The Roy Adaptation Model in Practice
the roy adaptation model
implementing the roy adaptation model:
from theory to practice
Pamela Senesac, PhD, RN, MS, SM
For more than 30 years the Roy Adaptation Model (RAM) has been used to understand and direct nursing practice in the care of individual patients. In a review of the literature, most articles describe the use of the RAM to do just that – individual nurses use the model as a framework to conceptualize and plan the care of patients one at a time, or use the model to create an intervention for a discrete clinical population. There are fewer examples of organizations adopting the model as a shared framework for practice within a unit or across an institution. What attempts have been made to implement the model in an institutional practice setting, and what have been the outcomes?
The RAM has been implemented in a NICU as an ideology for nursing (Nyqvist & Sjoden, 1993); on an acute surgical ward as a means of documenting compliance with the nursing process (Lewis, 1988); on an 18-bed unit in a rehab facility to integrate the professional basis of patient care (Mastal, Hammond, & Roberts, 1982); on two units of a general hospital as a conceptual framework to guide practice and as an integral part of a shared governance strategy (Weiss, Hastings, Holly, & Craig, 1994); in a 125-bed orthopedic hospital to facilitate an integrated system of nursing (Rogers et al., 1991); on a neurosurgical unit to establish a professional practice environment for student training, enhance professional autonomy, and aid recruitment and retention of staff (Frederickson, 1991, 1993); and in a 145-bed hospital to increase clarity in provider roles, and strengthen interdisciplinary collaboration and effectiveness (Connerley, Ristau, Lindberg, & McFarland, 1999).
What has been learned about strategies that facilitate implementation? Successful implementation strategies include: the development of specific assessment and documentation tools emphasizing the particular areas of the model most applicable for the population to be served; reformatting the principles of the model and the development of multi-modal training tools for your learners, including just-in-time training and use of adult learner principles; attending to issues of authority, leadership style and communication; establishing an implementation committee that includes early involvement of those affected by the change; increasing the project’s visibility through RAM nursing care conferences, bulletin board case studies, journal clubs and self-learning modules. If the model is to be implemented as a practice philosophy for an entire institution, it should be reflected in the mission and vision statements of the facility, referenced in job descriptions and evaluation tools, and used as the framework for patient assessments, care plans and related documentation.
What challenges have been identified in the implementation process? To paraphrase one author, implementation is facilitated by a lack of appreciation of the width of the theory/practice chasm and the size of the leap required to cross it. Others advise: making the theory operational by developing concrete tools for specific practice settings; acknowledging that translating an abstract theory into practice requires hard work and determination; considering that adopting a nursing model will require changing the administrative and documentation systems around it; understanding that initially documentation will be more time-consuming than whatever preceded it; developing a plan to access additional resources for implementation including people, services, materials and a budget allocation; and planning for continuing attention to varying educational needs at different stages. Full implementation and internalization takes years, and is best described as a journey rather than a destination.
Connerley, K., Ristau, S., Lindberg, C., & McFarland, M. (1999). The Roy Model in Nursing Practice, The Roy Adaptation Model (second ed., pp. 515-534). Stamford, CT: Appleton & Lange.
Frederickson, K. (1991). Nursing Theories-A Basis for Differentiated Practice: Application of the Roy Adaptation Model in Nursing Practice. Paper presented at the Proceeding of Annual Meeting Differentiating Nursing Practice into the Twenty-first Century.
Frederickson, K. (1993). Translating the Roy Adaptation Model into Practice and Research. In M. E. Parker (Ed.), Patterns of Nursing Theories in Practice (pp. 230-238). New York: NLN Press.
Lewis, T. (1988). Leaping the Chasm Between Nursing Theory and Practice. Journal of Advanced Nursing, 13, 345-351.
Mastal, M. F., Hammond, H., & Roberts, M. P. (1982). Theory into Hospital Practice: A Pilot Implementation. The Journal of Nursing Administration, 12, 9-15.
Nyqvist, K. H., & Sjoden, P.-O. (1993). Advice Concerning Breastfeeding from Mothers of Infants Admitted to a Neonatal Intensive Care Unit: the Roy Adaptation Model as a Conceptual Structure. Journal of Advanced Nursing, 18, 54-63.
Rogers, M., Paul, L. J., Clarke, J., Mackay, C., Potter, M., & Ward, W. (1991). The Use of the Roy Adaptation Model in Nursing Administration. Canadian Journal of Nursing Administration, 4(2), 21-6.
Weiss, M. E., Hastings, W. J., Holly, D. C., & Craig, D. I. (1994). Using Roy's Adaptation Model in Practice: Nurses Perspectives. Nursing Science Quarterly, 7(2), 80-86.
To apply the Roy Adaptation Model to nursing practice, the nurse works collaboratively with the individuals and groups to assess adaptive strengths and to help deal with issues they encounter in promoting their health. This can be seen in the case of Julie P. Julie was diagnosed with juvenile diabetes when she was a toddler and with her mother as the primary care giver learned to manage her own health care related to the diabetes very well as a young child and in her school-age years. Now as a 13 year-old she is having difficulty and her laboratory results show that more frequently her estimated value of blood glucose for the previous 2 to 3 months is above the level recommended for the prevention of diabetes related complications.
The nurse plans the time at Julie’s next clinic visit to review with the teen-ager her own abilities to deal with her health and where these are being challenged (Whittemore and Roy, 2002). The nurse is aware that any teen-ager is dealing with rapid periods of growth, increasing influence of the peer group, more activities away from home, as well as new stresses such as expectations to succeed in school and to be popular among ones classmates. Each of these factors may be providing challenges to the previous well-learned coping strategies that Julie used to deal with control of her insulin-dependent diabetes. In the physiological mode, Julie is showing some compromised level of adaptation reflected in the blood glucose levels and in reports of not getting enough exercise. In the self-concept mode, Julie is showing efforts to compensate for feeling different than her friends in her physical self by not telling them that she has diabetes. Her self consistency and self-ideal remain strong because she has always been proud that she has handled her diabetes mainly by herself with her mother’s guidance. Julie knows that her roles are beginning to change and will change even more as she prepare to go to high school. She still has a good relationship with both her parents and her younger brother, but wishes her mother would “just leave me alone.”
With past successes to build on, Julie can work with the nurse to look at the new challenges she is facing. Together they can work out ways that Julie can handle each challenge in ways that will work for her now and in the future. As the nurse provides Julie with information about each challenge, she is dealing with the stimuli of lack of knowledge in that area. At the same time she recognizes the mature attitude that Julie has brought to her own health care and encourages her to take the next step of being an expert on managing diabetes in the teen-age years. The nurse can provide resources such as books for teen-agers provided by the local or national Diabetes Association. She can encourage Julie to volunteer at a Diabetes summer camp where she can help younger children to do as well as she has done and also relate to other volunteers her age who are dealing with the same challenges.
Julie can get her best friend to be her “health partner.” Julie’s friend is gaining weight beyond what is expected for her age. Julie and her friend can work out diet and exercise patterns that are similar, but take each one’s special needs into consideration. Julie’s “health partner” can also be the back-up person for observing whether Julie is having a blood sugar difficulty and can suggest some help without making an issue of the incident. It will be important for Julie to define her independence within her parents’ need to watch over her health. One suggestion is for Julie to sit down with her parents and together they can write down everything that needs to be done to manage diabetes. Julie and her parents can decide who is responsible for each thing on the list (2003 American Diabetes Web Site). The list can be reviewed every couple of months or so to see how the plan is working. The nurse can encourage Julie to be grateful that she can begin to be on her own with her parents still providing some guidance.
Throughout the process of working with Julie, the nurse is promoting her best adaptive strategies in all four adaptive modes. This will promote health as the integration of adaptation in all four adaptive modes. Julie can maintain control of her diabetes at the same time that she has the healthy development of self, role and interdependence changes of a teenager.