adaptation instruments. Sister
has identified many propositions in relation to the Callista Roy continues to refine the adaptation model
regulator and cognator mechanisms and the self- for nursing research, education, and practice.
concept, role function, and interdependence modes. According to Roy, persons are holistic adaptive
These propositions have received varying degrees of systems and the focus of nursing. The internal and
support from general theory and empirical data. Most external environment consists of all phenomena that
of the propositions are relational statements and can surround the human adaptive system and affect their
be tested (Tiedeman, 1983). Over the years, many development and behavior. Persons are in constant
testable hypotheses have been derived from the model interaction with the environment and exchange infor-
(Hill & Roberts, 1981). mation, matter, and energy; that is, persons affect and
In spite of the progress made over the last 25 years, are affected by the environment. The environment is
the greatest need to increase the empirical precision the source of stimuli that either threaten or promote a
of the Roy Adaptation Model is for researchers to person’s existence. For survival, the human adaptive
develop middle-range theory based on the Roy Adap- system must respond positively to environmental
tation Model with empirical referents specifically stimuli. Humans make effective or ineffective adap-
designed to measure concepts proposed in the derived tive responses to environmental stimuli. Adaptation
theory. Roy has explicated a significant number of promotes survival, growth, reproduction, mastery,
propositions, theorems, and axioms to serve in the and transformation of persons and the environment.
development of middle-range theory. The holistic Roy defines health as a state of becoming an inte-
nature of the model serves nurse researchers world- grated and whole human being.
wide who are interested in the complex nature of Three types of environmental stimuli are described
physiological and psychosocial adaptive processes in the Roy Adaptation Model. The focal stimulus is
(Roy, 2011a; 2011b). that which most immediately confronts the individual
and demands the most attention and adaptive energy.
Importance Contextual stimuli are all other stimuli present in the
The Roy Adaptation Model has a clearly defined nurs- situation that contribute positively or negatively to the
ing process and is useful in guiding clinical practice. strength of the focal stimulus. Residual stimuli affect
The utility of the model has been demonstrated globally the focal stimulus, but their effects are not readily
by nurses. This model provides direction for quality known. These three types of stimuli together form the

CHAPTER 17 Sister Callista Roy 321

adaptation level. A person’s adaptation level may be time. The basic need of the self-concept mode is psy-
integrated, compensatory, or compromised. chic or spiritual integrity. The self-concept is a com-
Coping mechanisms refer to innate or acquired posite belief about self that is formed from internal
processes that a person uses to deal with environmen- perceptions and the perceptions of others. The self-
tal stimuli. Coping mechanisms may be categorized concept mode is composed of the physical self (body
broadly as the regulator or cognator subsystem. The sensation and body image) and the personal self (self-
regulator subsystem responds automatically through consistency, self-ideal, and the moral-ethical-spiritual
innate neural, chemical, and endocrine coping pro- self). The role function mode refers to the primary,
cesses. The cognator subsystem responds through secondary, and tertiary roles a person performs in
innate and acquired cognitive-emotive processes that society.
include perceptual and information processing, learn- The basic need of the role function adaptive mode
ing, judgment, and emotion. is social integrity or for one to know how to behave and
Behaviors that manifest adaptation can be observed what is expected of him or her in society. The interde-
in four adaptive modes. The physiological mode refers pendence adaptive mode refers to relationships
to the person’s physical responses to the environment, among people. The basic need of the interdependence
and the underlying need is physiological integrity. adaptive mode is social integrity or to give and receive
The self-concept mode refers to a person’s thoughts, love, respect, and value from significant others and
beliefs, or feelings about himself or herself at any given social support systems (Table 17–1).




TABLE 17-1 Overview of the Adaptive Modes
Subsystem Adaptive Mode Coping Need
Regulator Physiological Oxygenation: To maintain appropriate oxygenation
Neural Chemical The physiological adaptive mode refers through ventilation, gas exchange, and gas transport
Endocrine to the way a person, as a physical Nutrition: To maintain function, to promote growth,
being, responds to and interacts with and to replace tissue through ingestion and
the internal and external environment assimilation of food
Basic need: Physiological integrity Elimination: To excrete metabolic wastes primarily
through the intestines and kidney
Activity and rest: To maintain balance between
physical activity and rest
Protection: To defend the body against infection,
trauma, and temperature changes primarily by
way of integumentary structures and innate and
acquired immunity
Senses: To enable persons to interact with their
environment by sight, hearing, touch, taste,
and smell
Fluid and electrolyte and acid-base balance:
To maintain homeostatic fluid, electrolyte,
and acid-base balance to promote cellular,
extracellular, and systemic function
Neurological function: To coordinate and control
body movements, consciousness, and
cognitive-emotional processes
Endocrine function: To integrate and coordinate
body functions
Continued

322 UNIT III Nursing Conceptual Models

TABLE 17-1 Overview of the Adaptive Modes—cont’d

Subsystem Adaptive Mode Coping Need
Cognator Self-Concept Physical Self
The self-concept adaptive mode refers Body sensation: To maintain a positive feeling about
to the psychological and spiritual one’s physical being (i.e., physical functioning,
characteristics of a person. sexuality, or health)
The self-concept consists of the Body image: To maintain a positive view of one’s
composite of a person’s feelings about physical body and physical appearance
himself or herself at any given time. Personal Self
The self-concept is formed from internal Self-consistency: To maintain consistent self-organization
perceptions and the perceptions of and to avoid dysequilibrium
others’ reactions. Self-ideal or self-expectancy: To maintain a positive
The self-concept has two major or hopeful view of what one is, what one expects
dimensions: the physical self and the to be, and what one hopes to do
personal self. Moral-spiritual-ethical self: To maintain a positive
Basic need: Psychic and spiritual integrity evaluation of who one is
Interdependence To maintain close, nurturing relationships with people
Basic need: Relational integrity or who are willing to give and receive love, respect,
security in nurturing relationships and value
Role Function To know who one is and what society’s expectations
Basic need: Social integrity are so that one can act appropriately within society



The goal of nursing is to promote adaptive
responses. This is accomplished through a six-step CASE STUDY
nursing process: assessment of behavior, assessment of A 23-year-old male patient is admitted with a
stimuli, nursing diagnosis, goal setting, intervention, fracture of C6 and C7 that has resulted in quad-
and evaluation. Nursing interventions focus on man- riplegia. He was injured during a football game at
aging environmental stimuli by “altering, increasing, the university where he is currently a senior. His
decreasing, removing, or maintaining them” (Roy & career as a quarterback had been very promising.
Andrews, 1999, p. 86). At the time of the injury, contract negotiations
Meleis (1985) proposed that the focus of nursing were in progress with a leading professional foot-
theorist works as the following three types: ball team.
1. Those who focus on needs 1. Use Roy’s criteria to identify focal and con-
2. Those who focus on interaction textual stimuli for each of the four adaptive
3. Those who focus on outcome modes.
Meleis (1985, 2007) classifies the Roy Adaptation 2. Consider what adaptations would be necessary
Model as an outcome theory. In applying the concepts in each of the following four adaptive modes:
of sy’stem and adaptation to person as the patient of (1) physiological, (2) self-concept, (3) interde-
nursing, Roy has presented her articulation of the pendence, and (4) role function.
person for nurses to use as a tool in practice, educa- 3. Create a nursing intervention for each of the
tion, and research. Her conceptions of person and of adaptive modes to promote adaptation.
the nursing process contribute to the science and the
art of nursing. The Roy Adaptation Model deserves
further study and development by nurse educators,
researchers, and practitioners.

CHAPTER 17 Sister Callista Roy 323

CRITICAL THINKING ACTIVITIES

1. Karen, a recent graduate from a nursing program 2. Although it would be easy to assume that Mr.
based on the Roy Adaptation Model, is performing Shadeed’s nursing care needs stem from anxiety
her morning assessments. She enters Mr. Shadeed’s during the preoperative period, this assumption
room. Mr. Shadeed is awaiting preoperative prepa- may or may not be true. Assessment of stimuli in
ration for a laparotomy to explore an unknown each of the four adaptive modes will enable Karen
mass. Mr. Shadeed is very irritable this morning. to assess focal, contextual, and residual stimuli
He says that he is thirsty. Karen continues her and come to the correct diagnosis. Identify the
assessment of Mr. Shadeed. What additional data additional assessment data that Karen will need to
will she need from each of the four adaptive modes collect for each of the following adaptive modes.
before implementing nursing interventions? What • Physiological adaptive mode
are the focal stimuli, contextual stimuli, and resid- • Self-concept adaptive mode
ual stimuli? What are possible interventions? What • Role function adaptive mode
process can Karen use to select the best nursing • Interdependence adaptive mode
intervention?


POINTS FOR FURTHER STUDY
n Nursing Science Quarterly, 24(4) (issue dedicated n Roy, C. (2007). Update from the future: Thinking
to honoring Roy and her work). of theorist Sr. Callista Roy. Nursing Science Quar-
n Phillips, K. D. (2010). Roy’s adaptation model in terly, 20(2), 113–116.
nursing practice. In M. R. Alligood, (Ed.), Nursing n Sr. Callista Roy. Portraits of excellence: The nurse
theory: Utilization & application (4th ed., pp. 309– theorists video/DVD series, vol 1. Athens, (OH):
335). Maryland Heights, MO: Mosby-Elsevier. Fitne, Inc.
n Roy, C., & Jones, D. (Eds.). (2007). Nursing knowl- n Sr. Callista Roy. Adaptation: Excellence in action
edge development and clinical practice. New York: video/DVD. Athens, (OH): Fitne, Inc.
Springer.

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Reynolds, P. D. (1971). A primer in theory construction. model: Theoretical update and knowledge for practice.
Indianapolis: Bobbs-Merrill. In M. E. Parker (Ed.), Patterns of nursing theories in
Riehl, J. P., & Roy, C. (1980). Conceptual models for nursing practice. (NLN Pub. 15–2548). New York: National
practice (2nd ed.) New York: Appleton-Century-Crofts. League for Nursing.
Roy, C. (1970). Adaptation: A conceptual framework for Samarel, N., Tulman, L., & Fawcett, J. (2002). Effects of two
nursing. Nursing Outlook, 18, 42–45. types of social support and education on adaptation to
Roy, C. (1971). Adaptation: A basis for nursing practice. early-stage breast cancer. Research in Nursing & Health,
Nursing Outlook, 19, 254–257. 25, 459–470.
Roy, C. (1973). Adaptation: Implications for curriculum Samarel, N., Fawcett, J., Krippendorf, K., Piacentino, J. C.,
change. Nursing Outlook, 21, 163–168. Eliasof, B., Hughes, P., et al. (1998). Women’s percep-
Roy, C. (1975). A diagnostic classification system for nursing. tion of group support and adaptation to breast cancer.
Nursing Outlook, 23, 90–94. Journal of Advanced Nursing, 28(6), 1259–1268.
Roy, C. (1976a). Introduction to nursing: An adaptation Samarel, N., Fawcett, J., Tulman, L., Rothman, H., Spector,
model. Englewood Cliffs, (NJ): Prentice-Hall. L., Spillane, P. A., et al. (1999). A resource kit for women

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with breast cancer: Development and evaluation. Oncol- Weiland, S. (2010). Integrating spirituality into critical
ogy Nursing Forum, 26(3), 611–618. care: An APN perspective using Roy’s adaptation
Senesac, P. (2003). Implementing the Roy adaptation model. Critical Care Nursing Quarterly, 33, 282–291.
model: From theory to practice. Roy Adaptation Review, Weiss, M., Fawcett, J., & Aber, C. (2009). Adaptation, post-
4(2), Chestnut Hill, (MA). partum concerns, and learning needs in the first two
Silva, M. C. (1986). Research testing nursing theory: State weeks after caesarean birth. Journal of Clinical Nursing,
of the art. Advances in Nursing Science, 9, 1–11. 18, 2938–2948.
Silva, M. C. (1987). Needs of spouses of surgical patients: Whittemore, R., & Roy, C. (2002). Adapting to diabetes
A conceptualization within the Roy adaptation model. mellitus: A theory synthesis. Nursing Science Quarterly,
Scholarly Inquiry for Nursing Practice, 1, 29–44. 15, 311–317.
Smith, C. E., Garvis, M. S., & Martinson, I. M. (1983). Woods, S. J., & Isenberg, M. A. (2001). Adaptation as a me-
Content analysis of interviews using a nursing model: diator of intimate abuse and traumatic stress in battered
A look at parents adapting to the impact of childhood women. Nursing Science Quarterly, 14(3), 215–221.
cancer. Cancer Nursing, 6, 269–275. Yeh, C. H. (2002). Health-related quality of life in pediatric
Starnes, T. M. & Peters, R. M. (2004). Anger, expression, patients with cancer—A structural equation approach with
and blood pressure in adolescents. Journal of School the Roy adaptation model. Cancer Nursing, 25, 74–80.
Nursing, 20, 335–342. Young-McCaughan, S., Mays, M. Z., Arzola, S. M., Yoder,
Swimme, B., & Berry, T. (1992). The universe story. L. H., Dramiga, S. A., Leclerc, K. M., et al. (2003).
San Francisco: Harper. Research and commentary: Change in exercise tolerance,
Tiedeman, M. E. (1983). The Roy adaptation model. activity and sleep patterns, and quality of life in patients
In J. Fitzpatrick & A. Whall (Eds.), The Roy adaptation with cancer participating in a structured exercise
model (pp. 157–180). Bowie, (MD): Brady. program. Oncology Nursing Forum, 30, 441–454.
Tsai, P. F. (2003). Middle-range theory of caregiver stress. Zeigler, L., Smith, P. A., & Fawcett, J. (2004). Breast cancer:
Nursing Science Quarterly, 16(2), 137–145. Evaluation of Common Journey Breast Cancer Support
Tsai, P. F., Tak, S., Moore, C., & Palencia, I. (2003). Testing Group. Journal of Clinical Nursing, 13, 467–478.
a theory of chronic pain. Journal of Advanced Nursing, Zhan, L. (2000). Cognitive adaptation and self-consistency
43, 158–169. in hearing-impaired older persons: testing Roy’s adapta-
Villareal, E. (2003). Using Roy’s adaptation model when tion model. Nursing Science Quarterly, 13(2), 158–165.
caring for a group of young women contemplating Zhan, L., & Shen, C. (1994). The development of an instru-
quitting smoking. Public Health Nursing, 20, 377–384. ment to measure self-consistency. Journal of Advanced
Wagner, P. (1976). The Roy adaptation model. Testing the Nursing, 20, 509–516.
adaptation model in practice. Nursing Outlook, 24,
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Roy, C. (1983). Theory development in nursing: A pro- osophical foundations. In Maria Elisa Moreno et al. (Eds.),
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McGraw-Hill. Roy, C., & Anway, J. (1989). Roy’s adaptation model: Theories
Roy, C. (1983). The expectant family: Analysis and application and hypotheses for nursing administration. In B. Henry,
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model. In I. W. Clements & F. B. Roberts (Eds.), Family education, and practice (pp. 75–88). Boston: Blackwell
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(Ed.), Nursing science: Major paradigms, theories, and Parker (Ed.), Patterns of nursing theories in practice
critiques (pp. 35–45). Philadelphia: Saunders. (pp. 215–229). New York: National League for Nursing.
Roy, C. (1987). The influence of nursing models on clini- Roy, C., & McLeod, D. (1981). Theory of the person as an
cal decision making II. In K. J. Hannah, M. Reimer, adaptive system. In C. Roy & S. L. Roberts (Eds.),
W. C. Mills, & S. Letourneau (Eds.), Clinical judgment Theory construction in nursing: An adaptation model
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(pp. 42–47). New York: Wiley. Roy, C., & Zhan, L. (2001). The Roy adaptation model:
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Journal Articles Roy, C. (1997). Future of the Roy model: Challenge to rede-
Artinian, N. T., & Roy, C. (1990). Strengthening the Roy fine adaptation. Nursing Science Quarterly, 10(1), 42–48.
adaptation model through conceptual clarification. Roy, C. (2000). A theorist envisions the future and speaks
Commentary (Artinian) and response (Roy). Nursing to nursing administrators. Nursing Administration
Science Quarterly, 3(2), 60–66. Quarterly, 24(2), 1–12.
Hanna, D. R., & Roy C. (2001). Roy adaptation model Roy, C. (2000). Critique: Research on cognitive consequences
perspectives on family. Nursing Science Quarterly, of treatment for childhood acute lymphoblastic leukemia.
14(1), 9–13. Seminars in Oncology Nursing, 16(4), 291.
Pollock, S. E., Frederickson, K., Carson, M. A., Massey, V. H., Roy, C. (2000). The visible and invisible fields that shape the
& Roy, C. (1994). Contributions to nursing science: future of the nursing care system. Nursing Administration
Synthesis of findings from adaptation model research. Quarterly, 25(1), 119–131.
Scholarly Inquiry for Nursing Practice, 8(4), 361–374. Roy, C. (2003). Reflections on nursing research and the Roy
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Roy, C. (1973). Adaptation: Implications for curriculum Roy, C. (2011a). Research based on the Roy adaptation
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Quarterly, 3(2), 64–66. (pp. 110–129). Oxford: Reed.
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nursing: Analysis and application (4th ed., pp. 146–176). dissertation, Widener University). Dissertation
Englewood Cliffs, (NJ): Prentice Hall. Abstracts International, 63, 737.
Giedt, J. F. (1999). The psychoneuroimmunological effects
Dissertations of guided imagery in patients on hemodialysis for end-
Ahern, E. (2006). Elaboration d’un modele theorique de stage renal disease (Doctoral dissertation, Wayne
l’agression en milieu psychiatrique et developpement State University). Dissertation Abstracts International,
d’instruments de mesure. (Doctoral dissertation. Universite 61, 192.
de Montreal, 2006). Dissertation Abstracts International, Gipson-Jones, T. L. (2005). The relationship between
68, 3698. work-family conflict, job satisfaction and psychological
Arcamone, A. A. (2005). The effect of prenatal education well-being among African American nurses. (Doctoral
on adaptation to motherhood after vaginal childbirth in dissertation, Hampton University). Dissertation
primiparous women as assessed by Roy’s four adaptive Abstracts International, 66, 2512.
modes. (Doctoral dissertation, Widener University). Harner, H. M. (2001). Obstetrical outcomes of teenagers with
Dissertation Abstracts International, 66, 4722. adult and peer age partners (Doctoral dissertation,
Beck-Little, R. (2000). Sleep enhancement interventions and University of Pennsylvania, 2001). Dissertation Abstracts
the sleep of institutionalized older adults. (Doctoral dis- International, 62, 2256.
sertation, University of South Carolina). Dissertation Henderson, P. D. (2002). African-American women
Abstracts International, 61, 3503. coping with breast cancer (Doctoral dissertation,
Black, K. D. (2004). Physiologic responses, sense of well- Hampton University). Dissertation Abstracts Interna-
being, self-efficacy for self-monitoring role, perceived tional, 63, 5764.
availability of social support, and perceived stress in Hinkle, J. L. (1999). A descriptive study of variables explain-
women with pregnancy-induced hypertension. (Doctoral ing functional recovery following stroke. (Doctoral disser-
dissertation, Widener University). Dissertation Abstracts tation, University of Pennsylvania, 1999). Dissertation
International, 65, 1773. Abstracts International, 60, 6021.
Burns, D. P. (1997). Coping with hemodialysis: A midrange Huang, C. M. (2002). Sleep and daytime sleepiness in first-time
theory deduced from the Roy adaptation model (Doctoral mothers during early postpartum in Taiwan. (Doctoral
dissertation, Wayne State University). Dissertation dissertation, University of Texas at Austin). Dissertation
Abstracts International, 58, 1206. Abstracts International, 64, 3189.
Cacchione, P. Z. (1998). Assessment of acute confusion in Jenkins, B. E. (2006). Emotional intelligence of faculty
elderly persons who reside in long-term care facilities members, the learning environment, and empowerment
(Doctoral dissertation, St. Louis University). Disserta- of baccalaureate students. (Doctoral dissertation,
tion Abstracts International, 59, 156. Columbia University). Dissertation Abstracts Interna-
Chayaput, P. (2004). Development and psychometric evalua- tional, 67, 3701.
tion of the Thai version of the Coping and Adaptation Kan, E. Z. (2007). Adaptive behaviors and perceptions of
Processing Scale. (Doctoral dissertation, Boston College). recovery following coronary artery bypass graft surgery.
Dissertation Abstracts International, 65, 2864. (Doctoral dissertation, Widener University). Dissertation
Cheng, S. (2002). A multi-method study of Taiwanese Abstracts International, 68, 4390.
children’s pain experience (Doctoral dissertation, Kittiwatanapaisan, W. (2002). Measurement of fatigue
University of Colorado Health Sciences Center). in myasthenia gravis patients. (Doctoral dissertation,
Dissertation Abstracts International, 63, 1265. University of Alabama at Birmingham). Dissertation
Chung, C. (1999). Sense of coherence, self-care, and self- Abstracts International, 63, 4595.
actualizing behaviors of Korean menopausal women Klein, G. J. M. (2000). The relationships among anxiety, self-
(Doctoral dissertation, Case Western Reserve University concept, the impostor phenomenon, and generic senior
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61, 776. competency. (Doctoral dissertation, Widener University).
Dunn, K. S. (2001). Adaptation to chronic pain: Religious and Dissertation Abstracts International, 61,5236.
non-religious coping in Judeo-Christian elders (Doctoral Kline, N. E. (1999). Sleep disturbances in children receiving
dissertation, Wayne State University). Dissertation short-term, high dose glucocorticoid therapy for acute
Abstracts International, 62, 5640. lymphoblastic leukemia. (Doctoral dissertation, Texas
Frame, K. R. (2002). The effect of a support group on per- Women’s University). Dissertation Abstracts Interna-
ceptions of scholastic competence, social acceptance and tional, 61, 194.
behavioral conduct in preadolescents diagnosed with Kochniuk, L. (2004). We never buy green bananas: The oldest
attention deficit hyperactivity disorder (Doctoral old. A phenomenological study. (Doctoral dissertation,

330 UNIT III Nursing Conceptual Models

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65, 2318. tracheal suctioning by nurses caring for individuals
Kruszewski, A. Z. (1999). Psychosocial adaptation to termi- with spinal cord injury. (Doctoral dissertation, Loyola
nation of pregnancy for fetal anomaly. (Doctoral disser- University, 2005). Dissertation Abstracts International,
tation, Wayne State University). Dissertation Abstracts 66, 2518.
International, 61, 194. Taival, A. S. (1998). The older person’s adaptation and the
Lefaiver, C. A. (2006). Quality of life: The dyad of caregivers promotion of adaptation in home nursing care: Action
and lung transplant candidates. (Doctoral dissertation, research of intervention through training based on the
Loyola University). Dissertation Abstracts International, Roy adaptation model. (Doctoral dissertation, Tamper-
67, 4978. een Teknillinen Korkeakoulu). Dissertation Abstracts
Lu, Y. (2001). Caregiving stress effects on functional capabil- International, 60,113.
ity and self-care behavior for elderly caregivers of persons Thomas-Hawkins, C. (1998). Correlates of changes in func-
with Alzheimer’s disease. (Doctoral dissertation, Case tional status in chronic in-center hemodialysis patients.
Western Reserve University, Health Sciences). Disserta- (Doctoral dissertation, University of Pennsylvania,
tion Abstracts International, 62,1807. 1998). Dissertation Abstracts International, 59, 5792.
Mahoney, E. T. (2000). The relationships among social Toughill, E. H. (2001). Quality of life: The impact of age,
support, coping, self-concept, and stage of recovery in severity of urinary incontinence and adaptation.
alcoholic women. (Doctoral dissertation, Catholic (Doctoral dissertation, New York University). Disserta-
University of America). Dissertation Abstracts Interna- tion Abstracts International, 61, 5240.
tional, 61, 1872. Tsai, P. F. (1998). Development of a middle-range theory
Malinski, V. M. (2000). Commentary. Nursing Science of caregiver stress from the Roy adaptation model.
Quarterly, 13, 16–17. (Doctoral dissertation, Wayne State University, 1998).
Otten, R. (2005). History of associate degree nursing at Dissertation Abstracts International, 60, 133.
Mount St. Mary’s College: 1970–2005 (California). Velos Weiss, J. C. (1998). Lifestyle and angina in the elderly
(Doctoral dissertation, Pepperdine University). Disser- following elective coronary artery bypass graft surgery.
tation Abstracts International, 67, 492. (Doctoral dissertation, University of Pennsylvania,
Phahuwatanakorn, W. (2004). The relationships between 1998). Dissertation Abstracts International, 59, 1589.
social support, maternal employment, postpartum Wood, A. E. (1998). An investigation of stimuli related to
anxiety, and maternal role competencies in Thai baccalaureate nursing students’ transition toward role
primiparous mothers. (Doctoral dissertation, Catholic mastery. (Doctoral dissertation, University of Tennessee,
University of America). Dissertation Abstracts Interna- Knoxville, 1998). Dissertation Abstracts International,
tional, 64, 5451. 59, 4023.
Sabatini, M. (2003). Exercise and adaptation to aging in older Woods, S. J. (1997). Predictors of traumatic stress in
women. (Doctoral dissertation, Widener University). battered women: A test and explication of the Roy
Dissertation Abstracts International, 64, 3748. adaptation model. (Doctoral dissertation, Wayne
Saint-Pierre, C. (2003). Elaboration et verification d’un State University). Dissertation Abstracts International,
modele predictif de l’adaptation aux roles associes de 58, 1220.
mere et de travailleuse a statut precaire. (Doctoral Wright, R. R. (2007). Experiences of emergency nurses:
dissertation. Universite de Montreal). Dissertation What has been learned from traumatic and violent
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spinal cord injured patient. (Doctoral dissertation, Saint Wunderlich, R. J. (2003). An exploratory study of physiolog-
Louis University). Dissertation Abstracts International, ical and psychological variables that predict weaning
65, 1783. from mechanical ventilation. (Doctoral dissertation,
Salazar-Gonzalez, B. C. (1999). Responses to exercise in Saint Louis University). Dissertation Abstracts Interna-
elderly Mexican women. (Doctoral dissertation, Wayne tional, 64, 3750.
State University). Dissertation Abstracts International, Zbegner, D. K. (2003). An exploratory retrospective study
61, 197. using the Roy Adaptation Model: The adaptive mode
Senesac, P. M. (2004). The Roy Adaptation Model: An variables of physical energy level, self-esteem, marital
action research approach to the implementation of a pain satisfaction, and parenthood motivation as predictors
management organizational change project. (Doctoral of coping behaviors in infertile women. (Doctoral disser-
dissertation, Boston College). Dissertation Abstracts tation, Widener University). Dissertation Abstracts
International, 65, 2872. International, 64, 3751.

CHAPTER 17 Sister Callista Roy 331

Journal Articles well adolescents: Seeking a new direction. Issues in Com-
Chiou, C. (2000). A meta-analysis of the interrelationships prehensive Pediatric Nursing, 21, 229–241.
between the modes in Roy’s adaptation model. Nursing Newman, D. M. L., & Fawcett, J. (1995). Caring for a
Science Quarterly, 13(3), 252–258. young child in a body cast: Impact on the care giver.
Dawson, S. (1998). Adult/elderly care nursing: Preamputa- Orthopedic Nursing, 14(1), 41–46.
tion assessment using Roy’s adaptation model. British Niska, K. J. (1999). Family nursing interventions: Mexican
Journal of Nursing, 7(9), 536, 538–542. American early family formation: Third part of a three-
Decker, J. W. (2000). The effects of inflammatory bowel part study. Nursing Science Quarterly, 12(4), 335–340.
disease on adolescents. Gastroenterology Nursing, 23(2), Niska, K. J. (2001). Mexican American family survival,
63–66. continuity, and growth: The parental perspective.
Dixon, E. L. (1999). Community health nursing practice Nursing Science Quarterly, 14(4), 322–329.
and the Roy adaptation model. Public Health Nursing, Orsi, A. J., Grandy, C., Tax, A., & McCorkle, R. (1997).
16, 290–300. Nutritional adaptation of women living with HIV:
Dunn, H. C., & Dunn D. G. (1997). The Roy adaptation A pilot study. Holistic Nursing Practice, 12(1), 71–79.
model and its application to clinical nursing practice. Robinson, J. H. (1995). Grief responses, coping processes,
Journal of Ophthalmic Nursing and Technology, 6(2), and social support of widows: Research with Roy’s
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