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2009 22: 355Nurs Sci QMadeya and Jacqueline Fawcett−Susan DeSanto

Toward Understanding and Measuring Adaptation Level in the Context of the Roy Adaptation Model  

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Nursing Science QuarterlyVolume 22 Number 4

October 2009 355-359© 2009 The Author(s)

10.1177/0894318409344753http://nsq.sagepub.com

The Roy adaptation model (RAM) is a nursingdiscipline-specific conceptual model that is widely

used to guide practice, research, and education in many countries, including Canada, Colombia, England, Japan, Scotland, Sweden, Switzerland, and the United States (Fawcett, 2005). Adaptation of human beings, the raison d’être of the RAM, is defined as “the process and out-come whereby thinking and feeling persons, as individu-als or in groups, use conscious awareness and choice to create human and environmental integration” (Roy & Andrews 1999, pp. 32-33). According to the RAM, people adapt to constantly changing focal, contextual, and residual environmental stimuli within four modes of adaptation—physiological, self-concept, role function, and interde-pendence. The path from environmental stimuli to modes of adaptation is mediated by two coping pro-cesses, called the regulator and the cognator.

Conceptual model concepts, such as adaptation, envi-ronmental stimuli, coping processes, and modes of adap-tation, are too abstract to be measured directly. Each conceptual model concept must instead be translated into a middle-range theory concept, which can then be mea-sured by various types of research instruments or prac-tice tools (Fawcett, 1999). The purpose of this paper is to describe how a RAM conceptual model concept, adapta-tion level, was translated into the logically congruent middle-range theory concept of adjustment and mea-sured in two studies of adaptation to life events.

Related Literature

Textbooks and other theoretical and empirical publi-cations about the RAM from 1976 to 2008 were reviewed for this paper. The relevant literature was identified through searches of the CINAHL and Medline data-bases, bibliographies of RAM-based publications (Boston-Based Adaptation Research in Nursing Society, 1999; Fawcett, 2005), and our own RAM-based work.

Numerous reports of RAM-based studies have included explanations of translations of the conceptual model concepts of environmental stimuli and modes of adaptation to middle-range theory concepts, as well as the measurement of the middle-range theory concepts with existing instruments and new investigator-developed instruments (Boston-Based Adaptation Research in Nursing Society, 1999; Fawcett, 2005). A few studies have also included translation of the RAM concept of the cognator coping process to a middle-range theory con-cept, which has been measured primarily by an existing instrument (Boston-Based Adaptation Research in Nursing Society, 1999).

Adaptation Level

In contrast, the RAM concept of adaptation level has not received much attention by researchers. Roy (1977) exam-ined the relations of decision-making, powerlessness,

Toward Understanding and Measuring Adaptation Level in the Context of the Roy Adaptation Model

Susan DeSanto-Madeya, RN; DNScAssistant Professor, University of Massachusetts Boston

Jacqueline Fawcett, RN; PhD; FAANProfessor, University of Massachusetts Boston

The Roy adaptation model concepts of stimuli, coping mechanisms, and modes of adaptation have been translated into several middle-range concepts and measured using existing and new instruments. The concept of adaptation level, however, has rarely been used in Roy adaptation model-based research. This paper presents a description of how the Roy adaptation model concept of adaptation level was translated into the logically congruent middle-range theory concept of adjustment. A single-item instrument, the Adjustment Scale, is identified as one way to measure adjustment.

Keywords: adaptation level; adjustment; conceptual model; middle-range theory; Roy adaptation model

356 Nursing Science Quarterly

health, and levels of adaptation, but focused on the modes of adaptation rather than adaptation level as a distinct concept. Ide (1978) described the Self-Perceived Adaptation Level (SPAL) instrument, which she devel-oped to measure well older adults’ perceived ability to manage or cope with changes in their internal or external environment, within the role function and interdepen-dence modes of adaptation. Ide’s stated purpose was to operationalize adaptation level. She did not distinguish between the conceptual model concept of adaptation level and the middle-range theory concept measured by the SPAL, perhaps because such distinctions were not well understood at the time she developed the SPAL. Moreover, although Ide did not report any estimates of reliability and validity for the SPAL, she mentioned that the instrument “appears to be relatively efficient . . .[and] is appropriate for use with a ‘well’ elderly population” (p. 62). Grey, Cameron, and Thurber (1991) discussed and measured degrees of social, psychological, and physiological adaptation, but did not explicitly refer to adaptation level.

Although some understanding about adaptation level comes from continued refinement of the RAM, the mean-ing of the concept within the context of the RAM is not clear. In particular, it is unclear whether adaptation level should be considered a response to environmental stimuli or an environmental stimulus per se. In her first textbook, Roy (1976) defined adaptation level as “The condition of the person relative to adaptation, which helps to determine whether the response to a changing environment will be adaptive or maladaptive” (p. 4), and as “the client’s ability to cope” (p. 19). In an attempt to clarify and expand its meaning, Roy and Roberts (1981) explained that adapta-tion level “sets up a zone that indicates the extent of stimuli that will elicit a positive response . . . . This posi-tive response decreases the response necessary to cope with the stimuli and increases sensitivity to other stimuli” (p. 45). They further explained that environmental stimuli “pool to make up . . . the person’s adaptation level . . . . The adaptation level, then, is a constantly changing point that represents the person’s own standard of the range of stimuli that he [or she] will tolerate with ordinary adaptive responses” (p. 43). In addition, Roy and Roberts (1981) noted that adaptive responses “are a function of: (1) the stimuli coming in . . . and (2) the adaptation level” (p. 44). (In the RAM, adaptive responses are those that meet the person’s goals for survival, growth, reproduction, and mastery. Ineffective responses do not meet those goals and signal a need for nursing intervention.)

In the second edition of her textbook, Roy (1984) modi-fied the definition of adaptation level to “a constantly

changing point, made up of focal, contextual, and resid-ual stimuli, which represents the person’s own standard of the range of stimuli to which one can respond with ordinary adaptive responses” (pp. 27-28), and as “the person’s own standard of the range of stimuli that can be tolerated with ordinary efforts” (p. 30).

In a later textbook, Roy and Andrews (1991) further modified the definition of adaptation level to “a chang-ing point that represents the person’s ability to respond positively in a situation” (p. 4). They went on to explain that the “ability to respond positively depends on all three types of stimuli [focal, contextual, residual] and their current effect on the person” (p. 10). Roy and Andrews (1991) also pointed out that “the notion of adaptation level conveys that the person is not passive in relation to the environment” (p. 10).

In the next edition of their textbook, Roy and Andrews (1999) defined adaptation level as “a changing point influenced by the demands of the situation and the inter-nal resources . . . [including] capabilities, hopes, dreams, aspirations, motivations, and all that makes humans con-stantly move toward mastery” (p. 33). They also noted that adaptation level is “a significant focal, contextual, or residual stimulus in a situation” (p. 42).

In the 1999 textbook, Roy and Andrews introduced the idea of three levels of adaptation, which they regarded as conditions of the life process—integrated life process, compensatory life process, and compromised life process. Integrated life process is the level of adaptation “at which the structures and functions of a life process are working as a whole to meet human needs” (p. 31). Compensatory life process is the level “at which the coping mechanisms have been activated by a challenge to the integrated life processes” (p. 31). Compromised life process is the level “resulting from inadequate integrated and compensatory life process” (p. 31) and signals a problem in adaptation. The definitions for integrated life process, compensatory life process, and compromised life process suggest that they are hierarchical. That inference is supported by Roy and Andrews’ (1999) statement that “an integrated life process may change to a compensatory process which evokes attempts to reestablish adaptation. If the compen-satory processes are not adequate, compromised processes result” (p. 37).

Adaptation Level Translated Into Adjustment

For the purposes of our current work, we regard adap-tation level as a response to environmental stimuli.

DeSanto-Madeya, Fawcett / Adaptation Level 357

Following brainstorming and dialogue with colleagues, we identified adjustment as a logically congruent middle-range theory concept that can be used to represent adap-tation level in research and practice. We reasoned that inasmuch as the word, adjustment, refers to a process of regulating, arranging, or harmonizing (Oxford English Dictionary, 2007), it captured the essence of adaptation level as a changing point of responding to environmental stimuli. We deliberately limited the middle-range con-cept to one word, rather than identifying a specific type of or context for adjustment. Doing so facilitates explo-ration of the generalizability of adjustment to diverse health experiences, which is, after all, the point of middle-range theories. In contrast, a micro theory or a situation-specific theory would place adjustment within a specific context, such as a particular health experience (Kramer, 1997; Meleis, 1997).

Measuring Adjustment

We designed a single-item numeric rating scale, the Adjustment Scale, to measure adjustment. The conceptual-theoretical-empirical structure (Fawcett, 1999) that links the conceptual model concept of adaptation to the middle-range theory concept of adjustment, and adjustment to its empirical indicator, the Adjustment Scale, are depicted in Figure 1.

We decided to measure adjustment with one numeric item because single-item instruments that ask for an overall or global rating of a specific concept allow peo-ple to take personally salient features of the situation into account when providing a response (Youngblut & Casper, 1993). Theoretically, the research participant’s or patient’s perspective determines the rating, rather than the researcher’s or clinician’s perspective, which could be the case if many items were used. Practically, single-item instruments place little burden on a research par-ticipant who may also be asked to complete multiple-item instruments or on a patient who may be subjected to comprehensive assessments by several healthcare team members.

The single item of the Adjustment Scale is rated on a 10-point scale from 1(not well) to 10 (very well; Figure 2). The number selected represents the condition of the life processes, with lower numbers indicating more compro-mised life processes and higher numbers indicating more integrated life processes (Roy & Andrews, 1999).

To date, the Adjustment Scale has been used to mea-sure adaptation level in two RAM-based studies of adap-tation to life events. One study focused on adaptation to

living with spinal cord injury 1 to 3 years after the injury (DeSanto-Madeya, 2009); the other study focused on adaptation to motherhood during the early postpartum period (Aber, Fawcett, & Weiss, 2006). The data from the two studies were used to examine the correlation between the Adjustment Scale score and an adaptation score that measured the combined physical, emotional, functional, and social components of adaptation. Those four components of adaptation represent the physiologi-cal, self-concept, role function, and interdependence modes of adaptation, respectively. The adaptation score is calculated by dividing the total number of adaptive responses to open-ended questions about the four com-ponents of adaptation by the total number of responses (adaptive and ineffective responses) to the questions and multiplying by 100 (Fawcett, 2006). The potential range of adaptation scores is 0 to 100, with higher scores indi-cating greater adaptation. Examples of open-ended ques-tions for each component of adaptation are given in Table 1.

The correlation between the adaptation score and the Adjustment Scale score was .48 (N = 244) in the adapta-tion to motherhood study, and was .40 (N = 15) at 1 year and .19 (N = 15) at 3 years after injury in the adaptationto spinal cord injury study. We regard components of adaptation and adjustment level as two separate but related middle-range concepts. As such, we would expect any correlation between scores for instruments used to

Figure 1Conceptual-Theoretical-Empirical Linkages

for Studies of Adaptation Level

Roy Adaptation Model

Adaptation Level

Adjustment

Adjustment Scale

358 Nursing Science Quarterly

measure the concepts to be relatively low (for example, r ≤ .05). A high correlation (for example, r ≥ .80) would imply that the same concept was being measured by two different instruments. The relatively low correlations found in our studies suggest that adjustment and compo-nents of adaptation are, indeed, separate concepts.

Implications for Nursing Research

The single-item Adjustment Scale was designed as a measure of adjustment to life events in both research and

practice that is guided by the RAM. As can be seen in Figure 2, the label for any life event can be inserted. Youngblut and Casper (1993) pointed out that single-item indicators asking people for a global rating of a concept are consistent with nursing’s focus on holistic phenomena and individualized care, both of which are hallmarks of the RAM.

Although we have not yet systematically tested the psychometric properties of the Adjustment Scale, the reliability and validity of single-item instruments have been supported (Patrician 2004; Sagrestano et al., 2002; Youngblut & Casper, 1993). Youngblut and Casper pointed out that adequate estimates of test-retest reli-ability for single-item instruments have been obtained for intervals ranging from 1 hour to 8 months. A short interval, such as at the beginning and end of an inter-view or a comprehensive assessment, might be most appropriate for estimating the test-retest reliability of the Adjustment Scale. However, the issue of what inter-val is most appropriate led Nunnally and Bernstein (1994) to recommend against use of the test-retest approach to estimating reliability. They pointed out that memory of the initial score may influence the retest score if the interval is short, whereas real changes might have occurred if the interval was long. Furthermore, adjustment probably is a state that changes rapidly rather than a stable trait. Such rapidly changing con-cepts preclude any meaningful interpretation of test-retest reliability estimates (Patrician).

Perhaps alternate forms are a better approach to esti-mating the reliability of the Adjustment Scale. An exam-ple of an alternate form for the single-item numeric version of the Adjustment Scale is a single-item visual analog scale, which is a 100 millimeter horizontal or vertical line on which the person places a mark indicat-ing his or her score (Polit & Beck, 2008).

Substantial evidence supports the construct validity of single-item instruments. Patrician (2004) pointed out that the construct validity of single-item instruments is enhanced by their simplicity. Young and Casper (1993) explained, “[S]ingle-time measures are generally valid and sensitive to change in the phenomenon under study . . . [and] may yield more valid data than multi-item

Table 1Examples of Open-Ended Questions

for Physical, Emotional, Functional, and Social Components of Adaptation

Components of Adaptation

Examples of Open-Ended Questions:

Adaptation to Motherhood

Examples of Open-Ended Questions: Adaptation to

Spinal Cord Injury

Physical component

How have you been feeling physically since you went home from the hospital?

How have you felt physically since your spinal cord injury compared to what you expected to feel?

Emotional component

How have you been feeling emotionally since you went home from the hospital?

How have you felt emotionally since your spinal cord injury compared to what you expected to feel?

Functional component

How are you adjusting to: (for primparas) being a new mother; (for multiparas) having a new baby at home?

What do you perceive as your roles (roles are your daily activities) in life? How has your spinal cord injury affected those roles?

Social component

How is your husband /partner adjusting to having a new family member?

Since your spinal cord injury, how have your relationships with your partner, family members, and friends been compared to what you expected?

Figure 2Adjustment Scale

On a scale from 1 to 10, with 1 meaning “not well” and 10 meaning “very well,” how well do you think you are adjusting to [insert label for a life event, such as living with a spinal cord injury or being a new mother (primiparas) or the mother of another child (multiparas)]?

Not well 1 2 3 4 5 6 7 8 9 10 Very well

DeSanto-Madeya, Fawcett / Adaptation Level 359

measures” (pp. 461, 463). The low correlations between Adjustment Scale scores and adaptation scores found in the studies of adaptation to spinal cord injury and to motherhood provide a preliminary estimate of discrimi-nant validity (Polit & Beck, 2008). Further testing of the construct validity of the Adjustment Scale requires more thought about the possible similarity or difference between responses to measures of one or more concepts that rep-resent the four RAM modes of adaptation—physiological, self-concept, role function, and interdependence—and to the measure of a concept representing adaptation level, such as adjustment.

A challenge with use of the Adjustment Scale is to identify scores or cutoff points for integrated, compensa-tory, and compromised life processes. For example, should a score of 1, 2, or 3 be considered a compromised life process; a score of 4, 5, 6, or 7, a compensatory life process; and a score of 8, 9, or 10, an integrated life pro-cess? Or, should a compromised life process be indicated by a score of 1; an integrated life process, by a score of 10; and a compensatory life process, by all other scores? The answer to these questions requires further thought and empirical research.

Conclusion

We have made an initial attempt to translate the RAM concept of adaptation level to a middle-range theory concept using the concept of adjustment and to measure adjustment by means of a single-item instrument. We regard adaptation level and adjustment as logically con-gruent concepts within the context of the RAM. Much more theoretical and empirical work is needed to deter-mine whether adjustment is the best way to translate adaptation level and whether a single-item instrument is the best way to measure adjustment.

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