The Roy Adaptation Model Page 1
Roy began work on her theory in the 1960s. She drew from existing work of a physiological psychologist, and behavioral, systems and role theorists. She was keenly interested in the psycho/social aspects of the person from the start and concentrated her education on this aspect of Person. Thus, the language/thinking of psychology and sociology became second nature to her. The need for intense study of the language and ideas behind Roy's Adaptation Model is its biggest drawback in applying it to many clinical areas. The confusion in the physiological mode's categories could be explained by her concentrating on the psych social during her education.
In 1980, Roy and Reihl advocated a single unified model of nursing and suggested this would insure stability of the discipline of nursing. They maintained concepts and propositions of other models could be combined in summary statements related to person, goals of nursing and the nursing process. According to Fawcett, this position is a simplistic solution to a difficult problem. Nursing, with its limited experience with metaparadigms and conceptual models, is not ready for restrictions on its ways of thinking. It's my belief that this act of advocating a single unified model was an act of multi-oppressed thinking influenced by men, the Roman Catholic Church and the medical world.
During a 1987 conference of nursing theorists, Sister Roy made a number of deferring remarks to a speech made earlier by a male Bishop.
Fawcett also says the Roy Adaptation Model has an extensive
vocabulary and that some familiar words (ie adaption) have been given new meanings in Roy's attempt to translate mechanistic ideas into organismic ones.
Oppressed Group Behaviour:
-assimilating the values and characteristics of the Oppressors.
-Nursing leaders represent an elite group promoted because of their allegiance to maintaining the status quo.
-leaders of Oppressed Groups are controlling, coercive and rigid.
-education is important to maintaining the status quo.
-Roy's Model follows the Medical Model and tends to be Totalitarian and therefore is familiar to Medicine - they would want to encourage it.
-behaviour preferred by Oppressors is rewarded.
-token appeasement (approval) is given to halt change or revolt.
The contributions of this conceptual model are that it will lead to more systematic assessments of clients and an increased quality of nursing practice. It could foster nursing knowledge through organized research and it could provide a more organized curriculum.
Roy's definition of person
Roy defines the person as an Adaptive Open System. The Systems' Input is: a) three classes of stimuli: focal, contextual and residual, within and without the system and b) the systems' adaptation level or range of stimuli in which responses will be
adaptive. Inputs are mediated by the systems' Regulator (psychological) and Cognator (Psych/social aspects of person) subsystems. The system runs into difficulty when coping activity is inadequate as a result of need deficits or excesses. System effectors (body organs that become active with stimulation) are the four modes (physiological, self concept, role function and interdependence) that the Cognator and Regulator can demonstrate activity through. Output of the person as system may be adaptive or ineffective. Adaptive responses contribute to the goals of the system ie: survival, growth promotion, reproduction and self mastery. Ineffective responses do not contribute to the systems' goals.
The person receives nursing care. Roy implies the client has an active role in care and that he is a bio-psycho-social being who constantly interacts with a changing environment.
The focus of nursing is the person. Roy in 1978, commented that although the model may be applied to family, community in society it was developed specifically for the person (medical model influence - Totalitarianism)
Perception links the Cognator and Regulator. Inputs to the Regulator are transformed into perception. Perception is a process of the Cognator, responses following perception are feedback into both the Regulator and Cognator.
Of the Cognator, there are three modes described by Roy. Self concept is the need for psychic integrity and perception of worth.
Role function is the need for social integrity, and interaction
with others. Interdependence is the balance of dependence/ independence with others.
I like the concept of person as open systems and the concept of dividing 'stimuli' into focal, contextual and residual categories. There is definitely a need for more emphasis and understanding of the person's: cognitive coping mechanisms.
Again, Roy tends to imply that the person/adaptive system is reacting to and trying to 'fit' into his surroundings - another manifestation of the Roman Catholic fatalistic view of mankind.
Persons, family, communities are capable of affecting their environment and letting it affect and expand their capabilities at the same time. It does not have to be 'God's Will'. For example a person does not have to accept that he and his will be struck down by bowel CA, or heart disease. A change in diet, exercise, decreasing stress and not smoking will allow them to alter their future. Because the medical model is so dependent and fixated on treating pathologies, the public has gradually neglected or given up their ability to protect themselves against disease.
Think of the health care system or the prevailing medical model as the oppressor and the public as the oppressed. There is a clear understanding that the content of education/information is just as crucial to an oppressed group as access to it. Self esteem, or faith in their own ability to care for themselves and make the right decisions; is low. The doctor or nurse always knows or is right. For example, in the PACU, when we question some patients about their past health and how they feel now, it's very common to
hear 'I don't know, you should ask my doctor.' When they are reassured that it is their opinion I want, they will answer. If I express surprise that they have suffered so much, for so long, they often say something to the effect of: "I figured if the doctor wanted me to have more treatment/painkiller, he would have given it to me."
To paraphrase H. Jack Geiger, a civil rights worker: "Of all the injuries inflicted on the oppressed people, the most corrosive wound within, the internalized oppression that leads some victims, at an unspeakable cost to their own sense of self, to embrace the values of their oppressors."
Roy - Health
Roy's original model says that health is on a health-illness continuum from wellness to death. The degree of health or illness that the system experiences is an inevitable dimension of a person's life. The Roman Catholic Church, with it's fatalistic view of Human Life may have influenced Roy.
Currently, Roy defines Health as a process of becoming an integrated and whole person and a process of being. Health is the goal of the person's behaviour and the person's ability to be an adaptive organism.
Adaptation is a process of responding positively to environmental changes. The person encounters adaptation problems in a changing environment especially in situations of health and illness. Adaptive responses to pooled effects of focal, contextual
and residual stimuli are either positive ie: promote integrity of the system re: goals of survival, growth, reproduction and self mastery, or ineffective (do not contribute to goals). According to Chin and Kramer, theoretical conceptualizations of health as a state of adaption implies conforming or adjusting to environmental stimuli in order to "fit" within the environment. This suggests that (fatalistic) events external to the person are primary as a determinant of health and that person and environment are separate entities. This follows the totality paradigm. Roy's categorization of systems responses to a changing environment as adaptive or ineffective indicates health is seen as a dichotomy (a process of dividing into two mutually exclusive or contradictory groups). Unhealthy or healthy as seen by the medical model is another example of totality or mechanistic paradigms. Fawcett says that no explicit definition of health or illness is given by Roy so it must be inferred that adaptive responses signify wellness and that inadaptive responses signify illness.
My view of health is not based as firmly on the medical model or is as fatalistic as Roy's. For example: Anesthesia prescribing Valium pre-op for a normal response to impending surgery and the nurse administering it because it is an accepted (and quick) way of dealing with pre-op jitters.
In this case, the doctor and the nurse have decided on a course of action for the patient in place of providing pre-op answers to questions, different options and letting the patient expand his ability to manage his state of health and himself.
Roy - Environment/Society Page 7
Environment/Society constantly interacts with the individual and determines, in part, adaptation level. Stimuli originate in the environment. The environment: refers to all the internal/external conditions, circumstances and influences affecting the person, and his development and behaviour.
The internal and external environment provide input (or stimuli). The environment is always changing and interacting with the person. The stimuli are divided into focal; contextual and residual categories.
Focal stimuli immediately confronts the adaptive system ie: an M.I., a death in the family. Contextual stimuli or "background stimuli" is genetic makeup, sex, maturity, drugs, alcohol, tobacco, self concept, role function, interdependence, socialization, coping mechanisms (Cognator and Regulator), physical and emotional stress, culture, religion, environment. Residual stimuli are beliefs, attitudes, experiences, traits which may be relevant but effects are indeterminate and therefore cannot be validated.
Roy's general idea of the role Environment/Society play in the effects on the person make it seem like the person is a fairly passive, adaptive system - only reacting to stimuli from his environment, but not affecting it. My own earlier comments on Environment/Society are basically the same. I's like to emphasize that I've become more aware of the fact that Human beings/families/community can also affect or alter their inner and outer environment. That they don't have to accept the fatalistic view "that it's God's Will.", or that Doctors/Nurses know best.
The best example is the use of the PCA pumps for pain control. When instructed properly the patient has control over the amount of noxious, focal stimuli in his inner environment. He does not have the stress of waiting to see if the health care worker (Dr, Nurse, etc) is willing to alter his focal stimuli/environment for him. I have found it best in the PACU to hand over the control of the PCA pump as soon as possible as this ability to control this one aspect of their environment has it's own positive analgesic effect on patients.
During a 1987 lecture at a nursing theorist conference, Roy made the comment that although it might be the will of the client or the client's family to turn off the ventilator, that "the affects on society as a whole had to be considered, as the Bishop stated in his remarks this morning." To me, this appears to emphasize the idea in Roy's work that the person, as a adaptive system is only to be affected by external stimuli (in society, environment, R.C. church) and is not affecting his environment/society equally, that he should accept his fate.
Roy - Nursing
According to Roy, the Nurse using the Nursing Process, promotes adaptation responses during health and illness to free energy from ineffective/inadequate responses to increase health and wellness. Goals, mutually agreed on and prioritized, are proposed to meet the global goals of: Survival/Growth Promotion/Reproduction of race/society/attaining full potential or mastery of self.
The nurse uses activities to increase adaptive and decrease ineffective responses during illness and health. These activities alter or manipulate the client's focal, contextual and residual stimuli and expand his repertoire of effective coping mechanisms.
Nursing focuses on the person (adaptive system) as a biopsychosocial being at some point along the health-illness continuum. In contrast, Medicine focuses on biological systems and the patient's disease. It's goal is to move the patient along the continuum from illness to health. Nursing's goal is to increase adaptation in four modes of physiological, self concept, role function and inter-dependence. The nurse acts as an external regulatory force to modify stimuli affecting adaptation of the system (person). For example; instead of using the verbal analogue scale to assess whether I'll continue with I.V. morphine, I prefer to let the patient decide his care. Is a VAS of 4 O.K. for him, is he comfortable enough to rest, breath, move and cough?
My views are fairly similar to Roy's as far as the type of information that needs to be gathered before setting goals. It's a good framework for improving assessments of each patient. The emphasis on the Cognator (self concept, role function, inter-dependence) is assuming that all nurses understand the subtle differences between these modes and have the time to interview patients in depth. This concept of nursing could be more easily applied to psychiatric nursing, community nursing, or long term care facilities. Her grouping of needs in the physiological mode are also a source of confusion and frustration at Mt. Sinai where
I work. For example: a state of hypervolemia or hypovolemia could be under Oxygenation and/or Fluids and Electrolytes. The need to do neurovascular checks could come under Oxygenation/Activity and Rest/or Senses and Neuro functioning. Roy, herself, has said that in acute care areas, a need to prioritize and focus on survival is necessary and that adhering to closely to her model would be cumbersome in such settings.
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