419218 zak / Research IssuesNursing Science Quarterly

NSQXXX10.1177/0894318411419218Florc

Research Issues

Research Based on the Roy Adaptation
Model: Last 25 Years

Nursing Science Quarterly
24(4) 312­–320
© The Author(s) 2011
Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318411419218 http://nsq.sagepub.com Callista Roy, PhD; RN; FAAN1

Abstract
Two key events lead to the prominence of links among Roy’s grand theory, derived middle-range theories and the design of research. The author in this column describes this work in two formats. Essential details of two areas of research are presented in episodic form—the first is work on secondary analysis of Roy model-based research over 40 years and the author’s study of persons’ cognitive recovery from mild head injury.The second is a project on re-conceptualizing coping and adaptation processing in sequential detail within the context of work in the field and the significance of on-going work for nursing practice.
Keywords
adaptation, coping, middle-range theory, research, Roy adaptation model

The story of research based on the Roy adaptation model
(RAM) can be told in many ways. When asked to write about research based on the RAM in the past 25 years I considered the major events of those years and also how to organize a description of the resulting research. First, I considered that it was 20 years ago that the first group presented a synthesis and critique of studies based on the RAM by five different investigators (Pollock et al., 1991). This was the beginning of the Roy Adaptation Association (RAA) currently with five international chapters. It was the beginning of an on-going project to analyze, critique, and synthesize all published studies in English based on the RAM. Secondly, doing 4 years of full-time clinical research in neuroscience nursing, beginning with post doctoral work as a Robert Wood Johnson Clinical Nurse Scholar in 1983 at the University of California at San Francisco, provided the opportunity to focus my research on the cognator as a major element of the RAM.
In this column I present an overview of the major RAMbased research derived from these key events. Two different styles were selected to present the significant research of this timeframe. Synopsis of 25 Years of Roy ModelBased Research
The overall view of RAM-based research in Figure 1 depicts how major theoretical concepts (in rectangles) from a grand theory, guide middle-range theory development (in ovals) from which research projects (in squares) are designed. The theory of the cognator initially was described as part of the theory of the person as an adaptive system (Roy & McLeod,

1981). In explicating the cognator subsystem I had identified pathways for perceptual/information processing, learning, judgment, and emotion. This work was significantly refined by post doctoral studies in neuroscience nursing (Roy, 1988,
2001). The middle-range theory of cognitive processing
(Figure 2) was developed to show the major processes involved in the input, central, and output phases of cognitive processing. These processes were embedded in another major concept of the model, the environment. The environment includes focal stimuli as immediate sensory experience and contextual and residual stimuli involving education and experience. Early work on the RAM (Roy, 1976) also identified the major theoretical concept of coping in four adaptive modes.
These modes represent the categories whereby the nurse assesses behaviors that persons use to deal with their internal and external environments. The behaviors are viewed as stemming from the central processes of persons, the cognator and regulator. The modes were named from a content analysis of 500 samples of patient behavior collected by student nurses. The categories physiologic, self concept, role function, and interdependence have remained useful through the years for education, practice, and research (Roy, 2009).
The theory of coping in the adaptive modes was combined
1

Professor and Nurse Theorist, Boston College

Contributing Editor:
Kristine L. Florczak, RN, PhD, Associate Professor, Saint Xavier University,
7807 Janes Avenue, Woodridge, Illinois, 60517
Email: Florczak@sxu.edu

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

313

Roy

Theory of Cognator of Roy Adaptation Model

Middle-Range
Theory of Cognitive
Processing

Integrated Review of RAA Research and Testing of
Propositions
(BBARNS, 1999; Roy et al.,2005)

Theory of Coping in the Four Adaptive Modes

Middle-Range Theory Coping and Adaptation Processing

Cognitive
Recovery from
Mild Head Injury
(Roy, 2011)

Coping and
Adaptation
Processing
Instrument
Development

The Coping and
Adaptation Processing
Scale (CAPS):
Exploring Issues of State and Trait (Chayaput &
Roy, 2007)

The relationship between coping strategies and the impaired ADL in elderly stroke patients : The first report of CAPS in Japanese
(Toriya & Tsuhako,2008)

Effectiveness of an educational program focus on cognitive processing to modify the capacity of coping and adaptation processing(Gonzalez, 2007)

Coping capacity and adaptations in older adults
(Gutierrez, 2009)

Figure 1. Roy adaptation model research synthesis.

Note. RAA = Roy Adaptation Association, BBARNS = Boston-Based Adaptation Research in Nursing Society

with the middle-range theory of cognitive processing and empirical work, as described below, resulting in a middlerange theory of coping and adaptation processing.
This theoretical work was used to derive the major research projects reported here and named in Figure 1 within the squares. To handle the challenge of presenting this array of work in one column I turned to an image of two kinds of clocks (Carroll, 2011). The analogue clock has a numerically defined face and pointed hands that mark seconds, minutes, and hours by an endless succession of circles in motion with a context and a dynamic sequence. The digital clock, however generally shows only hours and minutes with the numbers remaining static until a shift occurs. The kind of time on this clock is episodic rather than continuous. Based on this image of time, I decided to present an episodic digital picture of two major research projects. Firstly, a secondary analysis research project used the 360 studies in an integrated review of Roy model-based research to test propositions derived

directly from the major theoretical concepts of the model. The rationale for this approach to this project is that it is the work of teams, the executive board of the RAA, all the investigators who published their research, and the student research fellows who have assisted us. Still, it provides clear and rich information on research based on the model from 1970 to the present and how the review has been used to develop knowledge for nursing. Secondly, one of the major foci of the middle-range theory of cognitive processing involved the design and testing of interventions for cognitive recovery of people with mild head injuries (Roy, 2010, 2011). This work calls for the essentials episodic approach because it is a recently completed comparative intervention study that was presented nationally as a paper (Roy, 2010) and locally (Roy, 2011) with two publications in preparation.
Another major focus of my research over these years lends itself to a presentation more like the analogue clock, that is, the dynamic process and context of the sequential

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

314

Nursing Science Quarterly 24(4)

Background: General Literature on Coping

Figure 2. Middle-range theory of cognitive processing.

stages. This involved a re-conceptualization of coping to develop a measurement tool based on the concept of coping and adaptation processing and to derive additional research projects. Coping and Adaptation Processing
Theory and Research Development in General Literature
Coping is recognized as the crucial variable in understanding the effect of stress on physical and mental health
(Aldwin, 2007). Based on the significant function of coping, healthcare clinicians often aim to promote coping abilities of patients and their families. Yet in spite of significant theoretical and research literature in many fields, knowledge effective in practice has remained elusive. Two approaches identified as showing the greatest promise were multidimensional (Frydenberg, 2002) and transactional processes
(Aldwin, 2007). The Roy adaptive modes and an in-depth understanding of cognator processing, representing both cognition and emotion, provided a basis for studying coping as a multidimensional and transactional process to add to knowledge for nursing practice. The revised conceptualization of coping, derived theory development, and inductive and deductive empirical strategies were the basis for developing, a middle-range theory, a new instrument, and intervention. Early work on coping tended to look at psychopathology.
Further cognitive and physiologic concepts and variables were used with little attention given to emotion. Through the decades of the 1980s and 1990s scholars continued to refine conceptualizations and measurement of stress and coping. In the 1990s there was a shift toward positive psychology and the positive role of emotions, crystallized by Seligman as president of the American Psychological Association (Snyder,
1999). Lazarus is credited with the shift from coping, viewed as a response to emotion, to coping and emotion understood in a dynamic relationship (Lazarus, 1991,1999). In the 1990s, issues in the field were identified as measurement styles versus processes (Aldwin, 1994); trying not entirely successfully to examine both the person and environment (Schwarzer &
Schwarzer, 1996); the need to balance deductive and inductive approaches to provide a theoretical base for scale items, and to have a closer match between concept and measurement
(Schwarzer & Schwarzer, 1996).
In 2007 Aldwin updated an earlier review to handle the burgeoning general literature that added 186,000 articles on stress and 37,000 articles on coping in the intervening years.
Aldwin addressed the on-going issues of conceptualizations and measurements. She divided the theoretical approaches that are person-based into three schools, that is, psychoanalytic, personality trait, and perceptual styles. Those who focused on situational determinants of coping noted that the types of strategies that individuals use in coping with problems depend on environmental demands, or the pull for different types of solutions. Aldwin further noted that cognitive approaches assumed: that individual coping is largely dependent upon appraisal of the situation; that individuals are flexible and coping strategies have some degree of situational specificity; that both problem-solving and emotion-focused strategies are used in coping efforts; and, that there is not necessarily a hierarchy of adaptation. The author’s analysis showed that a majority of coping researchers have adopted at least some aspects of the cognitive approach. However, many continued to regard the use of coping strategies primarily as a function of personality. Aldwin (2007) concluded that the extent to which coping strategies are a function of both the person and the environment is a matter of some debate and that “coping affects adaptation in extremely complicated ways” (p. 126). The issue of state versus trait was not yet settled.
In dealing with measurement, Aldwin (2007) stated that this is still the most controversial issue in the field.
Laboratory, paper and pencil tests, and qualitative research are all used. The person versus environment conceptualizations may be at odds or creative strategies are used to combine both. One way that researchers have addressed this problem is to develop coping scales that are specialized by

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

315

Roy situations or the strategies measured. Aldwin reported that in
1987 she identified over 20 coping scales; in 1994 the list was updated to 70; and in 2007 there were 200 references to coping scales. She identified increases in scales in languages other than English, those for children and adolescents, and those with highly specialized strategies. In a list of coping scales for clinical health situations, Aldwin included, for example, coping with asthma in everyday life.
Nursing research on coping has drawn extensively from the literature in psychology, notably Johnson's (1972) seminal work used in the conceptualization developed by Lazarus and associates (Lazarus & Folkman, 1984). Johnson and her colleagues studied individuals' levels of distress when they were given sensory information before threatening events in both clinical and laboratory situations. Later intervention studies (Johnson, Rice, Fuller, & Endress, 1978) made use of
Lazarus' distinction between problem-solving coping and emotion-focused stress related coping. Even this early work began to call this dichotomy into question. Johnson and colleagues found that teaching problem-solving coping was not more effective for recovery from surgery. They suggested that the most useful nursing intervention might be to support and teach effective use of the patient's own coping strategies, and that these strategies might incorporate elements of both the problem-solving and emotion-focused approaches.
Later Jalowiec (1993) reviewed a decade of stress and coping research in nursing and reported that 70 percent of nursing studies used Lazarus’ model. She specifically questioned whether or not nurse researchers were losing discrimination in measurement and in differentiation of outcomes by relying on the distinction between problem or emotion coping and not tapping into the rich cognitive and behavioral domains of coping. The persistent wide use of Lazarus’ conceptualization and instrument is reflected in a review of the Cumulative Index to
Nursing and Allied Health Literature (1998 to 2004) databases that showed 151 studies reported use of the questionnaire during those years. When the same search was repeated by this author the number of studies reported using Lazarus from
2005 to 2010 was 25. In some of these studies the instrument did not perform as predicted, for example, only one coping subscale was found to partially mediate the relationship between levels of stress and well-being in mothers of preschool children with asthma (Sangsuwan, 2006). The lack of evidence of cumulative knowledge in the nursing literature is notable. The Ways of Coping Questionnaire by Lazarus and associates has been referred to as the standard in the field.
However, a number of authors, as reported by Aldwin (2007) noted the construct validity of the instrument was not strong, given an unstable factor structure.
Later Folkman and Moskowitz (2004) reviewed 35 years of coping research across social and behavioral science, medicine, public health, and nursing and concluded that “we seem only to have scratched the surface of understanding the ways in which coping actually affects psychological, physiological, and behavioral outcomes both in the short-and the

longer-term” (p. 748). Further, these authors identified three issues they found reflected in the literature, that is, measurement, nomenclature, and the determination of effectiveness.
The authors highlighted that continuing interest in coping research is not only that it is an explanatory concept related to how people differ in response to stress, but it is also has potential as a basis for interventions.
Based on this state of the knowledge on coping and the identified issues, it was proposed that efforts to improve on conceptualization and measurement can focus on deriving a new multidimensional and transactional conceptualization.
The revised conceptualization and resulting research was based on the theory of coping in four adaptive modes and the middle-range theory of cognator processes of adaptation, using inductive and deductive approaches, within the situational context of health and illness. The purpose of this work was to contribute to the efforts of other disciplines to understand and measure this significant phenomenon. The aims were to develop knowledge needed to advance coping assessment, interventions, and outcomes in nursing research and practice.

Methods for Concept and Scale
Development
A sequential approach to inductive and deductive theoretical work was used to derive the middle-range theory of coping and adaptation processing that addressed the multidimensional and transactional nature of the construct of coping.
Observations and interviews in a number of clinical settings were used to develop categories within the theory. The principles of coding for parsimony, completeness, consistency in the level of abstraction and language, and authenticity relative to the middle-range nursing theory were used to organize the clinical data. The resulting items were arranged in a scaled instrument that was subjected to initial psychometric testing.

Theoretical Basis for Revised
Conceptualization of Coping
As noted in Figure 1 The theory of coping in four modes was synthesized with the middle-range theory of cognitive processing to derive a middle-range theory of coping and adaptation processing that reflects both multidimensionality and transaction (see Figure 3). The left side of the figure provides multidimensionality of the four adaptive modes and the right side depicts the three types of cognitive processing in transaction with the environment.

Scale Development based on Coping and
Adaptation Processing Conceptualization
The inadequate fit of current measurement tools for some clinical situations that nurses deal with has been noted. The next step was inductive and deductive empirical work based

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

316

Nursing Science Quarterly 24(4)

COGNATOR

Manifested in

Subsystem of the
Roy Adaptation
Model

ADAPTIVE
MODES
Physiologic
Self Concept

Uses
INFORMATION
PROCESSING

Inferred
ObservedCoping
CognitiveStrategies
Behaviors

Role Function

Input
Central
Output

Interdependence
Synthesized
Coping and
Adaptation Processing

Figure 3. Middle-range theory of coping and adaptation processing. on the middle-range theory to generate items for the Coping and Adaptation Processing Scale (CAPS) instrument and to do initial refinement and testing of the scale. The samples for each step of the project are summarized in Table 1. Since the cognator subsystem of the RAM is manifested by behavior in each of four adaptive modes, in an earlier project Roy
(1975) aimed to identify coping strategies of hospitalized patients. She conducted 10 patient interviews (step 1) and collected 36 recorded nursing care plans based on the RAM
(step 2). Content analysis was used on both data sets to inductively infer coping strategies within the adaptive modes. Forty-five discrete coping strategies were identified by the principle investigator using the principles for coding.
For example, an inferred coping strategy within the self concept mode was: differential focus on the good. The data from which this was derived was a patient who was asked how he was handling facing a diagnostic test and stated, “I felt it was necessary. I want to get it done. I want to find out what’s wrong.”
The inferred strategies were reviewed by two volunteer experts who were recruited because of their extensive work in both nursing theory and coping research. The review identified a) differing levels of generality of the items, and b) the need for another approach to organize the implied multidimensionality, as well as to emphasize the process of transaction with the environment. As a result, the nursing model of cognitive processing was used to deductively identify 26 categories within the three types of transaction with the environment (input, central, and output cognitive processing).
Roy (1988, 2001) has discussed the deductive categories and provided examples of behaviors in each category observed in clinical experience in neuroscience nursing practice. For example, the broad dimension of input processes included the conceptual strategies of arousal and attention. These strategies further had a subcategory of selective attention

that is useful for behavioral observations such as whether a person has focused attention or is distracted.
The categories derived inductively from the patient interviews and nursing care plans were compared with those from deductive categories and patient observations. It was noted that the inferred coping strategies and the behavioral observations within cognitive processing categories were related.
For example, differential focus on the good, inferred from a patient statement, was seen as a form of selective attention within the input level of the cognitive processing transaction with the patient environment. The original items from the inductive classification system were combined with the deductively derived categories of cognitive processing and their behavioral examples. The result was 73 statements in an item pool. Four experts were recruited to review the items, two with expertise in coping and adaptation theory and two with expertise in cognitive processes. Through independent judgments followed by discussion, 100% agreement on the relevance of the items to the proposed alternative coping and adaptation processing construct was reached.

Definition of Terms
Key terms based on the theoretical and empirical work by Roy
(1976, 1988, 2001) were defined as follows. Adaptation is the process and outcome whereby thinking and feeling persons use conscious awareness and choice to create human and environmental integration. Coping strategies are behaviors whereby adaptation processing is carried out in daily situations and in critical periods; the categories are synthesized from behaviors in four adaptive modes, physiologic, self concept, role, and interdependence. Adaptation processing is patterning of coping behaviors that take in, handle, and respond to stressors and are directed toward survival, growth, reproduction, mastery, and transcendence. Coping and adaptation processing is the patterning of innate and acquired ways of taking in, handling, and responding to a changing environment in daily situations and in critical periods that direct behavior toward survival, growth, reproduction, mastery, and transcendence. Capacity of coping and adaptation processing is the ability of persons based to respond to changes in the environment that use their coping styles and strategies to adapt effectively to challenges (Gonzalez, 2007).
The revised conceptual and behavioral understanding of coping and adaptation processing is both person and environment based; includes process, multidimensionality, and transaction. Further, it can be relevant for designing and testing interventions related to the study of people and their health. Scale Development and Testing
The middle-range theory and the related empirical work provided a pool of items for development of a coping and adaptation processing scale. A scaled instrument is most

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

317

Roy
Table 1. Description of Samples Used in Scale Development and Testing
Step
1
2
3
4

Description (n)

Men

Women

Mean Age (Range) in Years

Patients hospitalized on medical unit, half scheduled for diagnostic testing, half hospitalized more than one day (N = 10)
Nursing care plans of adult medical surgical patients recorded by student nurses using the Roy adaptation model, from 10 schools in United States and Canada (N = 36)
National mailing list of Spinal Cord Injury Association (N = 243)
National mailing list of Acoustic Neuroma Association (N = 104)

3

7

54 (33-78)

16

20

58 (23-83)

161
35

82
69

42 (18-80)
56 (27-77)

useful for research on interventions and outcomes of nursing practice. In his classic work, Likert (1932) recommended preparing and selecting more statements than are likely to be used in the final instrument. He noted that it is not important what the extremes of the continuum are called. The important fact is that persons do differ in the attribute under consideration, some being more toward one extreme and some more toward the other. However, later investigators found that instructions to the respondents on coping questionnaires are crucial and consistent context is important (Aldwin,
1994). In the development of the Coping and Adaptation
Processing Scale (CAPS), the instructions were carefully worded to evoke responses to the experience of a crisis, or extremely difficult event. Although perceptions and interpretations of respondents will vary, the instructions place some boundary on the possibilities of stimulus events. It was anticipated that such measurement would capture individual variability in coping that may be amenable to intervention and could change over time.
The multidimensional and transactional construct of coping and adaptation processing was identified within a middle-range theory. Because of the theoretical approach used to develop the items, there was reason to believe that the 73 items relate to the revised construct. In early testing of the instrument, 26 items were dropped by removing redundant items, that is, those that seemed to be saying the same thing.
Also, after exploratory factor analysis some items were dropped as described below.
The CAPS is a 47-item Likert scale with response choices ranging from 4 (always) to 1 (never). Each item of the CAPS is a short statement about how an individual responds to experiencing a crisis or extremely difficult event. Twelve items are reversed scored. The possible range of scores is from 47 to 188 with a high score indicating a more consistent use of the identified strategies of coping.
The psychometric analysis was conducted using a pooled sample from two groups who responded to the CAPS scale
(see Table 1, steps 3 and 4). These were nonprobability purposive samples from patient support groups obtained from two national mailing lists using proportional representation by region. Approval for each survey was obtained from the

university human research review committee. In the step 3 group, the CAPS tool was part of a mailed survey questionnaire to 1,000 members of the Spinal Cord Injury Association, living with the effects of spinal cord injury. The response rate was 29% (N = 243). The step 4 group had a 52% response rate obtained from 200 questionnaires mailed to members of the Acoustic Neuroma Association (N = 104). These were persons who had treatment for benign tumors at the base of the skull and were living with the effects of damage to one or more cranial nerves and/or the cerebellum.
The socioeconomic status of the subjects varied widely, with occupations ranging from administrator to unemployed and years of education ranging from 8 to 21 years. Fiftythree subjects (11%) had finished eighth grade, 186 (39%) finished high school and the remaining 50% had at least some college education. Racial variation was more limited with White being the predominant identifier. The total number of valid cases was 349. This number was considered adequate since the common rule used is to have 5 to 10 times the number of items. T-tests were run to confirm that the groups did not differ and the scores could be combined for further analysis.
Psychometric evaluation of the CAPS involved addressing issues of validity and reliability. The content validity of this instrument is based on the procedure used for the development of the scale. The theorist of the RAM has been the principle investigator of the work since its inception and experts were used at two stages to validate coding, thus including both expert and face validity. The exploratory factor analysis reflected the construct validity of the CAPS.
An exploratory factor analysis was necessary because theoretically the major dimensions had not been identified and because of the special issues related to multidimensionality and transaction. The Statistical Package for the Social
Sciences (SPSS) Version 11 (Norusis, 2002) was used to extract the factors of the CAPS using principle component
(PC) analysis with varimax rotation. Eigenvalues of 1 or greater and factor loadings equal to or larger than .30 were considered to have conceptual interpretability. Five factors emerged with factor loadings ranging from a high of .71 to a low of .31. Cronbach alpha coefficients ranged from .86 on

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

318

Nursing Science Quarterly 24(4)

Factor 2 to .78 on Factor 4. Each factor contained a set of items that lent themselves to conceptual interpretation according to the middle-range theory of coping and adaptation processing. The items were labeled with the adaptive modes involved and the type of cognitive processing represented. This was a way of linking the theory to the measurement and was helpful in interpreting factors.
The five factors were extracted in five iterations and identified on the scree plot where a sharp decline in the explained variance occurred (Polit & Beck, 2010). Factor 1, resourceful and focused, contains 10 items with factor loadings ranging from .71 to .49 and explained 26.6% of the variance.
Factor 2, physical and fixed, with 14 items having factor loadings from .72 to .43 explained 8.4 % of the variance.
Factor 3, alert processing, has 9 items with loadings from .61 to .49 explaining 3.8 % of the variance. Factor 4, named systematic processing, contains 6 items with loadings from .71 to .31 and explained 3.3% of the variance. Finally, Factor 5, knowing and relating, had 8 items whose loadings ranged from .63 to .31 and explained 3.2% of the variance.
Predictive validity was demonstrated in a study of elders with hearing impairment living in the community when the total scores on the CAPS scale explained 42% of the variance of self- consistency (Zhan, 2000). Convergent validity is a special case in the testing of this new instrument. The aim of this work was to re-conceptualize coping within a multidimensional and transactional framework and to develop a tool to measure the concept that addressed previous issues in the field. Thus, it is not anticipated that convergent validity would be demonstrated by a high correlation of the CAPS with any existing measurement scale. However, it was assumed that there would be some degree of shared conceptual space between the new instrument and tools in the field. To demonstrate this assumption, the Ways of Coping Questionnaire
(WCQ) (Folkman & Lazarus, 1988) was administered to both groups in the samples 3 and 4 (N = 347) along with the CAPS.
Pearson’s correlation with a 2-tailed test of significance between the WCQ and the CAPS was performed, as well as with each subscale of both instruments.
Findings indicated that there was only a low correlation between the total scale scores on the two measures with this sample. However, in looking at the correlations among the subscales, some statistically significant correlations of interest were identified. The CAPS subscale of resourceful and focused correlated negatively with the WCQ escapeavoidance scale, and positively with the positive reappraisal and planful problem solving scales. The CAPS subscale of physical and fixed, which is scored negatively in its contribution to overall coping and adaptation processing, correlated negatively with five scales from the WCQ
(escape-avoidance, seeking social support, confrontive coping, self controlling, and accepting responsibility). The third
CAPS subscale, alert processing, correlated negatively with the WCQ escape-avoidance scale and positively with planful problem solving. The systematic processing subscale

from the CAPS, as with the first subscale, correlated negatively with the WCQ escape-avoidance scale and positively with the positive reappraisal and planful problem solving scales. Likewise, the CAPS subscale of knowing and relating correlated negatively with the WCQ escape-avoidance scale and positively with the positive reappraisal and planful problem solving scales.
Two approaches to reliability lent credence to the ability of the CAPS to consistently measure the construct of interest. The Cronbach’s alpha coefficient for the total CAPS was calculated at .94. This indicated the desired internal consistency of the items, yet reflected that fine discriminations in levels of the construct could be made (Burns & Grove, 2009).
Further the Spearman-Brown split-half reliability scores for the five subscales were: .84 for factor 1, .84 for factor 2, .80 for factor 3; .72 for factor 4, and .78 for subscale 5. Spit-half reliability is considered less rigorous than test-retest reliability, but was deemed an appropriate indicator at this stage of development of the instrument.

Discussion and Recommendations
The CAPS was developed to address some of the unresolved issues in understanding and measuring the complex multidimensional and transactional construct of coping as an important variable for establishing research-based nursing practice.
The five factors identified provide major dimensions to understand the construct. Items in Factor 1, resourceful and focused, form a subscale that reflects behaviors using self and resources that concentrate on expanding input, being inventive, and seeking outcomes. Conversely the items in
Factor 2, physical and fixed highlight physical reactions and the input phase of handling situations. For Factor 3, alert processing, the behaviors represent both the personal and physical self and focus on all three levels of processing, input, central, and output. Factor 4, systematic processing, describes personal and physical strategies to take in situations and methodically handle them. Finally, in Factor 5, knowing and relating, there are items that describe strategies that use self and others, memory and imagination. The scale is easy to administer and to score and it reflects adequate psychometric properties in initial testing. The scale seems to provide conceptual clarity that can be useful in planning nursing care. To increase, maintain or enhance coping abilities the nurse will assess what adaptive modes are most prominent, for example, whether self concept or interdependence is most prominent. Further, one can assess what cognitive processes are being used or could be strengthened, such as input or central processing. The nurse can help patients to enhance their selected strategies in a given situation and provide opportunities and support for developing new strategies and flexibility in using them. In further testing in other clinical situations the tool can be assessed for usefulness in intervention nursing research.

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

319

Roy
The development of this instrument was derived from a multidimensional and transactional conceptualization to answer the difficulties identified in the measurement of coping. The conceptualization based on understanding the process of adaptation provided an integrated view of the person’s coping and used inductive and deductive approaches rooted in nursing practice. The psychometric analysis is promising as is its clinical usefulness. Recommendations for further testing include: a) Confirm the stability of both the construct and the instrument through confirmatory factor analysis; b) test usefulness in intervention nursing research; and c) explore cross-cultural use of the CAPS in other populations.

Summary
The link of middle-range theory development derived from a nursing grand theory to design research has been particularly prominent in the last 25 years of research based on the RAM.
The key events of the founding of the RAA and Roy’s postdoctoral studies and research in neuroscience nursing, sparked several decades of significant work by Roy, colleagues, and scholars in general. As a final example presented here, even as clarification and publication of the CAPS progresses, Figure
1 illustrates some examples of research stemming from this work. Because the scale development has been reported at meetings of the RAA, it has been translated into other languages (under the supervision of the principal investigator) and used by investigators globally. The tool was translated into Thai (Chayput & Roy, 2007) by one of Roy’s students and the tool has been in use for research in that country. The first use by members of the RAA, Japan Chapter (Toriya &
Tsuhako, 2008), is identified along with an on-going work of scholars of RAA, Colombia Chapter (Guiterrez, 2009). The intervention study by Gonzalez (2007), RAA, Panama
Chapter, was an important contribution to theory, methods, and practice. Roy continues to explore issues such as state and trait with colleagues as well.
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.

References
Aldwin, C. M. (1994). Stress, coping, and development: An integrative perspective. New York: The Guilford Press.
Aldwin, C. M. (2007). Stress, coping, and development: An integrative perspective (2nd ed.). New York: The Guilford Press.
Boston Based Adaptation Research in Nursing Society. (1999). Roy adaptation model-based research: 25 years of contributions to nursing science. Indianapolis, IN: Sigma Theta Tau International.

Burns, N., & Grove, S. (2009). The practice of nursing research: Conduct, critique and utilization (5th ed.). Philadelphia: Saunders.
Carroll, J. (2011, February 14). Time’s face, time’s digits. Boston
Globe, p. 34.
Chayaput, P., & Roy, C. (2007). Psychometric testing of the Thai version of coping and adaption processing scale—short form
(TCAPS-SF). Thai Journal of Nursing Council, 22(3), 29-39.
Gonzalez, Y. M. (2007, June). Efficacy of two interventions based on the theory of coping and adaptation processing. Paper presented at the 8th Annual Roy Adaptation Association Conference, Los Angeles, CA.
Guiterrez, C. L. (2009, June). Callista Roy’s Coping Adaptation
Processing Scale (CAPS)–A methodological proposal for its interpretation. Paper presented at the 10th Annual Roy Adaptation Association Conference, Boston, MA.
Folkman, S., & Lazarus, R. S. (1988). Manual for the ways of coping questionnaire. Palo Alto, CA: Consulting Psychologist
Press.
Folkman, S., & Moskowitz, J. (2004). Coping: Pitfalls and promise.
American Review of Psychology, 55, 745-774.
Frydenberg, E. (2002). Beyond coping: Meeting goals, visions, and challenges. New York: Oxford University Press.
Jalowiec, A. (1993). Coping with illness: Synthesis and critique of the nursing coping literature from 1980-1990. In J. S. Barnfather & B. L. Lyon (Eds.), Stress and coping: State of the science and implications for nursing theory, research and practice (pp.
65-83). Indianapolis, IN: Center Nursing Press.
Johnson, J. (1972). Effects of structuring patients’ expectations on their reactions to threatening events. Nursing Research, 21,
499-508.
Johnson, J., Rice, V., Fuller, S., & Endress, M. (1978). Sensory information, instruction in a coping strategy and recovery from surgery. Research in Nursing and Health, 1, 4-17.
Lazarus, R. (1991). Emotion and adaptation. New York: Oxford
University Press.
Lazarus, R. (1999). Stress and emotion: A new synthesis. New
York: Springer.
Lazarus, R. L., & Folkman, S. (1984). Stress, appraisal and coping.
New York: Springer Publishing Co.
Likert, R. A. (1932). A technique for the measurement of attitudes.
Archives of Psychology, 140, 1-55.
Norusis, M. J. (2002). SPSS 11.5 guide to data analysis. Upper
Saddle River, NJ: Prentice Hall.
Polit, D. F., & Beck, C. T. (2010). Nursing research: Principles and methods (6th ed.). Philadelphia: J. B. Lippincott.
Pollock, S., Roy, C., Frederickson, K., Massey, V., Carson, M., &
Germaine, C. (1991). Testing concepts from the Roy adaptation model. Symposium presentation at the Council of Nurse
Researchers, American Nurses Association, Los Angeles, CA.
Roy, C. (1975). Psycho-social adaptation and the coping mechanisms.Unpublished manuscript, Clinical site, West Covenia,
CA: Queen of the Valley Hospital.
Roy, C. (1976). Introduction to nursing: An adaptation model.
Englewood Cliffs, NJ: Prentice-Hall.

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015

320

Nursing Science Quarterly 24(4)

Roy, C. (1988). Altered cognition: An information processing approach. In P. H. Mitchell, L. C. Hodges, M. Muwases & C. A.
Walleck (Eds.), American Association of Neuroscience Nurses’ neuroscience nursing: Phenomena and practice (pp. 185-211).
Norwalk, CT: Appleton & Lange.
Roy, C. (2001). Alterations in cognitive processing. In C. StewartAmidei, J. Kunkel & K. Bronstein (Eds.), American Association of Neuroscience Nurses’ neuroscience nursing: Human responses to neurologic dysfunction (2nd ed., pp. 275-323).
Philadelphia: Saunders.
Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle
River, NJ: Prentice Hall Health.
Roy, C. (2010, September). Interventions: Cognitive recovery from mild head injury. Paper presented at the 2010 State of the Science Congress on Nursing Research, Washington, DC.
Roy, C. (2011, May). Interventions: Cognitive recovery from mild head injury. Poster presented at the Nursing Research Expo,
Yvonne L. Munn Center for Nursing Research, Massachusetts
General Hospital, Boston, MA.
Roy, C., Barone, S., & Hanna, D. (2005, April). Using theory-based research to re-define evidence for practice. Paper presentedat the
Annual Scientific Sessions of ENRS Pre-Conference, New York.

Roy, C., & McLeod, D. (1981). Theory of the person as an adaptive system. In C. Roy & S. Roberts, Theory construction in nursing: An adaptation model (pp. 49-69). Englewood Cliffs, NJ:
Prentice Hall.
Sangsuwan, W. (2006). Stress and well-being in mothers of preschool children with asthma in Thailand (Doctoral dissertation). Retrieved from Dissertation Abstracts International. (UMI
No. AAT 3226757)
Schwarzer, R., & Schwarzer, C. (1996). A critical survey of coping instruments. In M. Zeidner & N. S. Endler (Eds.), Handbook of coping: Theory, research, applications (pp.107-132). New
York: John Wiley & Sons, Inc.
Snyder, C. (1999). Coping: The psychology of what works. New
York: Oxford University Press.
Toriya, M., & Tsuhako, S. (2008, September). The relationship between coping strategies and the impaired ADL in elderly stroke patients : The first report of the CAPS Japanese Version.
Paper presented at the 9th Annual Roy Adaptation Association
Conference, Boston, MA.
Zhan, L. (2000). Cognitive adaptation and self-consistency in hearingimpaired older persons: Testing Roy’s adaptation model. Nursing Science Quarterly, 13, 158-165.

Downloaded from nsq.sagepub.com at MAYO CLINIC LIBRARY on September 8, 2015