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Using the Roy Adaptation Model to Develop an Antenatal Assessment Instrument

Linda Yin King Lee, Alan Yat Kwan Tsang, Ka Fai Wong and Joseph Kok Long Lee
Nurs Sci Q 2011 24: 363
DOI: 10.1177/0894318411419209

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et al. / Antenatal Assessment InstrumentNursing Science Quarterly
NSQXXX10.1177/0894318411419209Lee

Article
Nursing Science Quarterly
24(4) 363369

Using the Roy Adaptation Model to Develop The Author(s) 2011

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an Antenatal Assessment Instrument DOI: 10.1177/0894318411419209
http://nsq.sagepub.com

Linda Yin King Lee, RN; PhD1, Alan Yat Kwan Tsang, RN; MNurs2,
Ka Fai Wong, RN; MNurs3, and Joseph Kok Long Lee, RN; PhD4

Abstract
The utility of a nursing model as a framework to understand and explain a health phenomenon is fundamental to guide nursing
practice. In this article, the authors aim to provide an examination of the Roy adaptation model as a basis for the development
of an instrument used for assessing the health needs of pregnant women. With the congruence between the concepts in the
Roy adaptation model and antenatal practice, an antenatal assessment instrument is developed. The assessment areas focus
on pregnant womens behaviors in the four adaptation modes.The current experience is valuable for nurses who are involved
in instrument development and midwifery practice.

Keywords
antenatal assessment, instrument development, pregnancy, Roy adaptation model

Health assessment is a process whereby a nurse obtains
information that delineates clients responses to health prob-
lems, thus facilitating the planning of appropriate care (Fuller
& Schaller-Ayers, 2000). This has always been part of the
nurses role. The history of nursing health assessment can be
traced back to the 1850s when Florence Nightingale per-
formed battlefield assessments for wounded soldiers during
the Crimean War (Sims, DAmico, Stiesmeyer, & Webster,
1995). To facilitate health assessment various instruments
have been developed for clinical use today. These instru-
ments serve the purpose of providing an assessment frame-
work for nurses to follow, thus enhancing care planning,
facilitating documentation, and allowing the collected data
to be communicated clearly to others, increasing the effec-
tiveness of the entire nursing team.
In Hong Kong, various antenatal assessment instruments
currently adopted by nurses share a major limitation in that
they are developed based on the medical model rather than a
nursing model. The assessment areas mainly fall into the cat-
egories of demographic background, obstetrical history, gen-
eral health history, previous illness, family health history,
and simple physical examination findings. Performing the
health assessment, which is based on a medical model, only
enables nurses to formulate diagnoses relevant to medical
aspects of care. It does not allow nurses to formulate nursing
diagnoses. In fact, antenatal nursing practice aims to pro-
mote womens adjustment to the pregnancy changes through
education, support, and assistance (Hogan, 2007). A caring
rather than curing focus is highlighted. Utilizing an antenatal
assessment instrument following a nursing model is thus
essential for nursing practice.
Antenatal nursing practice carries distinct characteristics
that make it different from other fields of nursing. Regarding
clients background, the clients receiving antenatal care are
healthy women in their childbearing age. These women
encounter anatomic and physiologic changes in their body
systems that are essential to promote fetal growth and pre-
pare for childbirth. Furthermore, these women experience
complex emotional changes that are associated with the
introduction of a new family member and taking up the role
of a mother (Fraser & Cooper, 2003; Hogan, 2007). In short,
pregnant women experience a distinctive life event, which
they need to adapt to physiologically, psychologically, and
socially over a period of about 40 weeks. Regarding the
nature of care, antenatal nursing practice aims to facilitate
pregnant womens adaptation to the changes that are associ-
ated with pregnancy. It also aims to assist the whole family
in making a healthy adaptation to pregnancy-related changes
(Ladewig, London, & Olds, 1994). Adaptation is an impor-
tant concept in antenatal care and it is also the core element
of the Roy adaptation model. Previous pregnancy-related
empirical works also adopted this model as the theoretical
framework (Fawcett, Henklein, Pollio, Tully, & Baron, 1994;
Springer, 1996). The initial analysis from these empirical
works provides preliminary support for applying the Roy
adaptation model in antenatal assessment.
By providing an overview of the major concepts and phil-
osophical assumptions, the authors explicate how the Roy
1
Associate Professor, The Open University of Hong Kong
2
Assistant Professor, The Open University of Hong Kong
3
Lecturer, The Open University of Hong Kong
4
Associate Professor, The Open University of Hong Kong

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364 Nursing Science Quarterly 24(4)
adaptation model helped to frame the development of an
antenatal assessment instrument. The discussion is followed
by an analysis of the content and evaluation of the psycho-
metric properties of the antenatal assessment instrument.
Overview of the Roy Adaptation
Model
The Roy adaptation model was first published by Roy in
1970 and is continuously updated (Barone, Roy, &
Frederickson, 2008; Roy, 2009). This model views humans
as unique beings having bio-psycho-social characteristics
and who are in constant interaction with both the internal
and external environment. The points of interaction of the
human and environment that provoke responses are known
as stimuli. These stimuli can be categorized as focal, contex-
tual, and residual. Focal stimuli are those internal or external
stimuli confronting the person most immediately. Contextual
stimuli refer to the surrounding circumstances present at the
time and may contribute to the effect of the focal stimuli.
Residual stimuli are the environmental factors that have an
undetermined effect on human behavior. The human being
may not be aware of the influence of residual stimuli, which
may not be clear to the observers either. To maintain health,
humans make adaptive responses to the changing stimuli by
using both innate and acquired mechanisms, which are bio-
logical, psychological, and social in origin (Barone et al.,
2008; Roy, 2009; Roy & Andrews, 1999).
The model suggests that all humans have certain needs
that they need to meet in order to maintain integrity. These
needs are met through the four modes of adaptation, namely,
the physiologic mode, the self-concept mode, the role func-
tion mode, and the interdependence mode (Roy, 2009; Roy
& Andrews, 1999). The goal of nursing is to promote the
clients adaptation in each of these modes. Nursing assess-
ment has two distinct levels. The first-level assessment
involves describing the clients current behavior. The sec-
ond-level assessment focuses on making tentative judgment
about whether the behavior is adaptive or ineffective, and it
involves identifying the stimuli (causes) of the behavior,
which are then classified into the focal, contextual, and
residual categories (Moreno, Duran, & Herandez, 2009; Roy
& Andrews, 1999).
Concepts in Antenatal Assessment
and the Roy Adaptation Model
Underpinned by the four meta-paradigm concepts formu-
lated by Fawcett (1995), the following is an in-depth analy-
sis comparing the concepts in antenatal practice and the Roy
adaptation model.
Concept of Person
During pregnancy, women are vulnerable to physical, psy-
chological, and social stresses, and they need to adapt
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accordingly (Beddoe & Lee, 2008; Ladewig et al., 1994).
This idea agrees with Roys proposition, which depicts the
person as a bio-psycho-social being who interacts constantly
with the changing environment (Moreno et al., 2009; Roy &
Andrews, 1999).
Concept of Environment
For a pregnant woman, environment includes the physiolog-
ical, psychological, and social changes that occur during
pregnancy (Hogan, 2007). A pregnant woman is adapting to
these changes in order to maintain health (Springer, 1996).
Likewise, Roy regarded the environment as all the condi-
tions, circumstances, and influences that surround and affect
the development and behavior of a persons adaptive sys-
tems (Barone et al., 2008). Specifically, environment can be
interpreted as internal and external stimuli that surround and
affect the development and behavior of the person (Roy,
2009; Roy & Andrews, 1999). The stimuli from the environ-
ment can be categorized into the focal, contextual, and
residual categories. In both interpretations, the multidimen-
sional nature of the environment is highlighted.
Concept of Health
With respect to pregnant women, health can be seen as a
state of having adjusted to the changes that are associated
with pregnancy (Fraser & Cooper, 2003). Some of the
changes are physiologically-oriented, such as an increase in
blood volume; a womans body deals with this by increasing
the cardiac output. Some of the changes are psychologically-
oriented, and previous experience may have an impact on
the level of adjustment. For example, the personal coping
strategies developed through previous learning can help
women to manage the stress that occurs during the antenatal
period. When the pregnant woman manages to cope with the
changes, she will experience health. Conversely, if the preg-
nant woman cannot manage to cope with the changes, she
will experience illness. Furthermore, these changes are inter-
related and have an impact on one another. For instance,
excessive weight gain, being physiological in nature, is
found to have adverse psychological implications, such as
depression and stress (Smith, Hulsey, & Goodnight, 2008).
In short, health is an integrated concept and should be
addressed holistically.
Similarly, Roy defined health as a state and a process of
being and becoming an integrated whole. A persons ability
to remain healthy relies on having sufficient energy and abil-
ity to make positive adaptation to stimuli (Roy & Andrews,
1999). When a persons coping mechanisms are ineffective,
illness will occur (Frederickson, 2000). Roy highlighted that
a persons responses to environmental stimuli are channeled
through the physiological and psychological coping mecha-
nisms, namely, the regulator and the cognator (Moreno et al.,
2009; Roy & Andrews, 1999). Consistent in both under-
standings, health is the positive adaptation to environmental
Lee et al. 365
changes. In view of the integrated nature of health, maintain-
ing health should be achieved through a variety of
mechanisms.
Concept of Nursing
A nurse, being external to the person, takes care of the preg-
nant womans physiological, psychological, social, and
spiritual needs. In antenatal practice, nursing aims to help
women adjust positively to the changes that are associated
with pregnancy, which in turn promotes maternal and fetal
health (Fraser & Cooper, 2003).
Equally, Roy stated that nursing is an external regulatory
force that works to modify stimuli affecting adaptation by
increasing, decreasing, or maintaining them. Nursing care is
holistic by being centered on the person as a whole. It
involves physical, psychological, social, and spiritual
aspects, recognizing that the entire person has particular
unique features (Roy, 2000). The main goal of nursing is to
promote adaptation in each of the four adaptive modes,
which is important to preserve the energy of the human sys-
tem and to encourage the achievement of well-being (Moreno
et al., 2009). Through the use of the nursing process, nurses
enter the client system and manage the stimuli for promoting
adaptation. Nursing assessments focus on identifying the
ineffective behavior and the corresponding stimuli. Planning
serves to sketch out the necessary interventions. The imple-
mentation of the nursing interventions aims to change or
modify the stimuli that precipitate ineffective behavior and
broaden the clients coping ability. Finally, evaluation
focuses on judging the effectiveness of nursing interventions
in relation to promoting clients adaptation (Frederickson,
2000; Moreno et al., 2009). Whereas nursing assessment
serves to identify the stimuli affecting adaptation, nursing
interventions act as a powerful force for managing the stim-
uli to promote adaptation. Clearly, the concept of enabling
clients adaptation is emphasized in both antenatal nursing
practice and the Roy adaptation model.
It can be concluded that antenatal practice carries distinct
characteristics, making it particularly relevant to the proposi-
tions underpinning the Roy adaptation model. Therefore,
using the Roy adaptation model to guide the development of
the antenatal assessment instrument is justified.
The Antenatal Assessment
Instrument Framed by the Roy
Adaptation Model
The antenatal assessment instrument (Figure 1) adopts
the Roy adaptation model as its theoretical framework.
Its content is formulated through literature reviews and
clinical consultations. The instrument has two sections.
Section A focuses on assessing the antenatal womans
general characteristics and section B addresses the womans
behaviors in each of the four adaptive modes.
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Assessment of the General Characteristics
Section A of the instrument collects a womans socio-demo-
graphic data, obstetrical history, previous health history, fam-
ily health history, and menstrual history. Each set of
information imposes implications for nursing practice.
Acknowledging womens socio-demographic backgrounds
enables nurses to have a general understanding of the clients.
In fact, womens socio-demographic characteristics are found
to have an impact on their perception of antenatal care quality
(Oladapo & Osiberu, 2009) and obstetrical outcome (Nair,
Rao, Chandrashekar, Acharya, & Bhat, 2000). Understanding
a womans obstetrical history can predict or even prevent pos-
sible maternal and fetal complications. Recording womens
past and present medical problems is significant because dis-
eases, such as hypertension, diabetes mellitus, or other endo-
crine disorders, place the pregnant woman at greater risk
(Fraser & Cooper, 2003). Assessing a womans and her hus-
bands family health history can predict the occurrence of
family-related conditions such as multiple pregnancy and
congenital problems. Early identification and referral can thus
be made. Lastly, collecting information about a womans
menstrual history is significant for estimating the babys
maturity and the expected date of confinement.
Section B of the instrument directs nurses to assess a wom-
ans behavior in each of Roys adaptive modes. The assess-
ment items are presented in four sections, each one representing
one of the adaptive modes. For each there is a column labeled
Behavior, which records the data obtained during the first-
level assessment, wherein the nurse makes a tentative judg-
ment to determine the womans behavior as adaptive or
ineffective. There is another column labeled Stimuli, which
records the data obtained during the second-level assessment.
At this stage, the nurse performs an assessment on those inef-
fective behaviors. Stimuli are then identified and categorized
into the focal, contextual, or residual type.
Assessment of the Physiologic Mode
The physiologic mode of adaptation emphasizes the mainte-
nance of the physiologic integrity of the person (Roy, 2009).
During pregnancy, a number of physiological changes, such
as growth in uterine size, increased cardiac output, decreased
bowel motility, and alteration in endocrine levels, occur
gradually. Although physiological changes are expected,
ineffective behaviors indicating unsuccessful adaptation
may occur and should be addressed. During the assessment,
a womans responses to changes in a number of aspects are
assessed. These aspects are oxygenation, nutrition, elimina-
tion, activity and rest, protection (regulation), senses, fluid,
electrolyte and acid-base balance, neurologic function, and
endocrine function (Hanna & Roy, 2001; Roy & Andrews,
1999). According to Roy, these nine components form the
basis of nursing assessment of the physiologic mode of an
individual. They are the components that have to be met in
order to maintain physiologic integrity (Roy, 2009).
366 Nursing Science Quarterly 24(4)

Antenatal Assessment Instrument

Section A: General Information
Socio-demographic information:
Name
Age
Marital status: Single / Married / Widow / Divorced
Address
Telephone number
Education level
Ethnicity
Religion
Language
Occupation
Husbands name
Husbands age
Husbands education level
Husbands occupation
Total Family Income

Obstetrical history:

Previous health history:

Family health history:

Menstrual history:

Section B: Four Adaptive Modes

Physiologic-Physical Mode Behavior Stimuli

Focal Contextual Residual
1. Oxygenation
- breathing pattern
- hemoglobin level
2. Nutrition
- diet and fluid intake
- episode of nausea and vomiting
- dental health and state of gum
3. Elimination
- bowel elimination pattern
- urinary elimination pattern
4. Activity and rest
- pattern of activity and rest
- activity tolerance level
- posture and gait
5. Protection (Regulation)
- blood pressure
- pulse
- heart rate
- temperature
6. Senses
- unusual sensation
7. Fluid, electrolyte and acid-base balance
- edema
- varicosities
8. Neurologic function
- pain and discomfort
9. Endocrine function
- blood glucose level
- skin pigmentation

Self-Concept-Group Identity Mode Behavior Stimuli

Focal Contextual Residual
1. Physical self
- personal feelings about changes in
physical appearance
- aspects of appearance liked / disliked
most
- social and cultural perception about the
changes in physical appearance of a
pregnant woman
2. Personal self
- personal feelings towards oneself as a
mother
- social and cultural expectation of the
performance of a pregnant woman

Role Function Mode Behavior Stimuli

Focal Contextual Residual
1. Primary
2. Secondary
3. Tertiary

Interdependence Mode Behavior Stimuli

Focal Contextual Residual
1. Relationship with husband
2. Relationship with child / children
3. Relationship with other family members
4. Relationship with neighbors
5. Relationship with the unborn baby

Date of assessment:
Assessors name:
Assessors signature:

Figure 1. The Antenatal Assessment Instrument.

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Lee et al. 367
Moreover, a comprehensive physiological assessment is,
indeed, necessary as pregnancy-related physiological
changes happen in almost all the body systems. In the
assessment instrument, the items under the nine physiologi-
cal needs represent the major and common areas of physio-
logical change that are associated with pregnancy.
Assessment of the Self-concept Mode
The self-concept mode of adaptation addresses psychologi-
cal and spiritual integrity, and focuses on the way one per-
ceives ones body and oneself (Moreno et al., 2009). The
assessment of the self-concept mode can be further divided
into the physical self-assessment and the personal self-
assessment. Physical self is concerned with how people
actually perceive themselves with regard to their appearance
and body image (Hanna & Roy, 2001). During pregnancy,
changes in physical appearance are especially obvious when
the body figure gradually decreases and skin pigmentation
progressively increases. More importantly, how a woman
perceives her physical appearance during pregnancy can be
related to her own attitude toward the pregnancy. To a
woman, an expanding abdomen can be a source of pride in
a planned pregnancy but an object of shame in an unplanned
pregnancy. Therefore, a womans feelings about the changes
in her physical appearance and the aspect that she refers to
as most liked or disliked should be assessed. A womans
perception can also be influenced by social and cultural fac-
tors. For example, womens attitude toward maternal obesity
is significantly influenced by todays social pressure to
remain thin (Smith et al., 2008). Therefore, the womans
perceived social and cultural interpretations about the
changes in physical appearance during pregnancy should
also be explored.
Personal self is concerned with the consistency of per-
sonal standards and behaviors, ideals, and moral-ethical
issues (Roy, 2009). Pregnancy is a process of changes in the
womans self in preparation for a new level of responsibility.
An important developmental task during this stage is the
development of maternal representations of the self as a
mother (Hart & McMahon, 2006). In this regard, a pregnant
woman is in a stage of re-assessment and re-development of
self-image, behavior patterns, beliefs, values, and problem-
solving skills, which are particularly related to motherhood
and childbearing. To have successful adaptation, a pregnant
woman needs to develop the personal self as a mother. The
womans feelings toward her personal self, as well as her
perceived social and cultural expectations on her personal
self, should be assessed.
Assessment of the Role Function Mode
The role function mode of adaptation deals with social integ-
rity by focusing on the performance of activities associated
with the various roles (Hanna & Roy, 2001). Roy described
role as the title given to the individual and the behaviors that
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society expects the individual to perform in order to main-
tain the title (Roy & Andrews, 1999). An individual can have
three different types of roles. Primary roles refer to rela-
tively consistent pre-determined roles such as being a
woman. Secondary roles are relatively permanent in nature,
but they may be chosen by the individual and are usually
linked with stages in life. Wife and mother are some of the
examples. Lastly, tertiary roles are usually temporary, freely
chosen, and relatively minor in nature such as being a par-
ticipant in a childbirth education class. During pregnancy, a
woman experiences a sudden change in her secondary role
because she is becoming a mother. As the inability to master
a role or conflict between different roles frequently causes
problems in the individual (Roy & Andrews, 1999), it is
necessary to assess womens roles comprehensively in order
to have a better understanding of their health needs.
Assessment of the Interdependence Mode
The interdependence mode of adaptation also deals with
social integrity but with particular concern for the way in
which one gives and receives social support. Roy viewed
interdependence as the balance between dependence on oth-
ers and independence in achieving things for oneself. An
individual needs to maintain a close relationship with others
to satisfy needs for affection, development, and resources to
achieve relational integrity (Hanna & Roy, 2001). During
pregnancy a woman reorders her relationships with her sig-
nificant others to prepare them for welcoming the newly
born baby. At the same time, she needs the support from her
significant others to adjust and adapt to the various preg-
nancy-related changes. Independence from and dependence
on others during pregnancy are highlighted. To perform an
interdependence assessment, the womans relationship with
the people with whom she is in constant and close contact
with are also assessed. These people generally include the
husband, children, other family members, neighbors, and the
unborn baby. The relationship with the husband is particu-
larly important because a poor marital relationship is found
to be associated with psychological problems during preg-
nancy (Mchichi, Kadri, & Berrada, 2006). The relationship
with the unborn baby is usually an overlooked but essential
aspect. In fact, the establishment of mother-baby relation-
ship commences well before birth. If the baby is intended,
most likely, the woman will face the pregnancy in a positive
way. If the baby is unintended, the woman will most likely
experience adverse psychological consequences because the
pregnancy is likely to become a stressful life event (Mchichi
et al., 2006).
Evaluation of the Psychometric
Properties of the Instrument
The evaluation of content validity of the antenatal assess-
ment instrument was based on experts feedback. An expert
panel of two academics and three clinical midwives were
368 Nursing Science Quarterly 24(4)
invited to rate the appropriateness of the content of the
assessment instrument in relation to antenatal assessment
using a four-point Likert scale with choices of: 1 (not rele-
vant), 2 (unable to assess relevance without item revision or
item is in need of such revision that it would no longer be
relevant), 3 (relevant but needs minor alteration), and 4
(very relevant and succinct). The content validity index was
calculated based on the percentage of items that were rated
as relevant by the panel members. The index was reported as
0.82, indicating high content validity (Lynn, 1985).
The evaluation of face validity of the antenatal assess-
ment instrument was performed by undertaking a brief trial
to ascertain whether the clinical midwives accepted the
instrument, found it relevant in routine daily practice, and
would continue to use it after the trial. It is indispensable to
establish the face validity of the instrument because this
groundwork ensures that the instrument is acceptable to
those who will administer it (Polit & Beck, 2008). Five clini-
cal nurses who had knowledge of the Roy adaptation model
were invited to participate in testing the face validity.
Instruction was provided to the participants, and they were
taught how to use the instrument to perform the antenatal
assessment. During the first trial, the participants were unfa-
miliar with the terms in the Roy adaptation model. After sev-
eral trials, the participants became accustomed to the
wordings and the format of the instrument. They indicated
that the instrument was helpful for guiding antenatal assess-
ment, as it could help them perform more in-depth assess-
ments, collect information systematically, and formulate an
effective care plan. Because testing for validity, reliability,
and clinical applicability is a process that takes time, further
systematic evaluation of psychometric properties of the ante-
natal assessment instrument will take place accordingly.
Conclusion
Health assessment plays an important role in nursing prac-
tice. It is the initial and vital step in the nursing process.
Accurate and comprehensive health assessment enables the
formulation of an appropriate nursing care plan that can
contribute to promoting clients health. To achieve this
aim, the use of an assessment tool that is grounded in a
nursing model is indeed significant. Although pregnancy is
basically physiological in nature, it frequently carries psy-
chological and social implications for the pregnant woman
and her family. The Roy adaptation model, with a sturdy
knowledge structure, supports the nursing process and
nursing practice related to holistic and human adaptation
(Hanna, 2006). This model is considered appropriate to
guide antenatal practice.
The authors discussed the development of an antenatal
assessment instrument using the Roy adaptation model as the
theoretical framework. The use of the four metaparadigm
concepts as a reference of analysis allows the analysis to be
performed with a theoretical orientation. From the current
experience, such approach is proven to be effective. The
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instrument assesses clients four modes of adaptation, and
the assessment is unquestionably significant because it helps
nurses identify clients ineffective behaviors and explore
stimuli accordingly. Furthermore, the broad nature of the
Roy adaptation model allows the examination of the inter-
related health needs of pregnant women from an integrated
and holistic nursing perspective. The use of an antenatal
assessment instrument that is grounded in the Roy adaptation
model can be considered as theoretically-based and has
much relevance for the antenatal nursing practice. The pres-
ent experience shows how nurses develop nursing model-
based health assessment tools in the future.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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