FEATURE ARTICLE

Roy’s Adaptation Model to Promote PhysicalActivity among Sedentary Older Adults

Carol Rogers, RN, APRN-BCColleen Keller, PhD, RN-C, FNP

The aging population is rapidly increasing insize, and with this increase there is a grow-ing need for age-appropriate physical activ-

ity (PA) programs to help older adults agesuccessfully. Older adults face many challengesin adaptation to aging and related physical func-tion, emphasizing the importance of developinginterventions to promote adaptation to aging,such as increasing PA among older adults.

A primary concern for the aging individual isthe decline in physical function, compoundedwith the increased prevalence of sedentary be-havior. In 2005, 47% of the young-old (thoseaged 65–74 years) reported no leisure-time activ-ity, with 60% of the old-old (those aged over 75years) reporting no leisure-time activity.1 Thesedata indicate that the aging population is fallingshort of Healthy People 2010 goals and the Amer-ican College of Sports Medicine/American HeartAssociation guidelines for PA in older adults.2

Those guidelines recommend at least 30 minutesof moderate-intensity PA at least 5 times perweek, strength training and flexibility 2 timesa week, and balance training. Further, they rec-ommend that sedentary older adults begin withbalance, flexibility, and strength training to buildendurance before participating in moderate- tovigorous-intensity aerobic PA.2

The interplay of mind-body theoretical con-cepts and PA has increased in popularity sincethe 1990s and makes up 30% of the exercise pro-grams in fitness centers.3 Mind-body practicesthat blend physical movement or postures witha focus on the breath and mind to achieve deepstates of relaxation include, but are not limited

The project described was supported by Award No.

F31NR010852 from the National Institute of Nursing Research.

The content is solely the responsibility of the authors and does not

necessarily represent the official views of the National Institute of

Nursing Research or the National Institutes of Health. This research

was also supported by a John A. Hartford Building Academic Geri-

atric Nursing Capacity (BAGNC) Scholarship, 2008–2010.

The authors have no commercial, proprietary, or financial interest

in the products or companies described in this article.

Geriatric Nursing, Volume 30, Number 2S

to, familiar forms such as yoga, tai chi (TC),Qigong, and other less familiar forms such asSign Chi Do (SCD).4-6 SCD, grounded in the princi-ples of traditional Chinese medicine, incorporatesdeep breathing and mental concentration duringmovement to achieve harmony between bodyand brain and is a novel form of PA that hasmultiple health benefits, including strengtheningmuscles and improving balance using a mind-body approach.4 Both the mind-body interactionsand the potential for improved functional out-comes resulting from these forms of PA makethem particularly appealing for older adults.7,8

SCD is particularly suitable for older adults,because it is implemented without the aerobicand musculoskeletal strain that is sometimes asso-ciated with higher-intensity exercise, while provid-ing mild- to moderate-intensity PA. A growing bodyof research indicates a wide range of potentialhealth benefits from mind-body exercise.9 How-ever, there has been limited research exploringmind-body PA interventions for adaptation andphysical function among older adults. This discus-sion is focused on the description of the develop-ment of a theory-based intervention to promotesuccessful adaptation to an active lifestyle basedon Roy’s Adaptation Model (RAM) and guidedby evaluation theory to address theoreticalintegrity.10

Theoretical Approach

The broad nature of the RAM, developed bySister Callista Roy, allows an examination of PAand the development of a theory-based interven-tion from an expanded, integrated, and holisticnursing perspective. According to the RAM, nur-sing’s biobehavioral knowledge ‘‘balances under-standing of the person as both a physiologic beingin a physical world and as a thinking and feelingbeing with human experience in a cosmicworld.’’11 Human beings and groups are perceivedas holistic, adaptive systems that constantlychange and interact with their environment.

21

Health is a process of being and becoming inte-grated and whole; it reflects the environmentand person mutually. According to Roy, the over-all goal of nursing is to focus on promoting healthof the individual and group by promoting adapta-tion in each of 4 adaptive modes: physiological-physical, self-concept, role function, andinterdependence.11

Adaptation is assessed and measured in physi-cal (physiologic) and psychosocial (self-concept,role function, and interdependence) modes:physiologic-physical, measures bodily functionand, specific to this study, the level of activityand function; self-concept, measures compositeof beliefs including spirituality and feelings onehas of oneself at a given time operationalized asconfidence to exercise or self-efficacy; role func-tion measures a set of expectations about howa person functions and relates with others; andinterdependence measures giving and receivinglove through nurturing relationships.11 Althoughall of these modes are important, this interven-tion focuses on adaptation to aging using Roy’stheoretical physiologic-physical and self-conceptmodes to evaluate the effect of SCD on physicalfunction and personal beliefs.

The RAM has been used in studies of physicalactivity and cancer to promote adaptation andquality of life.12,13 Flood14 used the RAM to defineadaptation to successful aging. The optimal levelof adaptation is consistent with active aging asdefined by the World Health Organization andothers to include the importance of treating theperson as a whole, emphasizing physical and psy-chological function, as well as spirituality.11,14,15

The goal of the intervention described here is topromote adaptation by enhancing the physiologi-cal-physical and self-concept modes througha meditative movement (SCD) intervention thatenhances physical activity performance, spiritu-ality, and self-efficacy.

Problem Definition

Adaptation is the primary concept of interest inthe RAM. It is the dynamic process whereby peo-ple use conscious awareness and choice to createhuman and environmental integration. The RAMmodel depicts the individual as a biopsychosocialbeing who is able to adapt to environmental stim-uli categorized as focal, contextual, or residual.When assessing physical function, sedentary life-

22

style is viewed as the focal stimulus, which leadsto maladaptive responses for older adults (disuseconsequences and negative beliefs). Contextualstimuli are indirectly related to the focal stimulisuch as PA and personal beliefs. The residualare all other stimuli that affect the focal and con-textual stimuli, such as relationships with familyand friends.

Adaptation includes 2 processes called the reg-ulator and cognator subsystems.16 The regulatorsubsystem includes automatic bodily responsesthrough neural, chemical, and endocrine adapta-tion channels.11 The cognator subsystem re-sponds through 4 cognitive-emotional channels:perceptual and information processing, learning,judgment, and emotion.11 The effects of the regu-lator and cognator interact but cannot be mea-sured at this level; however, they are measuredin behavioral outcomes assessed in adaptation.11

Adaptation occurs when the cognator and regula-tor subsystems are stimulated, resulting in behav-ior changes measured in physiologic andpsychosocial modes.

The physiologic mode measures all bodily func-tion and, specific to this intervention, physicalfunction. In the RAM, the psychosocial or mindand spirit modes are self-concept, role function,and interdependence.11 Self-concept deals withpersonal aspects of human systems—specifically,psychic and spiritual integrity.11 It is a compositeof beliefs one holds at a given time. In an olderadult who is sedentary, self-concept is character-ized by a decreased confidence in the ability toexercise and spirituality. Maladaptive responsesoccur when adaptive mechanisms are inadequate,resulting in activity intolerance and disuseconsequences for sedentary aging adults.11 The‘‘problem,’’ then, used to develop the following in-tervention, is the ‘‘maladaptive’’ response of olderpersons—sedentary behavior—that is amenableto ‘‘treatment’’ or an intervention that promotesadaptation through Sign-Chi-Do. See Table 1 fora description of the intervention components.

Critical Inputs

Roy’s conceptualization of adaptation definessedentary adults as being in a maladaptive statebecause of an inability to regulate their physio-logical and psychological state. An interventionneeds to affect both of these modes. It was theo-rized that SCD would promote adaptation by

Geriatric Nursing, Volume 30, Number 2S

Table

1.

Inte

rventi

on

Com

ponents

of

Roy’

sA

dapta

tion

Model

Pro

ble

mC

riti

cal

Inp

uts

Med

iati

ng

Pro

cesses

Exp

ecte

d

Ou

tco

mes

Exo

gen

ou

s

Facto

rs

Imp

lem

en

tati

on

Issu

es

Mala

dap

tati

on

to

ag

ing

du

eto

sed

en

tary

beh

avio

r

Reg

ula

tor

an

dco

gn

ato

r

su

bsyste

men

han

cem

en

t

Pers

on

al

beli

ef,

sp

irit

uali

ty,

self

-effi

cacy

Sp

irit

ual

en

han

cem

en

t

Self

-effi

cacy

en

han

cem

en

t

Self

-co

ncep

t

en

han

cem

en

t

Incre

ased

ph

ysic

al

fun

cti

on

:

6-m

inu

te

walk

,

Tim

ed

Up

&

Go

test,

blo

od

pre

ssu

re

Resid

ual

sti

mu

li,

ch

ron

icil

lness,

so

cio

eco

no

mic

sta

tus,

an

dcu

ltu

ral

co

nsid

era

tio

ns

Ch

ron

icil

lness

aff

ecti

ng

bala

nce

Safe

ty

Ro

om

setu

p

Dif

fere

nt

levels

of

ph

ysic

alfu

ncti

on

Geriatric Nursing, Volume 30, Number 2S

enhancing the regulator and cognator subsys-tems and by influencing the focal and contextualstimuli through the mind, body, and spirit con-nections of deep breathing and meditation com-bined with purposeful movements to promoteadaptation measured in the selected physiologicand self-concept modes. The regulator subsystemwill enhance adaptation through the physicalmovements that foster spiritual connections,which will improve balance and physical func-tion. The cognitive function of the cognator al-lows humans to obtain knowledge and promoteadaptation through increased self-efficacy mea-sured in the self-concept mode. In this interven-tion, a mind, body, and spiritual PA will betested to promote adaptation to aging by improv-ing the personal beliefs of community-dwellingolder adults and subsequent outcomes of im-proved physical function. Figure 1 details the crit-ical inputs of the intervention.

The dose of the intervention is the primary crit-ical input. Increases in the regulator and cognatorcritical inputs are achieved through 1-hourweekly sessions with groups of 15 participantseach over 12 weeks; the length of the interventionwas selected on the basis of a review of previousTC programs.17,18 Participants are given a copy ofan instructional DVD or video to facilitate prac-tice of movements at home between classes. Par-ticipants are encouraged to practice at least twicefor 10 minutes between classes the first week, in-creasing the time to include up to the recommen-ded 30 minutes at least 5 days per week.

Mediating Processes

Mediating processes are conceptualized by Royas the contextual stimuli.11 For this intervention,a combination of the physical movement of SCDand the self-concept enhancement of personal be-liefs mediate the adaptation process in sedentaryolder adults. These activities are the regulator andcognator inputs for the intervention, includingspiritual/self-reflection and physical movementas well as self-efficacy enhancement strategies.

Spirituality and Physical Movement

The regulator critical input for this interven-tion includes a mind-body-spiritual exercise,SCD. SCD uses slow, continuous movements ofthe arms and legs, similar to TC.4,9 The move-ments incorporate balance, postural alignment,

23

Regulator:Spiritual /self-

reflection

Physicalmovement

6-minute walk

BP

Timed Up &

Go

Spirituality

Self-efficacyCognator:Self-efficacyenhancementstrategies

Intervention Adaptation

Sign-Chi-Do30 minutes/

5 timesper week

Figure 1. Critical inputs.

concentration, and muscle strengthening.4,9 SCDmovements begin with the toe first; completion ofthe form while experiencing the meaning of a se-lected word phrase is the goal of SCD. The med-itative effect is achieved by concentrating onpositive word phrases or prayer.4 The wordphrases are taught in a three-step pattern: do

the movement (engaging the body), visualize

what the phrase means (engaging the mind),and feel the word phrase (engaging the spirit).Self-efficacy and spirituality are enhancedthrough this intervention, which is designed toask participants to select their own picture ofthe words in their mind and identify how theword makes them feel during the intervention.

There is a growing body of knowledge to sup-port the importance of spirituality among the ag-ing population.14,19,20 Spirituality is defined as thepersonal quest for understanding answers to ulti-mate questions about life, meaning, and a rela-tionship with the sacred or transcendent, whichmay (or may not) lead to or arise from the devel-opment of religious rituals and the formation ofcommunity.21 Low spirituality is reported tohave a high relationship with all-cause mortal-ity.22 Spiritual feelings are emphasized duringSCD.

Self-Efficacy

The intervention is anticipated to enhance the

cognator mode by improving personal beliefsthrough increased self-efficacy with a spiritual fo-cus to improve the way participants feel aboutthemselves. SCD uses a 3-step technique to en-gage the mind, body, and spirit in physical activ-ity. First, the physical boundaries of wordphrases are demonstrated by the instructor andpracticed by the group participants, encouraging

24

the participant to visualize and ‘‘feel’’ the wordphrase. This 3-step process also helps partici-pants remember the movements so they can berepeated, consistent with the learning principlesof the RAM.11 Self-efficacy is enhanced in 4ways: through demonstration of the SCD move-ments, participants watching others performingthe SCD movements, participants repeating theSCD movements, and participants increasingtheir daily performance of the SCD movements.

Assessment of confidence to exercise wouldalso evaluate personal beliefs at a given time.Levy and Meyers note that health problems are in-evitable with aging, and this contributes to an un-willingness to engage in PA and to maladaptiveadaptation.23 This belief is reinforced by the fol-lowing reported barriers to PA among olderadults: feelings of inability to perform PA (lowself-efficacy), fear of falling, and self-rated poorhealth accompanied by pain and fear ofpain.24,25 Self-efficacy is the confidence a personfeels in performing a behavior and overcomingthe associated barriers.26 Several studies have re-ported a significant positive relationship betweenPA and self-efficacy (r 5 0.30–0.70 andb 5 0.493).27-29 Assessment of confidence to exer-cise is evaluated in this intervention.

Expected Outcomes

The overarching outcome for this interventionis adaptation. Adaptation is improved physicalfunction, measured by the outcomes that relateto the physiologic mode, including improvedblood pressure, 6-minute walk, and Timed Up &Go. The Timed Up & Go is a performance mea-sure used to measure physical function for olderadults. It measures the time it takes one to standfrom a seated position, walk 10 feet, turn around,walk back to the starting position, and sit down.30

Mind-body exercises have been shown to im-prove physical function in older adults. Slowmeditative movements such as TC and SCDmay improve physiologic function (blood pres-sure, 6-minute walk distance, and Timed Up &Go) from a mind-body perspective, which maypromote adaptation on multiple levels.

Exogenous Variables

According to the RAM, residual stimuli are en-vironmental factors that have an unclear effect

Geriatric Nursing, Volume 30, Number 2S

on a current situation and may include family re-lationships or a previous fall—extraneous vari-ables that may be related to adaptation.11 Forexample, it has been reported that situationssuch as unplanned hospitalizations contribute todeclining functional status among previously ac-tive older adults.31 Other extraneous factors in-clude age in calendar years, sex (male andfemale), current chronic illness, level of educa-tion in years, ethnicity and race, life crisis, andnew diagnosis of chronic disease.

Implementation Issues

Implementation strategies are vital to the suc-cess of this theory-based intervention. SCD clas-ses are to be taught by a trained facilitator, andall course materials are available on a DVD toprovide a consistent delivery of the information.The SCD classes are taught in a classroom to pro-vide privacy to the participants, who are encour-aged to ask questions at any time. To ensure thesafety of the participants, chairs are provided,and those who are unstable will begin the classin a seated position. Class size is a concern forsafe implementation of this intervention, withno more than 15 participants per class witha co-facilitator providing teaching support.

Application to Clinical Practice

This discussion of the critical elements ofRoy’s Adaptation Model applied to the develop-ment of programs and interventions to guidepractice in health promotion in older persons of-fers clinicians several ways to use a theoreticalmodel to guide the development of a PA interven-tion for older persons. First, the elements of en-hancing spirituality and self-efficacy aredescribed in the context of an alternative formof PA to increase strength and endurance in olderpersons. Second, carefully detailing the signifi-cant elements of the theory increases our abilityto identify which components ‘‘work’’ in an inter-vention and which can be excluded.

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CAROL ROGERS, RN, APRN-BC, is a PhD student, College of

Nursing & Healthcare Innovation, Arizona State Univer-

sity, Phoenix, AZ. COLLEEN KELLER, PhD, RN-C, FNP, is

the Foundation Professor in Women’s Health and Director of

the Hartford Center of Geriatric Nursing Excellence and the

Center for Healthy Outcomes in Aging, College of Nursing

and Healthcare Innovation, Arizona State University,

Phoenix, AZ.

0197-4572/09/$ - see front matter

� 2009 Mosby, Inc. All rights reserved.

doi: 10.1016/j.gerinurse.2009.02.002

Geriatric Nursing, Volume 30, Number 2S