Nurse strategies that enhance students’ criticaltothinking, educators are continually challenged develop teaching problem-solving, and decision-making skills. Medicalsurgical nursing courses often require students to learn a large amount of material in a short time. Students frequently are overwhelmed with the amount and complexity of the material that is covered during each class meeting. Consequently, they may resort to memorizing facts instead of comprehending, applying, and transferring knowledge to practice. In addition, students rely on teachers to provide lecture notes and may not be adequately prepared to participate in class discussions. Case studies, which are an effective way of connecting critical thinking, problem solving, and decision-making to practice (Baumberger-Henry, 2003; Campbell, 2004), enhance students’ participation in class discussions. Conceptual models of nursing provide a unique body of knowledge that can be used to guide construction of case studies and enhance application of didactic course content to nursing practice. Students tend to undervalue the contributions of a nursing conceptual model to guide practice. By integrating a nursing conceptual model into the organization of course content and construction of case studies, students are exposed to how conceptual models can guide nursing practice. The purpose of this column is to explore the use of case studies for a senior level medical-surgical nursing course constructed within the context of the Roy adaptation model. Roy Adaptation Model The Roy adaptation model is a conceptual model of nursing that provides a solid foundation for nursing practice (Roy & Andrews, 1999). The philosophical and scientific assumptions of Roy’s model assert that the person is a holistic
Nursing Science Quarterly, Vol. 20 No. 4, October 2007, 324-326 DOI: 10.1177/0894318407307159 © 2007 Sage Publications

adaptive system in constant interaction with the environment. Roy and Andrews (1999) described people as biopsychosocial beings who adapt to environmental stimuli. Adaptation is defined as “the process and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration” (p. 30). The environment is the source of focal, contextual, and residual stimuli. The focal stimuli are the internal and external factors that immediately confront the person, family, or other group. Contextual stimuli are other internal and external factors that influence how people deal with or respond to the focal stimulus. Residual stimuli are factors, the effects of which in the current situation cannot be determined or are unclear. The classification of stimuli as focal, contextual, or residual depends on their influence on adaptation in a particular situation (Fawcett, 2005). All stimuli serve as inputs that provoke a response. Within the context of Roy’s adaptation model, responses to stimuli are channeled through regulator and cognator coping mechanisms in the process of coping to promote adaptation. The regulator coping mechanism responds to stimuli automatically through neural, chemical, and endocrine coping processes. The cognator coping mechanism responds to stimuli through four cognitive-emotive pathways: perceptual/information processing, learning, judgment, and emotions. Observable responses are called behaviors and are manifested in four modes of adaptation: physiological, selfconcept, role function, and interdependence. The physiological mode of adaptation emphasizes maintenance of the physiological integrity of the adaptive system and encompasses five basic needs: oxygenation, nutrition, elimination, activity and rest, and protection (immune processes); and four physiological adaptation processes: the senses, fluids and electrolytes, acid base, and neurologic/endocrine

Keywords: case studies, Roy adaptation model, teachinglearning

Teaching-Learning Processes function. The self-concept mode focuses on psychic integrity and deals with perception of the physical self in terms of body image and body sensation, as well as perception of the personal self, including self-consistency, self-ideal, and the moral-ethical-spiritual self. The role function mode deals with social integrity by focusing on performance of activities associated with the various roles that one enacts throughout life. The interdependence mode also deals with social integrity, by emphasizing behaviors underlying the development and maintenance of satisfying, affectionate, and supportive relationships with significant others, as well as the provision and receipt of social support (Roy & Andrews, 1999). Responses in each mode are classified as adaptive or ineffective (Roy & Andrews, 1999). Adaptive responses are those that promote the integrity of the person in terms of the goals of adaptation, which are survival, growth, reproduction, mastery, and person and environment transformation. Ineffective responses are those that neither promote integrity nor contribute to the goals of adaptation. Roy and Andrews (1999) defined nursing as “a theoretical system of knowledge which prescribes a process of analysis and action related to the care of the ill or potentially ill person” (p. 3). The nurse needs to intervene when unusually strong stimuli or weakened coping mechanisms are present and are affecting the individual’s adaptive responses. The goal of nursing is to promote adaptation in each of the four modes, by increasing adaptive responses and decreasing ineffective responses, thereby contributing to the person’s health and quality of life (Roy & Andrews). The Roy adaptation model includes a detailed nursing process, defined as “a problem-solving approach for gathering data, identifying the person’s needs, selecting and implementing approaches for nursing care, and evaluating the outcomes of care being given” (Roy & Andrews, 1999, p. 27). The nursing process consists of six steps: assessment of behaviors or responses, assessment of stimuli that influence the responses, nursing diagnosis based on behaviors and stimuli, patient and nurse mutual goal setting, interventions focused on management of stimuli, and evaluation. Case Studies A senior level medical-surgical course was designed using the Roy adaptation model as the framework for the presentation of course content. Each week’s class content is organized within the four modes of adaptation and the management of stimuli that influence patient and family adaptive responses. In addition, the Roy adaptation model was used to guide the construction of the faculty-designed case studies, which provide in-depth descriptions of realistic clinical situations. Each week a different case study of a fictitious patient with a health condition requiring medical and/or surgical treatment, as well as the patient’s family, is discussed. This happens through the examination of focal, contextual, and residual stimuli

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experienced by the patient and family with their responses to the stimuli as manifested in the four modes of adaptation, adaptive and ineffective responses within each mode of adaptation, and identification of nursing interventions that promote patient and family adaptation. In preparation for each class, students are required to complete the case study that corresponds to the class content. In keeping with the Roy adaptation model’s focus on holistic care, the case studies place equal emphasis on physiological and psychosocial responses to health and illness using the four modes of adaptation. The students are presented with information related to the disease pathophysiology and physical findings (physiological mode), emotions and feelings about self (self-concept mode), occupation and performance of daily activities (role function mode), and relationships and social support (interdependence mode). The Roy adaptation model nursing process is used to guide development of the student’s plan of care for the patient and family based on the case study content. Figure 1 presents the format for the weekly case studies. Using the case study as the source of data, students identify the focal, contextual, and residual stimuli. They then develop a nursing diagnosis for each mode of adaptation (physiologic, self-concept, role function, and interdependence). The nursing diagnoses have to be supported by the data found in the case study. Goals are stated in terms of outcomes that would be formulated after mutual agreement by the patient, family, and nurse. The students identify interventions for each nursing diagnosis that would resolve the problem and enable identified goals to be reached. A rationale for each intervention is required. The students then evaluate if the goals are met through the identification of an adaptive or ineffective response. The case study approach to learning facilitates further development and use of critical thinking by defining problems through discussion of relevant data and issues, and verifying facts so that decisions can be made (Baumberger-Henry, 2003). Specifying the reasons for choices with references helps the students to understand the material. The case study approach also facilitates synthesis of content knowledge and application to a patient and family care scenario. Each week students submit a written paper using the case study format. Students receive written feedback from the course instructor regarding identification of stimuli, and connection of nursing diagnoses and interventions to the modes of adaptation and relevant stimuli. In addition, each week a group of students presents the case study to the entire class. The presenters assist their classmates to identify stimuli and generate discussion of the most relevant nursing diagnoses, goals, and nursing interventions based on the stimuli confronting the patient and family described in the case study. Students frequently have differing views on identifying stimuli, as well as formulating appropriate nursing diagnoses within the modes of adaptation. Differing opinions stimulate

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Case Study Name _______________________________________ Date ________________

Care of a Patient with/undergoing: ______________________________________________ 1. Identify the focal stimulus affecting the patient (internal/external stimulus immediately in the awareness of the patient): 2. Contextual Stimuli (all other stimuli present in the situation that contribute to the effect of the focal stimulus): 3. Residual Stimuli (environmental factors within/without, the effects of which are unclear in the current situation): 4. Identify one nursing diagnosis for each of the modes of adaptation as relevant to the case study (support with findings from the case study). • • • • Physiologic mode Self-concept mode Role mode Interdependence mode

5. Identify an expected outcome for the nursing diagnosis most relevant to the case study. 6. Provide individualized, research based interventions with detailed rationales that assist in meeting the identified outcome. 7. Relevant collaborative care (please refer to each case study for specifics) with rationale.
Figure 1. Case Study Format

the students to re-evaluate the case study from other perspectives, similar to real-life patient situations encountered in nursing practice. The role of the course instructor is to facilitate critical thinking by asking questions, guiding the discussion, and refocusing the students to the case study. Sample Case Study Brad is a 28-year-old construction worker who sustained a T6 spinal cord injury while riding a motorcycle. Due to his level of injury, he is paraplegic with complete motor and sensory loss below the level of injury. He is being followed by the clinical nurse specialist in the spinal cord injury clinic. Using the Roy adaptation model as a framework, the students were provided with the following assessment of his behavior and responses.

Adaptation Modes Physiological T6 complete spinal cord injury. Lower extremities are spastically paralyzed, with clasp-knife response. Loss of proprioception, pain, temperature, touch and pressure sensation below level of mid-chest (T6 dermatome). No bowel and bladder control. No sensations of distention, urge to void, bowel control, or urge to defecate. Catheterizes self every 6 hours for clear yellow urine, approximately 1500 ml/day. Regular diet. He shared,
I know I should be eating more protein and such. Nothing really tastes good to me except sweet things. I feel like I have to stay awake all of the time. I’m afraid that if I fall asleep, I will wake up totally paralyzed. If I do fall asleep, I wake up with a real start at least once per night. I used to