that 550,000 new cases are diagnosed each year (Miller &
Introduction
Missow 2001). HF is primarily a condition of older people
Heart failure (HF) is an increasingly common health problem and thus the widely recognized ageing of the population also
with high morbidity and mortality and numerous hospital- contributes to its increasing incidence. The incidence of HF
izations (Braunwald et al. 2001, Lainscak & Keber 2003, approaches 10 per 1000 population after age 65 years (ACC/
Vavouranakis et al. 2003). Nearly 5 million Americans have AHA Practice Guidelines 2005). Approximately 50% of
HF [American Collage of Cardiology/American Heart Asso- patients aged 65 years and older with HF are readmit-
ciation (ACC/AHA) Practice Guidelines 2005, Washburn ted within 6 months of discharge from hospital (Washburn
et al. 2005], and data from the Framingham database suggest et al. 2005). In addition, there are more than 900,000
596 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Adaptation to heart failure
hospitalizations in the USA each year because of HF (Rhodes capacity, and psychological well-being. Rehabilitative exer-
& Bowles 2002). The European Society of Cardiology (ESC), cise also reduces the severity of symptoms, which can in turn
representing countries with a total population of over decrease depression (Artinian et al. 2003). In studying the
900 million, suggests that there are at least 10 million patients management of HF, Gottlieb et al. (1999) and McKelvie et al.
with HF in those countries. Half of patients with a diagnosis (2002) found that exercise increased 6-minute walking
of HF will die within 4 years, and more than 50% of those distance, but QOL was not improved.
with severe HF will die within 1 year (ESC Guideline 2005). 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
Background
HF, prognosis, activity, diet, medications, and compliance
In the past 20 years, there has been a large number of studies with the treatment plan. As patients and caregivers gain
evaluating HF management. Research results were summa- knowledge in these areas and participate in management
rized in evidence-based guidelines by the Agency for Health decisions, they are empowered to self-manage the illness
Care Policy and Research, now called Agency for Health (Washburn et al. 2005).
Care Policy and Research and Quality (AHRQ), the ACC/ Non-pharmacological advice is an important aspect of
AHA and the Heart Failure Society of America. Since the disease management and is included in recently published
widespread publication of these guidelines, advances have ESC guidelines (Lainscak & Keber 2003). The development
been made in the provision of evidence-based HF manage- of HF clinics, HF units and HF programmes, most of which
ment (Washburn et al. 2005). Multidisciplinary cardiac are nurse-led, has increased in developed countries with
rehabilitation programmes that include patient education, success (Gonzales et al. 2005). Moreover, observational
exercise training, and lifestyle modification can improve studies and randomized controlled trials have shown that
symptoms, functional performance and health-related quality disease-management programmes can reduce the frequency
of life (QOL) in older patients with HF (Gary et al. 2004, of hospitalization and can improve QOL and functional
Austin et al. 2005). status. Patients at high risk for clinical deterioration or
Vavouranakis et al. (2003) found that intensive home care hospitalization are likely to benefit from disease management
of patients with HF resulted in improved QOL and reduced programmes; such interventions are shown to be cost-
hospital readmission rates. Studies have shown that patients effective for this patient group (D’Alto et al. 2003, Wright
with HF had poor understanding of the importance of et al. 2003, Shievelv et al. 2005).
compliance and self-management strategies to optimize Corvera et al. (2004) found that a progressive home
control of the condition (Wright et al. 2003). Multidisciplin- walking exercise programme for patients with HF is accept-
ary and transitional care models with strong patient educa- able, increases walking distance, and decreases global rating
tional components have been effective in reducing of symptoms. Compared with the usual activity groups the
hospitalizations and improving QOL among patients with training group had significantly longer walking distances
HF (ACC/AHA Heart Failure Clinical Data Standards 2005). measured by the 6-minute walking test (6MWT) and
Patient education is vital for comprehensive HF manage- improved postglobal rating of symptoms.
ment. Nurses have an important role in educating and Social, physical, emotional and economic difficulties
supporting patients with HF to comply with the medical resulting from chronic disease make it difficult for the patient
regimen and practice self-care (Strömberg et al. 1999). A and the family to adapt to new conditions; these difficulties
team-based approach to patient education and patient are associated with decreased QOL (Tokem et al. 1999). Heo
empowerment has been advocated by the AHRQ, ACC/ et al. (2005) could not demonstrate any association between
AHA. Martensson et al. (1998) found that when primary social support and QOL. There are too few studies investi-
healthcare nurses received a patient’s report with information gating the relationship between social support and QOL in
on the patient’s mental, physical and social status, nurses patients with HF. In those rare studies, while some research-
could contribute to creating a safe and secure environment ers stated the presence of the association between emotional
for the patient. Nurses achieved this by increasing the quality support and QOL, others stated a completely opposite view
of the family’s emotional support through information and (Moser & Worster 2000, Bosson 2005).
continuous contact (Hanna & Roy 2001). The focus of the current article is use of the Roy
Cardiac rehabilitation through physical activity end exer- Adaptation Model (RAM) in the context of cardiac nursing
cise training is an important aspect of care for patients with (Patton 2004) There are no reports of previous studies in
HF. Physical activity improves exercise tolerance, functional which the RAM was used to offer care to patients with HF.
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 597
G. Bakan and A.D. Akyol
Research by DiMattio and Tulman (2003) used the RAM to should be considered the focal environmental stimuli in
guide a study of women’s functional recovery during the first determining adaptation (Samarel et al. 1998, 2002, Nuamah
6 weeks at home following coronary artery bypass graft et al. 1999). Villareal (2003) found that, in caring for a small
surgery. Functional recovery was measured in terms of group of female smokers, the RAM can be used as a guide to
performance of usual role activities, and the influence of provide comprehensive nursing care.
comorbidity, household composition, fatigue and surgical
pain on performance. Several studies on different chronic
Conceptual framework
diseases have been based on RAM and similar results have
been found. Burns (2004) studied the physical and psycho- The study was guided by the RAM (Figure 1), which is based
logical adaptation of participants of African origin to on scientific assumptions drawn from general system theory
haemodialysis and found an association between the prob- (Whittemore & Roy 2002) and adaptation level theory
lems perceived through role performance and social support (Whittemore & Roy 2002, Tsai et al. 2003). The RAM
dimensions of RAM. In a training programme designed to focuses on environmental stimuli and the bio-psycho-social
prevent amputation in patients with diabetes, Scollan-Koli- responses to the stimuli (Shin et al. 2006), and emphasizes the
opoulos (2004) compared the RAM and the Health Belief interaction between the person and the environment as the
Model, and found that the RAM was a better instrument for person adapts to environmental stimuli (Tourville & Ingals
designing a community-based plan. 2003). The RAM is one of the most fully developed and
Previous studies have found support for the proposition that widely used of all nursing conceptual models (Riehl & Roy
all modes of adaptation (physiologic, self-concept, interdepen- 1980, Velioğlu 1999). Nurses act to promote patients’ levels
dence, role function) were interrelated. The RAM is generally of adaptation during health and illness using the nursing
used to assess cancer patients. However, study results reveal process (Dixon 1999, Villareal 2003, Patton 2004). Environ-
that severity of illness and adjuvant cancer treatment had the mental stimuli include focal, contextual and residual stimuli
strongest association with bio-psycho-social responses and (Samarel et al. 1998, Willoughby et al. 2000, Hanna & Roy
Figure 1 Conceptual–theoretical–empirical structure of adaptation to heart failure. MLWHF, Minnesota Living With Heart Failure Ques-
tionnaire; ISEL, Interpersonal Support Evaluation List; 6MWT, 6-minute walking test.
598 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Adaptation to heart failure
2001, Scollan-Koliopoulos 2004). The focal stimulus is the provide a safe environment and the support necessary to
one most immediately confronting the person. Contextual allow the patient to succeed in managing their condition
stimuli are all other stimuli that contribute directly to (Martensson et al. 1998).
adaptation. Residual stimuli are other unknown factors that In the present study, health-related QOL (HRQOL) was
may contribute to adaptation. When residual stimuli are considered to be a latent variable that reflects overall
identified, they are reclassified as focal or contextual stimuli response of the adaptive system to environmental stimuli.
(Tolson & Mcintosh 1996, Gagliardi 2003, Tsai 2005). In the The components of HRQOL and social support were
current study, the experimental adaptation programme, social reflected in the four bio-psycho-social response modes. The
support, age, gender and disease severity were the environ- four modes of adaptation were used to measure levels of
mental stimulii of interest. When individuals are confronted adaptation to the disease as follows:
with stimuli, their coping processes, by way of regulator and • Physiological mode – various physical functioning and
cognitive subsystems, are activated and manifested in one or physiological measures.
more of Roy’s four interrelated modes (Cunningham 2002, • Self-concept mode – emotions.
_
Gagliardi et al. 2002, Tourville & Ingals 2003). • Role function mode – social functioning.
The physiologic mode relates to maintenance of the • Interdependence mode – interpersonal support.
physiologic integrity of the adaptive system. The self-concept
mode relates to people’s conceptions of their physical and
The study
personal selves. The interdependence mode deals with social
support and maintenance of satisfying relationships with
Aim
significant others. The role function mode deals with social
integrity by focusing on activities associated with the person’s The aim of this RAM-based study was to examine the effects
roles in life (Pearson et al. 1998, Nuamah et al. 1999, Chiou of a Roy Adaptation Model-based experimental education,
2001, Yeh 2002, Burns 2004). Adaptive responses promote exercise and social support programme on adaptation in
integrity and help to meet the goals of adaptation, which persons with heart failure.
include mastery, survival and growth. On the other hand, the
reproduction of ineffective responses does not promote
Design
integrity of the individual and does not contribute to the
goals of adaptation (Cunningham 2002). The data reported in this paper are a secondary analysis of
Research findings show that patients’ informal social data from a randomized controlled trial conducted in the first
support and education from fellow patients, family members 6 months in 2005. The secondary analysis was carried out at
and the healthcare team can influence adaptation to chronic the end of 2005.
disease (Samarel et al. 1998). Social support may be defined
as an interaction involving two or more people whose
Participants
purpose is to promote awareness and education, provide
emotional instrumental, financial support and assist with The study was conducted at a cardiology and internal disease
problem-solving (Moser & Worster 2000, Samarel et al. polyclinic in a state hospital in Turkey. The 44 patients who
2002, Shin et al. 2006). When the RAM is used, this affects participated in the study were randomized to the study
social functioning. Personal resources, such as self-control, conditions: 22 patients to intervention group and 22 patients
enhance the impact of social support for individuals with to control group. Of those randomized to intervention, 21
chronic illness dealing with stress (Tsai et al. 2003). completed 3 months of follow-up. One patient who had to
Social support has been identified as an important factor in leave the city during the study period was dropped from the
adjustment to chronic illness (Willoughby et al. 2000). As the study.
quality of emotional support from the family may have a Inclusion criteria for participants were literacy, ability to
significant effect on the patient’ emotional state, development communicate verbally, diagnosis of HF at least 6 months
of the family’s function and its capacity to support the patient before for the study, New York Heart Association (NYHA)
is an important component in nursing plans for this patient functional class II–III (Table 1), ejection fraction <40%,
group. Patients with HF need to feel empowered to be no hearing or visual detect, no mental disorder, no
managers of their own care so that the disability or illness myocardial infarction in the past year, and plans to remain
does not become their entire identity. Otherwise, HF may in the city during the study period or could be reached by
cause social isolation and loneliness. Nurses can help to telephone.
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 599
G. Bakan and A.D. Akyol
Table 1 New York Heart Association (NYHA) classification of heart 48-item Interpersonal Support Evaluation List (ISEL)
failure designed by Owen (2003). The interdependence mode of
Level Description adaptation was measured with the ISEL. This measure
assesses the perceived availability of the following specific
I Diagnosed with heart failure based on cardiac changes,
support resources. The instrument consists of three subscales:
but no symptoms present regardless of level of activity
II Symptoms (such as fatigue, dyspnoea, palpitations, tangible support, appraisal support and belonging support.
angina) with ordinary activity; slight activity limitation Each item is endorsed on a rating scale with the following
III Symptoms with less than ordinary activity; no symptoms response options: completely false, somewhat true and
when at rest; marked limitation with daily tasks completely true. Negatively phrased items on each scale are
IV Symptoms with any type of physical activity, or even
reverse scored so that higher scores reflect greater perceived
at rest
availability of the specific support resource reflected in each
subscale and for the total score (Owen 2003). Cronbach’s a
Instruments
coefficient in the present study was 0Æ79.
Patient identification form
An investigator-developed questionnaire was used to collect 6-Minute walking test
demographic information for each patient. Functional status was measured using the 6MWT. After
6 minutes elapsed, patients were instructed to stop walking
Assessment form for physiological data and the total distance walked was measured to the nearest
An assessment form was prepared to evaluate changes in foot. Before and after each 6MWT the patient’s pulse,
body mass index (BMI), cholesterol, high-density lipoprotein respiratory rate and blood pressure were recorded (McKelvie
(HDL) and low-density lipoprotein (LDL) levels; to deter- et al. 2002, Duncan & Rozehl 2003). Physical symptoms
mine changes in habits such as smoking, alcohol consump- observed by the investigator or reported by the participants,
tion, adaptation to diet and regular medication use; and to and the latest 6-minute walk test results were recorded (Gary
find out the number of hospital admissions because of HF et al. 2004). Physiologic mode of adaptation was measured
during the programme. using the 6MWT.
600 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH 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 symp- The investigator provided additional information to the
toms of HF and to contact the investigator and medical staff patient based on the patient’s interest in specific topics or
if early sign or symptoms of worsening HF occurred. questions raised during the session. Patients were encouraged
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 601
G. Bakan and A.D. Akyol
to engage in regular exercise and advised that it is safe to examined by calculating Pearson correlation coefficients.
exercise up to the level of moderate discomfort (e.g. fatigue of Between group differences at pretest and post-test were tested
the leg muscles, dyspnoea or angina). No adverse event using t-tests. The chi-squared test was used to test for
occurred throughout the duration of exercise regimen. Self- differences in categorical data. Repeated measures analyses of
monitoring techniques (e.g. recording daily weight) and variance (ANOVA s) with post hoc t-tests were used to analyse
positive verbal feedback were also part of the intervention. the study hypothesis that patients who participated in the
One-on-one interviews were 2 hours in length. Measures of adaptation programme would better adapt to living with the
6MWT, MLHFQ, ISEL-SF and blood testing for levels of HF than those who were assigned to the control condition.
cholesterol, HDL, LDL were chosen to reflect the impact of Statistical significance was set at P = 0Æ05 and 0Æ001.
the intervention and were applied to both intervention and
control group patients at baseline and at 3 months. The
Results
interview consisted of establishing specific goals with patients
related to healthier diet, increased quality and amount of Table 2 shows baseline clinical details of the randomized
exercise and increased social and interpersonal activities. The patients. There was no baseline difference between the
focus of the interview was on goal setting and individualizing intervention and control groups concerning education level,
health life-style changes for participants. Advice was rein- age, and sex and NYHA class. Mean age of patients in the
forced at each subsequent clinic visit during one-on-one intervention group was 62Æ67 years; 61Æ9% were female and
counselling sessions by the investigator. 52Æ4% were married. At least 20% of the patients were
Telephone contacts were made to verify functional status,
proper use of medications and to encourage the patients to
Table 2 Patient characteristics at baseline
adhere to the programme. Patients were also instructed to call
the investigator to report symptoms or any other problem Intervention Control
promptly. n = 21(%) n = 22 (%)
602 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Adaptation to heart failure
Discussion
Study limitations
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 603
G. Bakan and A.D. Akyol
Baseline, mean (SD ) 3 months, mean (SD ) Baseline, mean (SD ) 3 months, mean (SD )
Social Support 42Æ42 (3Æ82)* 47Æ38 (3Æ80)* 40Æ40 (4Æ62) 40Æ63 (5Æ03)
Cholesterol 199Æ86 (52Æ73)* 179Æ10 (39Æ71)* 195Æ91 (41Æ79) 189Æ32 (40Æ61)
HDL 41Æ33 (4Æ69) 41Æ81 (4Æ40) 41Æ27 (5Æ70) 40Æ73 (5Æ85)
LDL 138Æ90 (36Æ75)* 28Æ71 (27Æ05)* 136Æ00 (30Æ13) 135Æ41 (32Æ83)
hence only variables in the original study were available, which examined a similar cohort of patients, found fewer
which limited the possibility of operationalizing some con- hospitalizations and increased exercise capacity when
cepts. In addition, use of a convenience sample limited the patients were managed with a dedicated HF programme
generalizability of the findings. Further, although the findings (Vavouranakis et al. 2003).
provide preliminary evidence of causal relationship among Comprehensive HF programmes that include patient edu-
variables, better examination of causality will require longi- cation, self-management strategies and integrated follow-up
tudinal data. On the other hand, these study findings could be by a multidisciplinary team, show benefits in term of
culturally specific and the study would need to be replicated improved patient QOL and fewer hospitalizations (Wright
in different cultural settings. 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,
Discussion of results
Corvera et al. 2004, Gary et al. 2004, Shievelv et al. 2005) .
Intervention and control group differences for QOL, walk Austin et al. (2005) reported significant differences in all
distance and social support quality indicate that the RAM- MLWHF components (emotional, physical and total)
based adaptation programme had some effect on adaptation between experimental and standard-care patients at 8 and
to HF in relation to physiologic, self-concept, interdepen- 24 weeks. Investigating which components have the greatest
dence and role function modes. uptake by patients would help in the formulation of guide-
Exercise in management of HF has been studied exten- lines for the streamlined design of patient self-management
sively. The Clinical Practice Guidelines on HF recommended programmes for HF (Wright et al. 2003).
regular exercise in NYHA classes I–III for patients with HF. DeWald et al. (2004) developed and tested an educational
This recommendation was based on several studies which programme designed to meet the needs of patients with low
showed that patients with HF could exercise safely, improve literacy skills. Participants (n = 23) showed a significant
their functional status, and decrease symptoms (DeWald improvement in HRQOL that is likely to be of clinical
et al. 2004). In the current study, the improvement in distance importance. Disease management programmes have a posi-
walked at 3 months in the intervention group is equivalent to tive effect on patient outcomes and are associated with
an improvement in functional performance, the consequence decreased hospitalizations and readmissions (DeWald &
of which is enhanced daily activity. The finding that there was Gaulden 2000). The findings from the current study suggest
a significant improvement in the 6MWT is agreement with that the adaptation programme used is particularly effective
other studies (Gottlieb et al. 1999, Gary et al. 2004, Austin at improving HRQOL, as described by disease-specific and
et al. 2005). Corvera et al. (2004) found that patients in the utility measures, than a nurse-led outpatient clinic.
training group who improved had remarkably increased There have been few studies of the effects of exercise on
6MWT distances. These findings suggest that a simple QOL. However, most of the available studies demonstrate an
walking programme is beneficial for many patients with HF improvement in the QOL of patients with HF after an
and can result in increased walking distances in some exercise programme. In the current study, the significant
patients. improvement in QOL which is included in the physiologic
McKelvie et al. (2002) found that a comprehensive HF dimension of the RAM is also believed to be associated with
management programme led to improved functional status the exercise programme. Shievelv et al. (2005) found that
and an 85% decrease in hospital admission rate for heart intervention patients showed significantly improved MLWHF
transplant candidates. A study by Vavouranakis et al. (2003), physical dimension scores over time compared with control
604 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Adaptation to heart failure
1Æ000
MLWHF, Minnesota Living With Heart Failure Questionnaire; ISEL, Interpersonal Support Evaluation List; 6MWT, 6-minute walking test; HDL, high-density lipoprotein; LDL, low-
BMI only exercise in management of HF increased 6-minute walk
distance, and that QOL did not improve. For this reason,
0Æ344*
1Æ000
LDL
1Æ000
0Æ033
0Æ181
HDL
0Æ824**
0Æ435**
more able to perform their social functions when they have
0Æ174
1Æ000
good emotional status and social support.
Psychological symptoms have relevance because of their
6MWT
1Æ000
0Æ103
0Æ228
0Æ225
0Æ136
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
0Æ505**
1Æ000
0Æ013
0Æ225
0Æ191
0Æ009
1Æ000
0Æ190
0Æ107
0Æ003
0Æ118
0Æ405**
0Æ830**
0Æ398**
0Æ299
0Æ277
0Æ230
1Æ000
0Æ105
0Æ100
0Æ190
0Æ228
0Æ785**
0Æ346*
1Æ000
0Æ298
0Æ184
0Æ068
0Æ289
0Æ201
0Æ163
0Æ413**
MLWHF
1Æ000
0Æ066
0Æ119
0Æ027
0Æ221
0Æ197
0Æ157
0Æ255
0Æ238
0Æ700**
MLWHF
Emotioal
0Æ327*
0Æ038
0Æ212
0Æ124
0Æ249
0Æ225
0Æ255
0Æ031
0Æ179
1Æ000
0Æ271
0Æ161
0Æ027
000
6MWT
LDL
BMI
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 605
G. Bakan and A.D. Akyol
606 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH Adaptation to heart failure
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