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DNP 8114 Wk 2 Discussion Exploring Middle Range Theories and Framing Practice Issues

DNP 8114 Wk 2 Discussion: Exploring Middle Range Theories and Framing Practice Issues

The practice issue identified by this student is the lack of facility and community-based educational resources available to patients who have a new diagnosis of type 1 or type 2 diabetes or who have been previously diagnosed with type 1 or type 2 diabetes and are poorly controlled. Facility-level education for this patient population is inadequate due to the lack of a Certified Diabetes Educator. In fact, there is no staff member specifically tasked with the role of providing education to patients with diabetes. This places the burden of diabetes education on the nurse providing primary care to the patient. Primary care nurses face many barriers to providing sufficient diabetes education to patients, including time constraints due to nurse-patient ratios, failure to remain current on new technology and treatments, and even a personal lack of understanding regarding the nuances that differentiate type 1 from type 2 diabetes.

            Some communities are able to offset a lack of facility-based education by utilizing community-based diabetes education programs. These programs may be sponsored by a single facility, or they may be the product of a partnership between two or more health care entities or providers. Participants in these programs are not only provided with education related to self-care. They are also given an opportunity to network with other people who share intimate knowledge of the challenges associated with the day-to-day management of diabetes which leads to an increase in social support.

It is well known that health outcomes related to diabetes are largely dependent on how well the disease is managed. Unfortunately, the majority of diabetes management falls to the patient as he/she makes decisions related to their health throughout each day. This student believes a solid foundation of knowledge can assist persons with diabetes in making everyday decisions that will promote health and well-being. Therefore, this student will explore this practice gap by answering the question, “can formal education programs increase self-care behaviors in the diabetic population?’

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Two middle range nursing theories (MRT) will be applied to this practice issue to assist in answering the practice question. Sharpnack (2019) asserts the advancement of nursing will occur only if nurses place theory at the center of their practice and consistently apply it to their work. Several middle range theories applicable to this topic were identified, including Uncertainty in Illness, Health Promotion Model, Motivation in Health Behavior, Self-Efficacy Theory, Theory of Self-Care in Chronic Illness, and the Health Belief Model. This discussion will focus on the Self-Efficacy Theory and Motivation in Health Behavior.

Self-efficacy refers to a person’s belief and confidence in their own capability to manage activities successfully (Cambridge University Press, 2021). In relation to diabetes management, self-efficacy could be stated as confidence in the ability to monitor blood glucose, administer medications appropriately, recognize and treat glucose results outside the target range, select healthy diet options, and incorporate physical activity into each day. Karimy, Koohestani, and Araban (2018) state self-care behaviors are paramount for the successful management of diabetes. Additionally these authors state, “Proper adherence to self-care behaviors can reduce disease complications by up to 50%. Non-adherence to self-care practices, on the other hand, is the main cause of mortality in diabetics” (p. 1). Because self-efficacy is a major predictor of self-care, it is important for healthcare providers to recognize interventions that promote self-efficacy, such as education and social support. Self-care behavior has been shown to have a direct relationship to education, “Education level had a significant relationship with self-care behaviors, such that with the increase in the level of education, self-care behaviors augmented as well” (Karimy, Koohestani, & Araban, 2018, p. 3). These researchers also found social support to be a positive factor that resulted in increased self-care.

DNP 8114 Wk 2 Discussion: Exploring Middle Range Theories and Framing Practice Issues

Motivation in Health Behavior is a second theory applicable to this practice question. Swanson and Maltinsky (2019) agree that education is essential for diabetes management; however, they purport knowledge alone is not enough and it must be coupled with motivation. They define motivation as the “…degree of wanting, desiring, or intending to carry out actions in relation to specific goals” (p. 122). According to these authors, motivation can come from internal or external factors. External motivation can be increased by purposeful interactions between the patient and healthcare provider that are aimed at increasing knowledge, confidence, and coping strategies. The end-goal for these interactions is to increase the patient’s level of self-efficacy which, in turn, will increase their motivation to successfully manage their diabetes. Swanson and Maltinsky recognize the correlation between self-care and health outcomes, “Effective diabetes management leads to better health outcomes…improved mental health and physical well-being, better quality of life, and reduced health care costs” (2019,  p. 121).

In summary, self-care is critical to the successful management of diabetes. Education and social support increase self-efficacy. A rise in self-efficacy increases the motivation for self-care. The application of these two theories supports the belief that formal education programs can increase self-care behaviors in the diabetic population by increasing participant knowledge and providing social support.


Cambridge University Press. (2021). Self-efficacy In the Cambridge Dictionary. Cambridge University Press. https://dictionary.cambridge.org/us/dictionary/english/self-efficacy.

Karimy, M., Koohestani, H., & Araban, M. (2018). The association between attitude, self-efficacy, and social support and adherence to diabetes self-care behavior. Diabetology and Metabolic Syndrome, 10(86). 1-6. https://doi.org/10.1186/s13098-018-0386-6.

Sharpnack, P. (2019). Facilitating application of theory to practice through nursing education. 81-82. doi.10.1097/ANS.0000000000000253.

Swanson, V., & Maltinsky, W. (2019). Motivational and behavior change approaches for improving diabetes management. Practical Diabetes, 36(4). 121-125.

Framing Practice Issues

Mental health disorders and substance abuse is the population that I serve as a nurse practitioner.  Many of the clients have a dual diagnosis of substance abuse and mental health disorders.  Even though many of these clients have a mental health issue prior to substance abuse, many clients are undiagnosed.

The two theories that impact my practice are Tidal Model and Rural Nursing. Each of these theories provides a framework of holistic care and focuses on a need of unique care for each individual (McEwen & Wills, 2019). As a practitioner working with clients in crisis and with substance abuse issues, the Rural Model theory focuses on assisting clients to function independently and help them with housing and daily living assistance while focusing on recovery (McEwen & Ellis, 2019).

The Tidal Model, which is geared toward the psychiatric community, focuses on empowerment and change (McEwen & Wills, 2019). Empowerment and change agents are focused on a holistic approach.  My practice involves holistic care.


McEwen, M. & Wills, E.M. (2019). Theoretical basis for nursing (5th Ed.). Wolters Kluwer.

Knowledge development and the journey of novice to expert nurse is a long-debated topic. To become and expert in any topic, time must be invested. Nursing is seeing an all-time high rate of turnover. Nurse turnover is a significant problem that has led to a nursing shortage in hospitals, particularly in rural hospitals (Squillaci, 2015). Without time investment in the diverse fields of nursing, expertise can not be expected. Long-term care facilities are nearly completely staffed with short term travel nurses. Short-term nurses are focused on the present and not the future of the nursing unit. Additionally, leadership in long-term care is a revolving door. Leadership remains in a constant reactive phase with no time to identify problems and plan for prevention. There is a considerable delay in incorporating new evidence into clinical practice (White et. Al, 2021). With consistent staffing in long-term care, gaps can be identified and resolved. The discipline of nursing recognizes middle range theory as one of the contemporary trends in knowledge development (McEwen & Wills, 2019).



McEwen, M., & Wills, E. M. (2019). Theoretical basis for nursing (5th ed.). Wolters Kluwer

Squillaci, L. L. (2015). Preceptor Training and Nurse Retention ScholarWorks

White, K. M., Dudley-Brown, S., & Terhaar, M. F. (Eds.). (2019). Translation of evidence into nursing and healthcare (3rd ed.). Springer

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