INTERNATIONAL JOURNAL of ACADEMIC RESEARCH

Vol. 4. No. 4. July, 2012

Ghada Abu Shosha, Mahmoud Al kalaldeh. A critical analysis of using Roys adaptation model in nursing
research. International Journal of Academic Research Part B; 2012; 4(4), 26-31.

A CRITICAL ANALYSIS OF USING ROYS ADAPTATION

MODEL IN NURSING RESEARCH
PhD. RN. CNS. Ghada Abu Shosha, PhD. RN. CNS. Mahmoud Al kalaldeh
Faculty of Nursing, Zarqa University (JORDAN)
E-mails: ghada_abushosha@yahoo.com, kalaldeh82@yahoo.com
ABSTRACT
Roy's Adaptation Model (RAM) is one of the most common frameworks used in different nursing
aspects. The application of RAM is vary from design to another based on the anticipated goals and the nature
of adaptation level required for monitoring. Aim: This paper aims to critically analyze ten recent studies that
use RAM as a conceptual framework to identify the effectiveness of this model to guide nursing practice and
research. Method: ten published studies were selected randomly to show different application form of RAM in
nursing studies. Results: The four adaptive modes of RAM, the three environmental stimuli and the regulator
and cognator subsystem of coping process have been utilized appropriately in most of the reviewed studies.
Eight studies have completely supported RAM as an effective framework. Of all studies, RAM has played a
significant role in managing research direction and facilitating the adaptation level of participants. The
significance of RAM was more in nursing studies which entirely focus on individuals' adaptation secondary to
certain therapeutic protocol such as adaptation required to changes associated with treatment of cancer.
Conclusion: RAM is an applicable, flexible and useful model can be used in different aspects of nursing
research in a consistent manner. Researchers could effectively use different concepts of RAM to guide their
work. RAM has shown a robust theoretical and conceptual framework especially in studies concern with the
consequences of some medical treatment.
Key words: Roy's Adaptation Model, Nursing, Stress.
1. INTRODUCTION
Roy's Adaptation Model (RAM) is one of the most useful conceptual frameworks that guides nursing
practice, directs research and influences education (1). It focuses on individuals' adaptation to changeable
environment and guides the assessment of individuals' adaptation. RAM enhances nurses' abilities to improve
person interaction with the surrounded environment to provide an effective adaptation. The RAM has a consistent
nursing process that directs nursing practice toward providing a holistic care for patients (1, 2, 3). A number of
studies has been conducted using RAM; based on these studies, this paper criticizes and describes the application
of RAM as a conceptual framework in ten published studies.
2. DESCRIPTION OF ROY'S MODEL
Adaptation is defined by RAM as the process and outcome in which thinking and feeling persons use
conscious awareness to create integration between human perception and their environment. Adaptation is
manifested by four interrelated modes of behavior including physiological, self-concept, role function and
interdependence modes (4). According to RAM, individual is described as an adaptive system that is able to
respond to different internal and external environmental stimuli whether positively or negatively. Individuals'
responses to any environmental change are subject to their coping processes.
The environmental stimuli are divided into focal, contextual and residual stimuli (4). The focal stimulus is
what immediately confronts the individual. Contextual stimuli are other factors that contribute to the focal stimulus.
Residual stimuli are the unknown environmental factors that can influence the situation (1).
RAM has classified coping processes into two subsystems: regulator and cognator. In regulator subsystem,
individuals respond automatically to the environmental stimuli through innate, physiological adaptive processes.
These processes include neural, chemical and endocrine channels. The cognator subsystem processes changes in
the environment through cognitive and emotional channels involve personal perception and information processing,
learning, judgment and emotion (4).
Based on RAM, nursing activities involve the assessment of behaviors and stimuli that influence adaptation.
Nursing judgment is based on the assessment carried out before anticipating any intervention to manage the
stimuli systematically. Nurses are in a key place to ensure if the adaptive goals have been met (1). Nursing goal
promotes individuals and groups adaptation in each adaptive mode; consequently, it contributes to improving
health, quality of life and dying with dignity. Responses can be either adaptive or ineffective. Adaptive responses
promote integrity and help persons to achieve the adaptation goal. Ineffective responses do not promote
individuals' integrity and do not contribute to the adaptation goals (1). Finally, health was defined by Roy as the
process of achieving adaptation with the environmental stimuli, so, the person is integrated and a whole (1).

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3. CRITIQUE OF ROY'S ADAPTATION MODEL

RAM substantiate significantly in different nursing discipline. It has inspired the development of many middle
range nursing theories. It includes many major concepts, sub-concepts and relational statements, therefore, it is
considered as a complex model. However, the complexity of Roy's model helps to increase its empirical precision.
Roy's arrangement of concepts is logical, but the clarity of some terms and concepts is inadequate to reflect
nursing disciplines. This may decreases the clarity of the model when applied in any specialized area of practice. In
fact, The RAM is broad in scope and can be used to build or test nursing theories. Therefore, it is generalizable to
all approaches existed in nursing practice (1).
RAM is a researchable model can be applied on as a conceptual framework in many nursing research field.
It is useful, applicable and important for nursing practice, nursing education and development. It provides valuable
information about individuals' adaptation to different environmental stimuli (1).
4. ROY'S ADAPTATION MODEL AS A CONCEPTUAL FRAMEWORK
Many researchers have used RAM to guide their studies. The following studies have been selected to show
their use of that model (4-16).
Studies by Henderson et al. (2003), Waweru et al. (2008) and Wendler (2003) were completely dependent
on the environmental stimuli defined by RAM. Henderson et al. conducted a study to assess coping strategies used
by African American women with breast cancer to examine any relationship existed between socio-demographic
variables and coping strategies. Similarly, Waweru et al. (2008) conducted a study to explore the perception of selfconcept and the associated emotional indicators of children living with acquired immune deficiency syndrome
(AIDS) in the United States and Kenya. Wendler (2003) used a pretest, posttest repeated measures design to
examine the effect of Tellington Touch (T touch) on: 1) mean blood pressure (MBP); 2) heart rate (HR); 3) state
anxiety (SA); and 4) perceived procedural pain (PP) in healthy citizen soldiers waiting antecubital venipuncture and
to compare the result with a no-touch control group. The Researchers in the three previous studies used RAM as a
theoretical framework.
Henderson et al. (2003) used the three environmental stimuli defined by RAM to guide their study. The focal
stimulus in this study was the diagnosis of breast cancer; the contextual stimuli were demographic data such as
age, marital status, educational level, income and length of time since diagnosis, the residual stimuli were unknown
factors that may affect the coping strategies of the patients. However, Waweru et al. (2008) conceptualized the
adaptation of children living with AIDS in the self concept mode. They considered coping with AIDS as focal stimuli,
the environment of care as the contextual stimulus, while the developmental level of the school aged children was
the residual stimulus. Similarly, Wendler (2003) considered venipuncture as the focal stimulus which affects
adaptation, and T touch as the contextual stimuli which adjust the intensity of the focal stimulus. He stated that T
touch may enhance the regulator system that increases the effectiveness of adaptive response.
Henderson et al. (2003) did not support RAM that there is no relationship between contextual stimuli
(demographic data) and adaptive response. Positive reappraisal and seeking social support were the most
common coping strategies used by African American women with breast cancer. In conclusion, Henderson et al.
recommended further research to assess the contextual variables that may predict the coping process of African
American women with breast cancer. Wendler (2003) partially supported RAM in which the contextual stimuli (T
touch) modified the intensity of MBP and HR in the T touch group, while there were no significant differences
between the T touch group and control in SA and PP. The contextual stimuli (T touch) enhanced the regulator
system to increase the effectiveness of the adaptive response. However, Wendler illustrated the reasons of failure
in demonstrating differences between groups in state anxiety and perceived procedural pain. Firstly, soldiers were
trained to ignore what are considered as mild discomforts. Secondly, soldiers were discouraged to express their
anxiety and pain that might be recognized as a weakness. In contrast, Waweru et al. (2008) have completely
supported the RAM in which various stimuli are affecting the self concept mode; this study indicated that RAM
could be used cross culturally.
On contrary to that, other researchers created questions based on the four adaptive modes of RAM to
guide their interviews (8, 11, 12). Zeigler et al. (2004) reported the findings of a programme evaluation project
mentioned previously. This project was designed to identify the experience of both participants in and facilitators of
community breast cancer support group. Similarly, a study by Ramini et al. (2008) aimed to identify the experiences
of adaptive strategies used by adolescents with cancer. The questions have been used to reflect the physiological
mode in Zeigler et al's study was related to the most distressing physical problems. The self concept mode includes
questions associated with feelings about body and self. The role function mode includes questions about the
activities done by breast cancer support group and the satisfaction level indicated these activities. The questions
reflected the interdependence mode was related to the quality and quantity of support received by the support
group.
The questions that reflected the physiologic mode in Ramini et al's study (2008) described adolescents'
experience during normal days of treatment; physical well being and the worst side effect resulted from cancer
treatment. The self concept mode included questions associated with feelings and adaptation process of changes
related to cancer and its treatment. The role function mode involved questions about the role of the cancer camp in
helping patients with cancer, and any change in people attitude toward patients with cancer. The questions that
reflected the interdependence mode were related to the effect of cancer on the relationship between people.

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Both Zeigler et al. (2004) and Ramini et al. (2008) have supported RAM's proposition that adaptation is
manifested in four interrelated modes of behavior including physiologic, self concept, role function, and
interdependence. The information given to patients; social and emotional support; and the place of sharing
experience were very effective activities offered by the breast cancer support group. Additionally, Ramini et al.
supported RAM proposition that the adaptive behavior is a positive response to any change. Adolescents and
young adults have reported a positive adaptation as manifested by managing body changes and maintain positive
attitudes toward changes associated with cancer and its treatment.
Huang et al. (2004) used the four adaptive modes of RAM to: a) estimate daytime sleepiness and b) assess
factors disrupting the adaptation of sleep loss during the early postpartum period. The results showed that
depressed mothers had poorer sleep experience than non depressed mothers. Higher level of depression were
reported in mothers who experienced more sleep disturbances, short sleep duration, more daytime dysfunctions,
and who perceived their performance while infant care is being affected by daytime sleepiness. Using the four
adaptive modes in Huang et al's study to categorize daytime sleepiness was not completely clear. Therefore, more
clarification is required to explain how authors elucidate daytime sleepiness based on the four adaptive modes.
In the same way, Pollock et al. (2005) used RAM in order to categorize and rank the stressors associated
with first time fathers in the postpartum period. Stressors were classified as role function stressors, psychological
stressors and interdependence stressors. The findings have supported RAM in which role function stressors were
associated with having not enough time to do many responsibilities, concerns about child health and concerns
about the health of family members. Psychological stressors include financial problems, problems with job and
problems with housing and neighborhood. Interdependence stressors include difficulties with mother, problems with
family, problems with child's behavior, and problems with friends and neighbors.
On the other hand, Starner and Peters (2004) used other concepts of RAM developed in two subsystems of
coping processes. The researchers examined the relationship between anger and anger expression on blood
pressure (BP) in adolescents. They conceptualized anger expression by using RAM as an adaptive-behavioral
response to any environmental stimuli perceived as anger-provoking stimuli. BP was also defined conceptually as a
regulator coping mechanism that processes the physiological adaptive response through the autonomic nervous
system. The regulator coping mechanism automatically responds to the anger-provoking stimuli. The cognator
coping system used to support relief from feeling of anger. Starner and Peters (2004) have supported RAM when
revealing that adaptive responses promote integrity (providing relief from anger expression and BP remains within
normal limits) while ineffective responses do not promote integrity. The girls in the study had an ineffective
response to the increased blood pressure when scores were high to overall anger and anger suppression. The
boys in the study had adaptive behavior responses, as the high scores on anger expression did not result in
elevated blood pressure.
Poirer (2007) used a prospective, longitudinal design to explore factors that might affect patients' ability to
perform their usual activities while they are under radiation therapy. In order to obtain better examination of the
disruption of activities among patients undergoing radiation therapy, Poirer integrated different concepts of RAM.
The role function mode of RAM guided the design of the study and selected variables. The physiological mode
response was represented by the site-specific treatment-related side effects, fatigue, pain and sleep disturbances.
Contextual stimuli included patient's age, gender, education, living situation, employment patterns, disease stage,
radiation treatment and dose, concurrent or sequential chemotherapy, and comorbidities.
In the same study, the researcher supported RAM's propositions that contextual stimuli influenced
adaptation process and the modes of adaptation are interrelated (the role function mode and the physiologic
mode). Many factors were associated with reducing patients' ability to carry out their activities during the course of
treatment with radiation therapy. These factors were related to the site-specific treatment-related side effects and
fatigue, the presence of comorbidities, living alone and being exposed to chemotherapy along with radiation.
Finally, Posmontier (2008) used different concepts of RAM to compare the differences in functional status
between women with postpartum depression and women without postpartum depression. Posmontier chose RAM
in the study, because women with postpartum depression may experience some difficulties in adapting with
environmental changes occurred in postpartum period. Posmontier also used the functional status instrument after
childbirth which is theoretically based on (RAM). Childbirth in this study provides the focal stimulus; contextual
stimuli were the physical and psychosocial factors influencing childbirth. The author stated that women with
postpartum depression (self concept mode) would use ineffective responses in personal, household, social and
occupational activities, but would maintain adaptive responses in physical infant care (role function modes). The
result of this study indicated that postpartum depression can lower personal, household, and social functioning, but
not infant care.
5. DISCUSSION OF FINDINGS
The aim of this paper was to discuss ten published studies in which RAM was applied as an organizational
framework to guide these studies. The studies illustrated previously explicitly indicate the importance of using RAM.
The researchers discussed the reason of choosing RAM to guide their works because its ability to integrate
multiple adaptive modes of individuals. Therefore, RAM provides an effective framework to assess individuals'
adaptation regardless their ages or conditions. Strong assertion was introduced to show the importance of
assessing various stimuli which affect the levels of individuals' adaptation to any changes in their lives.
In comparison, all researchers have selected RAM for different reasons. Henderson et al. (2003); Waweru
et al. (2008); Wendler (2003); Huang et al. (2004); Starner and Peters (2004); Pollock et al. (2005); Poirer (2007)
and Posmontier (2008) have chosen RAM as a conceptual framework to conceptualize variables in their studies. In

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contrast, RAM was employed as a template to guide the interviews in Zeigler et al's (2004) and Ramini et al's
(2008) studies. Additionally, most of the researchers have adopted the three environmental stimuli significantly, for
instance, Henderson et al. (2003); Waweru et al. (2008); and Wendler (2003). Other authors generated questions
based on the four adaptive modes to guide their interviews like Zeigler et al. (2004) and Ramini et al. (2008). Also,
Huang et al. (2004) and Pollock et al. (2005) used the adaptive modes as organizational structure to assess
different variables in the postpartum period such as sleep pattern and different aspects of stressors in the
postpartum period. However, Starner and Peters (2004) used the two subsystems of coping processes. Poirer
(2007) and Posmontier (2008) integrated different concepts of RAM in their works. Henderson et al. did not support
the RAM. Wendler's study partially supported the RAM, while Waweru et al's study, Zeigler et al.'s study, Ramini et
al.'s study, Starner and Peters's study, Huang et al. (2004), Pollock et al.(2005), Posmontier (2008) and Poirer's
study completely supported the RAM propositions.
The distinct point of RAM is that its ability to guide the directions of studies, and its ability to classify
different environmental stimuli that affect the individuals' adaptation process, and its ability to help researchers to
conceptualize their questions and organize the data. RAM is applicable and flexible to be applied in different
approaches, designs, purposes, settings and age groups. Table 1
6. SUMMARY
RAM has greatly influenced nursing profession. RAM focuses on the concept of adaptation of individuals to
different environmental stimuli. Nurses have a unique role to promote health in each of the four adaptive modes
through managing the environment. Because of its generalizability, practicality, and testability; RAM is one of the
most frequently used models that guides nursing research. Ten studies that utilized different concepts and
propositions of RAM were discussed. The four adaptive modes and the three environmental stimuli were the most
concepts used among these studies. Eight of these studies supported RAM's propositions, one study provided
partially support, and one study did not.
Table 1. Summary of Studies That Utilized RAM
Authors/ years

Objectives

Henderson,
Fogel, and
Edwards (2003)

To assess the coping

strategies that are used
by African American
women with breast
cancer, and to examine
any relationship between
sociodemographic
variables and coping
strategies used by these
women.

Wendler (2003)

To examine the effect of

Tellington Touch (T
touch) on: MBP, HR, SA
and PP in healthy
soldiers waiting
antecubital venipuncture.

Approach/
design/ sample
Quantitative

Concepts
used
The three
environmental
stimuli

Reason for
using RAM
Organizational
framework

Quantitative

Focal stimulus

A pretest, posttest
repeated measures
design

Contextual
stimuli the

Organizational
framework
to classify the
variables of the
study

A significant decrease in the

MBP and HR in the T touch
group while there were no
significant differences between
the T touch group and control in
SA and PP.

Organizational
framework
in order to
identify both
degree and
nature of
difficulties in
adaptation to
sleep loss.

Depressed mothers had poorer

sleep experience than non
depressed ones. Higher level of
depression were in mothers who
experienced more sleep
disturbances, short sleep
duration, and more daytime
dysfunctions.

cross-sectional
design
86 adult AfricanAmerican women

47 adult
participants in the
intervention group.

Regulator
system.

Summary of Findings
Positive reappraisal, and
seeking social support are the
most common coping strategies
used by African American
women with breast cancer.
There were no relationship
between sociodemographic
variables and coping strategies
among these women.

46 adult
participants in the
control group.
Huang et al.
(2004)

To estimate daytime
sleepiness and to assess
factors disrupting the
adaptation of sleep loss
during the early
postpartum period.

Quantitative

Descriptive/ cross
sectional design

The four
adaptive
modes

163 first-time
mothers

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Starner and
Peters (2004)

To examine the
relationship of anger and
anger expression on
blood pressure (BP) in
adolescents.

Quantitative
Descriptivecorrelational study

Vol. 4. No. 4. July, 2012

The cognator
and regulator
subsystem

Organizational
framework to
conceptualize
anger
expression and
blood pressure.

For girls, there was a significant

positive relationship between
anger expression and BP, and
negative relationship between
BP and anger control. For boys,
there was no significant
relationship between anger
expression and BP.

The four
adaptive
modes of the
RAM

To generate
open ended
questions based
on the four
adaptive modes

Information given, social and

emotional support and a place
to share experience were very
effective activities that offered
by the breast cancer support
group.

The role
function,
psychological
demands, and
interdependen
ce stressors.

Organizational
framework to
categorize
stressors of
postpartum
period

Lack of time to do many

responsibilities, financial
concerns, and concerns about
the health of the child and family
member(s) were sources of
stress.

The role
function mode

Organizational
framework to
guide the design
of his study and
the selection of
variables.

Site-specific treatment-related
side effects, fatigue, the
presence of comorbidities, living
alone, being on chemotherapy
along with radiation were factors
that affected patients' ability to
perform their usual activities.

Organizational
framework to
conceptualize
the study
variables.

Postpartum depression can

lower personal, household, and
social functioning, but not infant
care.

To generate
open ended
questions based
on the four
adaptive modes

Adolescents and young adults

reported evidence of positive
adaptation. Many adaptive
strategies were used that reflect
the four adaptive modes of
RAM.

Organizational
framework
to
conceptualized
the adaptation of
children living
with AIDS in the
self concept
mode

Children in the United States

were found to have an average
or above average self concept.
Whereas in Kenya, 93% of the
participants had an average to
much above average self
concept.

63 urban high
school seniors
Zeigler,
A Smith, and
Fawcett (2004)

To identify the
experiences of both
participants in and
facilitators of a
community breast cancer
support group.

Qualitative
Repeated
measures survey
methodology
Ten adult women
with breast cancer
and two Registered
Nurse

Pollock et al.
(2005)

To assess the everyday

stressors of being firsttime fathers during the
postpartum period.

Quantitative
Non-experimental
design
19 participants
being first time
fathers

Poirer (2007)

To explore factors that

might affect patients'
ability to perform their
usual activities while they
are under radiation
therapy.

Quantitative
longitudinal design
77 adult patients

The
physiologic
mode
Contextual
stimuli

Posmontier
(2008)

To examine functional
status between women
with and without
postpartum depression
(PPD).

Quantitative
Cross-sectional
comparative design
23 women with
and 23 women
without PPD

The focal
stimulus
contextual
stimuli
The self
concept mode
The role
function
modes

Ramini, Brown,
and Buckner
(2008)

Waweru,
Reynolds, and
Buckner (2008)

To identify the
experiences and
adaptive strategies used
by adolescents with
cancer

Qualitative

To assess the perception

of self-concept and
associated emotional
indicators of children
living with AIDS in the
United States and Kenya

Quantitative
and Qualitative

Descriptive design

The four
adaptive
modes

Four adolescents
and young adults

A descriptive study

48 children from
United States and
42 children from
Kenya.

The
environmental
stimuli
Self concept
mode

30 | PART B. SOCIAL SCIENCES AND HUMANITIES

Emotional indicators were found

in 33% of American population
while it was 52% for those in
Kenya.

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