Sister Callista Roy is a nurse theorist and professor at the School of Nursing at Boston College, MA, where she

teaches doctoral, masters, and undergraduate classes. Sr. Roy has contributed greatly to the nursing field through numerous publications, lectures, and workshops throughout the U.S. and abroad. As result of her invaluable contributions, she has been named a Living Legend by the American Academy of Nursing and the Massachusetts Registered Nurses Association (Boston College William F. Connell School of Nursing, n.d.). Roy developed the conceptual model known as the Adaptation Model of Nursing, which is a problem solving approach utilized for collecting data, identifying the capacities and needs of humans, and guiding the selection and implementation of nursing care (Nursing Theory: A companion to nursing theories and models, 2011). Roys model involves a six-step nursing process comprising: 1) assessment of behavior, 2) assessment of stimuli, 3) nursing diagnosis, 4) goal setting, 5) intervention, and 6) evaluation. For each one of these steps the person is analyzed in four adaptive modes - psychological, self-concept, role function, and interdependence modes - for his/her ability to adapt to stressors (Nursing Theory: A companion to nursing theories and models, 2011). The adaptation model is also effective in the evaluation of nursing interventions and it has been adapted to more specific topics such as chronic diseases by other investigators. In addition to the development of this influential conceptual model, Roy has developed mid-range theories to address practical issues since nursing theories are often too broad and complex to be readily applicable to daily nursing practice. In an article published in the Nursing Quarterly Journal, Whittemore and Roy (2002) explain a middle range theory of adaptation to Diabetes Mellitus (DM), which is based on Roys Adaptation Model and Pollocks theory of adaptation to chro nic illness model (Pollock, 1993). I was intrigued by this article as diabetes - and chronic diseases in general - was one of the main reasons I became interested in the nursing field. In 2007 I began working on a large exercise trial for patients diagnosed with type 2 DM. My educational background was in exercise physiology and I had had several classes related to chronic diseases prior to beginning that position However, I was unaware of the pronounced lifestyle disruption diabetes can produce in patient s daily life. Thankfully, one of the members of our intervention team was a diabetes educator, which afforded me the opportunity to learn about the day-to-day challenges diabetic patients face, the various types of diabetes medications, their interaction with foods consumed, their effect on the ability to exercise, and possible hypoglycemic symptoms. I began to understand the intricacies of this health condition and the complexity of its management, which in turn changed my perception of patients challenges and the dramatic lifestyle adjustments it necessitates. Based on this experience, I decided I wanted to work with individuals diagnosed with DM or provide primary prevention to persons at high risk for developing this condition. Considering my background in exercise and nutrition, I realized having the nursing foundation was the missing piece of the puzzle. As I researched into the nursing career, I learned about other areas of nursing that appeal to me; however, diabetes education is still my number one interest. For this reason, I was excited to learn about the existence of this theoretical framework to guide holistic, patient-centered approach to nursing care of individuals diagnosed with DM. Prior to Whittemore and Roys development of the adaptation to DM theory, Pollock (1993) investigated the application of the adaptation model to chronic illness. She recognized the importance of psychological factors, while considering a key goal of living with a chronic disease is to identify the limitations resulting from the condition. She also acknowledged the importance of the patient reorganizing his/her environment as well as personal ideas as a means to successfully cope with chronic diseases. Interestingly, in many of the studies developed to test Pollock s theoretical framework, there was no association between psychosocial and physiological adaptation. The exceptions were the studies

observing patients with DM. This positive relationship between psychosocial and physiological adaptation was attributed to the fact that individuals diagnosed with DM are more likely to experience daily selfmanagement challenges as a result of their illness. For this reason, numerous health-promoting behaviors are required for successful self-management and adaptation to life with DM. This peculiarity of DM prompted Whittmore and Roy (2002) to further investigate how the adaptation model could be applied to the specifics of this psychologically and behaviorally demanding chronic disease. The adapting to DM theory begins at diagnosis and consists of three processes that are separate but interconnected. These processes are stabilization (physiologic adaptive responses to illness), integration (psychosocial adaptive responses to illness), and health-within-illness (union of stabilization and integration resulting in optimization of health potential). Another important construct of this theory is the patients perception, which filters the incoming stimuli, thus influencing behavior and adaptation. Moreover, Whittemore and Roy include health promotion behaviors as part of this model, which is essential considering the demanding nature of DM. In summary, this middle range theory, which is based on Roys adaptation theory and Pollocks adaptation to chronic illness theory, creates a comprehensive framework for nurses caring for individuals diagnosed with DM. The adapting to DM theory provides guidance in assisting these patients reach the lifestyle changes that are required for adequate control of their condition. It emphasizes the in dividuals perception and well as health promotion behaviors. References

Boston College William F. Connell School of Nursing. Retrieved from: http://www.bc.edu/schools/son/faculty/featured/theorist.html Nursing Theory: A companion to nursing theories and models (2011, January 6). Application of Roys adaptation model in nursing practice. Retrieved from:http://currentnursing.com/nursing_theory/application_Roy's_adaptation_model.html Pollock, S. E. (1993). Adaptation to chronic illness: A program of research for testing nursing theory. Nursing Science Quarterly, 6, 8692. Whittemore, R., Chase, S., Mandle, C. L, & Roy, S. C. (2001). The Content, Integrity, and Efficacy of a Nurse Coaching Intervention in Type 2 Diabetes.Diabetes Educator, 27, 887-898. Whittemore, R., & Roy, S. C. (2002). Adapting to diabetes mellitus: A theory synthesis. Nursing Science Quarterly, 15, 311-317. \

Application of Health Belief Model

This page was last updated on January 26, 2012

IntroductSeptember 9, 2013cal model that attempts to explain and predict health behaviors. HBM was first developed by social psychologists Hochbaum, Rosenstock and Kegels working in the U.S. Public Health Services inspired by a study of why people sought X-ray examinations for tuberculosis.

 The model was developed in response to the failure of a free tuberculosis (TB) health screening program. The study of social sciences helps to improve the care of the patient by increasing the nurses understanding of human behaviour and to stimulate intellectual and emotional growth and self knowledge. Mr.SM for my clinical assignment is a 60 year old, married, Hindu, male patient educated up to PDC suffering from diabetes for the last 10 years and frequent leg ulcers for the last one year.D i a b e t e s m e l l i t u s

Diabetes mellitus is a disease characterized by a chronically elevated blood glucose concentration, often accompanied by other clinical and biochemical abnormalities. The hyperglycaemia of diabetes results from an inadequate action of insulin, caused by low or absent insulin secretion, the presence of antagonists to the peripheral action of insulin or a combination of these factors.

The effects of the disease may be acute or chronic, involving many organs, including the eye, the kidney, peripheral nerves and large arteries. Primary diabetes mellitus is traditionally divided into either insulin dependent (IDDM or Type 1) or noninsulin dependent (NIDDM or Type 2). The classification is important because of the different genetic backgrounds, clinical presentations, metabolic effects, treatment and consequences of the two types. Diabetes may also be secondary to other disorders

1. General information Name Age Gender Marital status Place IP. No. Hosp. No. Date of admission Ward/Unit Diagnosis Occupation : Mr. SM : 60 years : Male : Married : ------: -------: -------: ------: ----------------: Diabetes mellitus type II, diabetic foot ulcer-rt : Farmer for 15 years,

Retired from military service, worked in ---Culture Religion : Hindu

Caste

: Thiyya

2. Developmental history

Normal birth at home No birth related or neonatal complications Norma childhood Started schooling at the age of 5 years Immunized for major infectious diseases He was a football player till the age of 32 He was recruited to military in Southern Command as a football player, played for military for 6 years, left military and joined in ----as a staff.

Scholastic History

He had normal schooling till PDC

3. Socioeconomic Status

He has 7-8 acres of farm land

4. Patients Knowledge of Present illness

Patient explains his illness: I have diabetes for the last 10 years. I have developed this ulcer a few weeks back. It was not getting healed from the local hospital, so, I have come here

5. What the patient wants to know about the illness?

I know, Diabetes is incurable But, why Im getting ulcers frequently I want to get discharged soon; will I be discharged next week? (Patient had a foot ulcer in another leg 6 months back and was treated in ----. Now ulcer has developed in the right leg.

6. What has been his past experience with illness?Past Illness History

History of Kochs disease 10 years back, took medicine for 6 months Patient had a gun shot injury about 20 years back on the left forearm He is diabetic for the last 10 years.

Family History

History of diabetes mellitus in brothers and sisters No major illness in his knowledge Father and mother died 30 years ago, he does not know whether they had any major illness.

Whether patient has accepted his illness?

Im not the person to develop this kind of an illness My food habits and exercise should have kept me free of this illness I used to take one or two pegs of brandy per day and some times more than that I have got it from my family

Inference: Patient has accepted the illness as a suffering which he has developed due to inheritance, but his food habits points to the life style has contributed to the illness significantly. He used to get double food in military because he was a football player in the MRC. He used to take 6 eggs per day till the age of 40 and reduced to 1 egg per day. 7. Patients beliefs about the illness

Patient is a firm believer of god, but does not believe in individuals as god. He does not have any wrong belief that his illness is due any black magic or some possession.

8. Does the patient have social support network?

Patient has a good circle of friends and family His bystander in the hospital is a friend He believes in politics and is a party member

9. Has the patients accepted his present condition?

Patient has accepted his present condition.

10. How does he cope with problems? As explained by patient?

He accepts his condition as a diabetic patient and understands the need for adherence to medication and life style modification. As he has adequate servants at home, he has not much trouble in carrying out his role. He watches TV and reads newspaper, which gives his some diversion from the problems.

11. Anxiety related to effects of illness, recovery, cost of treatment, and future state He is worried about the foot ulcer which is not heaing. His blood sugar fluctuates between normal and high value. He plans to follow all the instructions well that ulcer will not develop in future. He says he can bear the expense of treatment here, that he has 7-8 acres of agriculture land. That is enough to look after his expense for treatment. 12. Does he express concern about his present condition? Yes, he is worried whether the ulcer will get healed. When he developed ulcer in his left leg 6 months back, his two toes were amputated in a local hospital. He was advised a below knee amputation, but he decided to get discharged from there and came to -----. So he could save his leg. 13. How the patient has adapted to illness?

He is well adapted to the illness. He looks after his property well.

14. Which cultural differences can interfere with the patients treatment?

Patient is from ---district of ----. He expects details of his blood sugar level regularly, but the nursing staff was not giving attention to his concerns.

REFERENCES

1.
2.

Rosenstock IM (1966), "Why people use health services", Milbank Memorial Fund Quarterly 44 (3): 9412 Marriner TA, Raile AM. Nursing theorists and their work. 5th ed. Sakraida T.Nola J. Pender. The Health Promotion Model. St Louis: Mosby; 2005

How a health promotion model reduces disabling complications of diabetes

1 October, 2004
The incidence of diabetes is increasing worldwide, and in England 1.3 million people - 2 to 3% - have the condition (DH, 2001a). Diabetes affects physical and psychological wellbeing, as well as lifestyle, relationships, income and life expectancy, and the financial implications are significant: 5% of the total NHS budget and 10% of acute-sector resources are spent on diabetes. Gloria Daly, BA, BSc, RGN. Local Learning Manager for First Contact Care in London, NHSU, London These costs increase more than fivefold for treating disease-related complications (DH, 2001a), including:

Ischaemic heart disease Peripheral vascular and neuropathic disease

Cerebrovascular disease Diabetic eye disease Diabetic renal disease.

But complications are not inevitable and much can be done to prevent or greatly reduce them (Stratton, 1998). The St Vincent Joint Task Force Report (DH, 1995) challenged health-care professionals to develop models of care to reduce long-term complications. The underlying principles of documents such as The NHS Plan (DH, 2000) and The Expert Patient (DH, 2001b) are to support patients with diabetes in managing their own lifestyles through structured support and education. The article on page 37 highlights the work of the Desmond project in this area. Diabetes UK (2000) lists three key risk factors that can be tackled through effective health promotion: smoking, obesity and lack of physical activity. Health promotion activities should be co-ordinated through effective partnerships across disciplines, professions and agencies, and delivered in a culturally sensitive way. The Jakarta Declaration (WHO, 1997) identified five strategies for successful health promotion:

Build a healthy public policy Create a supportive environment Strengthen community action Develop personal skills Reorientate health services.

Partnership working
Partnership working has a major role in delivering the aims of the Jakarta Declaration (WHO, 1997). Broadening the base for health interventions means addressing socioeconomic and environmental issues, improving access to services, reducing inequalities and targeting education at all groups, transcending age, ethnicity, gender and status barriers.

Tackling health inequalities

Tackling health inequalities must be considered as part of developing an action plan or intervention. Acheson (DH, 1998a) highlighted 11 areas of inequality (Box 1). Professionals across all agencies have a role in delivering effective local interventions to reduce inequalities at the same time as addressing health promotion and prevention initiatives to reduce diabetes complications. Many of Achesons recommendations (DH, 1998a) can be delivered in a local setting, such as increasing the uptake of benefits within eligible groups, developing health promotion in schools, encouraging walking and ensuring that the needs of people from ethnic groups are taken into account when developing policies.

Frameworks
Several models exist to support health promotion. These fall into two broad types that can be simply defined as:

Models that define health promotion as a range of interventions (Tannahill, 1985; French and Adams, 1986; Beattie, 1991) Models that examine health determinants and recommend responsive serivces (Laframboise, 1973; Raeburn and Rootman, 1989; Hancock, 1993).
Within these models practitioners have a role as either leaders (authority figures) or facilitators (negotiators) (Naidoo and Wills, 2000).

Beatties health promotion model

We have successfully used Beatties health promotion model in practice (Figure 1), supported by an action plan (Table 1). Beattie (1991) identifies four paradigms:

Health persuasion Personal counselling Community development Legislative action.

These contribute to achieving a whole picture when developing local action plans for partnership working. Any model for health promotion activity needs underpinning by the patients intention to change behaviour. The theory of planned behaviour (Ajzen, 1991) is one of many models of behaviour change cited in the Health Development Agencys website resource (HDA, 2001). It lists three steps:

The individuals attitude, determined by their beliefs about consequences The expectations of others The individuals perceived control and belief in their ability to change.
Each partner or agency involved is encouraged to use the same models to support their own initiatives while creating a multi-partnership, strategic approach.

Action plan
The action plan in Table 1 is a guide to implementing a health promotion strategy to reduce complications of diabetes. The objectives are to build a healthy lifestyle support programme for people with diabetes, so they can manage their individual and community programmes. The underlying principle is founded on partnership working with communities and users, based on a multiprofessional, multi-agency approach. Achieving the plan depends on proactive communication and consultation skills. Any strategy must consider how? as well as why?, and its large and complex objectives should be factored into local action plans (Hrebiniak and Joyce, 1984). Bryson (1995) states: Strategic planning is simply a set of concepts, procedures and tools designed to help leaders, managers and planners think and act. A strategys action plan should recognise the need for organic practice and realise that local actions are a combination of what is intended and what emerges along the way (Bryson, 1995).

Evaluation

Traditional health promotion evaluation assesses activities in terms of their impact on goals, using a biomedical model. But this technique tends to be rigid, and Tones (2000) argues against using biomedical indicators to evaluate health-promotion activities. However, in todays climate of government targets, it is necessary to report milestone achievements to contribute to future decision-making and programme setting. Downie et al (1996) identify two main types of evaluation:

Measuring what has been achieved Measuring how the objective has been achieved.
Combining both methods enables health-care practitioners to monitor the process of change and to ensure that health promotion activity is relevant to the individual. Judd et al (2001) advocate a three-step process, integrating evaluation of process, impact and outcome - that is, measuring the changes taking place as well as targets achieved. There is a need to balance evaluation to accommodate community realities and professionals need for evidence of health improvement.

The long-term view

Health promotion activities must include socially empowering and enabling activities (Tones, 2000). The strategy used as an example here is based on the The National Service Framework for Diabetes (DH, 2001a), and the standards aimed at reducing complications of diabetes through promotion of healthy lifestyles. But it has been developed with a wider remit to sustain health promotion activities through community involvement and participation, and ensure the eradication of inequality of health care for people with diabetes within ethnic-minority groups. The Beattie strategy shown here recognises the need to move the emphasis in health promotion from doing to building relationships for the longer term, and ensuring that public health promotion, prevention, education, and protection are the responsibility of all - not just those with a health promotion remit. To be effective, health promotion must create healthy public policy and supportive environments, foster individual or group skills and capacities, strengthen community action and reorientate health services (WHO, 1986).

Latest Policy
Improving diabetes services and promoting lifestyle changes

The National Service Framework for Diabetes (DH, 2001a) sets out 12 standards aimed at prevention, improving services, helping people with diabetes manage their condition and preventing complications. Standards 3 and 4 target lifestyle changes that reduce complications Standard 3: People with diabetes are empowered to enhance their personal control over the day-to-day management of their diabetes in a way that enables them to experience the best possible quality of life Standard 4: To maximise the quality of life of all people with diabetes and to reduce their risk of developing long-term complications.

Authors contact details

Gloria Daly, Local Learning Manager, First Contact Care in London, NSHU, 88 Wood Street, London EC2V 7RS. Email:gloria.daly@nhsu.org.uk

Ajzen, I. (1991)The theory of planned behaviour. Organizational Behaviour and Human Decision Processes 50: 179-211. Beattie, A. (1991)Knowledge and control in health promotion: a test case for social policy and theory. In: Gabe, J., Calnan, M., Bury, M. (eds) The Sociology of the Health Service. London: Routledge/ Taylor and Francis. Bryson, J. (1995)A Guide to Strengthening and Sustaining Organisational Achievement. Riverside, NJ: Simon and Schuster. Department of Health and British Diabetic Association. (1995)St Vincent Joint Task Force of Diabetes; The Report. London: DH. Department of Health. (1998a)Independent Inquiry into Ine