Review of Roy Adaptation Model-Based

Qualitative Research

Stephanie E. Perrett, RN; BN

Registered Nurse, HM Prison, Cardiff, United Kingdom

The aim of this paper is to examine the role of qualitative research in the development of the Roy adaptation
model. An exploration of the findings from qualitative research using Roy’s adaptation model from 1995 to 2005
is compared with the findings and recommendations from a previous review over a 25-year period (1970-1995).
The usefulness of qualitative methods in furthering nursing theory is highlighted. Findings from both reviews sup-
port the assumptions of the model while generating new information and demonstrating the valuable place of
qualitative research in promoting nursing science.

T he use of qualitative methods within
nursing research began in the 1960s as a
trend as humanistic thought was spread-
ing throughout the social sciences.
Qualitative methods enabled full explo-
ration of the patients’ experiences, pay-
ing particular attention to relationships
and values, something that traditional
quantitative science had struggled to
discover (Streubert & Carpenter, 2003).
The boom in qualitative research took
place alongside the creation of several
nursing conceptual models and theories,
all striving to explain the nature of nurs-
ing and the role of the nurse.
This period saw the first debates
within nursing regarding the application
of research to develop nursing theory.
Nurse scholars differed in their views
of the raison d’etre of theory within
research, markedly qualitative research.
The majority of studies used to further
nursing theory were quantitative and
continue to be so. Some scholars see
qualitative research as purely inductive,
requiring an absence of preexistent the-
oretical suppositions, therefore inappro-
priate for advancing nursing science.
Others believe it impossible to deve-
lop new knowledge without the prior
influence of theory or recognition of
Nursing Science Quarterly, Vol. 20 No. 4,
October 2007, 349-356
DOI: 10.1177/0894318407306538
© Sage Publications
a specific epistemology (Mitchell &
Cody, 1993).
This paper is based purely on the
Roy adaptation model (RAM) (Roy and
Andrews, 1999) as an example of the
way qualitative research can be used
to build on the development of ideas
within a particular theoretical model. It
has been accepted that quantitative
research can be used alongside the
RAM, a conceptual model falling
within the totality paradigm, however
qualitative research has not been fre-
quently used with the RAM. There is a
growing body of evidence, which this
paper will demonstrate, to suggest that
qualitative research can advance con-
cepts of the model and that it has a valu-
able place in furthering nursing theory.
Both qualitative and quantitative
research have a fundamental role within
nursing. This paper points to specifi-
cally how qualitative research can have,
and has had, the potential to further
scholarly nursing debate on theoretical
issues. To do this, recommendations for
RAM-based research presented by the
Boston Based Adaptation Research in
Nursing Society (BBARNS) are drawn
upon, followed by a review of all quali-
tative research using RAM over the past
decade, examining method, theory, and
findings. The author demonstrates how
qualitative research can contribute to the
development of RAM, illustrating the
ways and contexts in which this has
previously taken place.
Background and Significance
Roy (Roy & Andrews, 1999) devel-
oped the RAM in the late 1960s,
redefining the major concepts in 1997.
The conceptual model, which describes
the person as an adaptive system func-
tioning toward a purpose, was built on
the work of existing theories such as the
adaptation level theory (Helson, 1964;
Roy & Andrews, 1999). RAM postu-
lates that as adaptive systems, humans
respond to stimuli, initiating a coping
process, and this in turn has an effect on
behavior, leading to responses that are
either adaptive or ineffective.
Stimuli, the input to the adaptive
system, are viewed as the various stres-
sors forcing the need for change. Roy
(Roy & Andrews, 1999) has divided
the stimuli into three categories: focal,
contextual, and residual. Responses
to stimuli can fall among one of four
adaptive modes: psychological, self-
concept, role function, and interdepen-
dence. If a response is ineffective, the
goal of adaptation is threatened, lead-
ing to a negative response. With this in
mind, Roy (Roy & Andrews, 1999)
views the role of the nurse as promot-
ing patient adaptation.
The philosophical assumptions of
the RAM are based on humanism and
veritivity. The person is the focus of
Keywords: qualitative research,
Roy adaptation model

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015

350 Nursing Science Quarterly, 20:4, October 2007
nursing, their subjective experience
is central to knowing and valuing.
Veritivity, a concept formulated by Roy
(Roy & Andrews, 1999), expresses a
belief in purpose, value, and high regard
to all human life. Roy also used the term
cosmic unity to express the intrinsic
relationships between people and the
earth. Pulling together the principles of
humanism, veritivity, and cosmic unity,
the five philosophical assumptions of
the RAM are as follows:
1. Persons have a mutual relationship
with the world and God.
2. Human meaning is rooted in an
omega point convergence with the
universe.
3. God is ultimately revealed in the
diversity of creation and is the com-
mon destiny of creation.
4. Persons use human creative abilities
of awareness, enlightenment, and
faith.
5. Persons are accountable for the
processes of deriving, sustaining and
transforming the universe. (Roy &
Andrews, 1999, p. 35)
With the philosophical assumptions
of the RAM, the focus of research,
as guided by the model, should be on
adaptation. Knowledge according to
Roy’s model (Roy & Andrews, 1999)
is described as “understanding people
as adapting within their various life sit-
uations” (p. 537). Research using the
RAM should aim to advance knowl-
edge in this way, focusing on human
life patterns that emerge from adaptive
processes, thus advancing the under-
standing of people as adaptive systems
(Roy & Andrews, 1999).
Qualitative inquiry stems from
descriptive science. Its philosophical
background is associated with the exis-
tentialists and humanists in their attempt
to explore how people perceive reality.
Qualitative research is therefore congru-
ent with the philosophical assumptions
of RAM, which seeks to understand the
subjective experience of individuals.
Roy’s model (Roy & Andrews, 1999)
addresses the meaning of existence and
the place of people within creation;
qualitative methods aptly offer a way of
gathering descriptions of each individ-
ual’s personal experience.
Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015
Roy’s adaptation model (Roy &
Andrews, 1999) is one of the most
widely used nursing models. The 25th
anniversary of the first publication of
the RAM was in 1995. The occasion
triggered an opportunity to review and
critique 25 years worth of research,
both qualitative and quantitative, that
had forwarded and strengthened the
model in its development. The aim of
the review was not just to reflect on
the past, but also to look to the future,
identifying new directions for theoret-
ical advancement.
Adaptation Research
Review (1970-1995)
BBARNS examined 163 research
studies identifying RAM as the under-
lying conceptual framework. The
review aimed to evaluate the relation-
ships of research to RAM, as well as to
synthesize the contributions of the
findings back to nursing practice,
making suggestions for future research
and further theoretical development
(BBARNS, 1999, p. 13). Of the 163
studies reviewed, a minority of just 16
(9.8%) used qualitative research
methods. This reflects a view of the
relevance of qualitative research in the-
oretical development.
The qualitative studies reviewed by
the BBARNS covered a variety of areas
demonstrating methodological flexibil-
ity. Among the studies the areas of inves-
tigation varied from the self-concept
mode (Lamb & Sheldon, 1994), the role
function mode (Legault, 1991; Nyqveist
& Sjoden, 1993), the interdepen-
dence mode (Smith, Moushey, Ross, &
Geiffer, 1993), and the physiologic
mode (Zungu, 1993). Several focused on
stimuli (Munn & Tichy, 1987); others
took into account all of the adaptive
modes (Florence, Lutzen, & Alexius,
1994; Gagliardi, 1991; Smith, Moushey,
Ross, & Geiffer, 1993). The subject mat-
ters varied from exploring the needs of
parents, families, mothers, and women.
Qualitative research was used in studies
in both hospitals and homes.
Of the qualitative studies reviewed by
BBARNS, all but one applied the results
to the conceptual model (implicitly or
explicitly). All supported the proposi-
tions of the model in some way (see
Table 1). Roy (Roy & Andrews, 1999)
said that the characteristics of the focal,
contextual, and residual stimuli influ-
ence adaptive responses. This statement
was supported through the results of sev-
eral studies (Florence et al., 1994; Lamb
& Sheldon, 1994; Legault, 1991).
Gibson (1994) verified this by indicating
that focal stimuli affecting a significant
other within a relationship may affect
adaptation within the interdependence
mode. Smith and colleagues (1993) sup-
ported this recognizing that the role of
care-giving can place demands on the
interdependence mode. Pollock (1982)
concluded that external stimuli might
place greater demands on the adaptive
system.
Results from the RAM qualitative
studies provided intriguing links
between adaptation and the cognator
and regulator processes. Gagliardi
(1991) and Florence and colleagues
(1994) identified patterns of cognator
processing within specific groups of
patients and related this as influencing
innate and acquired ways of adapting.
Smith and colleagues (1993) supported
fluctuating adaptation levels linked to
cognator and regulator responses.
The findings from the qualitative
studies in the BBARNS review demon-
strated that qualitative methods can pro-
vide detailed descriptions of adaptive
processes that can be used as frame-
works in other populations (BBARNS,
1999). Overall, from both the qualita-
tive and quantitative studies, the review
led to two major recommendations for
expanding and clarifying the concepts
of the RAM: the notion of time in rela-
tion to the process of adapting, and the
role of perceptions (BBARNS, 1999).
This is explored below to see if recent
qualitative studies have shed further
light on these notions.
The Concept of Time
Changes in adaptation levels over
time were identified in many of the
RAM-based studies. Lamb and Sheldon
 Roy Adaptation Model 351

Table 1
Propositions Derived From the Roy Adaptation Model
At an individual level, regulator and cognator processes affect innate and acquired ways of coping.
At the group level, stabilizer and innovator processes affect adaptation.
The characteristics of the internal and external stimuli influence adaptive responses.
The characteristics of the internal and external stimuli influence the adequacy of cognitive and emotional processes.
The adequacy of cognator and regulator processes will affect adaptive responses.
Adaptation in one mode is affected by adaptation in other modes through the cognator and regulator as connectives.
The pooled effect of focal, contextual, and residual stimuli determines the adaptation level.
Adaptation is influenced by the integration of the person with the environment.
The variable of time influences the process of adaptation.
The variable of perception influences the process of adaptation.
Perception influences adaptation through linking the regulator and cognator subsystems.
Nursing assessment and interventions relate to identifying and managing input to adaptive systems. (Roy & Andrews, 1999, p. 547)

(1994) identified that sexual adaptation
in those living with endometrial cancer
is a process that is continually evolving
over time. Following the complete
research review, a call was made for fur-
ther research into the effect of the pass-
ing of time on the adaptive modes (in
particular the interdependence mode).
Suggestions were made to investigate
the concept of time as a variable. This
could potentially lead to pinpointing the
most appropriate periods for providing
nursing interventions within an individ-
ual’s adaptive process (BBARNS,
1999). Qualitative methods can be well-
suited to inquiries that gather detailed
descriptions of events over a duration of
time, and are therefore well-placed to
investigate the concept of time within
the RAM.
The Role of Perceptions
Roy and Andrews (1999) defined
perception as “the interpretation of a
sensory stimulus and the conscious
appreciation of it” (p. 259). Perception
is viewed as a process of the cognator
subsystems within the model. Although
the need to explore this concept was
largely identified through quantitative
studies, there is a place for qualitative
research to develop this further. Quali-
tative methods may be particularly use-
ful in uncovering the meaning of
patients’ situations.
Quantitative research results indi-
cated that the perception of an event is a
stronger indicator of adaptation than the
focal stimuli triggering the event itself
(Armer, 1989; Dahlen, 1980), reinforc-
ing Roy’s (Roy & Andrews, 1999)
viewpoint that the focal stimuli needs to
be considered in light of the residual
and contextual stimuli to acquire per-
ception about a situation. Directions
for future qualitative research include
developing understanding of the role of
perception within clinical situations and
examining the role perception may play
in connecting regulator and cognator
processes (BBARNS, 1999).
To update the findings from the
BBARNS review, and evaluate whether
qualitative research has contributed to
the above recommendations, RAM-
based qualitative studies published from
1995 to 2005 have been reviewed. The
analysis has concentrated on analysis of
the methodologies used, the specific
area of RAM investigated, and the find-
ings of the research in relation to the
RAM.
Qualitative Research Using the Roy
Adaptation Model (1995-2005)
A search was conducted of all quali-
tative studies using the RAM (Roy
& Andrews, 1999) as a conceptual
framework between 1995 and 2005.
Databases such as British Nursing
Index, CINAHL, Swetswise, and Ingenta
were used, as well as a hand search of
the journals. Dissertations and theses
were excluded due to difficulty in
obtaining these studies. To maintain
continuity and allow for accurate com-
parison, inclusion criteria remained the
same as that of the BBARNS (1999)
review. This current review of studies
from 1995 to 2005 attempts to draw out
ways in which each research piece has
supported the propositions of the RAM
or highlighted explicit theoretical devel-
opments. The review identifies whether
the results support (or not) the proposi-
tions of RAM.
The criteria for evaluating the stud-
ies were adapted from those described
by Fawcett (2005). These points for
consideration were selected in order to
evaluate the use of qualitative research
with the RAM. The evaluation ques-
tions (Fawcett, 2005) were as follows:
1. Is the method congruent with the
philosophical claims and context of
the conceptual model?
2. Are the context (philosophical
claims and conceptual model) and
the content (concept and proposi-
tions) of the results from the research
congruent with that of the model?
3. Do the concepts reflect semantic
clarity and semantic consistency?
4. Do the propositions reflect struc-
tural consistency?
5. Are the descriptive findings from the
qualitative research congruent and
supportive of concepts and proposi-
tions of the conceptual model?
Studies were also evaluated to deter-
mine whether there was support or
rejection for the 12 propositions of the
RAM as seen in Table 1.
Nine qualitative studies were identi-
fied from the 10-year period from 1995
to 2005. Four of the studies examined
the self-concept mode (Brydolf &
Segesten 1996; Dobratz, 2002, 2004;
Gagliardi, 2003); one study focused on

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015

352 Nursing Science Quarterly, 20:4, October 2007

Table 2
Summary of Qualitative Studies Using the Roy Adaptation Model (1995-2005)
Reference and Area
of Investigation Purpose Sample Design Findings

(Brydolf & Segesten, To describe Adolescents with Descriptive, Eight identified categories
1996), self-concept adolescents’ ulcerative colitis grounded theory formed a model of the
experience of (n = 28) analysis disease process from onset
living with to present time. The main
ulcerative colitis variable was reduced living
pace, a strategy to manage the
new situation.
(Raeside, 1997), To assess and compare Mothers (n = 12); Descriptive Stress caused by the
stimuli mothers’perceptions nurses (n = 12) NICU environment
of stressors related was less than expected.
to the NICU Stress caused to the
environment with neonate by the
nurses’ perceptions environment was
of environmental rated lower by
stressors mothers than nurses.
experienced by
mother and neonate
(Lotus Shyu, 2000), To develop a Caregivers (n = 16); Grounded theory Role tuning was used
role function conceptual framework care-receivers by both caregivers
explaining interaction (n = 12) and care-receivers to
between caregiver achieve harmonious
and care-receiver during adaptation during
the discharge transition the transition from
hospital to home.
(Yeh, 2001), adaptive To establish a conceptual Pediatric cancer Content analysis Five aspects of adaptation
modes and framework for patients: boys were identified as
processes the adaptation (n = 23); girls physiological,
process of (n = 11) psychological, cognitive,
Taiwanese children interdependence,
with cancer and future orientation.
(Dobratz, 2002), Psychological Home hospice Grounded theory Emergence of seven
self-concept adaptation in patients (n = 15) process patterns,
home hospice patients including that of
becoming-self.
(Gagliardi, To examine how people Multiple sclerosis Content analysis Five themes were
Frederickson, & make sense of the patients (n = 18) identified: we are not
Shanley, 2002), experience of living completely the same,
adaptive modes with multiple sclerosis how I view my future
and processes let me tell you about
my feelings, how I see
work, and let me tell
you about my life.
(Gagliardi, 2003), To identify the experiences Multiple sclerosis Naturalistic case Three themes conceptualized
self-concept of sexuality as patients (n = 8) study the experience: how I feel
experienced by those about my appearance, I have
living with multiple feelings about my sexuality,
sclerosis and sexuality for me has both
positive and negative emotions.
(Zeigler, Smith, & To identify the experiences Women with breast Content analysis A combination of information,
Fawcett, 2004), of participants and cancer (n = 10); emotional, and social support
intervention facilitators of a registered nurse was effective in the breast
community breast cancer facilitators (n = 2) cancer support group.
support group
(Dobratz, 2004), To describe perceptions Persons receiving Secondary analysis Core theme of believing,
self-concept of spirituality in home home-hospice coding for followed by six other themes:
hospice patients palliative care spirituality comforting, releasing,
(n = 44) connecting, giving, reframing,
and requesting.

Note: NICU = neonatal intensive care unit.

Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015


role-function (Lotus-Shyu, 2000), two
on the adaptive modes and processes
(Gagliardi, Frederickson, & Shanley
2002; Yeh, 2001), one study focused on
the stimuli (Raeside, 1997), and one
study investigated nursing interventions
(Zeigler, Smith, & Fawcett, 2004). A
summary of the aim and findings of
each study can be seen in Table 2. Each
of the nine studies demonstrated unique
use of Roy’s model. All studies (within
varying degrees) explicitly related their
findings to the RAM.
Raeside (1997) covered the role of
perception, a concept highlighted as
needing further investigation from the
BBARNS (1999) review. The research
was directed at differences in perception
of stressors between nurses and mothers
within the neonatal intensive care unit
(NICU). Results were related to the
adaptive modes, physiologic, self-
concept, and interdependence, demon-
strating congruency with the RAM.
Mothers rated their perceptions of stres-
sors in the NICU as lower than the nurses.
Recommendations for practice were
drawn from the descriptive responses of
parents, including controlling room
temperature, noise, and illumination
levels, and providing quieter areas to
promote mother and baby bonding, aid-
ing women in their experience of adapt-
ing to motherhood (Raeside, 1997).
This supported the propositions of the
RAM that the characteristics of internal
and external stimuli influence both cog-
nitive and regulator processes, which in
turn influence the adaptive response
(Roy & Andrews, 1999). The research
demonstrated that tours for parents
around the NICU department were
helpful to their adaptation, despite being
stressful. This supported the proposition
of the RAM that adaptation is influ-
enced by the integration of the person
with the environment, and provides a
rationale for conducting the tours.
The study furthered some under-
standing about the concept of percep-
tion, although it did not explicitly make
any links between the regulator and
cognator subsystems and their role in
perception. The presentation of the
results would indicate that parents’ per-
ceptions of their baby’s response to
Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015
environmental stressors heavily influ-
enced their own cognitive adaptation.
The research builds on previous investi-
gations into nurses’ perceptions of
stressors within intensive care environ-
ments as conducted by Munn and Tichy
(1987); interestingly, this author does
not draw on or mention this study in her
review.
The second major recommendation
from the BBARNS (1999) review was
investigation into time as a variable in
the process of adaptation. Although this
has not been explicit within any of the
latest qualitative studies using RAM,
three studies focused on the experience
of illnesses from onset until the time of
study completion (Brydolf & Segesten,
1996; Gagliardi et al., 2002; Yeh, 2001).
Each provided insights into the whole
experience of illness over time, high-
lighting changes and fluctuations.
Research into the experience of illness
also allows for unmasking individual
perceptions. The following three stud-
ies explore both issues of time and
perception.
Brydolf and Segesten (1996) looked
at the experience of living with ulcera-
tive colitis for adolescents. Interviews
were conducted among 28 participants
focusing on the experience of diagno-
sis, discovery of symptoms, and feel-
ings. Grounded theory was employed
to analyze the data and create a model
outlining the process of disease over
time. Throughout the participants’
experiences, 2 phases were identified,
living in a state of transition preceded
by a subsequent altered lifestyle. Sub-
categories representing the experience
were labelled as alienation, reduced
living space, support, lack of support,
confidence in self, role identification as
a child and as an adult. The idea of liv-
ing space was linked to Roy’s (Roy &
Andrews, 1999) definition of environ-
ment within the model, highlighting the
need to create a supportive environment
for adolescents, providing them with
independence to make their own deci-
sions, thus aiding adaptation.
Roy’s (Roy & Andrews, 1999) defi-
nition of adaptation was supported
throughout the study (Brydolf &
Segesten, 1996), particularly within the
Roy Adaptation Model 353
phase of living in a state of transition.
Themes such as alienation and lack of
support highlighted the need for health
promotion within the interdependence
mode and recognized how these needs
may change throughout adolescence.
The research supported results of previ-
ous studies, which examined the self-
concept mode, by verifying that both
time and perception influence the
process of adaptation, thus supporting
the propositions of the RAM. The
results demonstrated the changing
nature of the trajectory of chronic ill-
ness. The study provided important
insights into the changes that occur, not
just over time, but also with age
through the focus on adolescents and
young adults. This supports the previ-
ous work of Bertch (1994) and Shaffer
(1989) in identifying fluctuations in
perceptions according to age. Additi-
onal insight could be gained through
examining the experiences of older
adults, identifying changes and differ-
ences from that of adolescents. Further
qualitative work could explore the role
of parents/guardians caring for adoles-
cents with ulcerative colitis. This could
advance Roy’s work on the role-
function and interdependence modes,
helping nurses understand how best to
support the family, as well as the child.
Yeh (2001) focused on the younger
population in a study of adaptation
among Taiwanese children with cancer.
Adaptation was viewed as “a coping
mechanism used by participants to
achieve an underlying goal of getting
back to normal life after the cancer was
identified” (p. 143), a definition similar
to Roy’s (Roy & Andrews, 1999). The
recorded interviews were analyzed
combining open coding and compari-
son. Although the method appeared
similar to that of grounded theory, this
was not overtly stated within the paper.
Results were coded according to the
four adaptive modes of the RAM. Links
were made to previous studies, as well
as to the RAM. Differences in adapta-
tion within age groups were noticeable,
reinforcing the results of Brydolf and
Segesten’s (1996) study. The concept of
future was not identified in any children
younger than 10 years of age, but was
354 Nursing Science Quarterly, 20:4, October 2007
found more frequently as age increased.
The impact of time on perception can
be associated with this fact. Within the
propositions of the RAM, time is seen
as a variable that influences the process
of adaptation. Yeh’s research indicated
that for young children (who have little
or no concept of time), time was not a
factor in their process of adapting.
Gagliardi and her colleagues (2002)
conducted the third qualitative study
considering the experience of illness
over time among adults living with mul-
tiple sclerosis (MS). Case study content
analysis was used in interviews with 9
men and 9 women, all living with MS
for a minimum of 2 years. Results were
coded according to themes and each
theme linked to the four modes of the
RAM. Five themes were uncovered:
“we’re not completely the same; how I
view my future; let me tell you my feel-
ings; how I see my work, and, let me tell
you about my life” (p. 233). Each
depicted Roy’s (Roy & Andrews, 1999)
definition of adaptation. Although the
data were categorized according to
Roy’s adaptive modes, specific links
regarding ways in which research
strengthens the theoretical foundations
of the model were not made. General
observation of the results within the
paper would indicate support for Roy’s
proposition that “adaptation is influ-
enced by integration of the person with
the environment” (BBARNS, 1999, p.
202). The descriptions used to develop
each theme also demonstrated that cog-
nitive processes have more influence on
coping with adaptation than regulator
body processes. Individual perceptions
of role function, interdependence, and
self-concept have a stronger influence
over achieving a positive adaptive
response than physical health. This
enabled those with chronic, physically
degenerative conditions such as MS, to
develop positive adaptive responses
despite their physical condition. The
research as a whole achieved the aims
from the BBARNS (1999) review
through uncovering the perceptions of
those with MS. As no previous studies
could be found using the RAM to inves-
tigate MS, this research provided valu-
able insight into the impact of chronic
illness on daily life.
Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015
Gagliardi (2003) continued to look at
MS in her following qualitative study,
uncovering the meaning of sexuality for
those with MS. The naturalistic case
study framed by the RAM identified
three themes: “How I feel about my
appearance,” “I have feelings about my
sexuality,” and “sexuality for me has
both negative and positive emotions”
(p. 575). All reflected the four modes of
the RAM and demonstrated their inter-
relatedness. Sexuality was raised as an
important issue to nearly all the partici-
pants (n = 8). The need for nurses and
health professionals to recognize this
and to provide opportunities for patients
to discuss sexuality was emphasized.
Through using the RAM in practice,
nurses can insure that they consider
each adaptive mode, therefore recogniz-
ing issues such as sexuality within their
patients’ lives. The research built on the
work of Lamb and Sheldon (1994) who
examined the sexual adaptation of
women with endometrial cancer. Both
studies found that the onset of illness
can have a profound effect on the way
persons feel about their sexuality, and it
can change their self-concept, role func-
tion, interdependent, and physiologic
mode adaptation. Both studies reiterated
the proposition that cognitive and regu-
lator processes affect adaptive responses
within the four adaptive modes.
The three remaining qualitative
studies published from 1995 to 2005
introduced new areas of interest. Lotus-
Shyu (2000) emphasised role-function
through looking at the relationships
between caregiver and care-receiver
during discharge transition. The
Taiwanese study used grounded theory
to uncover role-tuning as the transi-
tional means in which to achieve a har-
monious discharge from the hospital to
home. Both the care-receiver and care-
giver adjusted behaviors and expecta-
tions in order to meet the needs of each
other and the new situation in which
they found themselves. Role-tuning was
seen as containing three phases: role
engaging, role negotiating, and role set-
tling (Lotus-Shyu, 2000, p. 325). Role-
tuning was seen as consistent with the
RAM concept of role function. Each
phase was identified as supporting the
concepts of role transition. The study
suggested support for Roy’s (Roy &
Andrews, 1999) proposition that adapta-
tion is influenced by integration within
the environment. Integration is achieved
through the caregiver and care-receiver
developing an understanding of their role
function, self-concept, and group identity
in the way they perceive themselves
within the family. These ideas are fully
consistent with the concepts of RAM.
Lotus-Shyu (2000) highlighted the
importance of interaction in coping with
transition—a premise supported by
Roy’s concept of role-function. Lotus-
Shyu also took two nursing approaches
suggested by Roy to promote role
transition (role cues and role supple-
mentation), aiding the participant in
role-tuning, and therefore in adapting.
This supported Roy’s theory that nursing
interventions can help to manage the
input to adaptive systems, thus promot-
ing positive adaptation. Links of results
within the RAM allow for further clari-
fication of the concepts, strengthening
the model. The research demonstrated
the flexibility of the RAM, an American
model, through its application within the
Taiwanese nursing arena.
All studies within the BBARNS
(1999) review focusing on nursing
interventions were undertaken using
quantitative methodology. Zeigler and
colleagues (2004) have broken new
ground with the RAM in using open-
ended survey questions (reflecting the
four adaptive modes) and a qualitative
content analysis to evaluate the experi-
ences of a breast cancer support group.
This study is also unique in that it
included the voice of both participants
from and facilitators of the support
group. Questions were asked in accor-
dance with the four adaptive modes,
answers to the open-ended questions
were rated as describing either adap-
tive or ineffective responses. Adaptive
responses were found most frequently
within the role function and interde-
pendence modes. These addressed
issues such as support systems and
daily activities. The research indicated
that the role of the support group may
have assisted adaptation, demonstrat-
ing once again that adaptation is
indeed influenced by the integration of
the person with the environment.

Ineffective responses were found
more frequently within the physiologi-
cal and self-concept modes. Issues such
as body image and physical distress
were found as being the most signifi-
cant to overcome when living with
breast cancer. The responses differed
over the course of a year, some from
adaptive to ineffective, and others from
ineffective to adaptive. This displayed
the varying trajectory of breast cancer
and showed the influence of time on
adaptation, both affective and ineffec-
tive. The research study results testified
to the strength of the RAM in being
able to use all four adaptive modes to
guide evaluation of the total experience
of the support group (Zeigler et al.,
2000). The usefulness of using qualita-
tive research with the RAM to evaluate
nursing interventions is exhibited here.
The final studies to be reviewed
were conducted by Dobratz (2002,
2004). The grounded theory methodol-
ogy was used in the first study to inves-
tigate the psychological adaptation
among home-hospice patients. Results
generated a theoretical framework of
seven process-patterns occurring indi-
vidually and at once. The patterns were
labeled as: “the becoming-self; inter-
preting meaning; connecting others;
weighing expectations; sustaining acts;
adjusting expectations; bodily feelings”
(Dobratz, 2002, p. 138). The research
was supportive of the philosophical and
theoretical aspects of the RAM, and
added to the previous research looking
at perception. Dobratz (2002) related
the findings to the RAM in the follow-
ing areas:
1. The pattern of becoming-self in
death and dying was found to
support the adaptation process as
defined by Roy and Andrews (1999).
2. Dying individuals found purpose in
their existence through connecting
with others and to a spiritual force—
supporting Roy’s (Roy & Andrews,
1999) philosophical assumptions of
cosmology, veritivity, and humanism.
3. The cognitive-emotive channel, as
described by Roy (Roy & Andrews)
as handling perception, was acti-
vated by those within the study
seeking a sense of purpose.
Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015
Dobratz (2004) continued her work
with a secondary analysis, coding
previously transcribed data for the
theme spirituality. All 44 participants
were undergoing hospice care at the
time of their interview. A core theme of
believing was identified and underlined
by six other themes: comforting, releas-
ing, connecting, giving, reframing,
and requesting. These reflected Roy’s
assumptions that people have, and need,
a mutual relationship with God and the
world, as well as recognizing the impor-
tance of awareness and faith in daily
living, particularly when living with ill-
ness. The need to connect and be com-
forted reflected the need to maintain
relationships, as described in the interde-
pendence mode. This also has an impact
on the individual’s self-concept, needing
to give and to release. The overlapping
nature of the adaptive modes is evident
in aspects of spirituality
The fact that the research study was
a secondary analysis must be taken
into account when looking at the over-
whelmingly supportive nature of the
results toward RAM. Out of the 97
participants interviewed in the original
study, 44 referred to spirituality. The
interesting results from this study and
the unique subject area added credibil-
ity to the philosophical assumptions of
the RAM. Further studies investigat-
ing spirituality, across wide, perhaps
cross-cultural, populations are needed
to verify the philosophic assumptions.
Qualitative Research
If research is about extending knowl-
edge it is important to understand the
unique qualities that qualitative research
can bring to knowledge development in
nursing science. As previously men-
tioned, knowledge according to Roy
(Roy & Andrews, 1999) is “understand-
ing people as adapting within their vari-
ous life situations” (p. 537). Reaching
this level of understanding involves
delving to comprehend values, beliefs,
and emotions, as well as scientific facts.
Combining the knowledge gleaned
from qualitative research with the
scientific facts and propositions from
Roy Adaptation Model 355
quantitative research allows for a fuller,
more holistic understanding; in the case
of Roy’s model, it is the grasping of
human adaptive processes.
The 35 years of RAM qualitative
research studies reviewed here demon-
strate the versatility of the RAM within
a variety of situations and across cul-
tures. New contributions to the research
arena have been identified such as with
the concept of spirituality and patient
transfers between environments. The
influence of the environment over
adaptation was an ongoing theme seen
in several of the studies. The practical
environmental aspects identified can be
implemented within nursing practice,
aiding the promotion of adaptation for
both patients and families. The recur-
rence of support for this RAM proposi-
tion demonstrated the suitability of
qualitative research for identifying
environmental stimuli.
The original review identified the
concepts of time and perception as
needing further consideration. These
have been investigated but not to their
fullest potential. The research gave sup-
port for the propositions that both time
and perception influence adaptation.
More research is needed regarding
these phenomena. Research is also sug-
gested on the influence of time on per-
ception, and the way this can influence
adaptation.
The application of research-based
practice should be evaluated through
further research into nursing interven-
tions. This would demonstrate the cur-
rent influence of the RAM on nursing
practice. The work of Zeigler and col-
leagues (2004) demonstrated that qual-
itative methods could be used to study
nursing interventions.
Further thought is needed on the
influence of the RAM-based research on
RAM theoretical development. Infor-
mation on time and perception could be
woven into the theoretical propositions.
Another review specifically looking at
the theoretical contributions of each
study would also be useful, but is
beyond the scope of this paper.
Although qualitative methods are
just one way of obtaining information,
356 Nursing Science Quarterly, 20:4, October 2007
the rich descriptions and unreserved
detail that they may offer have proven
suitable to study the adaptive process,
modes, and responses in accordance
with Roy’s (Roy & Andrews, 1999)
model. The research that has been
reviewed clearly demonstrated the
strength of the RAM in helping nurses
to gain more understanding of adaptive
processes.
References
Armer, J. M. (1989). Factors influencing
relocation adjustment among commu-
nity-based rural elderly (Doctoral dis-
sertation, University of Rochester,
1988). Dissertation Abstracts Interna-
tional, 50, 1321-B.
Bertch, D. A. (1994). Life satisfaction in
persons with chronic obstructive pul-
monary disease (Masters thesis, Grand
Valley State University, 1993). Masters
Abstracts International, 345, 1165.
Boston Based Adaptation Research in
Nursing Society. (1999). Roy adapta-
tion model-based research: 25 years of
contributions to nursing science.
Indianapolis, IN: Centre Nursing Press.
Brydolf, M., & Segesten, K. (1996). Living
with ulcerative colitis: Experiences of
adolescents and young adults. Journal
of Advanced Nursing, 23, 39-47.
Dahlen, R. A. (1980). Analysis of selected
factors related to the elderly person’s
ability to adapt to visual prostheses fol-
lowing senile cataract surgery (Doctoral
dissertation, The Catholic University of
America, 1980). Dissertation Abstracts
International, 41, 389-B.
Dobratz, M. C. (2002). The pattern of the
becoming-self in death and dying.
Nursing Science Quarterly, 15, 137-142.
Dobratz, M. C. (2004). Life-closing
spirituality and the philosophic
assumptions of the Roy adaptation
model. Nursing Science Quarterly,
17, 335-338.
Fawcett, J. (2005) Contemporary nursing
knowledge: Analysis and evaluation of
Downloaded from nsq.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 8, 2015
nursing models and theories (2nd ed.).
Philadelphia: F. A. Davis.
Florence, M. E., Lutzen, K., & Alexius, B.
(1994). Adaptation of heterosexually
infected HIV positive women: A
Swedish pilot study. Health Care for
Women International, 15, 265-273.
Gagliardi, B. A. (1991). The impact of
Duchenne muscular dystrophy on fami-
lies. Orthopaedic Nursing, 10(5), 41-49.
Gagliardi, B. A. (2003). Experiences of
sexuality for individuals living with
multiple sclerosis. Journal of Clinical
Nursing, 12, 571-578.
Gagliardi, B. A., Frederickson, K., &
Shanley, D. A. (2002). Living with mul-
tiple sclerosis: A Roy adaptation model-
based study. Nursing Science Quarterly,
15, 230-236.
Gibson, C. H. (1994). The process of
empowerment in mothers of chronically
ill children. Journal of Advanced
Nursing, 21, 1201-1210.
Helson, H. (1964). Adaptation level theory.
New York: Harper & Row.
Lamb, M. A. (1991). Sexual adaptation of
women treated with endometrial cancer
(Doctoral dissertation, Boston College,
1991). Dissertation Abstracts Interna-
tional, 52, 2994-B.
Lamb, M. A., & Sheldon T. A. (1994). The
sexual adaptation of women treated for
endometrial cancer. Cancer Practice, 2,
103-113.
Legault, F. M. (1991). Adaptation within the
role function and self-concept modes
among women during the postpartum
period. (Masters thesis, D’Youville
College, 1990), Masters Abstracts
International, 29, 439.
Lotus-Shyu, Y. (2000). Role tuning between
caregiver and care receiver during dis-
charge transition: An illustration of role
function mode in Roy’s adaptation
theory. Nursing Science Quarterly, 13,
323-331.
Mitchell, G. J., & Cody, W. K. (1993).
The role of theory in qualitative
research. Nursing Science Quarterly,
6, 170-178.
Munn, V. A., & Tichy A. M. (1987). Nurses
perceptions of stressors in paediatric
intensive care. Journal of Paediatric
Nursing, 2, 405-411.
Nquveist, K. H., & Sjoden, P. O. (1993).
Advice concerning breast-feeding from
mothers of infants admitted to a neona-
tal intensive care unit: The RAM as
a conceptual structure. Journal of
Advanced Nursing, 18, 54-63.
Pollock, S. E. (1982). Level of adaptation:
An analysis of stress factors that affect
health status (Doctoral dissertation,
University of Texas, Austin, 1981)
Dissertation Abstracts International,
42, 436-B.
Raeside, L. (1997). Perceptions of environ-
mental stressors in the neonatal envi-
ronment. British Journal of Nursing, 6,
914-916, 918, 920-923.
Roy, S. C., & Andrews, H. A. (1999). The
Roy adaptation mode. Chestnut Hill,
CT: Appleton & Lange.
Shaffer, F. H. (1989). A comparison of
maternal identity in younger and older
primiparae during the third trimester of
pregnancy. Dissertation Abstracts
International, 49, 4236-B.
Smith, C. E., Moushey, L., Ross J. A., &
Geiffer, C. (1993). Responsibilities and
reactions of family caregivers of
patients dependant on total parenteral
nutrition at home. Public Health
Nursing, 10, 122-128.
Streubert, H. J., & Carpenter, D. R. (2003).
Qualitative research in nursing:
Advancing the humanistic imperative.
Philadelphia: Lippincott, Williams &
Wilson.
Yeh, C. H. (2001). Adaptation in children
with cancer: Research with Roy’s
model. Nursing Science Quarterly, 14,
141-148.
Zeigler, L., Smith, P. A., & Fawcett, J.
(2004). Breast cancer: Evaluation of the
common journey breast cancer support
group. Journal of Clinical Nursing, 13,
467-478.
Zungu, B. M. (1993). Assessment of the life
experiences of visually impaired adults
in the Empagni region of Kwazulu.
Curationis: South African Journal of
Nursing, 16(4), 38-42.