172

Evaluation of Two Assessment Techniquesfor Adaptation to Stress

JANET S. BARNFATHER, RN; PHD*MARY ANN PRICE SWAIN, RN; PHD*HELEN C. ERICKSON, RN; PHD†

* University of Michigan School of Nursing, Ann Arbor,MI.† University of Texas at Austin, Austin, TX.

Key Words: Adaptation to Stress, Roy’s Model, Modelingand Role-Modeling, Assessment of Adaptive PotentialReceived September 27, 1988.Accepted November 3, 1988.

This study was supported in part by a National Re-search Service Award, Predoctoral Nurse Fellowship,grant 5F31 NU-05657-03.

Two conceptual nursing models, Roy’s adaptation model and Ericksonand Swain’s adaptive potential assessment model are explained, andknowledge is identified within these two assessment techniques foradaptation to stress. The purpose is to identify common, noteworthyareas of nursing science as well as areas where further development innursing knowledge is needed. A case study is used to compare andcontrast these models. When assessing adaptation to stress, one simi-larity between the approaches appears to be a propositional linkage thatsupports the influence of developmental level on basic need satisfaction.A divergent area between the two models identifies a need for furtherdevelopment in nursing knowledge regarding the adaptive potential sta-tus. This includes information pertaining to what an individual canreasonably do or be expected to do when contending with stressors.

Models are useful in organizing knowledge.Conceptual models are useful in developingthe science of nursing. Whall (1989) addressessome important considerations about modelswhich include the following points. The term&dquo;conceptual model&dquo; is used in disciplines re-lated to nursing such as family sociology andlife span development psychology. The wordconceptual is an adjective that modifies model.There are models of various types includingthose made of clay and wood. A model con-structed of concepts is a conceptual model.Models are useful in identifying knowledgeand for comparison, to better understand thestructure of the knowledge. In this presenta-tion two conceptual nursing models, Roy’s ad-aptation model (Andrews & Roy, 1986; Roy,1984) and the adaptive potential assessmentmodel (Erickson, 1976; Erickson & Swain,1982) are explained, and knowledge is identi-fied within the two approaches. A case study

is used to compare and contrast these models,and judgments about the two assessment tech-niques are explored to highlight noteworthyareas in nursing science. The focus is on ex-amination of two assessment techniques re-garding adaptation to stress. Concurring anddiverging parts of the two models are identifiedand point to a need for further development inthe nursing knowledge.

Definition of terms are compared from eachmodel. Sound theoretical views of stressorsand stress (Lyon & Werner, 1987) are evidentin each approach. Stressors are described asstimuli that precede and elicit stress and stressis a nonspecific, holistic response to any stim-uli (Erickson, Tomlin, & Swain, 1988). Roy(1984) provides a similar definition by statingthat stressors are influencing stimuli resultingin the stress response which is viewed in termsof behavioral manifestations or resulting prob-lems. Erickson and Swain (1982) make thedistinction between stressor and distressor,using appraisal theory (Lazarus, 1966). Astressor is viewed as a challenge, and a dis-tressor is viewed as a threat to the individual.

Roy (1984) and Andrews and Roy (1986) citeexamples that implicitly agree with this ap-proach. A specific example includes the chal-lenge of learning to drive a car and the threatof an accident while driving (Andrews & Roy,1986, p. 40). The theoretical distinction forthe terms threat and challenge are not specif-ically addressed in Roy’s adaptation model.Further agreement includes the view of hu-man beings. Individuals are viewed in both

173

models as having biopsychosocial subsystemsin which dynamic interaction occurs.The authors define the following terms in

unique ways. Roy (1984) defines coping mech-anisms as cognator and regulator activitieswhich are acquired or innate ways of respond-ing to the changing environment. The cogna-tor subsystem responds through complex proc-esses of perception and information process-ing, learning, judgment, and emotion. Theregulator subsystem responds automaticallythrough neural-chemical-endocrine processes.Environment includes internal or externalstimuli or all conditions, circumstances andinfluences surrounding and/or affecting thedevelopment, and behavior of persons or

groups. Adaptive responses promote integrityof the person in terms of the goals of survival,growth, reproduction, and mastery. Ineffectiveresponses do not contribute to adaptive goals.And health is a state and a process of beingand becoming an integrated and whole (holis-tic) person. Erickson, Tomlin, and Swain(1988) define coping as the process of contend-ing with stressors and can be adaptive (healthand growth directed) or maladaptive (illnessdirected). A maladaptive response involves onesubsystem being taxed, and perhaps depleted,in an attempt to support another. Adaptiveand maladaptive coping responses are consid-ered to be holistic, which means individualsare more than the sum of their biophysical,psychological, sociological, and spiritual sub-systems. Health is a state of physical, mental,and social well-being, not merely the absenceof disease or infirmity (WHO, 1988) and as-sumes a balance among the subsystems.Since the focus in this presentation is lim-

ited to examination of two models as assess-ment techniques for adaptation to stress, nei-ther model is thoroughly represented; and onlya brief overview of each model is presented.The adaptive potential assessment model

(APAM) is part of a multidimensional assess-ment strategy used by nurses in the implemen-tation of the theory entitled &dquo;modeling androle-modeling&dquo; (Erickson, Tomlin, & Swain,1988). The APAM has three main states:arousal, equilibrium, and impoverishmentwith each state representing a different poten-ial to mobilize coping resources. Arousal andimpoverishment are considered stress stateswhereas equilibrium is considered a nonstressstate. Theoretically, persons in equilibrium arebuilding resources needed to contend withstressors and have the best potential for mo-bilizing coping resources. Individuals in thestress state of arousal have recently experi-enced stressors and are therefore mobilizingresources to contend with those stressors. In-dividuals in the stress state of impoverishmenthave experienced extensive or prolonged stres-sors and as a result have diminished, if not

depleted, resources needed to contend withthose stressors. Thus, individuals in impover-ishment are at even greater risk when they areconfronted with new stressors or are forced tocontend further with ongoing stressors.The APAM was developed by Erickson

(1976) who synthesized the physiologicalstress theory of Selye (1976) and the psycho-social theory of Engel (1962, 1968) into a sin-gle model to characterize certain mind-bodyrelationships. Although Selye and Engel hadproposed models of coping, each had proposeda model that considered only single subsys-tems of the person. Furthermore, theseauthors had proposed models that specifiedvarious stages of stress. The distinction ofErickson’s approach was in considering allsubsystems of the person and in identifyingstates of coping that would reflect the individ-ual’s ability to mobilize coping resources. Er-ickson (1976) and Erickson and Swain (1982)reasoned that Selye’s alarm reaction seemedlike Engel’s fight-flight and Selye’s exhaustionstage was close to Engel’s conservation-with-drawal response. In addition, another theorist,Seligman ( 1975), who studied the helpless-ness-hopelessness syndrome seemed to be inagreement with Selye’s exhaustion stage andEngel’s conservative-withdrawal response.Erickson (1976) and Erickson and Swain(1982) renamed these aggregate stress statesas arousal and impoverishment, respectively.Theoretical underpinnings for the APAM in-

clude the fight-flight reaction that is charac-terized by increased motor behavior and in-creased verbalization which is often assertiveor aggressive in nature. The differential acti-vation of neuroendocrine systems includessympathetic, adrenal-medullary, and cat-echolamine responses. Conversely, the con-servative-withdrawal response is character-ized by decreased motor behavior, decreasedverbalization and apparent introversion. Inaddition, the APAM includes an appraisalcomponent (Lazarus, 1966). A stressor can beperceived as a challenge or a threat. If a stres-sor is experienced as challenging, then thereis potential to achieve healthier states andgrowth for the individual. Adaptive energy isavailable to contend with the stressor. How-ever, when a stressor is experienced as threat-ening, then the response is potentially deplet-ing or diminishing the store of energy. In thecase of a threatening stressor, a new term,distressor, describes the stimulus whichmounts a maladaptive response when one sub-system is overtaxed by another and the formerbecomes depleted and contributes little to mo-bilizing coping resources for the individual.Indicators for classification of individuals intoone APAM state or another are based on thetheoretical underpinnings and include tense-ness/anxiousness, sadness/depression, fa-

174

tigue, motor-sensory behavior, autonomic re-sponses, and verbal anxiety. Furthermore, itis the patterning of these variables that deter-mines an individual’s APAM state (Barn-father, Swain & Erickson, 1989; Barnfather,1987; Erickson, 1976; Erickson & Swain,1982). The APAM was developed to provide ameans of assessing an individual’s ability tomobilize coping resources at any moment intime-that is, a state of coping.The reliability of the APAM depends, in part,

upon its linkage with the other concepts in themodeling and role-modeling theory and para-digm. These include understanding conceptsdrawn from the theoretical work of others-basic and growth needs (Maslow, 1968, 1970);psychosocial development (Erickson, 1963,1982); cognitive development (Piaget & In-

helder, 1969) and object relations (Bowlby,1981; Brody, 1980; Mahler, 1967; Winnicott,1965). Theoretical propositions linking theAPAM with concepts derived from all of theabove theorists appear in other works (Barn-father, 1987; Erickson, Tomlin & Swain,1983; Ozbolt, 1987; Stein, 1989). Erickson(1976) believed that a model which identifiedthe individual’s ability to mobilize coping re-sources would provide a base for nurses toplan interventions and clients would benefitfrom receiving nursing care more appropri-ately tailored to their particular needs andadaptive capacities. Results from a study con-ducted in a hospital setting demonstrated thatthe three APAM states are valid, can be relia-bly identified in medical-surgical patients (Er-ickson, 1976) and predict patients’ length ofstay (Erickson & Swain, 1982). Furthermore,construct validity was supported in healthyindividuals (Barnfather, 1987). The modelingand role-modeling paradigm includes severalspecific intervention goals as well as relatedaims of intervention.The Roy adaptation model (Andrews & Roy,

1986; Roy, 1984) also contains goals of nurs-ing that facilitate working with persons asadaptive systems contending with stressors.Roy (1984) values the humanistic base of hernursing model noting that the nurse is con-cerned about the person’s psychological, spir-itual, social, and physical health. Mind-bodyrelationships are characterized by the cogna-tor and regulator coping mechanisms throughwhich all stimuli are processed (Roy, 1984;Roy & Roberts, 1981 ). The regulator processesinternal and external stimuli through neural-chemical-endocrine channels to produce re-sponses. The other major adaptive copingmechanism is the cognator, which processesinternal and external stimuli that involve psy-chosocial and physiological stimuli, includingoutput of the regulator mechanism. These twomechanisms are explained and elaborated

upon elsewhere (Andrews & Roy, 1986; Roy,

1984; Roy & Roberts, 1981). The theoreticalwork on the cognator and regulator processesis still in the beginning stages, and it is pro-posed that complex relationships between cog-nator and regulator processes can lead to fur-ther understanding of the holistic nature ofhumans (Andrews & Roy 1986; Roy, 1984).Moreover, it is hypothesized that interactionsbetween the cognator and regulator are me-diated by perception, a function of the cogna-tor ; but how the actual transformation of bi-directional information flows between thesetwo coping mechanisms is still unknown (Roy,1984; Roy & Roberts, 1981 ).The cognator and regulator each act in re-

lation to four effector modes: physiologic, self-concept, role function, and interdependence.Observations of a large number of individualsin many health care situations (Roy, 1971)resulted in classifying observable behaviorinto these four categories. Each individual hasa unique adaptation level which constantlychanges representing the person’s own stand-ard range of stimuli that can be tolerated withordinary efforts. As a result of this uniqueadaptation level, adaptive and ineffective be-haviors are manifested by individuals in eachof the four major effector modes. Severalclasses of stimuli interact to determine the

adaptation level of an individual (Roy & Rob-erts, 1981). The stimuli are defined (Roy,1984) in the following ways: (a) focal stimulior the ’ stimuli immediately confronting theperson and the one that precipitates the be-havior ; (b) contextual stimuli, or all other stim-uli present that contribute to the behavior pre-cipitated by the focal stimuli; (c) residual stim-uli, such as beliefs, attitudes, or traits whichhave an indeterminate effect on the presentsituation. The pooled effect of these threestimuli are considered within each of the four

major effector modes and determines the in-dividual’s adaptive level.Many theorists guided Roy (1984) in the de-

velopment of the Roy adaptation model. Thefollowing theorists are highlighted by present-ing brief examples for each adaptive mode.Selye ( 1963, 1976) has influenced the physio-logical mode of adaptation in the model. Allcomponents of the physiological mode may beaffected by Selye’s &dquo;general adaptation syn-drome&dquo; in response to a stressor. These com-

ponents include oxygenation, nutrition, elimi-nation, activity and rest, skin integrity, thesenses, fluid and electrolytes, and neurological _,

and endocrine functions (Roy, 1984). Role-function draws from works of Goffman ( 1961 )and Parsons and Shils ( 1951 ) who provide sup-port for the importance of societal expecta-tions and instrumental and expressive behav-iors. Interdependence relies on Fromm (1956)and Havighurst (1953) for work pertaining tostimuli that influence interdependence behav-

175

iors. The self-concept mode has been influ-enced by several social interaction theoristssuch as Mead (1934), and Sullivan (1953) asthey expanded upon the work of Cooley (1902)who theorized that interaction with others

helps to control and alter one’s self appraisalthrough the concepts of &dquo;the looking-glassself&dquo; (Epstein, 1973). Other theorists includeCoombs and Snygg (1959) who describe a per-ceptual approach about self-concept that in-cludes oneself and one’s own abilities andGardner (1964) who proposed physical self-development, personal self-development, andlearning to live with others (which is relevantto the role function and interdependencemodes presented later). In addition, the Royadaptation model relies upon Erikson (1963),a developmental theorist, to identify develop-mental stage and corresponding tasks to mas-ter, which is useful information in all fourmodes. In addition, Maslow’s hierarchy ofneeds (1970) were compared to all four adap-tive modes and the two approaches were foundto have similarities (Roy, 1984). Recently, ref-erences to basic needs appear as the terms

physiological integrity, psychic integrity, af-fectional adequacy, and social integrity (An-drews & Roy, 1986).The Roy adaptation model has been imple-

mented in a variety of settings with promisingresults for nursing practice. Comprehensivelists appear elsewhere (Roy, 1984, 1988). Sev-eral projects from these lists include: a fieldstudy in episodic and distributive practice set-tings (Wagner, 1976); an example where anurse used the model with young hospitalizedchildren (Galligan, 1979); descriptions of im-plementation of the adaptation model with nu-merous clients of various age groups who arelocated along the wellness-illness continuum(Randell, Tedrow, & Van Landingham, 1982);and a demonstration project in orthopedic andrehabilitation settings, which revealed im-

proved patient care outcomes and enhancedprofessional nursing practice (Mastal & Ham-mond, 1980; Mastal, Hammond, & Roberts,1982).

Case StudySteve was a 19-year-old student at a large mid-west university in the second half of his soph-omore year. He was interviewed during midtermexamination time, and had already taken anexam on that day. He reported that he believedhe did poorly on the exam and felt anxiousabout another midterm in 2 days. Since leavingthe exam, Steve had been feeling a little faint-ness, had a lot of gas (eructation), and had beenhaving to urinate frequently. All other neuro-logical, gastrointestinal, and genitourinarysigns and symptoms were negative. Steve hadno history of any major illness or accident. Hehad mild-moderate acne with a few comedones

but there were too many present to actuallycount without a purposeful examination. Hisvital signs were 114/68, radial pulse 57, respi-rations 14, and his weight was stable and well-proportioned for his height of 5 ft 10 in. Appe-tite, fluid intake, and eating patterns were ad-equate and unchanged. In the past, Steve hadjogged approximately 4 mi several times a week,but reported that lately he ran only one dayevery 1-2 weeks for fewer than 4 mi. UsuallySteve sleeps 7-8 hours every night, but he hadbeen sleeping about 9 hours every night withoutfeeling refreshed upon arising.Steve was very interested in a political-socialorganization on campus and had been assignedthe job of canvassing local neighborhoods tocollect donations and contributions for the or-

ganization. He stated &dquo;I’m not doing so well....I’m not forceful with my arguments.... I’mjust not bold with my statements. There’s aquota to meet in three weeks and I haven’t metmine, which is really bad for me and the group.&dquo;Steve stated he took the last week or two off to

try and think about &dquo;it all.&dquo; He enjoyed andrespected his friends in this group saying, &dquo;We

get together every Wednesday night and go outfor pizza and beer and have a really good time.They are all real people and they enjoy beingwith me as well.&dquo;Steve described his future in the following way.&dquo;I think I’m going to take off school next year,maybe work in Montana this summer or inCalifornia, and then go over to Europe for a yearor so. Check that out and see how it goes. Andthen I’d like to come back here to school, butit’s not for sure. I’m actually, at this point,pretty down on school. I’m just ground into theground. I’m sick of studying and sick of exami-nations and things like that.&dquo; Steve went on tosay that he had a lot of trouble motivating him-self. He had previously thought of himself as anexcellent student who had been studying sci-ence, mostly physics and astronomy, but he hadcome to think that there was too much mathand theory involved, adding &dquo;I don’t see anypractical use for it.&dquo; Although he seemed veryunsure, majoring in English was one possiblearea that Steve suggested might be useful forhis future. As he talked, Steve sat very still,with shoulders flexed forward, not smiling,frowning, or using other facial expressions orbody animation; and eye contact was infre-quent after which he focused downward.Steve’s family consisted of parents and an oldersister, Jennifer, who attended the same univer-sity as Steve. At the end of her freshman yearSteve’s sister had applied for and was acceptedinto a study-exchange program in Europe. Jen-nifer was an outstanding student and had re-ceived many honors and awards. Steve’s fatherattended the same midwestern university andexpected his children to graduate from this uni-versity. Total family income was about

$80,000/year indicating socioeconomic statusof upper middle class. Steve’s mother was ahomemaker and involved in community serv-ices. Steve viewed his parents as supportive,loving, and interested in his welfare. Steve men-tioned that he and his sister had frequent dis-

176

cussions about their situations. Jennifer hadindicated that she suspected their parents maybe considering a trial separation.

Assessment Models

The Roy Adaptation ModelThe Roy adaptation model (Andrews & Roy,

1986; Roy, 1984) of assessing behavior in-volves a sequential process of examining cog-nator and regulator activities in each adaptivemode identified as physiological, self-concept,role performance, and interdependence. First-level assessment occurs when the nurse sys-tematically examines behavior in each adap-tive mode by means of interview and obser-vational skills in order to obtain measurementof internal and external client responses toenvironmental changes that require furtheradaptive responses and to gain subjective re-ports about the adaptive responses. The nursedetermines, in collaboration with the person,whether behavior is adaptive or ineffective.The next step in the assessment process, sec-ond-level assessment, involves further assess-ment of the adaptive modes for those behav-iors of concern identified in first-level assess-ment. Second-level assessment is not limitedto ineffective adaptation or behaviors of con-cern, because the nurse and/or client maywant to consider primary prevention strate-gies. At this point, or earlier if necessary,priorities are set for second-level assessment.Priority is defined as an order of urgency. Roy(1984) proposes the following hierarchy forindividuals, families, groups, or communities.The categories include situations that: (a)threaten survival; (b) affect growth; (3) affectcontinuation of the human race or of society;and (d) affect attainment of full potential. Sec-ond-level assessment means looking for influ-encing factors on behavior previously de-scribed as focal, contextual, and residual stim-uli (Andrews & Roy, 1986; Roy, 1984). Afterfirst- and second-level assessment is com-

plete, nursing diagnoses are made. Assess-ment data for Steve is described below.

Role performance mode

Roy (1984) states that &dquo;One of the first steps indoing the first- and second-level assessment inall four adaptive modes is to identify the per-son’s age and stage of development&dquo; (p. 265).The Roy adaptation model refers the reader toErikson (1963), although it is possible to drawupon other developmental theorists. Role-func-tion includes the primary role which considersage, sex, and developmental stage. Therefore, itis important to identify Steve’s primary role asthat of a 19-year-old who is in late adolescent-early adulthood. The data suggest Steve was

dealing with the conflict of identity versus rolediffusion associated with the adolescent task toknow &dquo;who I am.&dquo; The secondary roles, thoseassumed to complete this developmental task,include student, son, and brother roles. Steve’stertiary role, freely chosen and temporary, wasthat of political-social group member; but sinceit probably contributed to role mastery, the ter-tiary role may also be considered as a secondaryrole. In adolescence, peer groups are especiallyimportant in shaping values and in relating tosociety. Steve was ineffective in his student rolewhen he stated, &dquo;I’m actually, at this point,pretty down on school.... I think I’m going totake off school next year.... it’s not for sure.&dquo;The instrumental behaviors to accomplish thegoal of graduation were weak. The expressiverole performance behaviors included feelings ofdislike for the student role. Steve ranked hisrole as student lowest, group member in thepolitical-social organization highest, with sonand brother in between. Cognator/regulatorprocesses seemed to be especially ineffective ingoal attainment associated with his role of stu-dent. Data supporting the basic need of socialintegrity (Andrews & Roy, 1986) were scant, ifnot absent.

Physiological modeFirst-level assessment for physical adaptationrevealed several areas of concern. There was a

slightly elevated pulse pressure of 46 mmHg.Bradycardia was present which may have beenrelated to jogging. Rest/sleep/activity patterns

.

’

were altered to the point that activity was re-duced and sleep was increased without feelingsof being refreshed. Steve mentioned there wastoo much work to do so that jogging had becomedifficult. Posture was poor as his anatomical

alignment of shoulders and trunk were flaxedforward. Skin was warm, dry and pink; andfacial skin had acne with comedones. Eructationand frequency of urination had occurred onlyin the past few hours since the end of the mid-term exam, and there was no accompanyingnausea, vomiting or diarrhea, or increasedthirst. Faintness began after leaving the ex-amination whereas other neurological signsand symptoms such as confusion, disorienta-tion, dizziness, pain, numbness, tingling, andinappropriate or limitation of movement werenegative. Cognator/regulator processes were,for the most part, maintaining physiologicalfunctioning. The five basic needs of oxygena-tion, nutrition, elimination, activity and rest,and protection were judged as not threateningsurvival, although growth and achievement ofpotential were possible concerns.

Self-concept mode

First-level assessment for self-concept includedthe following areas of concern. Under personalself is the concept self-consistency, how oneviews oneself in relation to actual performance.Steve mentioned he was not forceful or bold

177

enough, and he viewed his actual performanceas inadequate. Furthermore, he believed his in-adequacy was found in more than one role bothas student and as a member of a peer group.Self-expectancy (ideal self) seemed to includetrying to improve his behavior so that it wasconsistent with his peer group expectations. Itwas not clear that he intended to improve hisbehavior in order to master his science studies.Instead he saw himself leaving the sciences andperhaps eventually becoming more involvedwith English studies. He was very unsure of hiseducational goals. The content of his verbalcommunication, posture, tone of voice, and eyecontact suggested ambivalence and discourage-ment. Steve’s moral-ethical-spiritual self ap-peared shaky. Steve believed he should be moremotivated about school to meet his father’s ex-

pectations, but he felt &dquo;ground into the ground&dquo;and sick of studying. In the past, he had thoughtof himself. as an excellent student and as alikeable person who tried to do the right thingin a given situation. Cognator/regulator proc-esses were ineffective in this mode. The basicneed identified as psychic integrity (Andrews &

Roy, 1986) was shattered leaving no sense ofunity.

Interdependence mode

Steve believed Jennifer was a very importantperson in his life. Each had assumed a contri-butive and receptive role in their relationshipregarding nurturing behaviors and meeting hu-man needs (Roy, 1984). His peer group had beenanother major source of social support. SinceSteve had yet to meet his quota and the deadlinewas approaching, he was less confident in con-tinued peer acceptance. Steve stated he did notknow whether or not his parents would sepa-rate. He wished he could tell his parents that heloved them. Cognator/regulator processes seemadaptive but identification of potential areas ofconcern should be necessary. Evidence of thebasic need of affectional adequacy (Andrews &

Roy, 1986) was present regarding Jennifer butuncertain for his parents.Behaviors of concern appeared in all four adap-tive modes. In general, the physiological mode

had many more adaptive responses than inef-fective responses. Survival concerns were notas apparent as they were with self-concept,role-function and to a lesser extent interde-pendence modes. A decision was made by thenurse to track first-level physical assessmentdata for Steve instead of moving to second-levelassessment. Person-systems (Andrews & Roy.1986; Roy, 1984) have holistic responsesamong all four effector modes as dynamic in-teraction occurs. It is possible to observe

changes in the physiological mode as feedbackfrom all four modes is reprocessed by the cog-nator and regulator. Thus, first-level assess-ment should be tracked over time to determinewhether or not second-level assessment is nec-

essary. Interdependence had adequate adaptiveresponses with at least one individual, Jennifer,but past adaptive responses with parents werenot entirely known. Although interdependenceseemed somewhat adequate, further assess-ment may have prevented possible ineffectiveresponses. Self-concept and role performanceseemed to have few, if any, adaptive responsesespecially for growth and mastery. Survival ofSteve’s student role and accompanying growthwere at risk as he dealt with the adolescentconflict of identity. The cognator/regulatorprocesses in the self-concept and role perform-ance modes resulted in ineffective responses.Thus, second-level assessment was carried outto show focal, contextual and residual stimuliin the self-concept (Table 1 ), role performance(Table 2), and interdependence (Table 3) modes.In the above tables, second-level assessmentwas examined for within mode responses to

influencing stimuli. An additional point of in-terest was that the between mode relationshipsreflected Steve’s developmental status. An ex-ample which relates developmental status tobetween mode relationships is included in thefollowing explanation. Inherent in Steve’s de-velopmental stage of identity versus role diffu-sion were several crises and necessary deci-sions about self-concept, role performance, andintense peer group interdependence. Steve wastrying to establish his identity in the competi-tive setting of a leading university which ex-pects the highest academic quality of its stu-dents. Social development was through Steve’s

Table 1

Secondary Assessment

178

Table 2

Secondary Assessment

Table 3

Second-Level Assessment

peer group which had somewhat of an idealworld view. His intense involvement in his peergroup was consistent with adolescent develop-mental tasks, but it had been at the expense ofhis education and career goals. Steve was feel-ing inadequate, but asking for help was devel-opmentally difficult when one was trying to beindependent. Although at a low point in parent-child relationship, consistent, loving, and sup-portive parents are important; and Steve didnot have complete confidence about future pa-rental nurturing. Possible nursing diagnoseswere low self-esteem (self-concept mode) relatedto possible loss of social support (interdepend-ence mode), and role failure and conflict (roleperformance mode) related to adolescent devel-opmental tasks. A nursing diagnosis supportinga strength was: adequate love and respect withJennifer and parents related to interdepend-ence adaptation.

Adaptive potential assessment modelA nurse using the adaptive potential assess-

ment model within the modeling and role mod-eling approach (Erickson, Tomlin, & Swain,1988) emphasizes a client’s ability to mobilizeresources needed to contend with the stress

response or the possible stressor-stress rela-tionships among the subsystems. Subjectivedata regarding stressors, distressors, and needdeficits are addressed by modeling a client’sworld. Modeling includes understanding theclient’s model (view) of the world and has sev-eral steps identified as data collection, dataanalysis, and diagnosis. Role-modeling meanshelping individuals redesign their role(s) byassisting them in developing a healthier rolein the world and includes planning and inter-vention. Data are collected for assessment us-

ing four categories: description of the situa-tion, immediate and long term expectations,internal and external resources, and currentand planned goals. The client is the primarysource of information; secondary sources arefamilies, significant others, and the nurse; ter-tiary sources are all other health care pro-viders. A paragraph of data from primary, sec-ondary, and tertiary sources in each of thefour categories is usually collected; but thispresentation is limited to only the primary andsecondary (nurse) sources. Data are inter-

preted and then analyzed within the philo-sophical and theoretical propositions set forth

179

in the above publication. Special emphasis isplaced on determining the client’s strengths,virtues, and available internal resources. Im-

portant theory bases include stressor-stress-coping responses (Engel, 1962, 1968; Lazarus1966; Selye, 1976), basic and growth needs(Maslow,. 1968, 1970); developmental proc-esses (Erikson, 1963, 1982), and object attach-ment (Bowlby 1981; Mahler, 1967).

Description of the situation

Steve’s job with the political-social group wasnot going well. He had not met his quota in thepast and had another three weeks to meet it.Steve viewed this situation as &dquo;really bad for meand the group.&dquo; He had been spending a lot oftime with his friends in this group because hebelieved in their national goals and he enjoyedtheir friendship. Steve believed &dquo;he’s not force-ful and bold enough with his statements.&dquo; Heperceived a threat of loss of status as an ac-cepted group member if he did not meet hisquota. Secondary data, considering Steve’s de-velopmental status, meant loss of peer supportwas a distressor. Another potential loss of sup-port was from his father. Steve’s father ex-pected him to graduate from the same midwest-ern university as he did. Previously, Steve hadthought this was what he wanted, too; but nowhe was not sure. He believed his father wouldbe very disappointed in him if he did not grad-uate from the same university. Furthermore,consistent support from his parents might bealtered given their potential marital problems.Steve self-reported feelings of anxiousnessabout his midterm exams. During the interview

’

with the nurse, Steve described a recent onsetof faintness, gas, frequent urination, and in- .

creased sleep that did not refresh him. Second-ary data assessment was that Steve had de-scribed another possible distressor, a threat ofloss of his father’s respect and parental nurtur-ance. The two psychosocial distressors whichhave been identified are beginning evidence ofa maladaptive response where psychosocial re-sources are depleted and physical resources areused to contend with the psychosocial distres-sors. Steve was experiencing ongoing tense-ness-anxiousness regarding threats to basicneed satisfaction of belonging. Develop-mentally, belonging needs are met primarilythrough peer group association with parentsbeing less important.

ExpectationsSteve was very unsure about his future. He maydecide to &dquo;take off school next year to work inMontana or California.... And then go over toEurope for a year or so. Check that out and seehow it goes.... Then I’d like to come back hereto school, but it’s not for sure.&dquo; He planned tochange the focus of his studies from sciencesto English for which he stated, &dquo;I don’t see thepractical use of it (sciences).&dquo; In the past he hadviewed himself as an excellent student and aworthwhile person who was expected to gradu-ate from the university that his father had.

Resource potentialSteve stated that he knew his father would be

disappointed in him if he did not continue onwith his studies but he explained, &dquo;I’m prettydown on school. I’m just ground into the ground.I’m sick of studying and sick of examinationsand things like that.&dquo; Steve stated his relation-ship with Jennifer was the only thing that&dquo;keeps me going.&dquo; However, he had felt less andless interested in school. He could not remem-ber when his interest seemed to change, but heknew the past semester had not been the sameas his first year at the university which hedescribed as &dquo;really neat,&dquo; but no accompanyingfacial smiles appeared. In fact, secondaryanalysis revealed conservative-withdrawal pos-ture (Engel, 1962) with shoulders flexed, infre-quent eye contact, and a gaze focused down-ward. Facial expressions were absent as hetalked. A fatigued appearance was evident ashe described his perception of too much schoolwork and a decreased ability to jog his usual 4miles. Further secondary data included: Stevemost probably had progressed through Erik-son’s stages of development to identity versusrole diffusion with possible past strengths ofdrive (trust versus mistrust); self-control (au-tonomy versus self-doubt); direction (initiativeversus guilt); and competence (industry versusinferiority) indicated, in part, by his status at aworld class university. It seemed possible thatSteve had developed many resources in his cog-nitive subsystem but had not been able to drawupon these resources for use in his psychosocialsubsystem. One unanswered question was towhat extent did Steve have a strong, positivebalance of the first Eriksonian crisis regardingtrust versus mistrust, which promotes secureattachment with accompanying attributes ofhope and drive. He may have received condi-tional acceptance from his parents. This meansthat there is an overt or unspoken message thatone is valued (loved, accepted) on the conditionthat one is doing well in school. Unconditionalacceptance means one is valued regardless ofone’s performance. Anxious attachment to par-ents (and others) may result from unconditionalacceptance which results in constantly havingto demonstrate one’s worth through excellentperformance. In contrast to behavior motivatedby basic needs of love and belonging is behaviorthat is motivated by growth needs (Maslow,1968, 1970).

Goals

Steve’s planned goals were uncertain, whichcould easily be related to the developmentaltasks of seeking out an identity in the world.He might leave school to travel and work, he didnot know his major in college, and he was un-sure about how his peers viewed him and pos-sibly unsure of continued nurturance from hisparents. Chronologically, Steve was enteringyoung adulthood, but intimacy did not seem tobe a goal for him. Steve was still very muchinvolved with adolescent tasks and goals.Steve expressed feelings of tenseness-anxious-ness regarding basic needs of belonging and

180

self-esteem which are very important develop-mentally to one who is primarily concerned withissues of identity and independence. At leasttwo ongoing distressors were identified as aresult of perceived threat of loss of support andrespect from peers and parents. Steve’s uncer-tainty about the future was evident, and heappeared to demonstrate a conservative-with-drawal bodily response with accompanying fa-tigue. The pattern suggested an impoverishedstate where basic needs are perceived to beunmet and an individual is unable to mobilize

coping resources to contend with stressors. InSteve’s case, distressors had depleted psycho-social resources, and he was drawing energyfrom physiological resources, which was evi-denced by gastrointestinal genitourinary dis-turbances, faintness, a somewhat elevated

pulse pressure, and increased sleep withoutfeeling refreshed. Possible nursing diagnoseswere: impoverishment related to ongoing dis-tressors of loss of support and respect frompeers and parents, and unresolved tasks ofidentity versus role diffusion related to per-ceived unmet basic needs of belonging and self-esteem. A positive nursing diagnosis was: ade-quate unconditional acceptance received fromJennifer related to basic need satisfaction.

Evaluation of the Two Assessment Techniques

An important reminder is that, within thispresentation, only portions of each theoryhave been used due to space constraints. Itshould be noted that although adaptation ac-counts for the central theme in the Roy model,the APAM represents only one component ofthe theory entitled modeling and role-model-ing. Both approaches use adaptation as anassessment strategy and comparing the two isimportant for the reasons cited earlier byWhall ( 1989).Extensive work regarding evaluation of con-

ceptual models related to metaparadigm con-cepts of environment, health, person, and

nursing are discussed elsewhere for Roy’smodel (Fawcett, 1984). Similar metaparadigmconcepts are found in the literature for theAPAM within the modeling and role-modelingframework (Erickson, Tomlin, & Swain, 1983;Marriner, 1986). The intent of this presenta-tion is not to repeat earlier efforts but to iden-tify noteworthy areas in nursing science aswell as gaps in knowledge by comparing themodels. Several criteria were identified to eval-uate the assessment techniques. Examina-tions and judgments were based on: (a) com-prehensiveness-completeness and inclu-siveness regarding life span concepts; (b)structure-how the parts of the model relatedto each other including the overall construc-tion ; (c) outcome-how the model assisted instating nursing diagnoses.

ComprehensivenessBoth approaches have the strength of draw-

ing upon a broad range of theorists and syn-thesizing a unique nursing perspective fromthe literature. An important commonality isthat individuals are viewed across the life spanin particular ways. In this regard, brief exam-ples of comprehensiveness are presented.Models developed by Roy, and Erickson andSwain, have an important similar theoreticalbase in their use of developmental tasks (Er-ikson, 1963). Adaptation is considered withinthe life span concept which, in turn, guidesassessment. In addition to developmental sta-tus, both models consider human needs ap-proach across the life span. Roy (1987) men-tions that the concept of human needs is apart of the Roy model which is yet to be devel-oped. However, some important work has beenaccomplished in this area. Roy ( 1984, p. 311)aligned the several adaptive modes with hu-man basic needs (Maslow, 1970). Recently,human basic needs have been identified underthe four adaptive modes as concepts of phys-iological integrity, psychic (self-concept) integ-rity, affectional (interdependence) adequacy,and social (role function) integrity (Andrews &Roy, 1986). These recently identified conceptsare consistent with Roy’s initial alignment ofadaptive modes (physiological, self-concept,role function, interdependence), with Maslow(1970). Identifying the usefulness of these twotheories across the life span facilitates a hol-istic approach which can best be discussedunder the next heading.

StructureThe two theory bases, developmental status

and human needs, are essential to under-

standing how subsystems of a person interactin a holistic way. For example, when assessingadaptation to stress, developmental level caninfluence basic need satisfaction, includinghow physiological and psychosocial needs aremet by the individual. It appears that bothapproaches value this propositional linkage.The difference between the two approaches isthat the APAM guides the nurse in assessingthe client holistically by the introduction ofseveral concepts. Identification of three con-cepts, stressors, distressors, and maladaptiveresponses, seems to be an important featurein this regard. The difference is especially truein the function of physiological data withineach model. In the APAM, physiological dataare an inherent part of the assessment. TheAPAM integrates biophysical-psychosocialphenomena to empirically establish the indi-vidual’s potential for mobilizing adaptive re-sources. Patterns of biophysical and ~psycho-social variables determine the classification ofadaptive potential. Results of several studies

181

(Barnfather, 1987; Barnfather, Swain, & Er-ickson, 1989; Erickson, 1976; Erickson &Swain, 1982) suggest that the patterned vari-ables identified as feelings of tenseness-anx-iousness, sadness-depression, fatigue, hope,verbal anxiety, as well as autonomic signs andsensorimotor behavior, are important deter-minants in viewing clients holistically. Bio-physical and psychosocial phenomena are

clearly integrated regarding individual’s dif-ferential potential for mobilizing adaptive re-sources. In the Roy adaptation model the hol-istic concept is present but does not comethrough as a strong contributor in assessmentof the client. The model seems weak with re-

spect to integration of the adaptive modes witheach other. By and large, assessment strate-gies remain within the four adaptive modeseven though this approach suggests that nurs-ing diagnoses cut across the modes (Andrews& Roy, 1986; Roy, 1984). Beginning integra-tion is evident in the nursing diagnosis &dquo;lowself-esteem related to possible loss of socialsupport.&dquo;

In the overall construction of the two models,there is a divergence between the two ap-proaches. The Roy model gives much morestructure for data collection and assessmentincluding priority setting (Roy, 1970, 1984).An advantage to this structured approach isthat the Roy model reveals areas where furtherdata collection is needed. For example, resid-ual stimuli provides the nurse with a system-atic way to find out what data are missing.This was especially evident under interde-pendence for religious beliefs.Outcome

Both models had considerable influence inguiding and assisting with the statement ofnursing diagnoses. To some extent the nursingdiagnoses from both models addressed similarcontent areas. Thus, important domains ofnursing practice and nursing knowledge areidentified by both models. It should be notedthat the APAM appears to expand upon nurs-ing knowledge. The APAM provides evidenceto support the adaptive potential of the clientwhereas the Roy model does not clearly ad-dress this issue. The impoverished state of theclient means he was unable to mobilize copingresources to contend with ongoing distressors.Specifically, Steve perceived he had depletedhis psychosocial resources and was taxing hisphysiological subsystem to contend with thesedistressors. It appears that an area where fur-ther development in nursing knowledge isneeded relates to understanding more aboutadaptive potential status which elicits infor-mation about ability to respond to stressors. Inother words, what can an individual reasona-bly do or be expected to do when contendingwith stressors?

The concurring parts of the two assessmenttechniques regarding adaptation to stress thatwere examined help to identify important do-mains of nursing science. Several interestingfindings became clear, one of which is a simi-lar propositional linkage between develop-mental level and basic need status. Further-more, nurses using these two assessment

strategies can refer to the above differencesbetween the two models to become aware of

important areas for further development ofnursing knowledge within each method.

References

Andrews, H. A., & Roy, C. (1986). Essentials of the RoyAdaptation Model. Norwalk, CT: Appleton-Century-Crofts.

Barnfather, J. S. (1987). Mobilizing coping resources re-lated to basic need status in healthy, young adults.Dissertation Abstracts. International, 49, 02-B. 0306.(University Microfilms No. AAD 88-01275)

Barnfather, J. S., Swain, M. A. P. & Erickson, H. C. (1989).Construct validity of an aspect of the coping process:Potential adaptation to stress. Issues in Mental HealthNursing. 10, 23-40.

Bowlby, J. (1981). Loss. New York: Basic Books.Brody, S. (1980). Transitional objects: Idealization of aphenomena. Psychoanalytic Quarterly, 49, 563-603.

Coombs, A., & Syngg, D. (1959). Individual behauior—Aperceptual approach to behavior. New York: Harper &Row.

Cooley, C. H. (1902). Human nature and the social order.Glencoe, IL: Free Press.

Engel, G. (1962). Anxiety and depression-withdrawal. In-ternational Journal of Psychoanalysis, 43, 82-97.

Engel, G. (1968). A life setting conductive to illness: Thegiving-up-given-up complex. Annals of Internal Medi-cine, 69, 293-300.

Epstein, S. (1973). The self-concept revisited or a theoryof a theory. American Psychologist, 28, 404-416.

Erickson, H. (1976). Identification of states of coping uti-lizing physiological and psychological data. Unpublishedmasters thesis, The University of Michigan, Ann Arbor,MI.

Erickson, H. C., & Swain, M. A. P. (1982). A model forassessing potential adaptation to stress. Research inNursing and Health, 5, 93-101.

Erickson, H. C., Tomlin, E., & Swain, M. A. P. (1988).Modeling and role-modeling: A theory and paradigmfor nursing. Lexington, SC: Est, Pine Press of Lexington.

Erikson. E. H. (1963). Childhood and society (2nd Ed.).New York: W. W. Norton.

Erikson, E. H. (1982). The cycle of life. New York: W. W.Norton.

Fawcett, J. (1984). Analysis and evaluation of concep-tual models of nursing. Philadelphia: F. A. Davis.

Fromm, E. (1956). The art of loving. New York: Harper &Row.

Galligan, A. C. (1979). Using Roy’s concept of adaptation.The American Journal of Maternal Child Nursing, 4,24-28.

Gardner, B. D. (1964). Development in early childhood.New York: Harper & Row.

Goffman, E. (1961). Encounters. Indianapolis: Bobbs-Merrill.

Havighurst, R. T. (1953). Human development and edu-cation. New York: Longmans, Green.

Lazarus, R. S. (1966). Psychological stress and the cop-ing process. New York: McGraw-Hill.

Lyon, B. & Werner, J. (1987). Stress. In J. J. Fitzpatrick &R. L. Taunton (Eds.). Annual Review of Nursing Re-search, 5, 3-22.

Mahler, M. S. (1967). On human symbosis and the vissi-