As the nursing profession continually evolves, practice knowledge is increasing and closing the theory-practice gap. The purpose of this discussion is to explore how nursing theory is used as a framework in nursing research, building the body of professional nursing knowledge.
Instructions
- Using one of the articles provided in this week’s course announcement, identify the nursing theory used to frame the nursing research.
- Analyze the selected nursing theory and describe how the theory applies to nursing’s metaparadigm, including each of the following:
Person
Health
Environment
Nursing
Required article
Rosa, W. E., Dossey, B. M., Koithan, M., Kreitzer, M. J., Manjrekar, P., Meleis, A. I., Mukamana, D., Ray, M. A., & Watson, J. (2020).
Nursing theory in the quest for sustainable development goals. (Links to an external site.)
Nursing Science Quarterly, 33(2), 178-182. https//:10.1177/0894318420903495
Select only one of the four nursing theories and then using the selected theory analyze the nursing paradigm (person, health, environment, and nursing).
Comfort and fluid retention in adult patients receiving hemodialysis. (Links to an external site.)
Estridge, K.M., Morris, D.L., Kolcaba, K., & Winkelman, C. (2018). Comfort and fluid retention in adult patients receiving hemodialysis. Nephrology Nursing Journal, 45(1), 25-33, 60.
************************************************************************************
*
https://doi.org/10.1097/HNP.0000000000000164 (Links to an external site.)
Barutcu, C.D. & Mert, H. (2016). Effect of support group intervention applied to the caregivers of individuals with heart failure on caregiver outcomes. Holistic Nursing Practice, 30, 272-282. https://doi.org/10.1097/HNP.0000000000000164
************************************************************************************
https://doi.org/10.1097/NMC.0000000000000570 (Links to an external site.)
Miller Westmoreland C., & Wojnar, D. (2019). Breastfeeding support guided by Swanson’s theory of caring. MCN, American Journal of Maternal Child Nursing, 44, 351-356. https://doi.org/10.1097/NMC.0000000000000570
*************************************************************************************
The effect of education and telephone follow-up intervention based on the Roy Adaptation Model after myocardial infarction (Links to an external site.)
Turan Kavradim, S., & Canli Ozer, Z. (2020). The effect of education and telephone follow-up intervention based on the Roy Adaptation Model after myocardial infarction: Randomised controlled trial. Scandinavian Journal of Caring Science, 34, 247–260. https://doi.org/10.1111/scs.12793
DNPDiscussion Guidelines
Purpose
The purpose of the graded collaborative discussions is to engage faculty and students in an interactive dialogue to assist the student in organizing, integrating, applying, and critically appraising knowledge regarding advanced nursing practice. Scholarly information obtained from credible sources as well as professional communication are required. Application of information to professional experiences promotes the analysis and use of principles, knowledge, and information learned and related to real-life professional situations. Meaningful dialogue among faculty and students fosters the development of a learning community as ideas, perspectives, and knowledge are shared.
Due Date
The initial posting to the graded collaborative discussions is due by Wednesday, 11:59 p.m. MT. Peer and faculty responses are due by Sunday, 11:59 p.m. MT. All posts for Week 8 are due by the close of class on Saturday, 11:59 p.m. MT. Please note that the late assignment policy does not apply to the collaborative discussions.
Discussion Criteria
Review the discussion criteria:
Application of Course Knowledge
· The student post contributes unique perspectives or insights gleaned from personal experience or examples from the healthcare field. The student must accurately and fully discuss the topic for the week in addition to providing personal or professional examples. The student must completely answer the entire initial question.
Engagement in Meaningful Dialogue
·
The student responds to a student peer and course faculty to further dialogue.
· Peer Response: The student responds substantively to at least one topic-related post by a student peer. A substantive post adds content or insights or asks a question that will add to the learning experience and/or generate discussion.
· A post of “I agree” with a repeat of the other student’s post does not count as a substantive post. A collection of shallow posts does not equal a substantive post.
· The peer response must occur on a separate day from the initial posting.
· The peer response must occur before Sunday, 11:59 p.m. MT.
· The peer response does not require a scholarly citation and reference unless the information is summarized and/or direct quotes are used, in which APA style standards then apply.
· Faculty Response: The student responds substantively to at least one question by course faculty. The faculty question may be directed to the student, to another student, or to the entire class.
· A post of “I agree” with a repeat of the faculty’s post does not count as a substantive post. A collection of shallow posts does not equal a substantive post.
· The faculty response must occur on a separate day from the initial posting.
· Responses to the faculty member must occur by Sunday, 11:59 p.m. MT.
· This response does not require a scholarly citation and reference unless the information is summarized and/or direct quotes are used, in which APA style standards then apply.
Integration of Evidence
· The student post provides support from a minimum of at least three (3) sources which may include assigned readings, or weekly module content, or outside scholarly sources. The scholarly source when used is: 1) evidence-based, 2) scholarly in nature, 3) published within the last 5 years, and 4) an in-text citation. The student initial response to the graded discussion must include at least 1 source. Responses to peer and/or faculty, citations and references are included when information is summarized/synthesized and/or direct quotes are used, in which APA style standards then apply.
· It is important that student utilizes support from the literature that is grounded in the literature providing sources relevant to the discussion posting. One source may come from the online weekly content.
· Scholarly Sources
· Two (2) scholarly sources should be used in the discussion board assignments across the week.
· These include peer-reviewed publications.
· Textbooks are not considered scholarly sources. However, in some assignments, support from textbooks may be used on a limited basis when accompanied with additional scholarly sources if specified in the assignment guidelines or with instructor approval.
· Scholarly sources may be present in the weekly readings and students may choose to utilize these.
· Wikipedia, Wikis, .com website or blogs should not be used.
· Sources should be no more than five years old unless they are historical or seminal references or approved by your instructor.
· Literature Sources:
· Grey literature is scholarly but not peer-reviewed. These resources can be used but do not meet requirements for peer-reviewed sources.
· Refer to the assignment guidelines to determine which grey literature sources (e.g., professional organization website, white papers) are appropriate to be used for discussions or assignments and would constitute receiving full credit for using this resource in the paper or discussion.
· Government reports are actually part of the grey literature – they are not peer reviewed and the government’s main purpose is not the publication of literature.
· Internet resources on dissertations, a form of grey literature, provide additional views on the scholarly level of this literature
· Papers written for Chamberlain College of Nursing should be the student’s original work and contain no more than one short quotation for every three pages or as designated in the assignment guidelines. Quotations should be avoided if possible.
(Chamberlain Guidelines for Writing Professional Papers, 2020)
Professionalism in Communication
· The post presents information in logical, meaningful, and understandable sequence, and is clearly relevant to the discussion topic. Grammar, spelling, and/or punctuation are accurate.
Wednesday
Participation
Requirement
· The student provides a substantive response to the graded discussion question(s) or topic(s), posted by the course faculty (not a response to a peer), by Wednesday, 11:59 p.m. MT of each week.
Total Participation Requirement
· The student provides at least three substantive posts (one to the initial question or topic, one to a student peer, and one to a faculty question) on two different days during the week.
Rubric
Discussion Criteria |
Highest Level Performance: A |
Very Good or High Level of Performance: B |
Acceptable Level of Performance: C |
Failing Level of Performance: F |
||
Left blank |
10 points |
9 points |
8 points |
0 points |
||
Application of Course Knowledge: Answers initial discussion question(s)/ topic(s), demonstrating knowledge, understanding of weekly concepts. |
Addresses all aspects of the initial discussion question(s) applying experiences, knowledge, and understanding. |
Addresses most aspects of the initial discussion question(s) applying experiences, knowledge, and understanding. |
Addresses some aspects of the initial discussion question(s) applying experiences, knowledge, and understanding. |
Does not address the initial question(s). |
||
Engagement in Meaningful Dialogue with Peers and Faculty: The student responds to a student peer and course faculty to further dialogue. |
Responds to student peer AND course faculty furthering dialogue by providing more information and clarification, adding much depth to discussion. |
Responds to a student peer AND course faculty furthering the dialogue by adding some depth to the discussion. |
Responds to a student peer and/or course faculty, adding minimal depth to the discussion. |
No response post to another student or course faculty. |
||
Integration of Evidence: Includes assigned readings, or weekly module content, or outside scholarly sources. Includes three sources to support weekly concepts. A scholarly source is defined on page 2 of these guidelines. These sources may be evident across the 3 postings. |
Sources are credited.* At least 3 sources to support posts. |
Sources are credited.*
At least 2 sources to support posts. |
Sources are credited.*
At least 1 source to support posts. |
No scholarly source provided to support posts. |
Professionalism in Communication |
Presents information using clear, concise language in organized manner (0-1 error patterns in English grammar, spelling, syntax, and punctuation). |
Presents information using clear, concise language in organized manner (2-3 error patterns in English grammar, spelling, syntax, and punctuation). |
Presents information using understandable language; information is not organized 4-5 error patterns in English grammar, spelling, syntax, and punctuation). |
Presents information that is not clear, logical, professional, or organized; reader has difficulty understanding the post; 6 or more error patterns in English grammar, spelling, syntax, punctuation). |
Participation
5 points |
||
Participation Wednesday Response: Responds to initial discussion question(s) by Wednesday, 11:59 p.m. MT. |
Posts substantive response to initial discussion question(s) by Wednesday, 11:59 p.m. MT. |
Does not post substantive response to initial discussion question(s) by Wednesday, 11:59 p.m. MT. |
Total Participation Responses: Participates in discussion thread at least three times on at least 2 different days. |
Posts in discussion at least three times AND on two different days during discussion week. |
Posts fewer than three times OR does not participate on at least two different days during discussion week. |
NOTE: To receive credit for a week’s discussion, students may begin posting no earlier than the Sunday immediately before each week opens. Unless otherwise specified, access to most weeks begins on Sunday at 12:01 a.m. MT, and that week’s assignments are due by the next Sunday by 11:59 p.m. MT. Week 8 opens at 12:01 a.m. MT Sunday and closes at 11:59 p.m. MT Saturday.
A zero is the lowest score that a student can be assigned.
Faculty may submit any collaborative discussion posting to Turnitin in order to verify originality.
* Using APA style and formatting, in text citations are included for all sources. Matching references are included for all in-text citations. Due to the formatting constraints of Canvas, references included in the discussion must include complete information. Canvas will not allow a hanging indent; it is not required.
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 25
Comfort and Fluid Retention in Adult
Patients Receiving Hemodialysis
K
idney failure with subsequent
hemodialysis (HD) is not only
disruptive to lifestyles of
patients and families, but also
has concerning financial implications.
Decreasing the burden of treatments,
such as fluid restrictions for patients
with end stage renal disease (ESRD),
with the potential of improving
adherence may improve quality of
life and extend the lifespan.
Adherence to fluid restrictions is
difficult for patients receiving HD
(Welch, 2001). Adherence can
demand major lifestyle modifications
because of the many restrictions
imposed by the treatment regimen,
not only in one’s physical routines,
but also in aspects of imposed social
interruptions that can impact quality
of life (Tovazzi & Mazzoni, 2012).
Nonadherence to fluid restrictions
among patients receiving HD, lead-
ing to fluid retention between treat-
ments, may result in increased co-
morbidities and death. Research has
been inconclusive in determining
options to enhance adherence to fluid
restrictions in adult patients receiving
HD. There is a lack of knowledge
about which factors affect this popula-
tion’s health-seeking behaviors relat-
ed to fluid restriction adherence.
Karen M. Estridge
Diana L. Morris
Katharine Kolcaba
Chris Winkelman
Continuing Nursing
Education
Karen M. Estridge, DNP, RN, is an Assistant
Professor, Assessment Coordinator; College of
Nursing and Health Sciences, Ashland University,
Ashland, OH.
Diana L. Morris, PhD, RN, FAAN, FGSA, is
an Associate Professor, Director of the University
Center on Aging and Health; Frances Payne Bolton
School of Nursing, Case Western Reserve
University, Cleveland, OH.
Katharine Kolcaba, PhD, RN, is an Associate
Professor, Emeritus; School of Nursing, University
of Akron, Akron, OH.
Chris Winkelman, PhD, APRN, CCRN,
CNE, FCCM, FAANP, is an Associate Professor;
Frances Payne Bolton School of Nursing, Case
Western Reserve University, Cleveland, OH.
Further examination about this
aspect of treatment for kidney failure is
needed to inform potential new oppor-
tunities for intervention. Therefore,
this project sought to answer the fol-
lowing research question: What is the
relationship between comfort and fluid
retention among adults receiving
chronic HD? Based upon the theoreti-
cal framework and literature, we
hypothesized that patients with greater
comfort would be associated with a
lower fluid retention.
Problem
The number of patients undergo-
ing HD continues to increase in the
United States. According to the 2017
annual report by the United States
Renal Data System (USRDS), there
were over 703,243 prevalent ESRD
cases, which is an increase of 3.4%
from the previous year. Of those
cases, 63.3% were treated with HD
therapy. There was also an increased
incidence of newly reported cases of
ESRD that reached 124,114 in 2015.
For year 2015, estimated Medicare
spending for patients with chronic kid-
ney disease (CKD) and ESRD aged
65 years and older exceeded $98 bil-
lion (USRDS, 2017).
One major contributor to CKD
and ESRD costs is the failure of
patients to follow prescribed treat-
Copyright 2018 American Nephrology Nurses Association.
Estridge, K.M., Morris, D.L., Kolcaba, K., & Winkelman, C. (2018). Comfort and fluid
retention in adult patients receiving hemodialysis. Nephrology Nursing Journal, 45(1),
25-33, 60.
Successful hemodialysis treatments for patients with renal failure depend on patient
adherence to prescribed treatment regimens. Lack of adherence may contribute to patient
discomfort between hemodialysis treatments. This article reports a descriptive, correla-
tional feasibility study that utilized Kolcaba’s Comfort Theory as a framework. The pur-
pose of the study was to determine a potential relationship between comfort and fluid
retention (a proxy for adherence) in adults with end stage renal disease receiving
hemodialysis. A convenience sample of 51 patients receiving hemodialysis was studied.
Comparisons of patient weight gain between hemodialysis treatment sessions measured
fluid retention by proxy. Results indicated no significant relationship between the vari-
ables of comfort and adherence to fluid restrictions. However, this finding has potential
to support clinical practice to minimize weight gain to sustain comfort. Awareness of
comfort as a consideration for adherence to prescribed treatment regimens may help
nurses coach individuals to improve treatment adherence.
Key Words: Hemodialysis, comfort, adherence, interdialytic weight gain.
Acknowledgement: The authors would like to thank Dr. Jacqueline K. Owens for her kind and invaluable
assistance with manuscript preparation and editing.
Statement of Disclosure: The authors reported no actual or potential conflict of interest in relation to this
continuing nursing education activity.
Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can
be found on page 34.
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 126
Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
ment regimens. Poor patient adher-
ence is a serious problem that leads to
medical, social, emotional, and eco-
nomic consequences that could ulti-
mately compromise empirically
based treatment guidelines (Howren
et al., 2016). The meta-analysis by
Welch and Thomas-Hawkins (2005)
was inconclusive in determining suc-
cessful options to avoid fluid retention
and promote fluid restriction adher-
ence in patients receiving chronic
HD, and noted insufficient data avail-
able to inform clinical practice guide-
lines. Tovazzi and Mazzoni (2012)
suggested that adherence to restric-
tions includes individual motivations,
mental control, and patient experi-
ences, including time and a support
system.
Theoretical Framework
The guiding framework for this
preliminary feasibility study was
Kolcaba’s (1994) Comfort Theory.
Comfort is essential for all persons,
especially those with healthcare
needs. Kolcaba (1991) defined com-
fort through the domains of ease,
relief, and transcendence in physical,
psychospiritual, environmental, and
sociocultural contexts. Increased
comfort for patients receiving HD
may lead to improved adherence to
fluid restrictions by these individuals
as needs are addressed or met.
Kolcaba’s (2007b) Comfort Theory
suggests that increased comfort leads to
health-seeking behaviors in the popula-
tion receiving HD. Positive patient out-
comes may include improved adher-
ence, decreased dialysis times, reduced
dialysate usage, decreased nursing
hours, and overall improved lived
experience for patients. As a result,
improved institutional outcomes of
reduced co-morbidity and mortality
rates could occur (see Figure 1).
Kolcaba (2003) stated that “adopting
the Theory of Comfort will demon-
strate that institutions with higher nurs-
ing staffing, professional atmosphere,
and patient-oriented value systems are
more likely to achieve financial and
health-related goals” (p. 153).
Literature Review
Multiple studies have been conduct-
ed related to Comfort Theory. Kolcaba
and associates have studied patients in
hospice care (Kolcaba, Dowd, Steiner,
& Mitzel, 2004; Vendlinski & Kolcaba,
1997), those with early stage breast can-
cer (Kolcaba & Fox, 1999), patients with
chronic urinary bladder syndrome
(Dowd, Kolcaba, & Steiner, 2000), and
those undergoing end of life experi-
ences (Novak, Kolcaba, Steiner, &
Dowd, 2001). Additional studies consid-
ered holistic comfort in perianesthesia
patients (Wilson & Kolcaba, 2004), pro-
tocols in pediatric patients (Kolcaba &
DiMarco, 2005), hand massage in nurs-
ing home residents (Kolcaba, Schirm, &
Steiner, 2006), and comparison of
touch, coaching, and interventions in
college students (Dowd, Kolcaba,
Steiner, & Fashinpaur, 2007). In these
studies, comfort interventions produced
positive correlations with various
health-seeking behaviors.
Davison and Jhangri (2010) sur-
veyed 591 patients receiving HD and
concluded that symptom burden in
patients with ESRD was substantial
with a tremendous impact. Approxi –
mately 50% of patients with ESRD
experienced chronic pain, with 82%
reporting this pain as having moder-
ate to severe intensity. Bourbonnais
and Tousignant (2012) studied 25
patients receiving outpatient HD and
found that actual discomfort could be
categorized into 4 themes: physical
(procedural and joint pain), clinic dis-
comfort (chairs, temperature), emo-
tional and social pain (time sacrifice
and isolation from lengthy treat-
ments), and managing pain in the
context of the dialysis unit (seeking
Figure 1
Kolcaba’s Conceptual Framework
Conceptual Framework for Comfort Theory
Healthcare
Needs of
Patient/
Family
Comforting
Interventions
Intervening
Variables
Enhanced
Comfort
Health-
Seeking
Behavior
Institutional
Integrity
Best
Practices
Best
Policies
External
Behaviors
Peaceful
Death
Internal
Behaviors
Source: Kolcaba, 2007b. Used with permission.
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 27
comfort measures during HD treat-
ments). The more fluid retention
patients experienced, the longer the
actual dialysis treatment, and thus,
more discomforts. They further found
that unresolved discomforts can have
a profound effect on patients’ willing-
ness to continue dialysis or other
treatment regimens.
Factors identified in the literature
have suggested why patients receiving
HD may not practice adherence to
prescribed fluid regimens. For exam-
ple, Kugler, Maeding, and Russell
(2011) conducted a cross-sectional,
multicenter, comparative study of 456
adult patients receiving HD in 12 out-
patient HD clinics. This study con-
cluded that nonadherence persists as
one of the most challenging tasks for
patients with chronic conditions, sug-
gesting that patient condition-related,
socioeconomic, and healthcare sys-
tem-related factors may contribute to
nonadherence to diet and fluid restric-
tions.
In relation to HD and the impact
on comfort, a study by Kutner,
Zhang, McClellan, and Cole (2002)
found an association of three psy-
chosocial variables that also impacted
adherence during treatment to which
the patients consented. Variables
included little or no perceived control
over future health, depression, and
perceived effects of kidney disease on
daily life.
It is evident that adherence to fluid
restrictions is difficult and can lead to
negative outcomes. Adherence can
impact care, patient comfort, and ulti-
mately, institutional outcomes, includ-
ing costs for this population. The pur-
pose of this study was to determine
the relationship between comfort and
fluid retention (a proxy for adherence)
in adults with ESRD who receive HD.
Methods
Design
The study was a descriptive, corre-
lational, cross-sectional design. This
feasibility study sought to determine if
a relationship existed between the
two variables of adherence to fluid
restrictions (measured via fluid reten-
tion) and comfort.
Setting
The study was conducted at two
for-profit dialysis clinics in the
Midwest of the United States. Both
clinics were proximately located,
managed by the same corporation,
and shared a medical director and
upper level administrative team. The
clinics were housed in free-standing,
single-story buildings with surround-
ing private parking lots and easy
entry access for patients. Patients
reported for treatments three days per
week with varying shifts. Most HD
treatments lasted approximately four
hours.
Sample
A convenience sample of adults
with ESRD was enrolled. Eligibility
criteria included persons aged 18 years
or older who received HD treatments
in one of two dialysis clinics in the
Midwest. Participants were required
to obtain a score of at least 8 of 10 on
the Short Portable Mental Status
Questionnaire (SPMSQ), a brief ques-
tionnaire to assess patients for organic
brain dysfunction (Pfeiffer, 1975); have
decisional capacity; and possess the
ability to read. Co-morbidities (dia-
betes, hypertension, lung disease,
heart disease, or primary renal disease)
were permitted and recorded. Ex –
clusion criteria were weight greater
than 500 pounds and/or patients who
experienced an acute event (new onset
influenza, dialysis-related conse-
quences requiring non-typical, intense
care) on a day of data collection.
Variables
Comfort. The operational defini-
tion of comfort was the score on a
Likert-type scale using Kolcaba’s
(2007c) General Comfort Question –
naire (GCQ), adapted for this popula-
tion per Kolcaba’s (2007a) guidelines
(see Figure 2). The instrument for this
study contained 48 self-report items.
Responses to items were scored on a
6-item Likert scale ranging from 6
(strongly agree) to 1 (strongly dis-
agree). Higher scores reflect higher
levels of comfort. Twenty-five nega-
tively worded questions appeared on
the questionnaire to reduce response
bias. The questionnaire was adminis-
tered at the beginning of the study to
determine the comfort level for each
participant.
Previous reliability testing of
Kolcaba’s General Comfort Ques –
tionnaire yielded a Cronbach’s alpha
of 0.88 (Kolcaba, 1992). The adapted
Hemodialysis Questionnaire yielded a
Cronbach’s alpha of 0.85. The reading
level of the tool was grade 2.5 accord-
ing to the Flesch-Kincaid Grade Level
via Microsoft Windows 2007
(Microsoft Corporation, 2007).
Fluid retention. Fluid retention as
a proxy for adherence was opera-
tionally defined as the patient’s inter-
dialytic weight gain (IDWG) of 2.5
kilograms (kg) or less during the week
and 3.5 kg or less over a 2-day week-
end or holiday period, as suggested by
the study dialysis clinics. The mean
was calculated by averaging the
IDWG of visits over the 2-week study,
excluding holidays. The IDWG was
measured as the amount of weight
gained between the conclusion of one
dialysis treatment and the beginning
of the next dialysis treatment. Welch
(2001) reported that although the
weight gain criterion for nonadher-
ence varies among studies, generally,
daily weight gain greater than 1 kg to
1.5 kg is considered in excess.
López-Gómez, Villaverde, Jofre,
Rodriguez-Benítez, and Pérez-García
(2005) defined IDWG as “mainly the
result of salt and water intake between
two dialysis sessions” (p. S-63). López-
Gómez and colleagues (2005) also
noted that IDWG varies between
patients but is a common method of
measuring compliance/adherence.
Ideally, when patients receiving
chronic HD followed the prescribed
fluid restriction regimen, the patient’s
IDWG should not increase beyond
expected parameters as determined
by the physician. Fluid retention was
measured by pre-HD and post-HD
weight measurements in increments
of 0.1 kg via electronic scale.
Demographic items. The pri-
mary investigator (PI) created a
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 128
Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
demographic tool consisting of 16
items, found in Table 1. Items includ-
ed age; sex; race, marital status; edu-
cation level; history of HD treat-
ments, fluid intake, salt intake via
consumed foods, and urinary output;
health insurance; and co-morbidities.
Protection of Human Subjects
The study commenced upon ap –
proval from the university’s and dial-
ysis setting’s Institutional Review
Boards (IRBs). All participants re –
ceived three weekly HD treatments at
one of two dialysis clinics in the
Midwest. Patients were approached
two weeks prior to the study and
informed of the opportunity to partic-
ipate. Signed consent was obtained at
that time.
Procedure
The Hemodialysis Questionnaire
was adapted according to instructions
provided on Dr. Kolcaba’s website
(Kolcaba, 2007a). To establish face
validity of the adapted comfort tool,
two authors (Estridge and Kolcaba),
reviewed each question for clarity.
Prior to administration of the
Hemodialysis Questionnaire, the sur-
veys (Hemodialysis Questionnaire
and demographic questionnaire) were
piloted with seven patients at a similar
HD clinic in the Midwest.
We anticipated that some patients
might need assistance due to the
number of items on the Hemodialysis
Questionnaire and completing the
questionnaire during their HD treat-
ment. The PI also developed a proto-
col to use should a participant request
assistance in completing the surveys.
The protocol included individual
assistance by the PI at the bedside,
instructions for reading questions to
the subjects if necessary, and offering
a large-print visual card to assist in
readability and understanding of the
survey’s Likert scale.
Approximately 80% of partici-
pants required at least some assis-
tance to complete all items in the sur-
veys; this may be because all patients
were connected to the HD machines
Figure 2
Adapted General Comfort Questionnaire
Hemodialysis Questionnaire
1. My body is relaxed right now.
2. I feel useful because I’m working hard.
3. I have enough privacy.
4. There are those I can depend on when I need help.
5. I don’t want to exercise.
6. My condition gets me down.
7. I feel confident.
8. I feel dependent on others.
9. I feel my life is worthwhile right now.
10. I am inspired by knowing that I am loved.
11. These surroundings are pleasant.
12. The sounds keep me from resting.
13. No one understands me.
14. My pain is difficult to endure.
15. I am inspired to do my best.
16. I am unhappy when I am alone.
17. My faith helps me to not be afraid.
18. I do not like it here.
19. I am swollen right now.
20. I do not feel healthy right now.
21. This room makes me feel scared.
22. I am afraid of what is next.
23. I have a favorite person(s) who makes me feel cared for.
24. I have experienced changes which make me feel uneasy.
25. I am hungry.
26. I would like to see my doctor more often.
27. The temperature in this room is fine.
28. I feel very tired.
29. I can rise above my pain.
30. The mood around here uplifts me.
31. I am content.
32. This chair (bed) makes me hurt.
33. The view inspires me.
34. I am thirsty.
35. I feel out of place here.
36. I feel good enough to walk.
37. My friends remember me with their cards and phone calls.
38. My beliefs give me peace of mind.
39. I need to be better informed about my health.
40. I feel out of control.
41. I feel crummy because I am bored.
42. This room smells terrible.
43. I am alone, but not lonely.
44. I feel peaceful.
45. I am depressed.
46. I have found meaning in my life.
47. It is easy to get around here.
48. I need to feel good again.
Note: Adaptations from the original GCQ are bolded.
Source: Tool created by Karen M. Estridge; adapted from Kolcaba, 2007a.
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 29
Table 1
Demographic Data of Sample
Age
Mean 64 years
Median 65 years
Youngest 44 years
Oldest 87 years
Sex
Male 28 (54.9%)
Female 23 (45.1%)
Marital status
Married 21 (41.2%)
Never married 6 (11.8%)
Single (living with someone) 3 (5.9%)
Separated 2 (3.9%)
Divorced 14 (27.5%)
Widowed 5 (9.8%)
Race
Caucasian 24 (66.7%)
African American } other 15 (29.4%)
American Indian } other 2 (3.9%)
Education level
Less than 8 years 2 (3.9%)
High school or equivalent 35 (68.6%)
Vocational/technical degree 9 (17.6%)
Bachelor’s degree 2 (3.9%)
Master’s degree 1 (2.0%)
“Other” 2 (3.9%)
Employment status
Employed 36 hours/week 1 (2.0%)
Employed 16 to 35 hours/week 3 (5.9%)
Unemployed 5 (9.8%)
Unable to work 25 (49%)
Retired 17 (33.3%)
Payment source
Medicare/Medicaid 51 (100%)
Additional insurance (non-exclusive) 23 (46%)
Diseases/other conditions (non-exclusive)
Cardiovascular disease 47 (92.2%)
Diabetes mellitus 29 (56.9%)
Lung disease 5 (9.8%)
Other 12 (23.5%)
More than one medical condition 35 (68.8%)
Treatment history
Received treatments 4 months to 1 year 15 (29.4%)
Received treatments 2 to 5 years 29 (56.9%)
Received treatments more than 6 years 5 (9.8%)
Other 2 (3.9%)
Treatment session duration
3 hours in length 4 (7.8%)
More than 3, but fewer than 4 hours 22 (43.1%)
4 hours 20 (39.2%)
More than 4 hours in length 5 (9.8%)
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 130
Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
during data collection and eagerly
accepted the offer of help. The PI fol-
lowed the protocol to provide assis-
tance. No missing data were noted
because of assistance from the PI with
survey completion.
Data Management
Data were entered into the
Statistical Package for the Social
Sciences (SPSS) – 19 (SPSS for
Windows, Rel. 19.0., 2010) for analy-
sis. Correlations were calculated
between the summed one-time com-
fort scores and mean IDWG, as meas-
ured over a period of four weeks.
Planned Analysis
All data were planned to be sum-
marized by means (ratio level) and
frequencies (interval, ordinal, and
nominal level) as appropriate. A test
of association was planned for the
study’s single research question:
What is the relationship between
comfort and fluid retention among
adults receiving HD? This was an
early feasibility study with no previ-
ous reports in the literature, so a test
of association was a reasonable
approach. Both variables (comfort
and IDWG) were ratio level; thus,
Pearson’s r was the best test of associ-
ation. If assumptions for this test sta-
tistic (i.e., linearity, outliers/extreme
values, and restriction of range) were
not met, we planned to use a
Kendall’s rank test to ensure viola-
tions of assumptions around Pearson’s
would not lead to erroneous results.
Secondary analysis of selected
patient characteristics to determine if
there were differences in either com-
fort or IDWG were also undertaken
using independent t tests. Assumptions
for this test statistic were examined (the
need for a correction when unequal
variances occurred) were undertaken
to yield optimal results.
Results
Sample
Fifty-one adult subjects participat-
ed in this study. Demographic infor-
mation was obtained to describe per-
sonal characteristics and lifestyle
related to being a patient receiving
HD. Complete demographic infor-
mation is presented in Table 1.
The demographic survey also
included questions about dietary habits
that may contribute to IDWG. There
were seven items related to food intake,
fluid intake, and urinary output. These
data are summarized in Table 2.
Regarding usual comfort and/or
discomfort, 13 (25.5%) subjects took
prescription medications for pain
more than once daily. Subjects were
also asked about the number of edu-
cational sessions they received
regarding fluid restrictions. Twenty-
four (47.1%) received less than 5 ses-
sions, 11 (21.6%) received 6 to 9 ses-
sions, 9 (17.6%) received 10 or more
events, 5 (9.8%) were not sure of the
number of educational events, and 2
(3.9%) did not know if they had
received any education.
Comfort
The Hemodialysis Questionnaire,
used to measure comfort, contained
48 self-report, comfort-related items
as described above. The maximum
obtainable comfort score was 288. In
this sample, total comfort scores
ranged from 146 to 258, with a mean
score of 203.25 (standard deviation
[SD]=26.09) and median score of
202.00 (see Table 3).
Interdialytic Weight Gain
Subjects were weighed prior to
and immediately following each treat-
ment per clinic policy. Subjects’
weights were extracted from patient
charts for measurement from two
weeks immediately prior to the
administration of the Hemodialysis
Questionnaire to avoid any
Hawthorne effect, bias, or change in
routine by participants. Holidays and
Table 2
Participants’ Salty Food Consumption
Foods consumed
greater than once weekly
• Potato chips, corn chips, pretzels 13 (25.5%)
• Pickles, canned meats, clam soups, salty fish 18 (35.5%)
• Frozen, prepared meals 4 (7.8%)
• Packaged meat, cheese, prepared pasta 23 (45.1%)
• Salty meat: hot dogs, deli lunch meats, sausage 16 (31.4%)
Daily fluid intake
• Less than 8 ounces 5 (9.8%)
• Up to 16 ounces 9 (17.6%)
• Up to 24 ounces 12 (23.5%)
• UP to 32 ounces 15 (29.4%)
• Greater than 32 ounces 10 (19.6%)
Daily urinary output
• 0 ounces 1 (21.6%)
• 4 to 8 ounces 19 (37.3%)
• Greater than 8 ounces 21 (41.2%)
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 31
extended weekends were avoided to
preserve subjects’ normal pattern of
weight gain. The average IDWG
ranged from 0.92 to 5.8 kg. The mean
average weight gain was 2.71 kg, with
an SD of 1.1. Table 4 reports weight
gain overall and by sex.
Hypothesis Testing
The association between comfort
and fluid retention was not significant
(r=0.028; p=0.844). Scatter plots indi-
cated a restricted range in weight
gain, and restricted ranges of vari-
ables may deflate the correlation
value; thus, a Kendall’s tau (rank) was
undertaken. This test does not have
an assumption around data distribu-
tion. Kendall’s rank analysis was also
insignificant (r=0.01; p=0.909). The
confidence interval (CI) was small
and crossed zero, further supporting
no effect. Assuming an insignificant
effect size of less than 0.10 (0.09), this
preliminary feasibility study had a
power of 59.5% to detect an associa-
tion between comfort and IDWG.
Secondary Analyses
To further understand how patient
characteristics may relate to comfort
and IDWG, we undertook additional
analyses. We investigated correlations
between sex and race with comfort
scores because both women and non-
Whites have different expectations
related to comfort and healthcare out-
comes (fluid-related weight loss) in
the literature (Novak et al., 2001;
Zhang & Baik, 2013).
Gender and comfort. Women
rated comfort slightly higher (n=23;
M=205.17; SD=26.89) compared to
men (n=28; M=201.68; SD=25.79).
An independent t test indicated there
was no significant difference based on
sex regarding comfort (t=0.472;
df=49; p=0.639).
Race and comfort. Summary
data revealed the mean comfort score
for Whites at 204.47 (SD=19.25) and
all others at 202.65 (SD=229.12).
These differences were tested with an
independent samples t test, and no
significance was demonstrated in
comfort reported between Whites
and nonwhites (t=0.266; df=44.85;
p=0.791).
Gender and weight gain. The
mean IDWG was 2.55 kg for women
and 2.83 kg for men, further detailed
in Table 4. Independent samples t test
supported a finding of no significant
difference between weight gain in
women compared to men (t=0.362;
df=49; p=0.364).
Race and weight gain. For com-
parison purposes related to race, non-
whites included African Americans
(n=15) and Native Americans (n=2).
The IDWG for Whites (n=34;
M=2.49 kg; SD=1.00) was lower than
the IDWG for nonwhites (n=17;
M=3.14 kg; SD=1.17). These results
are summarized in Table 5. An inde-
pendent t test for differences for
IDWG for race was significant
(t=1.106; p=0.015). There was a signif-
icant difference in weight gain, with
nonwhites gaining more weight
between dialysis treatments in this
sample.
Discussion
There was no significant relation-
ship between comfort and IDWG.
This finding was different than what
Table 3
Comfort Scores of Participants
Minimum Score Maximum Score Mean Score Standard Deviation
Total Sample 146 243 203.25 26.09
Male 146 243 201.68 25.79
Female 150 242 205.17 28.89
Table 4
Participant Interdialytic Weight Gain (IDWG) in Kilogram by Sex
Minimum IDWG Maximum IDWG Mean IDWG Standard Deviation
Total Sample 0.92 5.80 2.71 1.10
Male 1.03 5.81 2.83 1.20
Female 0.92 4.93 2.55 0.97
Table 5
Participant Interdialytic Weight Gain (IDWG) in Kilogram by Race
Mean IDWG Standard Deviation
Total Sample 2.71 1.10
Caucasian (N=34) 2.49 1.00
Other (N=17) 3.14 1.17
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 132
Comfort and Fluid Retention in Adult Patients Receiving Hemodialysis
we hypothesized based on Kolcaba’s
theory. Although results were not sta-
tistically significant, this finding has
potential clinical importance. Com –
fort Theory suggests that as persons
pursue comfort interventions, they
also engage in health-seeking behav-
iors (Kolcaba, 2003). In a study by
Smith and colleagues (2010), psycho-
logical factors, physical factors,
beliefs, attitudes, self-efficacy, and
environmental factors affected pa –
tients receiving HD and adherence to
fluid restrictions. A pattern of seeking
healthy behaviors was not strongly
supported in this preliminary study.
This study’s results are similar to
Welch’s (2001) study results, which
determined that successful adherence
to treatment regimens was influenced
by patient willingness (or not) to fol-
low restrictive and often uncomfort-
able lifestyle changes. Study results
offer evidence to support current clin-
ical practice to minimize IDWG to
sustain comfort.
Specifically, data did not support
the assertion that subjects with the least
weight gain had greater association
with comfort or vice versa. In this
study, correlations between comfort
scores and weight gain were very
small, ranging from 0.01 to 0.28, indi-
cating a small rather than moderate
effect size. These small correlations and
lack of significance initially suggested
that comfort and IDWG of an average
of 3 kg were not related. However,
because most patients were dialyzed at
2- to 3-day intervals, and averaged a
weight gain of 3 kg between dialysis
periods, it is not surprising that patients
did not report a change in comfort. The
mean IDWG in this study (2.7 kg) is
very close to guidelines suggested for
patient management (i.e., 2.5 kg is the
goal). It may be that an average of
under 3 kg of weight gain is not suffi-
cient to be associated with a decrease in
comfort; it is a weight gain that neither
increases nor decreases comfort.
Alternatively, this study was under-
powered, and a larger sample size or
one with a wider range of weight gain
may yield significant associations
between comfort and IDWG.
Secondary analyses did not sup-
port a difference in reports of comfort
between sexes; comfort was similar
between women and men. Similarly,
self-reported comfort was compara-
ble between Whites and non-Whites.
This is somewhat different than what
has been reported in the literature
and may be specific to the sample of
patients with ESRD and receive HD
regularly. Further, there was no signif-
icant difference between men and
women in the IDWG.
One recent report indicates men
are more likely to have a greater
IDWG (Artan et al., 2016). In our
study, men and women had similar
IDWGs. It may be because our study
was underpowered to detect this dif-
ference or that these subjects were
more compliant/adherent to treat-
ment because they had weight
changes close to clinical goals.
The only significant finding was
that Whites had a significantly
reduced IDWG compared to non-
whites. In this sample, Whites had an
average IDWG at the clinical goal of
less than 2.5 kg between HD treat-
ments. However, the difference of
0.65 kg IDWG may not be clinically
important, and the average of 3.14 kg
IDWG in nonwhites is very close to a
20% variation (considered reasonable
in many patient-centered outcomes).
It is not clear if the clinical goal of 2.5
kg was based on a homogenous or
heterogeneous population. The clini-
cal implication for nurses who spe-
cialize in dialysis treatment is that
non-Whites may need more educa-
tion or increased effort around self-
management approaches to help
them achieve clinical goals.
Limitations
The greatest limitations of this fea-
sibility study were its preliminary
nature and the convenience sam-
pling. As a preliminary study, it was
not powered adequately to detect dif-
ferences in comfort. However, an
effect size can now be used to deter-
mine sufficient sample size for future
studies. Convenience sampling may
limit generalizability. Subjects were
fairly homogenous, self-selected, and
voluntarily reported dietary and fluid
intake. Finally, patients who were less
successful in adhering to fluid restric-
tion guidelines may have opted out of
this study.
Other potential limitations includ-
ed a possible bias in subject responses
from overhearing socially desirable
responses by other participants.
Question fatigue due to the number
of items (48 questions with six possi-
ble responses on the Hemodialysis
Questionnaire) may have contributed
to the narrow range of results. In
addition, scheduling practices and
clinic policy sometimes meant
patients were at the facility much
longer than the scheduled HD treat-
ment, which may also have con-
tributed to subject fatigue.
Implications for Clinical
Practice
Consistent with Kolcaba’s (2003)
theory, determining patient health-
care needs, providing comfort inter-
ventions, identifying challenges, set-
ting goals to establish health-seeking
behaviors, and instituting supportive
nursing actions to promote well-being
will lead to best practices in providing
comfort measures to patients receiv-
ing HD. It is yet to be determined if
enhanced long-term comfort because
of following restricted fluid intake
guidelines will occur. Awareness of
unique comfort needs as a considera-
tion for adherence to prescribed treat-
ment regimens may help nurses
coach individuals with ESRD.
Ghimire, Castelino, Lioufas,
Peterson, and Zaidi (2015) and Zhang
and Baik (2013) suggest significant
findings of an IDWG difference in the
context of race. This finding, and the
call from Frazão and colleagues
(2015) for individualized education,
may offer implications for practice
helpful to address various patient dis-
parities. Specific implications for clin-
ical practice resulting from this cur-
rent study include:
• Increase nurse awareness about
potential population differenc –
es. With increased awareness of
potential differences in comfort
and adherence needs, nurses can
individualize interventions to sup-
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 1 33
port difficult treatment regimens.
More precise nursing interventions
that include variables, such as cul-
tural practices or food preferences
of different races, may help in –
crease adherence.
• Consider comfort care specifi-
cally with respect to adherence
to difficult regimens. Careful
evaluation of comfort care tenets,
specifically as they may impact
adherence, may assist vulnerable
patients to achieve better out-
comes. According to the Comfort
Theory, holistic comfort is the
immediate experience of being
strengthened through ease, relief,
and transcendence (Kolcaba,
2003). Nurses providing HD must
accurately assess specific individ-
ual patient comfort needs because
these may vary by race, ethnicity,
or other patient lifestyle practices.
This holistic comfort may empow-
er patients receiving HD to
improve self-care and increase
adherence to fluid restrictions.
• Continue to set weight gain
goals during HD to minimize
IDWG. It is important to learn that
a weight gain of 2.7 kg (average)
between dialysis treatments is not
associated with comfort/discom-
fort. This finding begins to establish
the mid-to-upper value of weight
gain that may impact comfort.
It is important for nurses to
explore individual characteristics and
needs to effectively plan care with
patients struggling to address difficul-
ties of managing fluid intake (Tovazzi
& Mazzoni, 2012). By intentionally
learning more about each patient,
including personal responses and
overall comfort status, nurses provid-
ing HD may better target unique
aspects of nursing care to meet each
patient’s needs.
Conclusion and Recommendations
for Further Research
Further studies about patients
receiving HD based on Comfort
Theory are necessary to determine
relevant nursing interventions to sig-
nificantly impact comfort for this pop-
ulation. This study yields preliminary
results that support the clinical goal of
gaining about 1 kg/day of no dialysis.
It would be interesting to study the
outliers in future research because
extremely high (6 to 7 kg) or low (less
than 2 kg) weight gainers may have
different perceptions of comfort.
Expanding the study to include
eight or more weeks of IDWG meas-
urement may help accurately deter-
mine a potential relationship between
comfort and adherence to fluid restric-
tions. In addition to extending the
duration of measurement, repeated
Hemodialysis (comfort) Question –
naires would provide additional infor-
mation about adherence of patients
receiving HD and accompanying val-
ues of comfort. Studies that include
numerous HD clinics with greater
numbers of subjects would provide
useful data to assist nurses to more
accurately provide supportive care to
this population of patients.
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continued on page 60
Nephrology Nursing Journal January-February 2018 Vol. 45, No. 134
Comfort and Fluid Retention in Adult Patients
Receiving Hemodialysis
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Aji, L., & Beck, D. (2017). Effect of fluid status on access blood flow measure-
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Nephrology Nursing Journal January-February 2018 Vol. 45, No. 160
Comfort and Fluid
Retention
continued from page 33
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EMPIRICAL STUDIES
The effect of education and telephone follow-up intervention
based on the Roy Adaptation Model after myocardial
infarction: randomised controlled
trial
Selma Turan Kavradim PhD, RN (Assistant Professor) and Zeynep Canli €Ozer PhD, RN (Professor)
Department of Internal Medicine Nursing,
Faculty of Nursing, Akdeniz University, Antalya, Turkey
Scand J Caring Sci; 2020; 34: 247–260
The effect of education and telephone follow-up
intervention based on the Roy Adaptation Model
after myocardial infarction: randomised controlled
trial
Background: Patients’ lifestyle changes after myocardial
infarction reduce the risk of infarction. Nursing interven-
tions are important for the initiation and maintenance of
life
style adaptation.
Aim: The aim of this study was to evaluate the effect of
edu
cation and telephone follow-up intervention based on
the Roy Adaptation Model for improving myocardial
infarction patients’ self-efficacy, quality of life and life-
style adaptation.
Method: In this parallel, randomised controlled trial,
patients were randomly allocated to a control group or
an intervention group (n = 33/group). The control
group
received routine care, while the intervention group
received routine care plus a telephone follow-up inter-
vention, which consisted of a predischarge education pro-
gramme and three telephone follow-up sessions. Data
were collected before discharge, in the 12th week after
discharge between April 2016 and August 2017. All
outcomes were assessed at baseline and at 12 weeks, and
included quality of life, coping adaptation process, self-ef-
ficacy and lifestyle changes. The CONSORT checklist was
used in the study.
Results: In the 12th week after discharge, patients in the
intervention group had significant improvements in self-
efficacy, quality of life and coping adaptation process
compared with the control group. The intervention group
also had more adaptation lifestyle changes concerning
patients nutrition and physical activity in the 12-week
follow-up.
Conclusion: This study demonstrated that education and
telephone follow-up intervention based on Roy Adap-
tation Model was had positive and significant results
after 12 weeks compared with usual care. The findings
of this study are important for supporting nursing
practice and health professionals who care for individ-
uals with myocardial infarction to develop nursing
care.
Keywords: lifestyle change, myocardial infarction, nurs-
ing, telephone follow-up, Roy Adaptation Model, self-
efficacy.
Submitted 28 May 2019, Accepted 17 October 2019
Introduction
According to the European Society of Cardiology Guide-
line (2018), cardiovascular disease is the leading cause of
deaths; it was responsible for 17.5 million deaths with
46% of these deaths, an estimated 7.4 million, due to
ischaemic heart disease (1). Myocardial infarction (MI)
has an important place in ischaemic heart diseases. It
commonly appears during productive age, together with
acute postrhythm problems, heart failure, angina and
recurrence of MI (2,3). The social, psychological and
physical problems that occur after MI affect the quality of
life and self-efficacy (4) and make it difficult to adapt to
lifestyle change (3,5).
Lifestyle interventions for secondary prevention are
strongly emphasised by the guidelines of the European
Society of Cardiology and the American Heart Associa-
tion (1,6). Key lifestyle interventions include cessation of
smoking, diet advice, weight control and encouraging
physical activity (1). During the hospitalisation after MI,
the time for implementing secondary prevention is lim-
ited and nursing interventions are important for the initi-
ation and maintenance of lifestyle interventions (1,7).
Studies show that patients’ lifestyle changes after MI
Correspondence to:
Selma Turan Kavradim, Department of Internal Medicine Nursing,
Faculty of Nursing, Akdeniz University, Antalya, Turkey
E-mail: selmaturan@akdeniz.edu.tr
Name of trial registry of Clinical Trials: The Effect of Education and
Telephone Follow-up Intervention Based on the Roy Adaptation
Model, Identifier: NCT03771937
247
© 2019 Nordic College of Caring Science
doi: 10.1111/scs.12793
https://orcid.org/0000-0002-2302-6823
https://orcid.org/0000-0002-2302-6823
https://orcid.org/0000-0002-2302-6823
https://orcid.org/0000-0001-8405-1208
https://orcid.org/0000-0001-8405-1208
https://orcid.org/0000-0001-8405-1208
mailto:
reduce the risk of infarction (1,6), but patients have diffi-
culty in making the changes. Because lifelong habits are
not easily changed, these changes take a long time (1,7).
Many techniques are used to improve adaptation to
lifestyle changes, such as home visits, telephone follow-
ups, self-management enhancement, patient education
and counselling (8,9). Among these interventions, it has
been stated that education is an effective method for risk
factor control and adherence to lifestyle change in that it
increases awareness and responsibility and also that fol-
low-up of these changes is important (1). Telephone fol-
low-up is an effective method of increasing quality of life
and self-efficacy, reducing stress and avoiding recurrent
hospitalisations (7,10,11). Recent meta-analyses of RCTs
have reported that telephone follow-up interventions are
associated with improvements in adaptation and lifestyle
changes (12–14). To reduce the rate of repeated cardio-
vascular events and improve adaptation, single methods
are commonly used in the literature, but it is thought
that the use of theoretical intervention applications in
combination with other methods based on evidence to
improve adaptation may be more effective. It is known
that the theory-based interventions contribute to an
increase in the effectiveness of nursing interventions
(15,16). Although some studies have been found in the
literature on improving quality of life, self-efficacy and
adaptation for patients with MI (7,10,11), no studies
have been reported on the education and telephone fol-
low-up intervention of patients with MI based on Roy
Adaptation Model (RAM).
RAM is an adaptation theory and interaction model,
which focuses on interaction between humans and the
environment as the basis of a conceptual model of nurs-
ing. It was developed in the 1960s by Sister Callista Roy
(16,17). The model is the most widely used and is being
continuously tested and developed in the field of nursing
research, practice and education (17). Physiological pro-
cesses (regulator subsystem) and cognitive and emotional
processes (cognator subsystem) holistically interact to
maintain personal integrity and foster adaptation and
personal growth. Because the regulator and cognator
subsystems are internal processes and cannot be directly
observed, these subsystems have been defined as adap-
tive modes (physiological mode, self-concept mode, role
function mode and interdependence mode) (16,18).
According to the model, the main concept of which is
adaptation, the purpose of nursing is to create effective
adaptive behaviours in these adaptive modes by using
the regulator subsystem and cognator subsystem of indi-
viduals against stimuli (focal, contextual and residual)
and to take the individual to an excellent level of adapta-
tion (16,18). The reason for preferring the RAM in this
study is its potential to be continuously used, tested and
improved in different patient groups. It strengthens adap-
tation by affecting the areas of physiology, self-concept,
role function and interdependence of individuals with
MI. According to the RAM, ‘person’ is the individual
who has undergone MI; ‘environment’ according to Roy
is the environment of the individual who has undergone
MI and consists of focus stimuli, affecting stimuli and
potential stimuli. ‘Health’ is the passing of the person
who has undergone MI from a state of unbalance to a
state of balance. ‘Nurse’ is the person who supports the
patient in the four adaptive fields by means of the nurs-
ing care given, who evaluates factors affecting behaviours
and adaptation skills, and who contributes to the health
and quality of life of the patient by increasing environ-
mental interaction. After MI, patients can show negative
coping behaviours such as denial of the disease and emo-
tional exhaustion, feelings of shame and guilt, insecurity,
and depressive and disease-centred behaviours (19). An
increase in adaptation enables patients to return to an
active life after MI, to pursue their lives in a healthy way
and to continue life under the best physical, mental and
social conditions (9,20).
Aims
The specific aim of this study was to evaluate the effect
of education and telephone follow-up intervention based
on RAM for improving MI patients’ self-efficacy, quality
of life and lifestyle adaptation. We hypothesised that edu-
cation and telephone follow-up intervention based on
RAM would (a) increase quality of life, (b) improve the
coping and adaptation process, (c) increase self-efficacy
and (d) enhance adaptation to lifestyle changes.
Methods
Study design
This study had a prospective, parallel, RCT research
design. Patients were randomly allocated who were
being treated for myocardial infarction in the hospital
and who met the inclusion criteria of the control group
or the intervention group. This study is based on rec-
ommendations from CONSORT Statement (See
Appendix S1) (21).
Participants and setting
This study was conducted at the Clinic and Polyclinic of
the Department of Cardiology of University Hospital in
Antalya, Turkey, between April 2016 and August 2017.
Inclusion criteria of the study were as follows: (a) partici-
pants were adults aged ≥ 30 years and had been admitted
to the hospital with a diagnosis of MI (which must be
supported by ECG and an increase in biomarkers), (b)
were clinically stable, (c) willing to participate, (d) able
to understand and write Turkish, (e) able to receive
248 S. Turan Kavradim, Z. Canli €Ozer
© 2019 Nordic College of Caring Science
telephone calls or fill in questionnaires, and (f) able to
come to the hospital for checkups. Patients were
excluded from the study if according to medical file
records they had chronic renal failure, cancer, heart fail-
ure, and severe aortic stenosis, if they were planned for
surgical treatment or had chronic cognitive and psychi-
atric disease, if they had problems with hearing and
speaking on the phone, or if they had mobility
restriction.
Randomisation
The simple randomisation method was chosen as the
randomisation method to provide an equal number of
samples in the intervention and control group. During
the study period, patients were recruited from the cardi-
ology clinic according to the inclusion criteria and ran-
domly assigned to either the intervention group
(n = 33) or the control group (n = 33) before pretest
data were collected. In order to randomise patients
according to the date of admission to the hospital, the
next envelope of those that had been prepared was
opened, and this determined whether the patient was
assigned to the intervention or the control group. Once
group allocation was decided, each subject was informed
in writing what his or her participation in the study
involved. The allocation was kept in sequentially num-
bered opaque envelopes by researcher. Single blinding
was provided that included inclusion criteria and agree-
ment to participate in the study. Patients did not know
whether they were included in the intervention group
or the control group. The patients were told that this
was a study with two parallel monitored groups. How-
ever, they were not told about the interventions applied
to the other group.
Data collection
The aims of the study and the research process were
explained to the patients who were being treated and fol-
lowed up at the cardiology clinic because of MI, who had
had an acute period of illness and who fitted the inclu-
sion criteria, after which their informed voluntary con-
sent was obtained with an Approval Form prepared in
line with the Helsinki Declaration. Collection of research
data was performed by the researcher by face-to-face
interview. Baseline data on quality of life, self-efficacy
and the coping adaptation process and adaptation to life-
style changes were collected at the hospital after ran-
domisation. Baseline data of the study were collected by
providing a quiet environment in the patient’s room in
the cardiology clinic between 9.00 and 12.00 hours, out-
side visiting time. Demographic and clinical data were
collected by self-report and from medical records during
hospital stays. The data collection period lasted
approximately 30 minutes for each participant. After this,
patients in the intervention groups were given education
by the researcher, with the help of an education booklet.
After the patients in the intervention group were dis-
charged from hospital, they were followed up and given
counselling by telephone by the same researcher. Post-
test data were collected by the researcher in the 12th
week after discharge when the patients arrived at the
polyclinic for checkup.
Preliminary application
To examine the feasibility of the research and the inter-
vention, research processes were applied as preliminary
applications to three patients with MI and patients inter-
viewed were not included in the study sample. Following
the preliminary application, a number of changes were
made to the study. Two sessions were originally planned,
but because patients were discharged from hospital in a
short time, this was reduced to one.
The intervention
The intervention group received face-to-face education
with an education booklet during the hospital, and after
discharge, three structured telephone call follow-up
interventions were conducted.
The education booklet was prepared by the researcher
according to the needs of the patients to know their risk
factors, to help the patients to establish an attitudinal
and knowledge foundation and adapt to the postdisease
lifestyle changes of patients with MI, based on evidence-
based treatment guidelines and RAM (1,6,18,22). In
accordance with the Discern Guide (23), ten expert opin-
ions were obtained. In addition, the booklet and the edu-
cation plan were translated into English and sent to
Sister Callista Roy via e-mail. We received positive feed-
back from Roy regarding the suitability of the booklet,
the CTE diagram and the education plan. The education
booklet had 33 pages and covered a range of topics
including cardiovascular risk factors, lifestyle change and
psychosocial support, the use of drugs, healthy nutrition,
active life and exercise, sexual life, smoking and alcohol
use, emotions and coping, and tests used in cardiology.
This education booklet was supported by visuals and
tables.
Education with the booklet. Education was delivered by
the research assistant, who had previous experience and
training in cardiology nursing and interviewing. Each
education session was conducted for 30-45 minutes and
in line with the goals set out in the education plan. Dur-
ing the education session, patient participation and ques-
tioning was encouraged and supported. In order to make
it easy to remember important points, marking was done
Education and telephone follow-up intervention 249
© 2019 Nordic College of Caring Science
with the patient in the booklet, and the booklet was
given to the patients to recall and read again.
Telephone follow-up. Three structured phone calls were
conducted in the first, third and eighth weeks following
discharge from the hospital and each call was limited to
15—20 minutes. During these phone calls, the researcher
engaged the patient in sharing potential barriers to
adherence or other factors that might contribute to poor
disease control, discussed the patient’s readiness to mod-
ify behaviours and worked with the patient to agree on a
shared plan of strategies to improve adherence and dis-
ease control. For telephone calls, a form was prepared
including telephone follow-up and interview steps by the
researcher. The form consisted of appropriate lifestyle
measures and adaptation to follow, and covered patient
assessment, identification of problems, experience of
physical and emotional problems, adherence the lifestyle
change and reminders on issues patients deemed neces-
sary, health checks, identification of common goals, and
encouragement and enhancement of self-efficacy, finish-
ing and planning. Individually tailored telephone consul-
tation was also conducted by the researcher. In the
telephone calls, the researcher was available and coun-
selling was provided to patients any time it was needed.
Counselling was conducted under a protocol. In this pro-
tocol, patients were directed to the emergency clinic if
they had chest pain that lasted more than 15 minutes, a
pain which spread to the neck, lower jaw or left arm, a
pain which did not respond to nitroglycerin, palpitations,
severe breathlessness, symptomatic hypotension, uncon-
sciousness or syncope, and they were directed to the
polyclinic if they had side effects of medicines.
The process of using a conceptual model to guide
research requires the construction of a conceptual–theo-
retical–empirical (CTE) structure and communication of
that structure in a diagram and a narrative (15). The CTE
structure for this study is given in Fig. 1. This CTE struc-
ture provided a systematic framework to guide the evalu-
ation of patient data through a holistic approach,
planning and analysis of applications.
Control group. All patients in the control group received
usual care. Usual nursing care at the hospital consisted of
giving drug prescriptions, giving diet recommendations to
patients with a high cholesterol level and giving the
times to come for checkup at the time of discharge. Ethi-
cally, the patients in the control group were trained by
the researcher with the education booklet when they
completed the study.
Outcome measures
The primary outcomes were patients’quality of life, cop-
ing adaptation process and self-efficacy from baseline (in
hospital) to 12 week after randomisation. The secondary
outcomes were the change from baseline to 12 week
after randomisation of fasting triglyceride, high-density
Complications, Drugs
life activities
(Diet, exercise, …)
Psychosocial
changes
Changing roles
and functions
Social
support
needs
MIDAS
Morisy Scale
CAPS
MIDAS
CAPS
General Self-
Efficacy Scale
CAPS MIDAS
CAPS
Coping mechanisms
Physiological processes after disease
Dealing with the problem after disease
Coping and Adaptation Process Scale
Stumuli
Focal Contextual Residual
Biyo-Psycho-Social response
modes
Physiological Self-concept Role-function
Inter-
dependence
Subsystems
Regulator Cognator
Age, gender, genetics,
education level,
knowledge about the
disease and treatment,
economic conditions
Lifestyle (nutrition-
exercise-stress,
alcohol, smoking),
obesity
Beliefs about the
disease, cope with
the unknown factor
that will affect
Myocardial
infarction
Conceptual
Theory
Empirical
Hospital
records
Data collection form based on RAM
Research design
Randomised
Controlled Trial
Samples
MI patients
Self-efficiency Adaptation level in health
behavior
Quality of life
Intervention
Nursing Care Based on RAM
Education and telephone follow-up
Neural,
chemicals,
endocrine
Perceptual,
informational, learning,
decision making,
emotional
Ineffective Responses Adaptive
responses
Figure 1 Conceptual–theoretical–experimental structure to myocardial infarction
250 S. Turan Kavradim, Z. Canli €Ozer
© 2019 Nordic College of Caring Science
lipoprotein cholesterol (HDL) and LDL, body mass index,
dietary behaviour, smoking behaviour and walking for
exercise.
All participants completed a Personal Information
Form which contained 50 items that included demo-
graphic and disease-related information and cardiac
physiological risk parameters. This form was created by
the researcher and was piloted by nursing professionals
(15–18). The self-efficacy levels of the patients were
measured by the General Self-Efficacy Scale (GSES). The
GSES contains 10 items, and each item score ranges
from 0 to 5 (24). Cronbach’s a of the GSES was 0.83.
The highest and lowest possible score is between 10 and
40. High score indicates that the individual perceives
high self-efficacy (25). To evaluate the coping and adap-
tation processes, the Coping and Adaptation (CAPS)
scale was used. The CAPS was developed by Callista Roy
(22). The Turkish validity and reliability study of the
scale was conducted by C�atal and Dicle (2015) (26), and
the Cronbach alpha value was 0.82 for the total scale.
The highest and lowest possible score is between 47 and
188. Higher scores indicate better use of effective coping
methods (26).
To evaluate the quality of life after the disease, the
Myocardial Infarction Dimensional Assessment Scale
(MIDAS) was used. This was developed by Thompson
et al. in 2002. The Cronbach alpha values of the scale
were found in seven dimensions, and ranged from 0.74
to 0.95, showing it to be a useful and highly reliable tool
(27). The validity and reliability study of the scale was
made by Yilmaz et al. Cronbach alpha values ranged
from 0.79 to 0.90. The highest and lowest possible score
is between 0 and 100, with 0 indicating the best health
condition and 100 indicating the worst health condition
(28). Also, the Morisky Adherence Scale was used to
measure medication adherence. The scale was validated
by Morisky, Green and Levine in 1986. The Cronbach
alpha value was found to be 0.61 (29). The validity and
reliability study of the scale was conducted by Bahar
et al., and it was found to be a valid and reliable instru-
ment (30). Because of the participation in the research of
patients who did not have continuous medication, this
scale did not apply in baseline.
Data analysis
The sample size calculation was based on the conven-
tional method of power analysis by using a medium
effect size of 0.5, a power of 0.85 and a significance level
of 0.05. All statistical analyses were conducted with the
SAS 9.4 package. The test of conformity of the data used
primarily to normal distribution was performed with the
Shapiro–Wilk test. The results of the test indicated that
the data showed normal distribution, and parametric tests
were used. In two-way comparison between two-
category variables, t-test was applied for independent
groups, and in order to find the differences between vari-
ables with three or more categories, ANOVA analysis was
applied. As a test of the time of two different measure-
ments obtained from the same individuals, the paired
sample t-test was used. Repeated measures variance anal-
ysis was used to examine whether there were differences
over time and between groups in mean scale scores, and
chi-square or the Fisher’s exact chi-square test was used
to see whether there was a difference in categoric vari-
ables between the experimental and control groups. In
the whole of the study, the significance level was taken
as 0.05.
Results
Characteristics of study participants
During the application phase of the study, 141
patients with a diagnosis of MI were evaluated, and
of these, 66 consented to participate in this study.
However, four patients were lost to follow-up: contact
was lost with two patients, and two patients did not
come for checkups in the hospital (Fig. 2). The demo-
graphic and clinical characteristics of the patients are
shown in Table 1. No differences among the control
and the intervention group were noted in terms of
according to sociodemographic characteristics. The
majority of participants were male (51/66, 82.26%)
with a mean age of 57.79 years (SD = 11.17), 53.23%
were not working, and 66.13% had a family history
of heart disease.
Quality of life, self-efficacy and coping and adaptation
In a comparison of quality of life data with MIDAS, phys-
ical activity (F = 2.86, p = 0.0049), insecurity (F = 2.73,
p = 0.0072), emotional reaction (F = 2.72, p = 0.0074)
and side effects (F = 3.50, p = 0.0006) revealed a signifi-
cant difference between the two groups from the baseline
to the 12th week (Fig. 3). However, other domains of
MIDAS no statistically significant differences were
observed (Table 2; Fig. 3). As shown in Table 2, there
were also significant improvements in self-efficacy (F=
�4.22, p = 0.0001) in the intervention group. Addition-
ally, comparison of the coping and adaptation process
with CAPS between groups revealed a significant differ-
ence (F= �4.54, p = 0.0001) at 12 weeks (Fig. 3). There
were no statistical differences between the groups for
medication adherence. It was determined that 96.77% of
the intervention group and 93.55% of the control group
continued medication use. Also, both groups were found
to show high adherence to regular use of the medication
(83.87% in the intervention group and 77.42% in the
control group).
Education and telephone follow-up intervention 251
© 2019 Nordic College of Caring Science
Changes in lifestyle habits between the two groups during the
12-week study period
There was a higher adherence level in the intervention
group than in the control group on active lifestyle and
physical activity (p < 0.001). Also, a meaningful difference
was found in dietary behaviour between the two study
groups, with better results among patients who received
intervention (p = 0.023). The intervention was not effec-
tive on smoking cessation (p = 0.608) or symptoms experi-
enced (p = 0.194) (Table 3). The effect of the intervention
on physical parameters, serum high-density lipoprotein
(p = 0.045) and waist circumference (p = 0.011) was
confirmed and there was a significant difference between
the groups. However, no significant differences were
observed in other outcomes (p> 0.05) (Table 4).
Discussion
This study reported conducting a holistic intervention
related clinically important topic and aimed at improving
self-efficacy, quality of life and coping adaptation process
to lifestyle changes post-MI. The innovative aspect of this
study was that a nursing model was integrated into edu-
cation and telephone follow-up intervention on adapta-
tion for MI patients. To our knowledge, this study is the
first RCT to evaluate the effectiveness of education and
telephone follow-up intervention based on the RAM for
improving MI patients’ self-efficacy, quality of life and
lifestyle adaptation. This study demonstrated that educa-
tion and telephone follow-up intervention based on the
RAM was effective and applicable to increasing self-effi-
cacy, the coping and adaptation process and quality of
life, and to potentially enhancing exercise and diet
adherence in MI patients.
Quality of life, self-efficacy and coping and adaptation process
In this study results show that there was an increase in
the quality of life during the follow-up in the interven-
tion group, but that the control group showed a decrease
in quality of life during the follow-up period (Fig. 3).
Among the reasons why the intervention was effective, it
is thought that the MIDAS quality of life scale is related
to four bio-psycho-social response modes. There are simi-
larities between the physiological field and the quality of
Figure 2 Flow diagram of the study
252 S. Turan Kavradim, Z. Canli €Ozer
© 2019 Nordic College of Caring Science
Table 1
Characteristics of participants
Characteristics of participants
Intervention
group
(N = 31)
Control
group
(N = 31)
Total
(N = 62)
v2 P valuen % n % n %
Gender Female 5 16.13 6 19.35 11 17.74 0.111 0.740*
Male 26 83.87 25 80.65 51 82.26
Age (years) Mean �x � SS 56.23 � 10.16
59.35 � 12.05 57.79 � 11.17
t = 1.105 0.273
Educational status Primary school 16 51.61 19 61.29 35 56.45 1.477 0.478
High school 6 19.35 7 22.58 13 20.97
College/university 9 29.03 5 16.13 14 22.58
Marital status Single 6 19.35 6 19.35 12 19.35 0.000 1.000*
Married 25 80.65 25 80.65 50 80.65
Working status Working 16 51.61 13 41.94 29 46.77 0.583 0.445*
Not working 15 48.39 18 58.06 33 53.23
Living situation Alone 1 3.23 2 6.45 3 4.84 0.350 0.554*
With family 30 96.77 29 93.55 59 95.16
Income and expenditure situation Income less than Expenditure 4 12.90 11 35.48 15 24.19 4.543 0.103*
Income and Expenditure Balanced 23 74.19 18 58.06 41 66.13
Income more than Expenditure 4 12.90 2 6.45 6 9.68
Occupation Worker 11 35.48 7 22.58 18 29.03 2.346 0.504*
Office worker 3 9.68 2 6.45 5 8.06
Homemaker 1 3.23 3 9.68 4 6.45
Retired 16 51.61 19 61.29 35 56.45
Family history of heart disease Yes 22 70.97 19 61.29 41 66.13
No 9 29.03 12 38.71 21 33.87
Additional disease Yes 15 48.39 19 61.29 34 54.84 7.143 0.129*
Hypertension 3 9.68 11 35.48 14 22.58
Diabetes 1 3.23 2 6.45 3 4.84
Hypertension and diabetes 10 32.26 5 16.13 15 24.19
Other* 1 3.23 1 3.23 2 3.23
Explanation of cause of disease Smoking 6 19.35 6 19.35 12 19.35 2.730 0.742*
Nutrition 5 16.13 2 6.45 7 11.29
Obesity 1 3.23 0 0 1 1.61
Stress 16 51.61 20 64.52 36 58.06
Genetic 2 6.45 2 6.45 4 6.45
Destiny 1 3.23 1 3.23 2 3.23
Plan to change disease process Nothing to do 3 9.68 3 9.68 6 9.68 3.667 0.722*
Active life 1 3.23 2 6.45 3 4.84
Smoking cessation-reduction 7 22.58 8 25.81 15 24.19
Nutrition regulation 8 25.81 7 22.58 15 24.19
Obesity reduction 1 3.23 0 0 1 1.61
Stress reduction-coping 11 35.48 9 29.03 20 32.26
Praying 0 0 2 6.45 2 3.23
Sharing the disease process Yes 28 90.32 29 93.55 57 91.94 0.218 0.641*
No 3 9.68 2 6.45 5 8.06
Social support perception Yes 22 70.97 22 70.97 44 70.97 1.000 0.607*
Partly 7 22.58 5 16.13 12 19.35
No 2 6.45 4 12.90 6 9.68
Going to health control When ill 6 19.35 9 29.03 15 24.19 2.325 0.508*
Every few months 6 19.35 8 25.81 14 22.58
Once a year 5 16.13 2 6.45 7 11.29
I never went 14 45.16 12 38.71 26 41.94
*p> 0.05
Education and telephone follow-up intervention 253
© 2019 Nordic College of Caring Science
life subscale in the model. In addition to this, it is
thought that the detection of change in compliance areas,
stimuli and coping mechanisms of data collection form
based on the RAM and use of model-based intervention
is effective in increasing the quality of life. In the litera-
ture, there was no study evaluating the efficacy of educa-
tion or telephone follow-up on quality of life in coronary
diseases based on the RAM. However, studies in different
patient populations based on the RAM seem to show an
increase in the quality of life of patients (31,32). In addi-
tion, the results of our study show similar results to other
studies using education and telephone follow-up inter-
vention (33,34). When different studies of telephone fol-
low-up interventions were examined in patients with
cardiovascular disease, it was found that these interven-
tions had positive effects on patient satisfaction and par-
ticipation in cardiac rehabilitation, decreased stress and
hospital admissions (7,10,11). Also, training and tele-
phone follow-up interventions have significantly
improved the quality of life in cardiovascular disease
patients (33,34).
The self-efficacy of patients in the intervention group
was found to be significantly increased (Fig. 3). In this
regard, it is seen that the research hypothesis is con-
firmed. Among the reasons for the effectiveness of the
intervention are thought to be face-to-face predischarge
education and implementation of strengthening-encour-
agement strategies with structured telephone follow-up
interventions based on the RAM. Self-efficacy includes
four basic processes: cognitive, motivational, emotional
and selection (35). The cognitive and selection processes
of the patients were supported in this study by the edu-
cation, and motivational and emotional processes were
supported by telephone follow-up intervention. Further-
more, an aim of the study was to strengthen the coping
mechanisms of patients in order to establish effective
adaptation behaviours according to the RAM. There are
similarities between the coping mechanisms in the model
b. Change in the mean of the patients’ self-efficacy scale scores over time
Control Intervention
Baseline 12th week
a. Change in the mean of the patients’ quality of life subscale scores
over time
Control Intervention
c. Change in the mean of the patients’ coping and adaptation process scale scores over time
Control Intervention
Baseline 12th week Baseline 12th week
Physical activity
Diet
Insecurity Dependency
Medication Side effects
Emotional reaction
Baseline 12th week Baseline 12th week
Figure 3 (a) Change in the mean of the patients’ subscale scores over time. (b) Change in the patients’ self-efficacy scores over time. (c) Change
of mean score of patients’ coping and adjustment process scale over time
254 S. Turan Kavradim, Z. Canli €Ozer
© 2019 Nordic College of Caring Science
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Education and telephone follow-up intervention 255
© 2019 Nordic College of Caring Science
https://www.danielsoper.com/statcalc/calculator.aspx?xml:id=48
and the concept of self-efficacy. To our knowledge, there
is no study evaluating the efficiency of the RAM on self-
efficacy in coronary diseases, but it has been shown that
the application of this model with a care plan in elderly
individuals had positive effects on improving self-efficacy
(36). It is known that increasing self-efficacy in disease
management influences behavioural choices and has pos-
itive effects on lifestyle change (5,37,38).
In the present study, the coping and adaptation process
score increased in the intervention group of the study,
whereas it decreased significantly in the control group
(Fig. 3). It is thought that the telephone follow-up was
an important intervention that contributed to the coping
and adaptation processes in terms of early detection and
control of symptoms, the provision of fast, useful and
effective solutions, information exchange and improve-
ment in the quality of the health education of the
patients. It has been observed in studies that RAM con-
tributed to the coping and adaptation process of patients
(39,40).
Changes in lifestyle habits during the study period
In Turkey generally, there is no systematic cardiac reha-
bilitation programme at most centres after MI, and thus,
no routine monitoring system is applied to follow-up
changes in the lifestyle of patients. It is stated that the
period in which patients with cardiovascular disease are
most likely to discontinue their medication is one to
three months after discharge (41,42). In this study, medi-
cation adherence was high in both groups and there was
no statistically significant difference in drug adherence in
the groups. Although some studies were conducted by
telephone follow-up intervention, medication adherence
was significantly increased compared with the control
group (43,44). In contrast to these studies, other studies
determined that education and counselling interventions
were not effective (45,46). And also when studies of
RCTs were examined, it was shown that education and
telephone follow-up interventions had positive effects on
nutrition and physical activity (46–49).
Table 3 Treatment effects from baseline to 12th week for lifestyle habits
Variables
Baseline 12 weeks after discharge
v2 P value
Intervention
group
Control
group
Intervention
group
Control
group
n % n % n % n %
Symptoms experienced None 13 41.94 15 48.39 22 70.97 14 45.16 4.71 0.194
Fatigue and weakness 8 25.81 10 32.26 2 6.45 6 19.35
Shortness of breath 1 3.23 3 9.68 0 0 0 0
Chest pain 8 25.81 3 9.68 6 19.35 9 29.03
Other 1 3.23 0 0 1 3.23 2 6.45
Health status perception Good 16 51.61 11 35.48 23 74.19 10 32.26 11.08 0.004
Middle 13 41.94 18 58.06 7 22.58 17 54.84
Bad 2 6.45 2 6.45 1 3.23 4 12.90
Smoking habits Yes 16 51.61 14 45.16 9 29.03 10 32.26 0.99 0.608
Not smoking 7 22.58 11 35.48 15 48.39 17 54.84
Stopped smoking 8 25.81 6 19.35 7 22.58 4 12.90
Alcohol habits Yes 3 9.68 1 3.23 0 0 0 0
No 25 80.65 28 90.32 31 100 31 100 – –
Quit 3 9.68 2 6.45 0 0 0 0
Physical activity Yes 4 12.90 4 12.90 27 87.10 8 25.81 23.68 0.000
No 27 87.10 27 87.10 4 12.90 23 74.19
Active lifestyle Yes 16 51.61 12 38.71 20 64.52 10 32.26 23.60 0.000
Partly 7 22.58 9 29.03 11 35.48 4 12.90
No 8 25.81 10 32.26 0 0 17 54.84
Rest during the day Yes 18 58.06 22 70.97 28 90.32 23 74.19 3.49 0.175
Partly 9 29.03 5 16.13 3 9.68 6 19.35
No 4 12.90 4 12.90 0 0 2 6.45
Dietary behaviour I know what I need to eat 11 35.48 7 22.58 31 100 14 45.16 23.42 0.000
I do not know what to eat 20 64.52 24 77.42 0 0 17 54.84
I pay attention 10 32.26 11 35.48 29 93.55 19 61.29 9.53 0.023
I do not pay attention 2 6.45 1 3.23 0 0 2 6.45
I do not pay much attention 11 35.48 12 38.71 2 6.45 9 29.03
I never pay attention 8 25.81 7 22.58 0 0 1 3.23
256 S. Turan Kavradim, Z. Canli €Ozer
© 2019 Nordic College of Caring Science
Psychosocial adaptation fields
MI makes adaptation difficult by affecting an individual’s
physiological, self-concept, role function and interdepen-
dence fields. The aims of a nurse in this process were to
change ineffective adaptation behaviours into effective
ones and to maintain or develop existing effective adap-
tation behaviours. In research in the physiological field
relating to the fields of psychosocial adaptation, signifi-
cant results have been obtained on the topic of nutrition,
exercise and an active life. Examination of randomised
controlled studies in the literature in which education
and monitoring by telephone were used has shown that
they have beneficial effects on nutrition and physical
activity (46–49). Psychosocial problems such as feeling
bad about oneself, uncertainty about the future, hope-
lessness and feelings of guilt are related to the field of
concept of self. When the state of perception of health
was considered in the study, it was seen that the state of
feeling good was better in the intervention group than in
the control group.
No randomised controlled studies with cardiovascular
diseases were found in the literature based on the Roy
Adaptation Model. In studies with other patient popula-
tions using the RAM, the levels of effect of education on
adaptation fields were investigated. In two studies inves-
tigating the effectiveness on psychosocial adaptation
fields of theory-based patient education based on the
RAM in increasing adaptation in haemodialysis patients,
it was shown that patients’ adaptation in the physiologi-
cal and self fields increased in the intervention group
compared with the control group, providing physical,
psychological and social adaptation (4,50). In a ran-
domised controlled study examining the effects on physi-
cal and psychosocial adaptation of patient education
given based on the RAM to patients with chronic
obstructive pulmonary disease, it was found that the edu-
cation given to the intervention group increased adapta-
tion to the illness in three modes – psychological, self-
concept and role function modes. In addition to this, no
significant increase was observed in the interdependence
mode of the RAM (51). In another randomised controlled
study examining adaptation in individuals with heart fail-
ure to education based on the RAM, increases in
patients’ quality of life, functional capacities and receipt
of social support were seen compared with the control
group (31).
Limitations
While the study did have some strengths (single-blind,
concealed random assignment, clear inclusion/exclusion
criteria, the use of reliable and valid outcome measures,
obtaining some preliminary feedback on the intervention
and the assessment of range of potentially relevantT
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Education and telephone follow-up intervention 257
© 2019 Nordic College of Caring Science
outcome measures), the study did have some limitations.
The limitations of this trial were 1) the self-reported mea-
sure of physical activity and nutrition behaviour, 2) due
to the nature of the intervention it was impossible to
blind the researcher so patients provided data to a single
interventionist, 3) the study is limited to the patients
who had MI in University Hospital Cardiology Clinic
between April 2016 and August 2017, 4) the study had a
small sample and was performed at a single centre and 5)
the population was limited about primarily male, pre-
sumably of Turkish descent and related to only including
those patients with sufficient reading and writing skills,
as well as mobility and transportation access. Thus, the
results cannot be generalised to all patients.
Conclusion
In conclusion, it has been established that nursing care
given based on education based on the RAM and tele-
phone follow-up can be applied to individuals who have
undergone MI. The results from this study indicate that
education and telephone follow-up intervention based on
the RAM had positive and significant results after
12 weeks on quality of life, self-efficacy and coping and
adaptation process, and on enhancing exercise and diet
adherence compared to the control group. The findings
of this study are important for health professionals who
care for individuals with MI to develop nursing care.
Based on the research process and the results obtained, it
is recommended that education based on the RAM and
telephone follow-up should be performed, that an educa-
tion booklet should be used in education in the clinic
before the patient is discharged and that the education
booklet should be given to the patient, and that a post-
discharge tele-monitoring system should be formed for
management of the postillness process. Due to the small
number of participants in the study, further research is
recommended to conduct with larger sample. It is also
recommended that studies of education based on the
RAM and telephone follow-up studies should be carried
out in which the follow-up period is longer to obtain sig-
nificant positive results on smoking habits, physical
parameters and managing symptoms.
Acknowledgements
The authors want to thank the cardiology clinic team at
University Hospital for their support and advice and MI
patients for participating.
Conflict of interest
No conflict of interest has been declared by the authors.
Funding
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.
Ethical approval
Before starting the research, permission was obtained from
University Hospital. In addition, ethics committee approval
(Approval No: 2012-KAEK-20) was obtained from the
Ethics Committee for Clinical Investigations of University.
This study was conducted in accordance with the princi-
ples of the Helsinki Declaration. Written informed consent
also was obtained from each participant.
Author contribution
Selma Turan Kavradım and Zeynep €Ozer made substan-
tial contributions to conception and design. Selma Turan
Kavradım collected the data and a statistic expert anal-
ysed the data. Each author is responsible for the theoreti-
cal approaches. Zeynep €OZER supervised and reviewed
the drafting of the manuscript.
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Supporting Information
Additional Supporting Information
may be found in the online version
of this article:
Appendix S1. 2017 CONSORT
checklist of information to include
when reporting a randomized trial
assessing nonpharmacologic treat-
ments (NPTs).
260 S. Turan Kavradim, Z. Canli €Ozer
© 2019 Nordic College of Caring Science
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articles for individual use.
F E AT U R E S
Effect of Support Group Intervention Applied
to the Caregivers of Individuals With Heart
Failure on Caregiver Outcomes
■ Canan Demir Barutcu, PhD, RN ■ Hatice Mert, PhD, RN
This study was conducted to evaluate the effectiveness of support group intervention applied to the caregivers of
individuals with heart failure on caregiver outcomes. Quasi-experimental research was conducted with 69
caregivers as control (n = 35) and intervention (n = 34) groups in the cardiology outpatient clinic of a university
hospital. The intervention group participated in support group meetings structured according to the Neuman
Systems Model, and the data were collected from both the intervention and control groups before the intervention
and 3 and 6 months later. Caregivers in the intervention group had significantly lower burden scores compared with
the control group in all subdimensions except objective personal care, in terms of the group × time interaction in a
statistical way (P < .05). Caregivers in the intervention and control groups had similar scores of depression
symptoms (P > .05). The burden of caregivers in the intervention group showed a statistically significant decrease
compared with the preintervention in all dimensions at 3 months. Thus, it is suggested to extend the support group
interventions for caregivers of patients with heart failure and conduct these interventions in a longer period.
KEY WORDS: caregiver, heart failure, Neuman Systems Model, support group Holist Nurs Pract 2016;30(5):
272
–282
Heart failure is a frequent health problem whose
incidence rate increases each year with high mortality
and morbidity rates.1 It was reported that there were
more than 5.8 million patients with heart failure in the
United States, and 825 000 new cases, who were 65
years and older, are added to this number each year.2 It
was also reported that there were more than 15 million
patients with heart failure in Europe.3,4 Heart Failure
Prevalence and Predictors in Turkey (HAPPY) study
showed that the estimated prevalence of heart failure
is 6.9% in Turkey.5
Heart failure is a disease that leads to low quality of
life because of the patient’s failure to meet basic
needs, change in body image, lack of self-care
behaviors and activities of daily living, chronic
Author Affiliation: Department of Internal Medicine Nursing, Faculty of
Nursing, Dokuz Eylül University, İzmir, Turkey.
The authors thank all the caregivers who participated in this study.
The authors declared no potential conflicts of interest with respect to the
authorship and/or publication of this article.
Correspondence: Canan Demir Barutcu, PhD, RN, Department of Inter-
nal Medicine Nursing, Faculty of Nursing, Dokuz Eylül University, 35340
Inciraltı, Izmir, Turkey (canandemir2209@gmail.com; canan.demir@deu
.edu.tr).
DOI: 10.1097/HNP.0000000000000164
fatigue, sexual dysfunction, and concerns about the
future. 6,7 As the stages of the disease progress, the
patients require the help of others to meet their basic
needs, with most of the care being provided by family
members. Because heart failure requires a long period
of treatment after the diagnosis, this affects not only
patients but also caregiver families physically,
psychologically, socially, spiritually and also causes
an economic burden along with intense stress.8-12
Frequent hospitalization of patients with heart failure
because of the effects of their intensifying symptoms,
their cognitive deficiency, medication regimens, and
implanted devices can all cause an increase in the
stress levels and overall burden on caregivers, causing
them to experience depressive symptoms and the
impairment of their emotional and physical health.11
Although the importance of support in patients with
heart failure is emphasized, physical, psychological,
social, and economic burdens emerging on caregivers
who provide support are ignored.8,11,13-15
In previous studies, it has been indicated that
caregivers of patients with heart failure experienced
social isolation and depressive symptoms and were
unable to receive professional support and training
even though they needed it desperately during this
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
272
mailto:canandemir2209@gmail.com
mailto:canan.demir@deuglobal advance �reakcnt @ne penalty -@M .edu.tr
mailto:canan.demir@deuglobal advance �reakcnt @ne penalty -@M .edu.tr
Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 273
process.13,16-18 It has been indicated that caregivers’
increased knowledge about heart failure and care
contributed to patients’ lifestyle change, decision
making, self-care, compliance to medication, and
communication with health care professionals. In
addition, it was found that caregivers believe in
themselves more, their worries decrease, and they
support people whose care they are responsible for;
this increases the life quality of the patient with heart
failure.9,10,12,14,18-21 It has been found that the number
of interventional studies performed on caregivers of
heart failure patients was very low among
international studies in the literature, and no studies
could be found in Turkey on this subject. Although
social support is very important for patients with heart
failure, training and supporting caregivers providing
support for patients is very important in terms of
health care outcomes. This study was planned on the
basis of this finding.
AIM
The objectives of this study were to examine the
effects of the support group intervention
� on caregiver burden and
� on depressive symptoms of caregivers of
individuals with heart failure.
CONCEPTUAL, THEORETICAL, AND
EXPERIMENTAL STRUCTURE OF THE
RESEARCH
One of the important groups expecting care service
from nurses are caregivers. Nursing care services
include the assessment, planning and implementation
of the interventions necessary for the protection and
maintenance of health for all dimensions of an
individual’s life (physiological, psychological,
socio-cultural, developmental, and spiritual).22,23 In
this regard, the Neuman Systems Model (NSM)
provides a system-based and detailed conceptual
framework as it looks at human beings with a
multidimensional system understanding.
Variables used in this study were associated with
the concepts and variables of the NSM. The core
responses to study the caregiver burden were assessed
with the Dutch Objective Burden Inventory (DOBI).
Those who received at least 1.5 points or above from
at least 1 subdimension of the DOBI were included in
the study. Support group meetings were arranged for
caregivers to enhance resilience and reduce the care
burden. This is called secondary prevention in the
NSM. The characteristic of secondary prevention is
that it is applied after a reaction against stress occurs;
the aim is to support the individual and reduce the
reaction level after the formation of stress. Guiding the
support group members in using the communication
techniques by regarding the problems transmitted into
the group as opportunities and helping them solve the
current problem using the problem-solving techniques
are examples of secondary prevention.
The conceptual-theoretical-empirical structure of
the study’s intervention can be seen in Figure 1.
METHODS
Design
The study adopted a quasi-experimental design.
Sample
The research was carried out in the cardiology
polyclinic of a university hospital between March
2013 and January 2015. The sample consists of the
caregivers of patients admitted to the university
hospital because of heart failure. The inclusion criteria
for caregivers were a person who provided care to a
patient with heart failure identified as the primary
helper with their daily activities, voluntarily accepted
participation in the research, lived with the patient,
was literate in Turkish, had no hearing or speaking
impairment, and was 18 years and older. Because
there is not a cut-off of the care burden scale and each
subdimension score varies between 1 and 3, those who
received at least 1.5 points or above from at least 1
subdimension of the scale were included in the
sample; secondary prevention interventions were
applied according to the NSM. Factors that
disqualified caregivers from sampling were their
diagnosis with any psychiatric disease and their care
being provided to patients at a price. The aim for
participants was to come to at least 3 meetings, and
those who failed to complete the 3 meetings were
excluded from the sample. The distribution of the
research sample by intervention and control groups is
shown in Figure 2.
Data collection process
The data collection process started with the control
group data; after completing the control group data,
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
274 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2016
FIGURE 1. Conceptual-theoretical-empirical structure.
support group meetings started and the intervention
group data were collected. The first data collected
from the control group and the data collected in the
intervention group before the first support group
meeting constituted baseline data. Control group data
were collected in 3 parts: (1) baseline, (2) first
follow-up (3 months later), and (3) second follow-up
(6 months later after baseline). Intervention group data
were collected in 3 parts: (1) before the meeting
(baseline data), (2) first follow-up (3 months after the
intervention), and (3) second follow-up (6 months
after the intervention). In the baseline stage, data were
obtained using the caregivers’ demographic and
care-related characteristics from the DOBI and Beck
Depression Inventory (BDI), and in the first follow-up
and second follow-up, data were obtained using the
DOBI and BDI, in both the control and the
intervention groups.
Intervention
Caregivers sat in a circle thus enabling
face-to-face communication in group meetings,
and the temperature, light, and air-conditioning of the
environment were set appropriately. The participants
were offered food and drink before the support group
interaction while waiting for all participants to come
and to ensure social interaction. The meetings were
started with 42 caregivers in the intervention group,
and the meetings were completed with 34 caregivers.
The groups consisted of 6 to 12 people with 4 groups
in total. Four support group meetings were held with
each group. The support group meetings were held
once a week (90-120 minutes) in accordance with the
request of the caregivers. The researcher conducted the
meetings. Six questions, which are used to collect data
in NSM, were used in meetings: What do you think
your greatest problem is in terms of level of difficulty?
How did your current situation affect your accustomed
life style? Have you ever experienced a similar
problem? If you have experienced, what was the
problem and how did you deal with it? What do you
think about your situation in the future considering
your current situation? What can or do you do to
help yourself? What do you want your family, friends,
or others to do for you? Along with these questions,
experience on exchange was made with questions asked
by caregivers and researchers relating to the process
and group members proposed solutions and provided
support to each other for problems experienced.
Instruments
Demographic and care-related characteristics
This form is composed of 10 questions regarding
caregivers’ sociodemographic characteristics: age,
gender, marital status, educational status,
employment, social insurance, economic condition,
relationship to the patient, presence of a chronic
disease, and care giving period.
Dutch Objective Burden Inventory
The DOBI was developed by Luttik et al15 and it
measures objective and subjective burden in caregivers
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Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 275
FIGURE 2. Study plan and data collection process.
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276 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2016
for patients with heart failure. The scale is composed
of 38 items in total. It has 4 subscales including
personal care (11 items), practical-related support (11
items), motivational support (10 items), and emotional
support (6 items). Each item represents a specific
caregiving task. Using a 3-point Likert scale format,
caregivers were asked to rate both the frequency and
perceived burden for each caregiving task. If a
caregiver did not perform a specific task, no response
was required for the subjective component of that
specific item. Frequency responses represent objective
burden and perceived burden scores represent
subjective burden. Higher scores represent higher
levels of caregiver burden. Mean objective and
subjective burden scores are reported for each domain.
Total scores for all components range from 1 to 3.
Total scores for each component were computed by
adding the items values in each component and then
dividing them by the number of items in that
component. The internal consistency of the
components was calculated using the Cronbach α. The
components of DOBI’s objective burden displayed α
scores from 0.81 to 0.84.15 Unlike the initial DOBI
validation study, the validity and reliability study in
Turkey recruited both spousal and nonspousal
caregivers on the version of the DOBI tested in this
study. In the scale, practical support (second
component) has an 8-item (15-22) factor load, lower
than 0.30; for that reason these items are removed
from the scale because they are not appropriate to the
Turkish culture and health care systems. Validity and
reliability of the forms used in the study included over
30 items, and the Cronbach α coefficient of the scale
was found to be within reliable limits (minimum =
0.96 and maximum = 0.99).24
Beck Depression Inventory
Beck Depression Inventory (BDI)-I is a 21-question
multiple-choice self-report inventory, with each
answer being scored on a scale of 0 to 3 points. Higher
total scores indicate more severe depressive
symptoms. Participants choose 1 of the 4 statements
describing how they felt over the past 2 weeks. The
cut-off scores used are none to minimal depression,
<10; mild to moderate depression, 10 to 18; moderate
to severe depression, 19 to 29; and severe depression,
30 to 63.25 The BDI-I was validated in a clinical
sample of 259 participants and has acceptable
reliability (coefficient α = 0.80) and validity.26
Data analysis
Analysis was conducted using descriptive statistics in
the Statistical Package for the Social Services SPSS
15.0 (SPSS Inc, Chicago, Illinois). χ 2 and t tests were
used to determine differences between groups. To
determine the effectiveness of the intervention,
2-factor repeated-measures analysis of variance and
paired t test with Bonferroni correction were used
when appropriate. In the statistical analysis, the
burden and depression level scores for the caregivers
were compared with respect to time, group and group
× time interaction.
Ethical considerations
Written permission from the Dokuz Eylül University
Ethical Committee (246-GOA2011/22-19-30.06.2011)
and the Dokuz Eylül University Hospital
(334/25.05.2011) was also obtained. The objective of
the research was explained to the participants and
written permission was received from those agreeing
to participate.
FINDINGS
Sociodemographic characteristics
With the exception of marital and employment status,
the sociodemographic features of the caregivers in the
intervention and control groups were found to be
similar (Table 1). Whether marital and employment
status affect the scale score averages was assessed
using covariance analysis. It has been found that
marital status does not significantly affect the
variables (P > .05), whereas employment status
significantly affects the variables (P < .05). The
variance analysis in repeated measurements was
performed by taking the employment and marital
status variables under control. Initial score averages
for the caregiver burden subdimension and depression
symptoms of the caregivers in the control and
intervention groups were similar (P > .05).
Effects of support group intervention on burden
Except for the objective personal care subdimension, a
statistically significant difference in the third and sixth
months in the care burden score for the caregivers in
the intervention and control groups in all
subdimensions was found. It was determined that the
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Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 277
TABLE 1. Demographic and Clinical Characteristics of the Caregivers in the Intervention and Control Groups
at Baseline
Demographic and Clinical Characteristics
Control (n = 35)
Mean ± SD
Intervention (n = 34)
Mean ± SD
Age, y 57.00 ± 10.71 52.38 ± 12.67 t = 1.636 P = .107
Care-giving period, y 8.25 ± 7.98 7.02 ± 5.70 t = 0.733 P = .466
n (%) n (%)
Gender
Female 28 (80.0) 23 (67.6) χ 2 = 0.79a
Male 7 (20.0) 11 (32.4) P = .371
Marital status
Married 35 (100) 23 (67.6) χ 2 = 11.16a
Single 0 (0) 11 (32.4) P = .001
Educational level
Primary 17 (48.6) 9 (26.5) χ 2 = 2.70a
High school and more 18 (51.4) 25 (73.5) P = .100
Employment
Employee 4 (11.4) 15 (44.1) χ 2 = 13.53a
Retired 10 (28.6) 12 (35.4) P = .001
Unemployed 21 (60.0) 7 (20.6)
Social insurance
Have 35 (100) 32 (94.1) P = .239b
Have not 0 (0) 2 (5.9)
Economic status
Income > expense 2 (5.7) 4 (11.8) χ 2 = 1.96
Income = expense 22 (62.9) 16 (47.1) P = .375
Income < expense 11 (31.4) 14 (41.2)
His/her relationship to patient
Spouse 17 (48.6) 12 (35.3) χ 2 = 5.39
Adult child 13 (37.1) 21 (61.8) P = .067
Others (relatives, friend, etc.) 5 (14.3) 1 (2.9)
Chronic disease
Have 14 (40.0) 17 (50.0) χ 2 = 0.35a
Have not 21 (60.0) 17 (50.0) P = .553
Abbreviation: SD, standard deviation.
aYates correction was made because the number is under 25.
bCorrected Fisher χ 2 was used for that number expected under 5.
burden scores of the caregivers in the intervention
group in the third and sixth months were lower than in
the control group (Table 2). A significant difference
was found in the intervention group in all
subdimensions except for objective personal care
subdimension in terms of the group × time interaction
(baseline, third, and sixth months) (Table 2). The
burden score averages of the caregivers in the third
and sixth months in the intervention group were found
to be lower than the baseline score averages.
Except for the subjective personal care
subdimension, a statistically significant difference in
the third and sixth months in the care burden score for
the caregivers in the intervention and control groups in
all subdimensions was found. The burden scores of
caregivers in the intervention group in the third and
sixth months were lower compared with the control
group. In terms of the group ×time interaction, a
significant difference was found for the intervention
group in all subdimensions except for subjective
personal care subdimension (baseline, third, and sixth
months) (Table 3). The burden score averages of the
caregivers in the intervention group in the third and
sixth months were found to be lower than baseline
score averages.
Effects of support group intervention on
depression
No statistically significant difference in the third and
sixth months was found between the depression score
averages for the caregivers in the intervention and
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278 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2016
TABLE 2. Means and Standard Deviations for DOBI Objective Subscales by Group × Time Interaction
Effects
Group × Time Interaction Effects
Baseline
Mean ± SD
3 mo
postintervention
Mean ± SD
6 mo
postintervention
Mean ± SD Fa P
Personal care
Intervention group 1.87 ± 0.63 1.64 ± 0.38 1.74 ± 0.44
Control group 1.93 ± 0.73 1.90 ± 0.72 1.95 ± 0.74 1.731 .181
t 0.366 −1.882 1.407
P .715 .065 .165
Practical support
Intervention group 1.89 ± 0.46 1.82 ± 0.40 1.86 ± 0.43
Control group 2.20 ± 0.37 2.16 ± 0.16 2.22 ± 0.22 9.441 .000b
t −1.141 3.631 3.129
P .259 .001b .003b
Motivational support
Intervention group 2.46 ± 0.56 2.03 ± 0.36 2.05 ± 0.36
Control group 2.62 ± 0.29 2.70 ± 0.17 2.68 ± 0.18 24.871 .000b
t 1.496 9.641 8.942
P .141 .000b .000b
Emotional support
Intervention group 2.70 ± 0.46 2.15 ± 0.36 2.23 ± 0.34
Control group 2.82 ± 0.60 2.77 ± 0.15 2.80 ± 0.07 10.731 .000b
t 0.943 9.222 9.469
P .349 .000b .000b
Abbreviation: SD, standard deviation.
aRepeated-measures ANOVA with 2 between-group factor.
bP < .05.
control groups (pretest t = −1.152, P = .253;
posttest 1 t = −0.168, P = .867; posttest 2 t =
−0.616, P = .540) (Table 4). A significant difference
was found between the depression score averages in
time in the intervention group in terms of the group ×
time intervention. As a result of further analysis, a
statistically significant difference was determined
between pretest and posttest 1 (t = 3.238, P = .003)
and posttest and posttest 2 (t = −4.480, P = .000); no
statistically significant difference was determined
between pretest and posttest 2 (t = 2.183, P = .036).
DISCUSSION
Effects of support group intervention on burden
When the caregiver burden is assessed in all
subdimensions, it was found that caregivers in the
intervention group felt burden in terms of objective
and subjective burden dimensions mostly in
emotional, motivational, practical, and personal care
support dimensions, respectively. Evaluating average
scores after support group interventions, the most
significant were obtained in dimensions in which
caregivers felt the highest level of burden (ie, support
group interventions affected emotional, motivational,
practical, and personal care support averages). It is
believed that the support group interventions
conducted were quite effective in decreasing caregiver
burden. Three studies were encountered in the
literature assessing caregiver burden using the DOBI.
The first study was carried out by Luttik et al,15 who
developed the scale, and only the objective section
was studied; the authors found that caregiver burden is
highest in the practical dimension, then the emotional,
motivational, and lastly in the personal care
dimension. In another study, in which validity and
reliability of the scale was investigated for Canadian
society, Makdessi et al27 evaluated caregiver burden
solely in the objective dimension and found that
caregiver burden was at its highest in the emotional
dimension followed by practical, motivational, and
personal care dimensions, respectively. In this sense,
our findings are parallel with the results obtained by
Makdessi et al27 in that the highest level of burden was
found in the emotional dimension and the lowest level
of burden was found in the personal care dimension.
Other than these 2 studies, Hwang et al3 evaluated
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Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 279
TABLE 3. Means and Standard Deviations for DOBI Subjective Subscales by Group × Time Interaction
Effects
Group × Time Interaction EffectsBaseline
Mean ± SD
3 mo
postintervention
Mean ± SD
6 mo
postintervention
Mean ± SD Fa P
Personal care
Intervention group 1.81 ± 0.62 1.61 ± 0.36 1.65 ± 0.38
Control group 1.84 ± 0.72 1.85 ± 0.70 1.86 ± 0.70 10.351 .000b
t 0.193 1.747 1.549
P .848 .087 .127
Practical support
Intervention group 2.34 ± 0.63 1.91 ± 0.36 1.98 ± 0.40
Control group 2.09 ± 0.58 2.08 ± 0.53 2.13 ± 0.53 0.042 .959
t 1.595 2.300 2.310
P .115 .025b .024b
Motivational support
Intervention group 2.12 ± 0.52 1.87 ± 0.29 1.90 ± 0.31
Control group 2.22 ± 0.48 2.23 ± 0.48 2.24 ± 0.47 3.506 .033b
t 0.793 3.722 3.569
P .431 .000b .001b
Emotional support
Intervention group 2.62 ± 0.58 2.10 ± 0.45 2.17 ± 0.45
Control group 2.73 ± 0.48 2.67 ± 0.47 2.70 ± 0.50 19.070 .000b
t 0.855 5.089 4.632
P .396 .000b .000b
Abbreviation: SD, standard deviation.
aRepeated-measures ANOVA with 2 between-group factor.
bP < .05.
caregiver burden only in the objective dimension using
the inventory descriptively and found that 41% of
caregivers provided support for patients in the
emotional dimension and 40% of caregivers provided
support for patients in the personal care dimension.
In the third and sixth months, burden of caregivers
was lower than preintervention. The burden of
caregivers on the sixth month has been found slightly
higher than on the third month, however, lower than
preintervention. This situation shows that the
intervention is more effective in a short time. In a
study carried out by Garlo et al.28 with the caregivers
of heart failure patients, it was found that the burden
of the caregivers gradually increases in time
throughout the 12-month monitoring period. Our
results support this idea that the burden gradually
increases. In the study carried out by Etemadifar
et al,29 in which they examine the effect of the support
TABLE 4. Means and Standard Deviations for Beck Depression Inventory by Group × Time Interaction
Effects
Group × Time Interaction Effect
Beck Depression Inventory
Baseline
Mean ± SD
3 mo
postintervention
Mean ± SD
6 mo
postintervention
Mean ± SD Fa P
Intervention group 15.58 ± 10.24 12.79 ± 6.26 13.67 ± 6.40
Control group 13.02 ± 8.12 12.51 ± 7.50 12.62 ± 7.64 6.208 .003b
t −1.152 −0.168 −0.616
P .253 .867 .540
Abbreviation: SD, standard deviation.
a Repeated-measures ANOVA with 2 between-group factor.
bP < .05.
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280 HOLISTIC NURSING PRACTICE • SEPTEMBER/OCTOBER 2016
group training interventions on the burden of the
caregivers of patients with heart failure, the burden of
the caregivers in the intervention group decreased
significantly in the first year when compared with
preintervention; in addition, it was found that the
caregiver burden score averages increased 3 months
later. Again, this idea that caregiver burden increases
in time was in parallel with the results of our study;
that the burden decreases and even remains stable as a
result of our interventions shows the effectiveness of
the intervention made. In the literature, the support
groups studies structured by the NSM were carried out
with caregivers of patients with dementia30 and
parents of disabled children.31 However, an NSM-
based support group study conducted with caregivers
of patients with heart failure could not be found. In
this sense, our study shows the effectiveness of
NSM-based support group interventions on reducing
caregiver burden, and therefore it is one of the limited
numbers of studies in the heart failure literature, and
because it is the first support group intervention study
conducted using the model, it is believed that it can fill
the gap in the literature.
In this study, we attempted to reduce the care
burden, which is accepted as the main response in this
model. The intervention for the secondary prevention
defined by Neuman was applied as the caregivers
receiving a score of 1.5 points and above from the
caregiver scale and was included in the study. Because
it was thought that the flexible defense line in the
NSM was broken due to caregiving stress and the
normal prevention line was activated due to caregiving
responsibility’s being a big stressor, interventions
were performed with the aim of enhancing the
resistance lines. The caregivers shared the physical,
psychological, social, developmental, and spiritual
stressors they experienced in this process in the
support group meetings, and it was ensured that group
members supported each other by making solution
suggestions. That there is a decrease in the caregiver
burden after the intervention confirms the proposition
of Neuman that the main response can be reduced
through secondary prevention. The caregivers
frequently expressed their well-being emotion
verbally after the support group meetings. It was
expressed that the caregivers do not feel alone, feel
stronger physically and psychologically, could cope
with problems more easily, and the stress they
experience was reduced after the meetings; however,
these variables were not assessed in our
study.
Effects of support group intervention on
depression
A significant difference was detected between
depression symptom scores of the intervention and
control group caregivers in terms of the group × time
interaction. The depression signs significantly
decreased in the third month in the intervention group
when compared with preintervention. As for the
control group, the signs of depression scores of the
caregivers increased and there was no statistically
significant difference between the initial, third, and
sixth month score averages.
Depression levels of the caregivers differ in the
descriptive studies compared with caregivers of
patients with heart failure in the literature. Moreover,
the depression sign scores of heart failure caregivers
are quite high in some studies,11,32 whereas the
depression sign scores of the caregivers are low17,33-36
in others. The results of the studies examining the
effects of the interventions on caregivers of patients
with heart failure on depression signs are
contradictory. According to the training intervention
results by Schwarz et al37 on the caregivers of heart
failure patients, it was found that the depressive
symptoms of the caregivers did not decrease. In the
study carried out by Dunbar et al,38 no difference
between the intervention and control groups in terms
of the depression sign scores for caregivers resulted
from the training and support intervention. Likewise,
in the support group intervention study conducted
with caregivers of patients with heart failure by
Cockayne et al,39 it has been found that the depression
level of the caregivers does not decrease. Nonetheless,
Jaarsma et al40 found that the interventions decreased
the depressive symptoms of the caregivers in a study
examining the depression levels in caregivers of
patients with heart failure. It was found in our study
that there was a significant decrease in intervention
group caregivers’ depression symptoms in the third
month. It is thought that the fact that caregivers shared
the stressors in the psychological dimension they
experienced in the support group meetings, which is 1
of the 5 variables of the NSM, and that group
members offered solutions and provided support for
each other was effective in reducing depression
symptoms. However, considering average depression
scores, a slight increase was observed in the
intervention group in the sixth month compared with
the third month. That depression is affected by many
situational factors in the daily life process and thus the
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Support Group Intervention to the Caregivers of Individuals With Heart Failure on Caregiver Outcomes 281
improvement can be difficult are considered the reason
for this situation. The fact that an improvement was
seen in depression, or even that it remained at the
same level, could be interpreted as the interventions
being clinically effective because depression is a
concept that is influenced by a large number of factors
and usually worsens through the caregiving process.
STUDY LIMITATIONS AND FUTURE
RECOMMENDATIONS
The extension of support group studies aimed at heart
failure patient caregivers and the qualitative evaluation
of results is advised. Furthermore, support group
interventions can be executed in a longer period, and in-
terventions for the primary prevention level of the NSM
model can be planned and tested with the participation
of all caregivers in support group meetings.
Although the depression sign scores of the
caregivers in the intervention group and the caregivers
in the control group were found to be similar, the
depression sign scores of the caregivers in the
intervention group decreased significantly through the
follow-up process. However, because the purpose of
this study was to reduce depression levels of
caregivers, it is thought that the duration of the study
might have been too short to create the intended effect
on depression, a condition that is slow to respond to
intervention, and therefore studies with interventions
carried out for longer periods are needed.
CONCLUSION
A statistically significant difference in the care burden
scores of the caregivers in the intervention and control
groups in all subdimensions except for objective and
subjective personnel care subdimension was found. In
terms of the group × time interaction, a statistically
significant difference was found in time in the
intervention group in all subdimensions except for the
objective personnel care and subjective practical care
subdimensions. The burden score averages of the
caregivers in the intervention group were found to be
lower than the baseline score averages.
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