Roy
Adaptation Model: Application of Theoretical Framework
Bilal
S. H. Badr Naga
Esam
A. AL-Khasib (1)
(1) Hashemite University, Faculty of Nursing,
Department of Adult Health Nursing
Correspondence:
Bilal S. H. Badr Naga
Jordan
Email:
bilal_badrnaga@yahoo.com
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Abstract
Roy Adaptation
Model has the five main concepts of nursing
theory: the health, the person, the nurse,
the adaptation and the environment. Roy
views the person in a holistic way. The
core concept in her model is adaptation.
The concept of adaptation assumes that
a person is an open system who responds
to stimuli from both internal and external
aspects of the person. This study will
be guided by Roy Adaptation Model as a
conceptual framework in order to (1) to
investigate the relationship between environmental
stimuli (focal, contextual, and Residual
stimuli) and four adaptive modes of RAM
which causes cancer related pain (2) and
to note the effect of environmental stimuli
on coping mechanism (3) to correlate research
variable with theory concept, and to assist
the researcher to predict the results
and recommendations by answering the research
question.
Key words: cancer pain, Roy Adaptation
Model, barriers, barriers to cancer pain
management, pain management, attitude,
and beliefs.
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Breast Cancer is the most common malignancy
in women and accounts for 22.9% of all female
cancers worldwide (Ferlay, Shin, Bray, Forman,
Mathers, Parkin, 2010). One in 8 women will
be diagnosed with breast cancer in their lifetime
(National Cancer Institute, 2010). In Jordan,
breast cancer accounts for 18.8% of the total
new cancer cases and is ranked first among cancer
in females, accounting for 36.7% of all female
cancers, and is the leading cause of cancer
deaths among Jordanian women (Jordan National
Cancer Registry, 2008). Approximately 925 breast
cancer cases were registered among Jordanian
women in 2011, according to official figures.
Recently, oncology researchers indicated that
44% of breast cancer patients experience pain
(National Institutes of Health, 2002; Al Qadire,
2012; Potter, Wiseman, Dunn, et al. 2003). However,
cancer pain is still inadequately treated among
patients who are suffering from cancer disease
(Ward, Donovan, Owen, et al. 2000). Generally,
cancer pain may occur at any stage of the disease,
and depends on the type of tumor, and location
of metastases (Greenwald, Bonica, & Bergner,
1987). However, in breast cancer, pain is almost
iatrogenic, due to many factors such as chemotherapy
treatment, radiotherapy and postoperative complications
(Marchettini, 2008). This specificity could
be of some importance regarding barriers of
breast cancer pain management.
Uncontrolled cancer related pain is still a permanent,
feared, and prevalent problem throughout the world
(Bagciva, Tosun, Komurcu, Akbayrak, & Ozet,
2009). One in 8 women will be diagnosed with breast
cancer in their lifetime (National Cancer Institute,
2010).
There are many factors contributing to ineffective
pain management of cancer patients, including
barriers within systems of care, health care professionals,
and among patients and their family (Finley, Forgeron,
& Arnaout, 2008).
The American Pain Society recommended patient
involvement as a primary focus for improving the
quality of cancer pain management (Gordon et al.,
2005). Patients' beliefs about reporting pain
and using analgesics have an important function
in their pain levels (Vallerand, Templin, Hasenau,
& Doucet, 2007) and the effectiveness of their
pain management (Bagciva, Tosun, Komurcu, Akbayrak,
& Ozet, 2009; Gunnarsdottir, Donovan, Serlin,
Voge, & Ward, 2002).
Many researchers reported that patients are reluctant
to report their pain for reasons including fear
of side effects, fatalism about the possibility
of achieving pain control, fear of distracting
physicians from treating cancer, tolerance, addiction
and belief that pain is indicative of progressive
disease (Potter, et al. 2003; Miaskowski &
Dibble, 1995; Finley, Forgeron, & Arnaout,
2008). All of the factors mentioned previously
represent worse factors affecting all dimensions
of quality of life for patients and their families.
(National Institutes of Health, 2002)
Many researchers have studied the barriers of
pain management among cancer patients generally,
but there has been little investigation of the
barriers of pain management in breast cancer patients.
In Jordan, breast cancer is the most common cancer
afflicting women. According to statistics from
Jordan, major obstacles to patients reporting
pain and using available analgesics include misconceptions
regarding beliefs about disease and pain, and
pain medication (Dawson et al., 2002; Gunnarsdottir,
Donovan, Serlin, Voge, & Ward, 2002; Jacobsen
et al., 2012). However, little published research
was found that discussed the pain barriers of
Jordanian patients with breast cancer.
To enhance the quality of breast cancer pain management,
it is very important to better understand the
phenomenon of patient-related barriers to breast
cancer pain management. For this reason, it is
essential to explore the barriers from the patient's
point of view. However, there have been knowledge
gaps in the literature to date regarding barriers
of breast cancer pain management. Thus, investigating
the patient-related barriers to breast cancer
pain management, will help to fill the gaps in
knowledge related to patients' barriers and consequently
will enhance the quality of breast cancer pain
management. Thus, the aim of this study is to
investigate the barriers that have impacted pain
management of Jordanian breast cancer patients.
The purpose of this study is to correlate barriers
to effective pain management among breast cancer
patients and RAM.
The study will be guided
by Roy Adaptation Model,
1991 (RAM). (RAM) is one
of the most frequently
used conceptual frameworks
to guide nursing research,
education and practice.
The contributions of this
theoretical framework
are that it will lead
to a more systematic guide
for researchers and an
increased quality of nursing
practice, as well as organized
nursing knowledge through
research and provides
a more organized curriculum.
The model provides a way
of thinking about people
and their environment
that is useful in any
setting. (Roy & Andrews,
1999)
Overview of RAM
Roy Adaptation Model has
the five main concepts
of nursing theory: the
health, the person, the
nurse, the adaptation
and the environment. Roy
views the person in a
holistic way. The core
concept in her model is
adaptation. The concept
of adaptation assumes
that a person is an open
system who responds to
stimuli from both internal
and external aspects of
the person (Roy &
Andrews, 1999). Environmental
stimuli are categorized
as focal, contextual,
and residual stimuli.
Focal stimuli represents
an immediate and apparent
cause of the problem (Roy
& Andrews, 1999, p.
31); contextual stimuli
are other causative factors
whilst residual stimuli
relate to the patient's
past experiences with
the illness and how these
experiences may impact
upon the patient's current
condition. Regulator and
cognator activities as
a coping mechanism are
manifested through a patient's
illness. Regulator activities
are physiological in nature
whilst cognator activities
may range from a physical
attribute to a psychological
or social attribute (Roy
& Andrews, 1999, p.
32). The nurse's role
while caring for a patient
involves manipulating
the stimuli that comes
from the environment so
that they fall within
the client's field of
positive coping resulting
in adaptation. The adaptation
is considered as the effective
response to a stimulus,
whereas a negative response
is described as ineffective.
Adaptation takes place
in one physiological mode
and three psychosocial
modes. The psychosocial
mode of adaptation includes
self-concept; role function,
and interdependence mode,
four modes of adaptation
are an interrelated relationship.
This study will be guided
by Roy Adaptation Model
as a conceptual framework
in order to (1) to investigate
the relationship between
environmental stimuli
(focal, contextual, and
Residual stimuli) and
four adaptive modes of
RAM which causes cancer
related pain (2) and to
note the effect of environmental
stimuli on coping mechanism
(3) to correlate research
variable with theory concept,
and to assist the researcher
to predict the results
and recommendations by
answering the research
question.
Relationship between
Research Variables and
RAM Concepts
Three type of stimuli
that affect the four adaptive
modes by making barriers
to effective pain management
in breast cancer patients
are as follows: suffering
of patient from pain causes
physiological effect such
as absence of activity,
decreased rest, and poor
nutrition (physiological
mode); mastectomy affects
sensation of body image
among women, and could
cause social isolation
(self concept-group identity
mode); the cancer disease
itself and when adding
cancer pain, affects the
role of patients in family,
with friends, and society
and causes poor communication
with others (role function
mode); and it affects
the ability of patients
to love, respect, value,
and make close relationships
with others (interdependence
mode).
Focal (breast cancer);
contextual (cancer pain);
and Residual stimuli (fear
of addiction and side
effect, fatalism, and
belief) are considered
factors that affect coping
mechanism (regulator and
cognator). According to
RAM, the coping mechanism
in this study will be
the regulator subsystem
that helps patients to
overcome cancer pain in
response to neural, chemical,
and endocrine systems
(Roy and Andrews, 1999),
while cognator subsystem
helps patients to overcome
cancer pain through the
four types of systems
involved (cognitive emotion
channels, perceptual and
information processing,
learning, judgment, and
emotion (Roy & Andrews,
1999). For example, uncontrolled
pain and poor management
over some side effects
of pain medication such
as opioids could be the
causes of constipation
and the beliefs regarding
that pain medication is
harmful for the human
body creates a wrong belief
among patients and causes
a negative impact on this
mechanism in order to
cause the patients to
refuse treatment. This
is considered a barrier
to pain management (relationship
between regulator mechanism
and residual stimuli).
Learning, perceptual,
informational process,
and judgmental activity
have a strong relationship
between belief and judgment
of patients and their
family over cancer and
cancer related pain (Relationship
between cognator mechanism
and residual focal stimuli).
At the empirical level,
the relationship between
demographic data sheet
(DDS) and BQ have a significant
relationship between the
pain level in stage I
and stage II of cancer
disease; also the mentality
of patients regarding
cancer and cancer pain
differ according to age,
educational level, and
treatment method between
patients etc.. In this
study, the final result
(output) will be assessed
according to the following:
if the BQ score is more
than 2.5 and associated
with DDS variable this
patient is considered
to have a positive relationship
and have barriers to effective
pain management and needs
a feedback process immediately
to overcome this barrier
to alleviate suffering
by changing the perception
of patients toward pain
treatment or a need to
change or modify the treatment
plan. On the contrary,
if the patients have BQ
score less than 2.5 this
tends to have a negative
relationship between DDS
and BQ, thus there areis
no barriers to effective
pain management among
patients.
Click here for Figure
1: The Conceptual Framework
Research studies in the
oncology field of western
countries revealed several
barriers to effective
pain management such as
fear of addiction, fear
of developing tolerance,
fear of side effects,
and fatalistic beliefs.
Identifying barriers to
effective pain management
from the patient's perspective
in breast cancer patients
in Arab and Islamic culture
is the focus of this study.
Cancer pain and its under-treatment
is a major health issue
. Multiple factors are
associated with ineffective
cancer pain management
such as cultural factors,
misperception about pain
medication (fear of side
effects, fear of addiction,
and tolerance), patient's
demographic characteristics
and patient's beliefs
such as fatalism, which
increases the suffering
and reduces quality of
life for patient and their
families.
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