Question

Choose one of the middle-range theories. What impact would this theory most likely have on your individual practice? Give specific examples.

Answer 1

Middle RangeTheories: Middle-range theories target specific phenomena or concepts, such as pain and stress; they are limited in scope yet general enough to encourage research. It deals with concrete and relatively operational concepts and amenable to empirical testing. These theories are highly specific to nursing.

Health promotion can be defined as the process of empowering people to make healthy lifestyle choices and motivating them to become better self-managers. To accomplish this, health promotion strategies should focus on patient education, counseling and support mechanisms. Examples of health promotion approaches include education and counseling programs that promote physical activity, improve nutrition or reduce the use of tobacco, alcohol or drugs.

Dr. Nola Pender developed the Health Promotion Model (HPM) that is used universally for research, education, and practice. The health promotion model focuses on helping people achieve higher levels of well-being. It encourages health professionals to provide positive resources to help patients achieve behaviour specific changes. The goal of the HPM is not just about helping patients prevent illnesses through their behaviour, but to look at ways in which a person can pursue better health or ideal health.

According to Pender, the HPM makes four assumptions:

1. Individuals strive to control their own behaviour.
2. Individuals work to improve themselves and their environment.
3. Health professionals, such as nurses and doctors, comprise the interpersonal environment, which influences individual behaviours.
4. Self-initiated change of individual and environmental characteristics is essential to changing behaviour.

Theory

A theory presents a systematic way of understanding events. It is a set of concepts, definitions, and propositions that explain such events by demonstrating the relationships between variables. The theory behind the HPM is that you have personal experiences that affect your actions. There are three main focuses of the HPM: individual experiences, behaviour-specific knowledge and affect, and behavioural outcomes. The factors that are associated with the HPM are mainly an individual's lifestyle, outlook, psychological health, social and cultural traits as well as biological factors. Health promoting behaviour is the ideal behavioural outcome, making it the end point in the HPM.

Application of HPM-as applied to work as a Diabetic Nurse Educator:

As a float Registered Nurse in acute care settings, I often assist diabetic patients with their diabetes regimen compliance. I also anticipate becoming a Diabetic Nurse Educator with my MSN. The diabetic regimen is "complex, of life-long duration, and requires many behavior changes on part of the patient" (Becker & Janz, 1985, p.41). As nurses and educators, it's our responsibility to develop and execute health-promoting interventions to patients (McEwen & Ellis, 2011). Therefore, I combined my current and future practice with Diabetic Regimen using Pender's Health Promotion Model.

Importance of Health

Education is crucial for diabetic patients. Lannon (1997) states, "Verbal instructions and videotapes supplemented with written information which the person can take with them have the best impact." As nurses and educators, we should make sure that the patients are conscious of their medications, diabetic diet regimen, and the importance of checking blood sugars at least twice a day. "Each interaction with the patient provides an opportunity to review the patient's knowledge about their medications and to assess their motivation regarding compliance"(Lannon, 1997).

Perceived Control of Health

"The ability to develop health-promoting behaviors is enhanced by a perception of internal control. Compliance with medical care and treatment is attributable in part to a well-developed internal locus of control" (Lannon, 1997). As nurse educators, we must provide reasons to diabetic patients addressing why compliance is desirable and beneficial. Adhering to diabetic regimen will prevent patients from further complications such as amputation, retinopathy, kidney failure and so forth. With an internal locus of control the person feels empowered to act.

Perceived Self-Efficacy

"When the patient or family feels self-confident they are more likely to be able to cope with and maintain compliant behavior. When counseling the patient or family it is useful to offer a number of suggestions for methods which will increase compliance and then allow them to choose which method to adopt" (Lannon, 1997) As nurses and educators, we should suggest that patient or family members take blood sugars before each meal. One of the barriers to checking blood sugars is that patients often complain that "pricking their fingers hurts.” Educating them on pricking the side of the fingers, where there are fewer nerve endings, will be less painful to the patient. Also, encouraging patients to wear loose fitting footwear at all times to prevent complications from ulcers is another method to help patients cope with this chronic disease.

Perceived Health Status

"People who define health as the absence of illness are less likely to adopt health-promoting behaviors than those who view health as an optimum state of total well-being" (Lannon, 1997). A study on adherence to a diet regimen for diabetes found that patients who were compliant viewed their illness more seriously, were stricter with their diabetic regimen, and had fewer complications. These patients were "more realistic about the consequences of the disease and therefore [were] motivated to action to control their diabetes" (Becker & Janz, 1985, p.43). As nurses and educators, we should continue to act as health advocates for diabetes patients. We should also continue to support them with their medications, diet, and exercise regimen to help them attain the best quality of life.

Perceived Benefits of Health-Promoting Behaviors

"The person must realize some individual benefit out of engaging in health-promoting behaviors in order to continue them" (Lannon, 1997). As nurses and educators, "when contemplating a behavior which requires a lifestyle change, it is helpful to set both short- and long-term goals" (Lannon, 1997). For diabetic patients, short term goals would be to get the blood sugar under control and be compliant with medications. A long term goal is to facilitate a higher quality of life and more-normal daily functioning.

Perceived Barriers to Health-Promoting Behaviors

"Pender states perception of barriers to participating in health-promoting behaviors can be real or imagined" (Lannon, 1997). As nurses and educators, we must consider the patient's behaviors related to diabetes. If a patient is in denial, have the patient express how they feel about the diagnosis. "Major threats to compliance will come from the diabetic's perception of barriers to carrying out different elements of the regimen" (Becker & Janz, 1985, p.45). As nurses and educators, we must address each barrier with a simple regimen or intervention.

Modifying Factors Demographic Factors

"Age, sex, race, ethnicity, education and income are demographic factors identified by Pender" (Lannon, 1997). African Americans and Hispanics have a higher prevelance of diabetes. It is more common in low income minority groups. Income plays a significant role in compliance. "The nurse has an advocacy role to play for the patient. Physicians, especially residents, may need reminders to consider cost when suggesting medical treatment" (Lannon, 1997).

Interpersonal Characteristics

"The health beliefs and health practices of the family will influence whether or not they value compliance as a health-promoting behavior" (Lannon, 1997). A study found that patients who were married were more compliant as they felt it would have serious consequences for their family if they became sick. Black patients were more likely to view medical care as beneficial and perceived themselves as less susceptible to complications (Becker & Jenz, 1985). As nurses and educators, we need to evaluate the patient's knowledge concerning diabetes and its complications. We also have to assess patients’ access to preventive medical services. Do they get eye exams or see the opthomologist yearly? Do they smoke, drink, use recreational drugs, exercise, eat a healthy diet or practice sleep hygiene? How do they rank good health practices as part of their daily lives? This family "blueprint" helps decide what strategies to use when initiating a program to enhance compliance. (Lannon, 1997).

Situational Factors

"Availability of care and access to it also figure into how readily a person opts to practice health-promoting behaviors" (Lannon, 1997). As nurses and educators, we should assses for social supports. Does the patient have a strong support system to support them with diabetes? Does the patient take medications regularly? Does the patient have access to a pharmacy? What is the mode of transportation? Obtaining as much personal information as the patient is willing to share helps the clinician make plans to work around these situations. "Patients who feel they are respected and that their individual circumstances are regarded as important have a better chance of building a good relationship with their care provider" (Lannon, 1997).

Behavioral Factors

"Pender states that this factor is influenced by previous experience. The patient does not practice health-promoting behaviors in a void, rather their behaviors reflect a history of actions, reactions and interactions within their environment" (Lannon, 1997). As nurses and educators, it is crucial to assess for family history. Has anyone been diagnosed with diabetes? If yes, how is that person coping with chronic disease? Is the patient compliant with their diabetic regimen? "Determining these factors helps evaluate how well the patient and family will cope with the chronicity of their situation. It also gives insight into their planning skills" (Lannon, 1997).

Cues to Action

"The last category of the Health Promotion Model are cues to action. These can be either internal or external" (Lannon, 1997). The patient who achieves better control of blood sugars due to better compliance with diabetic regimen will internally reinforce that behavior. "Encouragement from family and friends, testimonials from others and positive reinforcement from professionals constitute external cues" (Lannon, 1997).