•Nursing is establishing itself as a scientificdiscipline.•Its thrust toward scientifically sound socialusefulness including the development ofconceptual models.•The nursing models provide the basis forselecting knowledge to be transmitted innursing education.INTRODUCTION
CONTD… It is the framework for nursingpractice and the direction fornursing research. Sister callista Roy’s adaptationtheory (Roy and Obloy1979,Roy 1980,1984,1989)views the client as an adaptivesystem.
BIOGRAPHICAL SKETCH OFTHE NURSE THEORIST Sister callista Roy was bornon oct, 14,1939. She did her bachelors of artsin nursing from mount st.Mary’s college, losAngeles in1963 and masters of sciencein nursing from ,University ofCalifornia,Los Angeles1966.
CONTD…. She also received her masters of arts(M.A) insociology from the same university in 1975 andPh.D in sociology . Roy was an associate professor and chairperson ofthe department of nursing at mount Saint Mary’scollege until 1982.
CONTD…. From 1983 to 1985; she was Post Doctoral fellow atRobert Wood Johnson at University of California,as a clinical nurse scholar in neuroscience. In 1988 Roy began the newly created position ofgraduate faculty at, Boston school of nursing.
CONTD…. According to Roy’s model, the goal of nursing isto help the person’s adaptive system. According to Roy’s model, the goal of nursing isto help the person adapt to change inphysiological needs, self-concepts, role functionand interdependent relations during health andillness .
CONTD….All individual must adapt tothe following demands:1. Meeting basic physiologicalneeds.2. Developing a positive self-concept.3. Performing social roles.4. Achieving a balancebetween dependence andinterdependence.
CONTD….It is role of nurse: To find out demands whichare causing problems for aclient. To assess how well theclient is adapting to them.Nursing care is thendirected at helping theclient to adopt.
ORIGIN OF THE MODEL: While a student of M.sc. nursing, at the universityof California sister C. Roy was challenged in aseminar by another nurse theorist DorothyE.JOHNSON to develop a theory of nursing ,subsequently in 1970 the ‘ROY ADAPTATIONMODEL’ was born as a derivation of Bertalanfty(1968) general system theory and Harry Helson’sAdaptation level theory (1964).
CONTD….1. The person is a bio-psycho-socialbeing includes biologic components(Anatomy and Physiology),psychological and socialcomponents.2.The person is in constantinteraction with a changingenvironment (interaction withphysical, social & psychologicalenvironment changes)
CONTD…3.To cope with a changing world,the person uses both innate andacquired mechanisms which arebiologic,psychological and socialin origin.4.Health and illness are aninevitable dimension of theperson’s life.5.To respond positively toenvironmental changes, theperson must adapt (changingenvironment demands positiveresponse)
CONTD….6.The person’s adaptation is afunction of the stimulus, he isexposed to and his adaptation level,which is determined by thecombined effect of three classes ofstimuli:*focal stimuli*contextual stimuli*Residual stimuli
CONTD….*Focal stimuli or stimuli demanding promptattention.*Contextual stimuli or stimuli present in asurrounding and situation.*Residual stimuli such as belief, attitude andhabits, which have an indeterminate on the presentsituation.
CONTD….7. The person’s adaptation level is such that itcomprises a zone indicating the range of stimulationthat will lead to a positive response. (if the stimulusis within the zone the person responds positively,however if the stimulus outside the zone ,the personcannot make a positive response)
CONTD….8. The person is conceptualized ashaving four modes of adaptation: psychological needs self-concept, role function, and interdependence relations.
Four philosophical assumptions basedon the humanist principles are asfollows.a. The individual shares in creativepower.b. Behaves purposefully, not insequence of cause and effect.c. Possesses intrinsic holism andd. Strives to maintain integrity & torealize the need for relationship.
CONTD….VERTIVITYThe term vertivity derivedfrom the Latin ‘veritas’meaning the trust, wascoined by Roy. It’s aprinciple of human naturethat affirms a “commonpurposefulness of humanexistence”.
The four principlesare : The individual isviewed in the context ofthe purposefulness ofhuman existence. Unity of purpose ofhuman kind Activity & creativity forthe common goods Value of meaning of life.
5. CONCEPTS OF MODEL Roy’s model is a system model that focuses onoutcomes. the major features of the system modelsare the:-System and its environment• A system is a set of parts connects to function as awhole for some purposes and are interdependenceof its parts.
CONTD…. Keys elements in the Royadaptation model are-1. The person who is recipient ofnursing care2. The goal of nursing.3. The concept of health4. The direction of nursingactivities.
CONTD… Person: Roy uses person in her model as a conceptto identify the recipient of nursing care. critical tothe model is the description of recipient of nsg careas holistic adaptive systems. Persons as living systems are in constantinteractions with their environments between thesystem and the environment occurs on exchange ofinformation, matter and energy.
Goal-the goal of nsg. as thepromotion of adaptive responsesin relation to the four adaptivemodes (physiological, selfconcept, role function andinterdependence)and contributeto health.
Nsg activities-The nursing activitiesare delineated by the model as those thatpromotes adaptive responses insituation of health and illness. The nsgactivities are identified as actions takenby nurses to manipulate the focal,contextual residual stimuli impringingon person.
CONTD…. The nsg process acc. to Roy’smodel consists of six steps-(1)Acceptance of behavior(2)Acceptance of stimuli(3)Nsg diagnosis(4)Goal setting(5)Intervention(6)Evaluation
Health-health has been defined as a “state andprocess of being and becoming an integrateand whole person’’ Health is a process where byindividuals are striving to achieve their maximumpotentials.
Environment-stimuli from within the person andstimuli from around the person represents theelement of environment acc. to Roy. Environment is specifically defined by Roy as “allconditions, circumstances influences surroundingand affecting the development and behavior ofpersons and groups.
6. THE PERSON AS ANADAPTIVE SYSTEMIn addition to the concept of person,goal ofnsg,health and environment and nsg activities inthe model ,the theory of person as an adaptivesystem employs additional concepts.
CONTD….(1)Input-input coming from external environmentas well as internally from the person as astimuli(a stimulus is a unit ofinformation,matter,or energy from theenvironment or a person who elicits aresponse).The stimuli immediately confrontingthe person are focal stimuli greatest degree ofchange impact on person.
CONTD… Contextual stimuli-observable, measureable andreported by the person. Residual stimuli-those make up characteristics ofthe person that are present and relevant tosituation.
CONTD…….Example: Mr. smith experiencing the chestpain, the stimulus immediately confrontingMr. smith,the focal stimulus ,is the deficit ofoxygen supply to his heart muscles.Thecontextual stimuli include the 90 degree oftemperature ,the sensation of pain ,Mr.smith’s age ,weight,blood sugar level,anddegree of coronary artery patency.Theresidual stimuli include his history ofcigarette smoking and work relate stress.
Adaptation level is a constantly changingpoint that represents the person’s ability tocope with the changing environment in apositive manner. Adaptation level sets up a zone or a rangewithin which stimulation will lead to adaptiveresponses. Stimuli falling outside their adaptive zone leadto ineffective responses. Suicide due to inability to cope up with thechild is an extreme example of an ineffectiveresponse.
Coping mechanisms some coping mechanisms areinherited or genetic such aswhite blood defense systemagainst bacteria seeking toinvade the body. some are learned as use ofantiseptics
CONTD…. Mechanisms are of 2 types:(1)Regulator is used primarily as a mechanismto cope with physiological stimuli.(2)Cognator used mainly as mechanism to copewith psychological stimuli dealing primarily inarea of cognition, judgment and emotion.-Regulator and cognator mechanisms are linkedthrough the process of perception.
CONTD…. It is important to recognize that it is themanifestation of the coping mechanism that can beobserved and measured within the adaptive modes.Thus adaptive modes are often referred aseffectors.
CONTD….Effectors: Roy has identified four adaptive modes; Physiological self concept role function interdependence.
CONTD….Adaptive responses output-The behaviors that contribute to the general goalsof the person(i.e survival,growth,reproduction andmastery)are considered adaptive response. Behaviors not contributing to general goals areconsidered ineffective responses. Adaptive responses being about a state ofadaptation.
7. THEORY OF ADAPTIVEMODES:The theory of adaptive modes was developed in 1981,consist of four parts: physiological, self concept, role function & interdependence.
CONTD…Each adaptive mode represents a grouping ofbehaviors that promote the individuals movementstowards the general goals (survival, growth,reproduction, mastery).
CONTD…..(1)PHYSIOLOGICAL MODEPhysiological wholeness is achievedby adapting to changes inphysiological needs. The regulator coping mechanism isprimarily responsible for attainingand maintaining this integrity. other complex process thatinfluences regulatoractivities are the senses, fluids andelectrolytes, neurological function &endocrine function.
Five primary needs have been identified asnecessary for physiological integrity: oxygen, nutrition, activity rest, protection, elimination
CONTD…(2)SELF CONCEPT MODESelf concept is one of the 3 psychosocial modes, thebasic human need within modes in psychicintegrity,which means people need to know whothey are so that can exist with a sense of unity.
CONTD….. Physical self: is an appraisal of one’s physical,attributes, appearance, functioning,sensation(feeling about self) sexually andwellness illness status. Personal self: is an appraisal of one’s owncharacteristics, expectations, values & worth.Personal self has been divided into the moralethical spiritual self ,self consistency & selfideal, self expectancy e.g. I believe God willhelp me through this surgery.
CONTD…..(3)ROLE FUNCTION MODE:The basic need in the role function adaptive modelis for social integrity. This means that people needto know who they are in relation to others so thatthey can act. All people have role in society. Witheach role there are expected behavior .Role havebeen divided into primary, secondary and tertiary.
CONTD….(4)INTERDEPENDENCE MODEInterdependence is a social adaptivemode,needs affection adequacy or the feeling ofsecurity in nurturing relationships. Interdependence means the close relationshipof people that involves willingness & ability tolove, respect & value others and to accept &responds to love, respect and value given byothers. Loneliness as a common adaptation problemresulting from a disruption in the modes.
Those currently identifiedneeds are listed below:(a) Basic physiological needs- Exercise and rest Nutrition Elimination Fluid and electrolyte Oxygen Circulations Regulations
CONTD….(b)self concepts: Physical self Personal self Interpersonal self(c) role mastery:-Role failure-Role conflict
CONTD….(d)interdependence:-Alteration,rejection,aggression,rivalry,hostility,loneliness,dominance,exhibition.-The aspects of care which are examined inview of the model are: The nature of the people receiving nursingcare. Cause of problems likely to require nsgintervention. Nature of assessment
CONTD…. Nature of planning and goal setting process The focus of nsg interventions during theimplementation of the nsg care plan The nature of the process of evaluating the qualityof effects of the care given.
NURSING PROCESS ACCORDING TORAMA problem solving approach for gathering data,identifying the capacities and needs of the humanadaptive system, selecting and implementingapproaches for nursing care, and evaluation theoutcome of care provided.o Assessment of Behavior: the first step of thenursing process which involves gathering data aboutthe behavior of the person as an adaptive system ineach of the adaptive modes.
CONTD…. Assessment of Stimuli: the second step of thenursing process which involves the identificationof internal and external stimuli that areinfluencing the person’s adaptive behaviors.Stimuli are classified as:1) Focal- those most immediately confronting theperson2) Contextual-all other stimuli present that areaffecting the situation3) Residual- those stimuli whose effect on thesituation are unclear.
Nursing Diagnosis: step three of the nursingprocess which involves the formulation of statementsthat interpret data about the adaptation status of theperson, including the behavior and most relevantstimuli
GOAL SETTING the fourth step of the nursing process whichinvolves the establishment of clear statements ofthe behavioral outcomes for nursing care.
Intervention: thefifth step of thenursing process whichinvolves thedetermination of howbest to assist theperson in attainingthe established goals
Evaluation: the sixthand final step of thenursing process whichinvolves judging theeffectiveness of thenursing interventionin relation to thebehavior after thenursing interventionin comparison withthe goal established.
DEMOGRAPHIC DATANameMr. NRAge 53yearsSex MaleIP number ------Education DegreeOccupation Bank clerkMarital status MarriedReligion HinduInformants Patient and WifeDate of admission 21/01/08
FIRST LEVEL ASSESSMENTPHYSIOLOGIC-PHYSICAL MODEOxygenation: Stable process of ventilation and stable process of gas exchange.RR= 18Bpm. Chest normal in shape. Chest expansion normal on either side. Apex beat felt on left 5th inter-costal space mid-clavicular line. Air entry equal bilaterally. No ronchi or crepitus. No abnormal heart sounds. S1& S2 heard. BP- Normotensive. .
CONTD….Nutrition He is on diabetic diet (1500kcal). Nonvegetarian. Recently his Weight reduced markedly(10 kg/ 6 month). He has stable digestive process. He has complaints of anorexia and nottaking adequate food. No abdominal distension. No tenderness. Bowel sounds heard. Percussion revealed dullness overhepatic area.
CONTD….Elimination: No signs of infections, nopain during micturation ordefecation. Normal bladder pattern.Using urinal formicturation. Stool is hard and hecomplaints of constipation.
CONTD…Activity and rest: Taking adequate rest. Sleep patterndisturbed at night dueunfamiliarsurrounding. Not following anypeculiar relaxationmeasure. Like movies andreading. No regularpattern of exercise.
CONTD….o Now, activity reduced due toamputated wound. Mobilityimpaired. Walking with crutches. Pain from joints present. Noparalysis. ROM is limited in the left leg due towound. No contractures present. Noswelling over the joints. Patient need assistance for doingthe activities.
CONTD….Protection: Left lower fore foot is amputated. Black discoloration present over the area. No redness, discharge or other signs of infection. Wound healing better now. Pain form knee and hip joint present while walking. Dorsalis pedis pulsation, not present over the left leg.Right leg is normal in length and size. All peripheral pulses are present with normal rate, rhythmand depth over right leg.
CONTD….Senses: No pain sensation from the wound site.Relatively, reduced touch and pain sensation inthe lower periphery; because of neuropathy.Using spectacle for reading. Gustatory, olfaction,and auditory senses are normal.Fluids and electrolytes: Drinks approximately 2000ml of water. Stableintake out put ratio. Serum electrolyte values arewith in normal limit. No signs of acidosis oralkalosis. Blood glucose elevated.
CONTD….Neurological function: He is conscious and oriented. He is anxious about the diseaseconditon Touch and pain sensationdecreased in lower extrimity.Endocrine function He is on insulin. No signs andsymptoms of endocrinedisorders, except elevated bloodsugar value. No enlargedglands.
CONTD….Personal self: Self esteem disturbed because of financial burden andhospitalization. He believes in god and worshipingHindu culture. ROLE PERFORMANCE MODE: He was the earning member in the family. His roleshift is not compensated. His son doesn’t have anywork. His role clarity is not achieved.INTERDEPENDENCE MODE: He has good relationship with the neighbours. Goodinteraction with the friends relatives. But hebelieves, no one is capable of helping him at thismoment. He says ”all are under financial constrains”.He was moderately active in local social activities
SECOND LEVEL ASSESSMENTFOCAL STIMULUS: Non-healing wound after amputation of greatand second toe of left leg- 4 week. A wound firstfound on the junction between first and secondtoe-4 month back. The wound was non-healingand gradually increased in size with puscollected over the area. He first showed in a local hospital,referred tomedical college; During hospital stay great andsecond toe amputated. But surgical wound turnedto non- healing with pus and black colour. So thephysician suggested for below knee amputation.That made them to come to ---Hospital, ---. Heunderwent a plastic surgery 3 week before.
CONTD….CONTEXTUAL STIMULI: Known case DM for past 10 years. Was on oralhypoglycemic agent for initial 2 years, butswitched to insulin and using it for 8 years now.Not wearing foot wear in house and premises.RESIDUAL STIMULI: He had TB attack 10 year back, and tookcomplete course of treatment. Previously, headmitted in ---Hospital for leg pain about 4 yearback. . Mother’s brother had DM. Mother hadhistory of PTB. He is a graduate in humanities,no special knowledge on health matters.
CONCLUSION Mr.NR who was suffering with diabetesmellitus for past 10 years. Diabetic footulcer and recent amputation made hislife more stressful. Nursing care of thispatient based on Roys adaptation modelprovided had a dramatic change in hiscondition. He studied how to use crutchesand mobilized at least twice in a day.Patient’s anxiety reduced to a greatextends by proper explanation andreassurance. He gained good knowledgeon various aspect of diabetic foot ulcer forthe future self care activities.
NURSING CARE PLANASSESS. OFBEHAVIOURASSESSMENTOFSTIMULINURSINGDIAGNOSISGOAL INTERVENTIONEVALUATIONIneffectiveprotectionand sensein physical-physiological mode(No painsensationfrom thewoundsite.) Focalstimuli:Non-healingwoundafteramputationof greatand secondtoe of leftleg- 4 week1. Impairedskinintegrityrelated tofragility ofthe skinsecondaryto vascularinsufficiencyLong-termobjective:1.amputatedarea will becompletelyhealed by20/5/082.Skin willremainintact withno ongoingulcerations. - Maintain thewound areaclean ascontaminationaffects thehealing process.- Follow steriletechnique whileproviding caresto preventinfection anddelay in healing.- Performwound dressingwith Betadinewhich promotehealing andgrowth of newtissue.Short termgoal:Met: size ofwounddecreased toless than 1x1cms.WBC valuesbecamenormal on24/4/08
ASSESS. OFBEHAVIOURASSESSMENTOF STIMULINSGDIAGNOSISGOAL INTERVENTIONEVALUATIONShort-TermObjective: i. Size ofwounddecreases to1x1 cm within24/4/08. ii. No signsof infectionover thewound within1-wk iii. NormalWBC valueswithin 1-wk iv. Presenceof healthygranulartissues in thewound sitewithin 1-wk -Do not movethe affectedareafrequently as itaffects thegranulationtissueformation.- Monitor forsigns andsymptoms ofinfection ordelay inhealing.- Administerthe antibioticsand vitamin Csupplementation which willpromote thehealingprocess. Long termgoal:PartiallyMet: skinpartiallyintact withno Continueulcerations.Plan,Reassess goal andinterventionUnmet: notachievedcompletehealing ofamputatedarea.ContinueplanReassessgoal and
ASSESS. OFBEHAVIOURASSESSMENTOFSTIMULINURSINGDIAGNOSISGOAL INTERVENTIONEVALUATION Impairedactivity in physical-physiologicalmode Focal stimuli:Duringhospital staygreat andsecond toeamputated.But surgicalwound turnedto non- healingwith pus andblack colour. 2. Impairedphysicalmobilityrelated toamputation ofthe leftforefoot andpresence ofunhealedwound Long termObjective: Patient willattainmaximumpossiblephysicalmobility within 6 months. - Assess thelevel ofrestriction ofmovement- Provide activeand passiveexercises to allthe extremitiesto improve themuscle tone andstrength.- Make thepatient toperform theROM exercisesto lowerextremitieswhich willstrengthen themuscle.Short termgoal:Met: usedcrutchescorrectly on22/4/08.he is selfmotivated indoing minorexcessesPartiallyMet: walkingwithminimumsupport.
CRITICISMINTERNAL CRITISIMSAdequacy synthesis of concepts from multiple paradigms. Conceptual models are grand theories. Difficult to understand because of abstractness.
CONTD…Clarity Clarification of assumption needed , especiallyphilosophical assumptions. Clarification of role , interdepence & selfconcepts. Ambiguity regarding concepts of cognatorregulator subsystems, effector mode/focal stimuli,adaptive modes/ mechanism,env./internalstimuli. Language is clear & easy to read &understand.
CONT… Consistency & congruency Physiologic mode not connected to other 3 modes. Unclear boundaries , abstract , lack ofoperational definition. Systemic assessment potential limked to nursingprocess.Level of theory development Exemplary theory on development (melius,2007) Grand theory used as conceptual framework formiddle range and micro theories. Used as a framework for addressing adaptiveneeds in individual , families & groups.
EXTERNAL CRITICISMComplexity/ simplicity /discrimination/pragmatism. Simplicity is based on the language & terms. Grand theories are inherently complex. Complexity doesn’t bend into operationalizabilityfor research . Studies based on the model moved from facevalidity to construct validity studies andrelational research studies.
CONTD….Reality convergence Nutrsing interfaces between the individual &health care system providing holistic care. Nurses need to continue to learn and adapt toavoid outsourcing. Roy belives nurses can avoid extinction of theprofession by not allowing themselves to nursesolely in the physiologi mode.
CONTD….Scope Grand theory RAM Middle range theory evolved RAM:- Caregivers’s effectiveness & well being. Coping with pain & chronicity. Coping with diabetes. Gentle touch in preterm infants.
CONTD…Significance 1987 – over 100,000 nurses havegraduated from program based onRAM Used by global scholars Models used in research , curriculumdevelopment, social issues , chronicillness & development of researchinstruments.
CONTD….Utility Research tool development Describes responses to health illness. Evaluates intervention Measures perception of adaptation levels. Measures perception of powerlessness & decisionmaking. Measures health care outcomes of cancer patients. Regaining functional abilities after delivery. Used to identify adaptive and maladaptivebehavior to stimuli. Lack of motivation to quit smoking. Assessing & planning care of surgical patients. Care of geriatric patients.
9. APPLICATION OF R.A.M INNURSING(1) Nsg practice- R.A.M is a very useful method innursing practice specially in those setting wherethere are convert psychological needs which are asessential as physical one. Roy’s models are veryeffective in pediatrics as well as community andrehabilatory nsg.
CONTD….(2)Nursing Research-R.A.M provide a conceptual model fornursing process and this has been abasis for number of research beingdone.for e.g measuring functionalstatus after child birth,functional statusduring pregnancy.If research is to affect practitioners’behavior, it must be directed at testingand retesting conceptual models fornursing practice. Roy has stated thattheory development and the testing ofdeveloped theories are nursing’shighest priorities. The model must beable to regenerate testable hypothesesfor it to be researchable.
CONTD….(3)Education-RAM useful in educational setting. Roy states that the model definesfor students the distinct purpose of nursing which is to promote man’sadaptation in each of the adaptive modes in situations of health andillness.