JAN

ORIGINAL RESEARCH

Theory-guided interventions for adaptation to heart failure

Gulcan Bakan & Asiye Durmaz Akyol
Accepted for publication 4 September 2007

Correspondence to A.D. Akyol:

e-mail: asiye.durmaz@ege.edu.tr
Gulcan Bakan MSc
Cardiology Nursing
_
Izmir
Ataturk Research and Education
_
Hospital, Izmir,
Turkey
Asiye Durmaz Akyol PhD RN
Assistant Professor
Internal Medicine, Ege University,
School of Nursing, Izmir, Turkey

B A K A N G . & A K Y O L A . D . ( 2 0 0 8 ) Theory-guided interventions for adaptation to

heart failure. Journal of Advanced Nursing 61(6), 596608
doi: 10.1111/j.1365-2648.2007.04489.x

Abstract
Title. Theory-guided interventions for adaptation to heart failure
Aim. This paper is a report of a study to examine the effects of a Roy Adaptation
Model-based experimental education, exercise and social support programme on
adaptation in persons with heart failure.
Background. In the past 20 years, a large number of studies have evaluated heart
failure. Several studies of other chronic diseases have been based on the Roy
Adaptation Model and show that this approach is useful in promoting adaptation
for patients.
Method. A randomized, parallel, controlled clinical trial was conducted in 2005
with 43 patients (21 intervention and 22 control patients). A booklet for patient
training was given to those in the intervention group. Participants received a patient
identification form, assessment form for physiological data, the Minnesota Living
with Heart Failure Questionnaire, Interpersonal Support Evaluation List and the
6-Minute Walk Test.
Results. Patients in the intervention group adapted well to their condition and the
four adaptive modes of Roy Adaptation Model were interrelated. Patients quality
of life was enhanced, their functional capacities increased and social support within
the interdependence dimension improved in patients in the intervention group.
Conclusion. This is the first study to use the Roy Adaptation Model in a study of
patients with heart failure. Roys model is an effective guide for nursing practice
when caring for patients with heart failure.
Keywords: 6-Minute Walk Test, heart failure, Interpersonal Support Evaluation
List, intervention study, Minnesota Living with Heart Failure Questionnaire,
nursing, Roy Adaptation Model

Introduction
Heart failure (HF) is an increasingly common health problem
with high morbidity and mortality and numerous hospitalizations (Braunwald et al. 2001, Lainscak & Keber 2003,
Vavouranakis et al. 2003). Nearly 5 million Americans have
HF [American Collage of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines 2005, Washburn
et al. 2005], and data from the Framingham database suggest
596

that 550,000 new cases are diagnosed each year (Miller &
Missow 2001). HF is primarily a condition of older people
and thus the widely recognized ageing of the population also
contributes to its increasing incidence. The incidence of HF
approaches 10 per 1000 population after age 65 years (ACC/
AHA Practice Guidelines 2005). Approximately 50% of
patients aged 65 years and older with HF are readmitted within 6 months of discharge from hospital (Washburn
et al. 2005). In addition, there are more than 900,000

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JAN: ORIGINAL RESEARCH

hospitalizations in the USA each year because of HF (Rhodes

& Bowles 2002). The European Society of Cardiology (ESC),
representing countries with a total population of over
900 million, suggests that there are at least 10 million patients
with HF in those countries. Half of patients with a diagnosis
of HF will die within 4 years, and more than 50% of those
with severe HF will die within 1 year (ESC Guideline 2005).

Background
In the past 20 years, there has been a large number of studies
evaluating HF management. Research results were summarized in evidence-based guidelines by the Agency for Health
Care Policy and Research, now called Agency for Health
Care Policy and Research and Quality (AHRQ), the ACC/
AHA and the Heart Failure Society of America. Since the
widespread publication of these guidelines, advances have
been made in the provision of evidence-based HF management (Washburn et al. 2005). Multidisciplinary cardiac
rehabilitation programmes that include patient education,
exercise training, and lifestyle modification can improve
symptoms, functional performance and health-related quality
of life (QOL) in older patients with HF (Gary et al. 2004,
Austin et al. 2005).
Vavouranakis et al. (2003) found that intensive home care
of patients with HF resulted in improved QOL and reduced
hospital readmission rates. Studies have shown that patients
with HF had poor understanding of the importance of
compliance and self-management strategies to optimize
control of the condition (Wright et al. 2003). Multidisciplinary and transitional care models with strong patient educational components have been effective in reducing
hospitalizations and improving QOL among patients with
HF (ACC/AHA Heart Failure Clinical Data Standards 2005).
Patient education is vital for comprehensive HF management. Nurses have an important role in educating and
supporting patients with HF to comply with the medical
regimen and practice self-care (Stromberg et al. 1999). A
team-based approach to patient education and patient
empowerment has been advocated by the AHRQ, ACC/
AHA. Martensson et al. (1998) found that when primary
healthcare nurses received a patients report with information
on the patients mental, physical and social status, nurses
could contribute to creating a safe and secure environment
for the patient. Nurses achieved this by increasing the quality
of the familys emotional support through information and
continuous contact (Hanna & Roy 2001).
Cardiac rehabilitation through physical activity end exercise training is an important aspect of care for patients with
HF. Physical activity improves exercise tolerance, functional

Adaptation to heart failure

capacity, and psychological well-being. Rehabilitative exercise also reduces the severity of symptoms, which can in turn
decrease depression (Artinian et al. 2003). In studying the
management of HF, Gottlieb et al. (1999) and McKelvie et al.
(2002) found that exercise increased 6-minute walking
distance, but QOL was not improved.
A clear and comprehensive plan is needed for optimal
patient education. The AHRQ guidelines identified six
important topic areas for HF education: the progression of
HF, prognosis, activity, diet, medications, and compliance
with the treatment plan. As patients and caregivers gain
knowledge in these areas and participate in management
decisions, they are empowered to self-manage the illness
(Washburn et al. 2005).
Non-pharmacological advice is an important aspect of
disease management and is included in recently published
ESC guidelines (Lainscak & Keber 2003). The development
of HF clinics, HF units and HF programmes, most of which
are nurse-led, has increased in developed countries with
success (Gonzales et al. 2005). Moreover, observational
studies and randomized controlled trials have shown that
disease-management programmes can reduce the frequency
of hospitalization and can improve QOL and functional
status. Patients at high risk for clinical deterioration or
hospitalization are likely to benefit from disease management
programmes; such interventions are shown to be costeffective for this patient group (DAlto et al. 2003, Wright
et al. 2003, Shievelv et al. 2005).
Corvera et al. (2004) found that a progressive home
walking exercise programme for patients with HF is acceptable, increases walking distance, and decreases global rating
of symptoms. Compared with the usual activity groups the
training group had significantly longer walking distances
measured by the 6-minute walking test (6MWT) and
improved postglobal rating of symptoms.
Social, physical, emotional and economic difficulties
resulting from chronic disease make it difficult for the patient
and the family to adapt to new conditions; these difficulties
are associated with decreased QOL (Tokem et al. 1999). Heo
et al. (2005) could not demonstrate any association between
social support and QOL. There are too few studies investigating the relationship between social support and QOL in
patients with HF. In those rare studies, while some researchers stated the presence of the association between emotional
support and QOL, others stated a completely opposite view
(Moser & Worster 2000, Bosson 2005).
The focus of the current article is use of the Roy
Adaptation Model (RAM) in the context of cardiac nursing
(Patton 2004) There are no reports of previous studies in
which the RAM was used to offer care to patients with HF.

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G. Bakan and A.D. Akyol

Research by DiMattio and Tulman (2003) used the RAM to

guide a study of womens functional recovery during the first
6 weeks at home following coronary artery bypass graft
surgery. Functional recovery was measured in terms of
performance of usual role activities, and the influence of
comorbidity, household composition, fatigue and surgical
pain on performance. Several studies on different chronic
diseases have been based on RAM and similar results have
been found. Burns (2004) studied the physical and psychological adaptation of participants of African origin to
haemodialysis and found an association between the problems perceived through role performance and social support
dimensions of RAM. In a training programme designed to
prevent amputation in patients with diabetes, Scollan-Koliopoulos (2004) compared the RAM and the Health Belief
Model, and found that the RAM was a better instrument for
designing a community-based plan.
Previous studies have found support for the proposition that
all modes of adaptation (physiologic, self-concept, interdependence, role function) were interrelated. The RAM is generally
used to assess cancer patients. However, study results reveal
that severity of illness and adjuvant cancer treatment had the
strongest association with bio-psycho-social responses and

should be considered the focal environmental stimuli in

determining adaptation (Samarel et al. 1998, 2002, Nuamah
et al. 1999). Villareal (2003) found that, in caring for a small
group of female smokers, the RAM can be used as a guide to
provide comprehensive nursing care.

Conceptual framework
The study was guided by the RAM (Figure 1), which is based
on scientific assumptions drawn from general system theory
(Whittemore & Roy 2002) and adaptation level theory
(Whittemore & Roy 2002, Tsai et al. 2003). The RAM
focuses on environmental stimuli and the bio-psycho-social
responses to the stimuli (Shin et al. 2006), and emphasizes the
interaction between the person and the environment as the
person adapts to environmental stimuli (Tourville & Ingals
2003). The RAM is one of the most fully developed and
widely used of all nursing conceptual models (Riehl & Roy
1980, Velioglu 1999). Nurses act to promote patients levels
of adaptation during health and illness using the nursing
process (Dixon 1999, Villareal 2003, Patton 2004). Environmental stimuli include focal, contextual and residual stimuli
(Samarel et al. 1998, Willoughby et al. 2000, Hanna & Roy

Figure 1 Conceptualtheoreticalempirical structure of adaptation to heart failure. MLWHF, Minnesota Living With Heart Failure Questionnaire; ISEL, Interpersonal Support Evaluation List; 6MWT, 6-minute walking test.
598

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2001, Scollan-Koliopoulos 2004). The focal stimulus is the

one most immediately confronting the person. Contextual
stimuli are all other stimuli that contribute directly to
adaptation. Residual stimuli are other unknown factors that
may contribute to adaptation. When residual stimuli are
identified, they are reclassified as focal or contextual stimuli
(Tolson & Mcintosh 1996, Gagliardi 2003, Tsai 2005). In the
current study, the experimental adaptation programme, social
support, age, gender and disease severity were the environmental stimulii of interest. When individuals are confronted
with stimuli, their coping processes, by way of regulator and
cognitive subsystems, are activated and manifested in one or
more of Roys four interrelated modes (Cunningham 2002,
_
Gagliardi et al. 2002, Tourville & Ingals
2003).
The physiologic mode relates to maintenance of the
physiologic integrity of the adaptive system. The self-concept
mode relates to peoples conceptions of their physical and
personal selves. The interdependence mode deals with social
support and maintenance of satisfying relationships with
significant others. The role function mode deals with social
integrity by focusing on activities associated with the persons
roles in life (Pearson et al. 1998, Nuamah et al. 1999, Chiou
2001, Yeh 2002, Burns 2004). Adaptive responses promote
integrity and help to meet the goals of adaptation, which
include mastery, survival and growth. On the other hand, the
reproduction of ineffective responses does not promote
integrity of the individual and does not contribute to the
goals of adaptation (Cunningham 2002).
Research findings show that patients informal social
support and education from fellow patients, family members
and the healthcare team can influence adaptation to chronic
disease (Samarel et al. 1998). Social support may be defined
as an interaction involving two or more people whose
purpose is to promote awareness and education, provide
emotional instrumental, financial support and assist with
problem-solving (Moser & Worster 2000, Samarel et al.
2002, Shin et al. 2006). When the RAM is used, this affects
social functioning. Personal resources, such as self-control,
enhance the impact of social support for individuals with
chronic illness dealing with stress (Tsai et al. 2003).
Social support has been identified as an important factor in
adjustment to chronic illness (Willoughby et al. 2000). As the
quality of emotional support from the family may have a
significant effect on the patient emotional state, development
of the familys function and its capacity to support the patient
is an important component in nursing plans for this patient
group. Patients with HF need to feel empowered to be
managers of their own care so that the disability or illness
does not become their entire identity. Otherwise, HF may
cause social isolation and loneliness. Nurses can help to

Adaptation to heart failure

provide a safe environment and the support necessary to

allow the patient to succeed in managing their condition
(Martensson et al. 1998).
In the present study, health-related QOL (HRQOL) was
considered to be a latent variable that reflects overall
response of the adaptive system to environmental stimuli.
The components of HRQOL and social support were
reflected in the four bio-psycho-social response modes. The
four modes of adaptation were used to measure levels of
adaptation to the disease as follows:
Physiological mode various physical functioning and
physiological measures.
Self-concept mode emotions.
Role function mode social functioning.
Interdependence mode interpersonal support.

The study
Aim
The aim of this RAM-based study was to examine the effects
of a Roy Adaptation Model-based experimental education,
exercise and social support programme on adaptation in
persons with heart failure.

Design
The data reported in this paper are a secondary analysis of
data from a randomized controlled trial conducted in the first
6 months in 2005. The secondary analysis was carried out at
the end of 2005.

Participants
The study was conducted at a cardiology and internal disease
polyclinic in a state hospital in Turkey. The 44 patients who
participated in the study were randomized to the study
conditions: 22 patients to intervention group and 22 patients
to control group. Of those randomized to intervention, 21
completed 3 months of follow-up. One patient who had to
leave the city during the study period was dropped from the
study.
Inclusion criteria for participants were literacy, ability to
communicate verbally, diagnosis of HF at least 6 months
before for the study, New York Heart Association (NYHA)
functional class IIIII (Table 1), ejection fraction <40%,
no hearing or visual detect, no mental disorder, no
myocardial infarction in the past year, and plans to remain
in the city during the study period or could be reached by
telephone.

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G. Bakan and A.D. Akyol

Table 1 New York Heart Association (NYHA) classification of heart
failure
Level

Description

Diagnosed with heart failure based on cardiac changes,

but no symptoms present regardless of level of activity
Symptoms (such as fatigue, dyspnoea, palpitations,
angina) with ordinary activity; slight activity limitation
Symptoms with less than ordinary activity; no symptoms
when at rest; marked limitation with daily tasks
Symptoms with any type of physical activity, or even
at rest

II
III
IV

Instruments
Patient identification form
An investigator-developed questionnaire was used to collect
demographic information for each patient.
Assessment form for physiological data
An assessment form was prepared to evaluate changes in
body mass index (BMI), cholesterol, high-density lipoprotein
(HDL) and low-density lipoprotein (LDL) levels; to determine changes in habits such as smoking, alcohol consumption, adaptation to diet and regular medication use; and to
find out the number of hospital admissions because of HF
during the programme.
Minnesota Living With Heart Failure Questionnaire
(MLWHF)
The latent variable, QOL, was measured using the MLWHF
questionnaire at baseline and at 3 months. Patients indicated
their perspective concerning disability using 21 items on a 6point response scale (05), with a maximum score of 105.
Lower scores indicate better QOL (Artinian et al. 2003). The
instrument consist of three separate scale scores: physical
(eight items), emotional (five items) and total score (Riegel
et al. 2002, Heo et al. 2005). The questions cover signs and
symptoms relevant to HF and their impact on physical
activity, social interaction, sexual activity, work and emotions (Duncan & Rozehl 2003). The physiologic mode was
measured with the physical subscale of the MLWHFQ, the
emotional subscale of the MLWHFQ was used in order to
measure the self-concept mode, and role function mode of
adaptation was measured by the other items on the MLWHF
questionnaire. In the present study, Cronbachs a coefficient
was 083 for the total score, 087 for the physical dimension
and 061 for the emotional dimension.
Interpersonal Support Evaluation List (ISEL) short form
The Interpersonal Support Evaluation List (Owen 2003) is a
15-item measure of perceived social support derived from the
600

48-item Interpersonal Support Evaluation List (ISEL)

designed by Owen (2003). The interdependence mode of
adaptation was measured with the ISEL. This measure
assesses the perceived availability of the following specific
support resources. The instrument consists of three subscales:
tangible support, appraisal support and belonging support.
Each item is endorsed on a rating scale with the following
response options: completely false, somewhat true and
completely true. Negatively phrased items on each scale are
reverse scored so that higher scores reflect greater perceived
availability of the specific support resource reflected in each
subscale and for the total score (Owen 2003). Cronbachs a
coefficient in the present study was 079.
6-Minute walking test
Functional status was measured using the 6MWT. After
6 minutes elapsed, patients were instructed to stop walking
and the total distance walked was measured to the nearest
foot. Before and after each 6MWT the patients pulse,
respiratory rate and blood pressure were recorded (McKelvie
et al. 2002, Duncan & Rozehl 2003). Physical symptoms
observed by the investigator or reported by the participants,
and the latest 6-minute walk test results were recorded (Gary
et al. 2004). Physiologic mode of adaptation was measured
using the 6MWT.

Intervention
The intervention programme consisted of two one-to-one
counselling sessions (clinical appointments) with patients,
two phone calls and one group meeting over a 3-month
period. Throughout the programme, patients were encouraged to attend with their spouse or partner. For 3 months the
intervention group (n = 22) participated in the adaptation
programme and the control group (n = 22) had usual care
(Figure 2).
Clinical appointments included one-to-one patient counselling and HF education by the researchers At the first
appointment each patient in the intervention group was given
a booklet, titled How Can I Learn to Live with Heart
Failure, developed by the investigator. This included information on medications; definition of HF; symptoms; types of
exercise; the walking schedule for the programme; important
points on diet; a sample diet list; cholesterol; liquid intake;
tobacco and alcohol consumption; and contact details for the
clinic. Patients were also given a crossword puzzle about HF;
a schedule of appointment and education sessions; and a
calendar on which to record weight on a daily basis. The
booklet focuses on supporting patients in adhering to their
treatments, adjusting medications and doing exercise. The

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Adaptation to heart failure

Figure 2 Flowchart of intervention programme. MLWHF, Minnesota Living With Heart Failure Questionnaire; ISEL-SF, Interpersonal Support
Evaluation List short form; 6MWT, 6-minute walking test; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

education materials taught patients to recognize the symptoms of HF and to contact the investigator and medical staff
if early sign or symptoms of worsening HF occurred.

The investigator provided additional information to the

patient based on the patients interest in specific topics or
questions raised during the session. Patients were encouraged

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G. Bakan and A.D. Akyol

to engage in regular exercise and advised that it is safe to

exercise up to the level of moderate discomfort (e.g. fatigue of
the leg muscles, dyspnoea or angina). No adverse event
occurred throughout the duration of exercise regimen. Selfmonitoring techniques (e.g. recording daily weight) and
positive verbal feedback were also part of the intervention.
One-on-one interviews were 2 hours in length. Measures of
6MWT, MLHFQ, ISEL-SF and blood testing for levels of
cholesterol, HDL, LDL were chosen to reflect the impact of
the intervention and were applied to both intervention and
control group patients at baseline and at 3 months. The
interview consisted of establishing specific goals with patients
related to healthier diet, increased quality and amount of
exercise and increased social and interpersonal activities. The
focus of the interview was on goal setting and individualizing
health life-style changes for participants. Advice was reinforced at each subsequent clinic visit during one-on-one
counselling sessions by the investigator.
Telephone contacts were made to verify functional status,
proper use of medications and to encourage the patients to
adhere to the programme. Patients were also instructed to call
the investigator to report symptoms or any other problem
promptly.
A group education session was offered at 1 month. This
session included explanation of monitoring of daily body
weight, plan of action if weight changed, effects of medications, importance of compliance and recommendations
regarding exercise and diet. For this purpose, a PowerPoint
presentation was given to patients. After this, patients shared
their experiences. Some patients participated with their
relatives and partners in the group session.
Patients in the control group were instructed to maintain
their normal daily activities and clinic visits. At the last oneon-one interview (after 3 months), 6MWT, MLHFQ, ISELSF and blood testing were applied to intervention and control
groups.

Ethical considerations
The study was approved by the ethics committees of both the
state hospital and the university nursing school. Participants
gave verbal informed consent to participate. All were given
information about opportunities to withdraw from the study
and told that there would be no disadvantages if they chose to
withdraw from the study.

Data analysis
Data were analysed with SPSS (version 100, SPSS Inc.,
Chicago, IL, USA). Relationships among variables were
602

examined by calculating Pearson correlation coefficients.

Between group differences at pretest and post-test were tested
using t-tests. The chi-squared test was used to test for
differences in categorical data. Repeated measures analyses of
variance (ANOVA s) with post hoc t-tests were used to analyse
the study hypothesis that patients who participated in the
adaptation programme would better adapt to living with the
HF than those who were assigned to the control condition.
Statistical significance was set at P = 005 and 0001.

Results
Table 2 shows baseline clinical details of the randomized
patients. There was no baseline difference between the
intervention and control groups concerning education level,
age, and sex and NYHA class. Mean age of patients in the
intervention group was 6267 years; 619% were female and
524% were married. At least 20% of the patients were

Table 2 Patient characteristics at baseline

NYHA class
NYHA II
NYHA III
Age group (years)
3039
4049
5059
60
Sex
Male
Female
Education
Literate/primary school
Middle school
High school
University
Marital status
Married
Widowed/divorced
Way of life
Lives alone
Lives with spouse
Children, spouse
Lives with children
Drugs
ACE inhibitor
b-Blocker
Diuretic
Digitalis
Anticoagulant
Other

Intervention
n = 21(%)

Control
n = 22 (%)

14 (667)
7 (333)

13 (591)
9 (409)

1
1
8
11

1
1
6
14

(48)
(48)
(381)
(524)

(45)
(45)
(273)
(636)

8 (381)
13 (619)

9 (409)
13 (591)

10
6
3
2

11
7
3
1

(476)
(286)
(143)
(95)

11 (524)
10 (476)

(500)
(318)
(136)
(45)

14 (636)
8 (364)

4
6
4
7

(190)
(286)
(190)
(333)

5
11
3
3

(227)
(500)
(136)
(136)

17
6
7

18
12

(283)
(100)
(117)
( )
(300)
(200)

16
6
8
4
17
16

(238)
(90)
(119)
(60)
(2549)
(239)

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taking an angiotensin-converting enzyme inhibitor (10%

b-blocker and 10% diuretic).
There was no inter-group difference in baseline QOL data.
Intervention patients showed statistically significantly improved scores on the MLWHF, physical dimension and
emotional dimension (Figures 3, 4 and 5) over time compared
with control patients. There was no statistically significant
baseline difference for 6-minute walk distance between the
control (376 5277 m) and intervention groups
(383 5244 m). There was a statistically significant increase in 6-minute walk distance compared with baseline at

Figure 3 Minnesota Living With Heart Failure Questionnaire total

scores.

Figure 4 Minnesota Living With Heart Failure Questionnaire physical dimension scores.

Adaptation to heart failure

Figure 6 Six-minute walk distance.

3 months for intervention (4619 m) group. There was a

statistically significant decrease in 6-minute walk distance
compared with baseline at 3 months for the control group
(582 m) (Figure 6). There was no group difference in
baseline data for social support. Intervention patients showed
a statistically significantly improved ISEL-SF total score and
over time compared with control patients. Differences
between mean scores of cholesterol and LDL levels of the
patients in the intervention group were statistically significant
from baseline to 3 months, but no statistically significant
difference was found for the control group for these dimensions. The difference between the mean HDL levels of the
two groups was not statistically significant from baseline to
3 months of follow-up (Table 3).
There was a positive association between total MLWHF
score and its physiologic, emotional and role performance
sub-dimensions. There was a negative relationship between
MLWHF, ISEL-SF and the 6-MWT scores: as the score on the
MLWHF questionnaire decreased, scores on ISEL-SF and 6MWT increased. There was a positive association between
the physiologic dimension of MLWHF questionnaire and
emotional function, role performance and total score of
MLWHF questionnaire. There were negative associations
between the Social Support Scale and 6-MWT; between the
Social Support Scale and the physiologic sub-dimension of
QOL and total score of QOL; and between and physiologic,
emotional, role performance and total score of the QOL
scale. However, there was a positive association between
scores for the 6MWT and the Social Support Scale; between
cholesterol level and LDL level and BMI; and between BMI
and LDL level (Table 4).

Discussion
Study limitations

Figure 5 Minnesota Living With Heart Failure Questionnaire emotional scores.

This study has several limitations. Exclusion criteria limited

the number of patients participating. No power calculation
was carried out as this was a secondary data analysis and

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G. Bakan and A.D. Akyol

Table 3 Social support and blood test results
Intervention (n = 21)

Social Support
Cholesterol
HDL
LDL

Control (n = 22)

Baseline, mean (SD )

3 months, mean (SD )

Baseline, mean (SD )

3 months, mean (SD )

4242
19986
4133
13890

4738
17910
4181
2871

4040
19591
4127
13600

4063
18932
4073
13541

(382)*
(5273)*
(469)
(3675)*

(380)*
(3971)*
(440)
(2705)*

(462)
(4179)
(570)
(3013)

(503)
(4061)
(585)
(3283)

HDL, high-density lipoprotein; LDL, low-density lipoprotein.

*P < 005.

hence only variables in the original study were available,

which limited the possibility of operationalizing some concepts. In addition, use of a convenience sample limited the
generalizability of the findings. Further, although the findings
provide preliminary evidence of causal relationship among
variables, better examination of causality will require longitudinal data. On the other hand, these study findings could be
culturally specific and the study would need to be replicated
in different cultural settings.

Discussion of results
Intervention and control group differences for QOL, walk
distance and social support quality indicate that the RAMbased adaptation programme had some effect on adaptation
to HF in relation to physiologic, self-concept, interdependence and role function modes.
Exercise in management of HF has been studied extensively. The Clinical Practice Guidelines on HF recommended
regular exercise in NYHA classes IIII for patients with HF.
This recommendation was based on several studies which
showed that patients with HF could exercise safely, improve
their functional status, and decrease symptoms (DeWald
et al. 2004). In the current study, the improvement in distance
walked at 3 months in the intervention group is equivalent to
an improvement in functional performance, the consequence
of which is enhanced daily activity. The finding that there was
a significant improvement in the 6MWT is agreement with
other studies (Gottlieb et al. 1999, Gary et al. 2004, Austin
et al. 2005). Corvera et al. (2004) found that patients in the
training group who improved had remarkably increased
6MWT distances. These findings suggest that a simple
walking programme is beneficial for many patients with HF
and can result in increased walking distances in some
patients.
McKelvie et al. (2002) found that a comprehensive HF
management programme led to improved functional status
and an 85% decrease in hospital admission rate for heart
transplant candidates. A study by Vavouranakis et al. (2003),
604

which examined a similar cohort of patients, found fewer

hospitalizations and increased exercise capacity when
patients were managed with a dedicated HF programme
(Vavouranakis et al. 2003).
Comprehensive HF programmes that include patient education, self-management strategies and integrated follow-up
by a multidisciplinary team, show benefits in term of
improved patient QOL and fewer hospitalizations (Wright
et al. 2003, Lainscak 2004). Previous research has shown that
exercise and education improves QOL in some, but not all,
studies of HF (Artinian et al. 2003, Vavouranakis et al. 2003,
Corvera et al. 2004, Gary et al. 2004, Shievelv et al. 2005) .
Austin et al. (2005) reported significant differences in all
MLWHF components (emotional, physical and total)
between experimental and standard-care patients at 8 and
24 weeks. Investigating which components have the greatest
uptake by patients would help in the formulation of guidelines for the streamlined design of patient self-management
programmes for HF (Wright et al. 2003).
DeWald et al. (2004) developed and tested an educational
programme designed to meet the needs of patients with low
literacy skills. Participants (n = 23) showed a significant
improvement in HRQOL that is likely to be of clinical
importance. Disease management programmes have a positive effect on patient outcomes and are associated with
decreased hospitalizations and readmissions (DeWald &
Gaulden 2000). The findings from the current study suggest
that the adaptation programme used is particularly effective
at improving HRQOL, as described by disease-specific and
utility measures, than a nurse-led outpatient clinic.
There have been few studies of the effects of exercise on
QOL. However, most of the available studies demonstrate an
improvement in the QOL of patients with HF after an
exercise programme. In the current study, the significant
improvement in QOL which is included in the physiologic
dimension of the RAM is also believed to be associated with
the exercise programme. Shievelv et al. (2005) found that
intervention patients showed significantly improved MLWHF
physical dimension scores over time compared with control

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd

MLWHF, Minnesota Living With Heart Failure Questionnaire; ISEL, Interpersonal Support Evaluation List; 6MWT, 6-minute walking test; HDL, high-density lipoprotein; LDL, lowdensity lipoprotein; BMI, body mass index.
*P < 005. **P < 0001.

1000
0562**
0404**
0884**
0470**
0350**
0514**
0522**
0741**
000
0271
0161
0027

1000
0327*
0739**
0212
0124
0249
0225
0700**
0038
0255
0031
0179

1000
0722**
0066
0119
0221
0027
0413**
0197
0157
0255
0238

1000
0298
0184
0448**
0346*
0785**
0068
0289
0201
0163

1000
0564**
0583**
0894**
0468**
0190
0105
0228
0100

1000
0405**
0830**
0305*
0299
0277
0230
0398**

1000
0730**
0530**
0107
0190
0003
0118

1000
0505**
0013
0225
0009
0191

1000
0103
0228
0225
0136

1000
0174
0824**
0435**

1000
0033
0181

1000
0344*

1000

Adaptation to heart failure

Physical MLWH
Emotional MLWHF
Role Function MLWHF
MLWHF
Tangible support ISEL
Appraisal support ISEL
Belonging support ISEL
ISEL
6MWT
Cholesterol
HDL
LDL
BMI

Emotioal
MLWHF
Physical
MLWHF

Table 4 Correlations between measures

Rol Function
MLWHF

MLWHF

Tangible
Support ISEL

Appraisal
support ISEL

Belonging
support ISEL

ISEL

6MWT

Cholesterol

HDL

LDL

BMI

JAN: ORIGINAL RESEARCH

patients after rehabilitation. Gottlieb et al. (1999) found that

only exercise in management of HF increased 6-minute walk
distance, and that QOL did not improve. For this reason,
rehabilitation programmes should include education, exercise, and emotional and social support.
Of the four RAM modes of adaptation, the physiologic
model was associated with the other modes. Patients with
good QOL on the physiologic dimension were found to be
more able to perform their social functions when they have
good emotional status and social support.
Psychological symptoms have relevance because of their
negative impact on HRQOL, adherence, morbidity and
mortality. Improving self-care is critical for patients with
HF (Zambroski et al. 2005). Lack of emotional support is a
predictor of cardiovascular events. Patient without emotional
support had a threefold increase in the risk of cardiovascular
events in the year (Bosson 2005). Psychological status of the
patients has a strong association with physiologic and role
performance. Good emotional status helps physiological
health and enables better performance of social functions.
In the current study social support was related to HRQOL,
although a few studies have found that social support was
unrelated to HRQOL. There was an association between
ISEL-SF and physiologic status. Patients with higher levels of
social support are likely to have fewer physiologic effects and
are physically in a better condition. As families and friends
play an important role in social support, their encouragement
had positive effects on the patients. It is suggested that social
support and demographic factors are of importance in
adaptation to exercise after a cardiac event. Those who
receive social support from their families and friends are
more likely to join exercise programmes (Moore & Chorvat
2002). Levels of depression are expected to be higher those
with chronic illness and less social support (Owen 2003).
Results reported in the literature indicate that social
relationship with other patients and support from healthcare
professionals assist patients in being able to adapt to chronic
illness (Samarel et al. 2002). For married women with
chronic illness, a spouse is the primary source of social
support (Martensson et al. 1998). Stromberg et al. (1999)
determined that the patients social relationships with their
families or friends increased their compliance. Some studies
suggest that social support has a direct effect on physical and
psychological well-being. Rintala et al. (2005) found that
social support had an important effect on life satisfaction.
Several researchers have determined that those who had
experienced myocardial infarction living socially isolated and
alone without social support run a greater risk of developing
another MI, or death risk months or even years after a
cardiac event. Some researchers have indicated associations

 2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd

605

G. Bakan and A.D. Akyol

What is already known about this topic

The Roy Adaptation Model has been used to guide

research conducted in various settings and with various
populations, but has not been used to guide studies of
patients with heart failure.
Several rehabilitation programmes for patients with
heart failure have had positive effects on quality of life
and functional abilities.
The Roy Adaptation Model is an appropriate guide
when providing nursing care for patients with chronic
diseases such as heart failure.

Acknowledgements

What this paper adds

Patients in the intervention group adapted well to their

condition and the four adaptive modes of Roy Adaptation Model were interrelated. Patients quality of life
was enhanced, their functional capacities increased
and social support within the interdependence dimension improved in patients in the intervention group.
At the end of the rehabilitation programme there were
statistically significant improvements in patients
quality of life, functional abilities, social support,
physiological findings and emotional status.
Roys model is an effective guide for nursing practice
when caring for patients with heart failure.

among social support, morbidity and HF (Moser & Worster

2000).

Conclusion
This is the first study of the RAM being used to study patients
with HF. The RAM can be used in adaptation programmes to
guide evaluation of the process of adaptation. The adaptation
modes of the RAM may be useful to all health educators and
are not limited in scope to nursing practice. The RAM is an
effective guide for nursing practice when caring for clients
with HF. The current researchers argue that there is strong
evidence of increased exercise capability after exercise adaptation programmes. Such programmes need to be tailored to
individuals.
Future RAM-based experimental studies should include
larger samples. Intervention research is needed to determine
behaviour-change strategies that will assist patients in
adopting more effective ways of coping with HF. Educational
programmes should focus on providing patients with the
incentives, knowledge and skills necessary to carry out these
606

health-related behaviours. Additional research is warranted

on the impact of family structure on patients health.
Future studies are needed in which a comprehensive
measure of social support is used to determine the relationship between social support and HRQOL in patients with
HF. The authors believe that adaptation should become an
important concept in the care of patients who have experienced HF. It appears that the model used in the current study
has the potential to be generalized to other areas of nursing
practice, education and research. Intensive management in
HF clinics can be effective in translating clinical guidelines
into practice.

This study was carried out at Ataturk Education and

Research Hospital, Izmir, Turkey. Patient education materials were printed by pfizer medicine firm. We thank all those
who supported us in conducting the study.

Author contributions
GB and AA were responsible for the study conception and
design and the drafting of the manuscript. GB performed the
data collection and GB and AA performed the data analysis.
GB provided administrative support. GB and AA made
critical revisions to the paper. GB and AA provided statistical
expertise. GB and AA supervised the study.

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