disadvantages of implementing a nursing model

Roy's Adaptation is a forever growing one. Despite the possible

problems o f the implementation o f a model,
Pearson & Vanghan (1986) believe that it is an
'essential prerequisite for effective nursing'.

Model and Accident

and Emergency ROY'S ADAPTATION MODEL

nursing
L. Ingrain
Liz Ingram RGN, BN, Cert,
Ed, ENB 199, Staff Nurse,
A & E Department, University
College Hospital, London, UK
Correspondence to: 48, St
AIbans Road, Bamet, Her~s,
EN5 4LA, UK
Manuscript accepted
27 May 1994
Accident and Emergency Nursing(1995) 3, 150-153 © Pearson Professional ktd 1995
This article aims to analyse Roy's
Adaptation Model and to discuss its
relevance to the Accident and
Emergency ( A & E) area. A brief
description of a model of nursing will be
given, initially, followed by an outline of
the major concepts of Roy's Adaptation
Model. An attempt will then be made
to apply the Model to the care of a
patient suffering severe chest pain who
presents at the A & E department.
Finally, the practicability of applying
Roy's Model to A & E will be
considered.
WHAT IS A M O D E L ?
Before this article examines an individual model
of nursing it will consider 'what is a model?'.
P e a r s o n & V a u g h a n (1986) give an
understandable definition - 'a descriptive
picture of...' nursing '...practice which
adequately represents the real thing'.
The same authors suggest that the positive
effects o f a m o d e l , i.e. that it p r o v i d e s
consistency of care on a ward, gives rise to less
conflict in the nursing team and provides a
means o f directing nursing care, are sound
reasons for its adoption.
However, models are not w i t h o u t their
problems. T h e majority use a lot o f j a r g o n
which is not understood by the majority o f
health professionals (Hardy 1986). Nursing staff
are often ill-prepared and ill-informed when a
model is introduced (Kenny 1993) and this can
lead to staff dissatisfaction and resistance to
change. Models are often adopted too rigidly
which can actually restrict questioning rather
than enhance it (Hardy 1986).
T h e d e b a t e a b o u t the a d v a n t a g e s and
R o y began the development of her model in
the late 1960s and it is now the most widely
used nursing model (Logan 1990) in N o r t h
America. Roy's work was heavily influenced
by the field o f p s y c h o l o g y (Gerrish 1989)
and particularly by the work o f Helson (1964)
who was a Professor o f psychology. Helson's
work looked at adaptation and suggested that
' . . . a n individual's attitudes, values, ways o f
structuring his experiences...' represent the
individual's level o f adaptation. It was Helson
who first devised the idea o f 'focal, background
and residual stimuli...' which he says affect an
individual's ability to adapt. Helson, in his turn,
acknowledges that the concept o f adaptation is
not new and that it has been used by biologists
for many years.
Roy's Model is a conceptual one (Roy 1980)
which identifies 5 elements that are essential to a
model: man, goal, health, environment and
nursing. R o y sees man as an adaptive system with
c o g n a t o r and regulator acting to maintain
adaptation in the 4 adaptive modes: physiological
f u n c t i o n , self c o n c e p t , role f u n c t i o n a n d
interdependence. The physiological mode is
related to problems with breathing, eating,
walking etc. The self concept mode encompasses
how the person views himself- his body image,
morals and standards ofbehaviour. Role function
mode refers to the position the person holds
w i t h i n a family or in society; a n d
i n t e r d e p e n d e n c e is the balance b e t w e e n
dependence on others and the ability to be
independent. People generally move along an
interdependence continuum from birth to death
where they are dependent at the start o f life,
become independent and then dependent again
in their elderly years. W i t h i n a life span an
independent person can become more dependent
if affected by illness, loss o f income etc.
A d a p t i v e levels
Every person has a different adaptive level which
is a constantly changing point and represents the
area where adaptation can take place using
known coping mechanisms. The adaptive level
is a changing point because it depends on the
number o f stimuli a person has to deal with at
one time. For e x a m p l e , u n d e r n o r m a l
circumstances a w o m a n w o u l d be able to
 Roy's Adaptation Model and Accident and Emergency Nursing 15 1
employ positive coping actions if her car broke
down on a main road. However, if she had not
slept for 3 nights because o f a crying baby and
h e r t o d d l e r had b e e n m i s b e h a v i n g all that
morning she may feel unable to cope.
T h e goal o f nursing, in this model, is to
promote positive responses and decrease
ineffective responses from the patient, and thus
contribute to the patient's health, quality o f life,
or (in the case o f the terminally ill) dying with
dignity.
Stimuli
R o y describes the environment as the focal,
contextual and residual stimuli which can affect
the behaviour o f the person. The focal stimulus
is the one w h i c h i m m e d i a t e l y confronts the
patient and is usualiy the primary cause o f the
problem, for example pain due to a fractured
leg, o r r e d u c e d b l o o d f l o w to t h e h e a r t .
T h i s s t i m u l u s is u s u a l l y s e l e c t e d f o r
m a n a g e m e n t , initially, as it is the p r i m a r y
influence on the behavioural responses (Fawcett
1990; Gerrish 1989). The contextual stimulus
is that w h i c h c o n t r i b u t e s to the b e h a v i o u r
w h i c h was caused by the focal stimulus, for
example nausea (the focal stimulus) caused by
IV Pethidine is made worse by the contextual
s t i m u l u s : smell o f a m m o n i a . T h e r e s i d u a l
stimulus is the effect of past experience, attitudes
and c u l t u r e o n the c o p i n g b e h a v i o u r . F o r
example, the patient may not cope well with his
incisional pain because he has never experienced
similar pain before.
First level assessment
The first step in Roy's Model is for the nurse to
make a first level assessment. This is carried out
by data c o l l e c t i o n . T h e nurse does this b y
interviewing the patient, measuring (i.e. blood
pressure) and o b s e r v i n g . O n c e this data is
c o l l e c t e d , the nurse must d e c i d e w h a t the
patient's current level o f adaptation is. The nurse
does this by identifying adaptive and maladaptive
behaviours within the 4 adaptive modes
m e n t i o n e d above. For example, there may be
maladaptive behaviours within the physiological
mode because o f a drop in blood pressure due to
h a e m o r r h a g e . T h e r e m a y be m a l a d a p t i v e
behaviours in the rote function mode if a man
has to give up his w o r k due to his coronary
disease. T h e nurse and the p a t i e n t i d e n t i f y
w h i c h b e h a v i o u r s are m a l a d a p t i v e a n d ,
therefore, require nursing intervention. These
behaviours must be prioritised. The maladaptive
behaviours which must come first in priority are
those w h i c h t h r e a t e n survival ( R o y 1980).
T h e s e are c o m m o n l y t h e p h y s i o l o g i c a l
behaviours.
Second level assessment
The second level assessment is to establish which
stimuli are causing the maladaptive behaviours.
For example, the focal stimulus for the drop in
blood pressure o f a patient could be the large
p u n c t u r e w o u n d to t h e a b d o m e n c a u s i n g
h a e m o r r h a g e . In this case t h e r e are no
contextual or residual sdmuh contributing to the
problem. However, the patient's ability to cope
with his fear and anxiety may be affected by
residual stimuli, such as a previous experience o f
a major operation.
Nursing diagnosis
The nurse must now make a nursing diagnosis.
F o r e x a m p l e , 'an a b n o r m a l d r o p in b l o o d
pressure due to reduced circulating volume'.
Together the nurse and the patient must set short
and long t e r m goals and plan the care that is
n e e d e d to achieve those goals. This care is
i m p l e m e n t e d and then evaluated. If the goals
have not been achieved then they must return to
first level assessment and decide what changes
are n e e d e d in order to p r o m o t e an adaptive
response.
A P P L Y I N G ROY'S M O D E L
TOA&E
This article will attempt to demonstrate how
Roy's Model could be applied to the care o f a
patient in the A & E department. It is not to say,
however, that the author feels that it is the most
appropriate model. Indeed problems with
i m p l e m e n t a t i o n m a y arise w h i c h m a k e it
inappropriate. These problems will be addressed
in the next section.
M r Davis arrives at the reception desk o f the
A & E department, accompanied by his wife,
complaining o f chest pain. H e is unable to give
any details to the receptionist because the pain is
too severe. The receptionist brings this to the
attention o f the triage nurse. W i t h most patients
w h o arrive at the front desk the triage nurse
would carry out both the first and second level
assessment in the triage area. However, the nurse
realises that she must get this patient into the
crash room as soon as possible. The nurse puts
M r Davis i n t o a w h e e l c h a i r and takes h i m
t h r o u g h to the crash r o o m . Here, the triage
nurse hands over her immediate observations to
the nurse in this area, who will then take over
M r Davis's care. The triage nurse returns to Mrs
Davis, w h o is giving details at the reception
desk, and takes her to a seat just outside the crash
room and explains that the doctor needs to do a
quick examination o f her husband and then she
will be able to go in and sit with him.
152 Accident and EmergencyNursing
It is the nurse in the crash room w h o then
carries out the first level assessment. This is
when data is collected. Measurements are made
o f blood pressure, heart rate, respiration rate,
oxygen saturation, and an E C G is performed.
Whilst the nurse is doing this she will try to
ascertain, from M r Davis, when the pain started;
how long it has lasted so far; how severe it is;
w h e t h e r it radiates; w h e t h e r the patient has
taken anything to relieve it so far; and whether
he has a history o f coronary disease. The other
method o f data collection is by observation. The
triage nurse used this to make her decision to
move Mr Davis into the crash room
immediately, and the nurse in the crash r o o m
will continue to observe h i m for changes in
condition.
The nurse will then decide whether there are
behaviours present which are maladaptive and
which mode they fall into. The most immediate
and survival-threatening maladaptive behaviour
falls into the physiological mode: severe chest
p a i n , also c a u s i n g n a u s e a , s w e a t i n g a n d
breathlessness. This is the behaviour which must
be treated as a priority as it threatens survival.
Other maladaptive behaviours may be anxiety
(in the self concept mode); concern about his
wife and loss o f the day's earnings (in the role
f u n c t i o n m o d e ) ; a n d n e e d for h e l p a n d
reassurance (in the interdependence mode).
Only the priority problem shall be addressed
in the second level assessment here (although
t h e n u r s e w o u l d n e e d to assess all t h e
maladaptive behaviours in a similar way). U n d e r
n o r m a l circumstances, the patient w o u l d be
involved in the decision making process about
w h e t h e r this b e h a v i o u r was a d a p t i v e o r
maladaptive. However, the patient has already
inferred that this is a p r o b l e m for w h i c h he
needs intervention by presenting himself in the
A & E department. The nurse must now decide
what are the stimuli causing the problem. The
focal stimulus is the lack o f blood supply to the
myocardium. This is the stimulus which would
be initially selected for management as it is the
primary cause o f the problem (Fawcett 1990;
Gerrish 1989). The contextual stimuli may have
been a flight o f stairs that M r Davis climbed just
before the pain started or anxiety related to a
family problem. A residual stimulus may be that
he has had this k i n d o f pain before and he
k n o w s that t h e r e is an end to it. This will
actually help him to adapt more quickly.
T h e nurse w o u l d n o w m a k e a ' n u r s i n g
diagnosis', such as 'severe central chest pain due
to inadequate myocardial perfusion'.
The nurse would plan and implement
interventions to relieve the pain. This would
include ensuring that M r Davis remains rested
on the trolley; administering oxygen; fanning
him; giving verbal information and reassurance;
and (under doctor's instructions) administering
analgesics, vasodilators and antiemetics.
Once interventions have been implemented
for all maladaptive behaviours then care should
be re-evaluated and a new plan made if
necessary.
- - .... ~ ~ •
W O U L D ROY W O R K IN A & E?
T h e r e has always b e e n the a s s u m p t i o n that
nursing models will not w o r k in A & E, but
there has been very little w o r k on the use o f
t h e m in this area (Sbaih 1992). Is the R o y
A d a p t a t i o n M o d e l practicable in the A & E
d e p a r t m e n t ? I w o u l d s u g g e s t t h a t , in an
u n m o d i f i e d form, it is not, b u t there is no
reason why the major concepts o f the model
could not be used very effectively.
Assessment time
I believe that the main problem is the length o f
time it takes to carry out the assessment stages.
G e r r i s h (1989) f o u n d a s s e s s m e n t t i m e -
consuming and Cardiff (1989) took 8 hours to
carry out the assessment stage. T h e patient in
A & E needs to be assessed immediately and
quickly. Admittedly, patients w h o are moved
into the crash room are with a nurse longer and,
therefore, there is more time for a more detailed
assessment, but initially even these patients have
to be assessed speedily. It is possible that a nurse
using Roy's model for a long time could apply
it almost intuitively; in a similar way that Benner
(1984) describes the 'proficient' or the 'expert'
nurse carrying out other aspects o f nursing care.
If this were so, then assessment could be much
more rapid. However, Morales-Mann & Logan
(1990) state that the model is most effective with
clients whose condition is stable and with w h o m
prolonged contact is possible.
Language
Familiarity with the model highlights another
problem, which it has in c o m m o n with many
others. The model introduces a new language
which can be difficult for nurses to grasp and to
apply. M o r a l e s - M a n n & Logan (1990) feel,
however, that nurses would become accustomed
to the language and be able to integrate it into
their vocabulary. O n e o f the advantages o f some
o f the new language is that the model presents a
broader perspective for assessment by
c o n c e n t r a t i n g o n p s y c h o l o g i c a l and social
aspects: self concept, role function and
interdependence (Gerrish 1989). However, this
is not necessarily an advantage in A & E, as it
w i l l d e t r a c t n u r s i n g focus a w a y f r o m t h e
 Roy's Adaptation Model and Accident and EmergencyNursing 153
physiological problems, which are usually the
p r i m a r y c o n c e r n s in A & E assessment and
action (Sbaih 1992).
Nursing diagnosis
The use of a nursing diagnosis is also a fairly new
concept, but fortunately is already applied in
triage in A & E (although the actual term is not
used). Field (1987) suggests that the use of a
n u r s i n g d i a g n o s i s i n R o y ' s M o d e l is
advantageous as it forces the nurse to be specific
a b o u t p r o b l e m s a n d to i d e n t i f y p r i o r i t i e s .
However, Logan (1990) criticised the way
nurses used the idea. She stated that nurses
tended to make diagnoses using medical terms
and that these problems could not be solved by
nursing i n t e r v e n t i o n only, for example pain,
constipation etc. Logan suggested that nurses
must o n l y make diagnoses a b o u t problems
for w h i c h t h e y w e r e able to p l a n care
independently. I would argue with this, and
suggest that the nurse should be able to make a
diagnosis using all her data collection and her
k n o w l e d g e . C a r i n g for a p a t i e n t does n o t
involve only the nurse, especially in A & E
where all members of the multi-disciplinary
team play a part. T h e plan o f care should,
therefore, reflect the whole team's role in the
patient's treatment. Cardiff (1989) makes one
further criticism of the use of nursing diagnosis.
Cardiff suggests that it is likely to reflect only
one person's perspective (probably the nurse's).
This is certainly possible when we consider the
work of Helman (1990) who discovered a wide
discrepancy in the understanding of anatomy
and physiology amongst lay people. Also, it is
n o t always p o s s i b l e to discuss p r o b l e m
identification with the patient due to the need
to make speedy decisions and '...nursing action
w i t h o u t p a t i e n t i n v o l v e m e n t m a y be
unavoidable at times...' (Sbaih 1992).
O n e o f the areas w h e r e R o y ' s M o d e l is
particularly relevant to A & E is in its promotion
of a healthy lifestyle found in Roy's description
of the goal of nursing (Morales-Mann & Logan
1990). The nurse in A & E is increasingly taking
on the role of a health educator and, therefore,
promotion of a healthy lifestyle is a large part of
the nurse's work.
CONCLUSION
Would Roy's Adaptation Model work in the
A & E department? Problems associated with
the application of the model in this area include
the length of time needed for assessment; the
paucity of testing the application of models in
A & E so far; the difficulty of introducing a new
language to nurses; the focus o f assessment
detracting from the physiological problems; the
difficulty in involving the patients in decision-
making; and the lack of information about what
s h o u l d be d o n e i f the p a t i e n t is u n a b l e to
participate in his care.
However, there are some advantages to the
application of this model in A & E. The idea
of a 'nursing diagnosis' is not a new concept
to A & E n u r s e s a n d it e n c o u r a g e s the
identification of specific problems. Goals are easy
to set because they are a i m e d at m a n a g i n g
ineffective behaviours (Morales-Mann & Logan
1990). The goal of nursing identified by the
m o d e l ( p r o m o t i o n o f a healthy lifestyle) is
congruent with the increasing role of the A & E
nurse.
However, in an umnodified form, this model
would be difficult to implement in the A & E
area. All nursing models need to be adapted
before introduction to A & E (Sbaih 1992), as
they do before use in other areas. If the problems
mentioned above can be overcome then Roy's
Adaptation Model may be a useful framework
for nursing care within the A & E department.
It w o u l d , u n d o u b t e d l y , n e e d m u c h testing
w i t h i n this area before this could be stated
irrevocably.
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