A Case Study in Health Promotion Theory Application: (Problem, Significance, Solution, Barriers)
Diabetes Mellitus: Problem, Significance, And Magnitude
(Including Nursing Implications)
According to the CDC, in 2012, there were 21 million Americans diagnosed with diabetes and an additional 8.1 million undiagnosed cases of diabetes ( "2014 National Diabetes Statistics Report," 2014).
It is projected that the prevalence of diagnosed diabetes in the United States will increase from one in ten Americans in 2010, to between one in five to one in three Americans by 2050 (Boyle, Thompson, Gregg, Barker, Williamson, 2010). According to Narayan, Boyle, Geiss, Saaddine, and Thompson (2006), for chronic illnesses, continued expansion can have major effects on health care cost. As health care costs related to diabetes rise, there are major societal implications: a large economic burden and lost productivity (Fu, Qiu, Radican, & Wells, 2009). In the United States, the health expenditures related to diabetes is 612 billion US dollars ("IDF Diabetes Atlas Sixth Edition 2014 Update," 2014).
The incidence of type 2 diabetes has grown with an increased prevalence of obesity and other metabolic diseases. Diabetes is associated with cardiovascular disease, hyperglycemic crisis, diabetic ketoacidosis, end stage renal disease, peripheral arterial disease, ulcer formation, infections, neuropathy, and visual impairment (Centers for Disease Control and Prevention, 2014). Diabetes is the leading cause of blindness, kidney failure, and non-traumatic amputations (Colon, 2010). Considering these striking correlations, it is no surprise that proper management of diabetes creates an improved health state for individual patients and a decreased societal impact.
The high prevalence of diabetes means that advanced practice nurses (APN)s and physicians can expect to see an abundance of diabetic related health problems in clinical practice. Due to the negative implications of diabetes for the patient and society, it is of the utmost importance for the health care professional to control the disease and delay the development of co-morbid conditions. The practitioners will be challenged to update regularly and implement state-of-the-art practice guidelines that meet or exceed the current standards of care for patients with diabetes.
The nurse practitioner profession has shown through a multitude of studies that their clinical abilities have a positive effect on patient satisfaction and overall cost savings related to diabetes. A study by Colon in 2010 demonstrated that nurse practitioners' interventions controlling diabetes lowered hemoglobin A1C and glucose to a greater extent compared to physician counterparts. Overall, the nurse practitioner group had more patients obtain a stable weight than the physician group. It is evident that nurse practitioners can have a significant impact on our nation's health, especially considering America's current primary care provider shortage. Regarding diabetes in particular, research indicates that the clinical expertise of advanced practice nurses can create better metabolic control, congruent with the standards of practice and expertise recommendations put forth by the American Diabetes Association. “Death is unavoidable, but the prevalence of chronic illnesses and the decline and disability commonly associated with them can be reduced (Centers for Disease Control and Prevention, 2013).”
It is projected that the prevalence of diagnosed diabetes in the United States will increase from one in ten Americans in 2010, to between one in five to one in three Americans by 2050 (Boyle, Thompson, Gregg, Barker, Williamson, 2010). According to Narayan, Boyle, Geiss, Saaddine, and Thompson (2006), for chronic illnesses, continued expansion can have major effects on health care cost. As health care costs related to diabetes rise, there are major societal implications: a large economic burden and lost productivity (Fu, Qiu, Radican, & Wells, 2009). In the United States, the health expenditures related to diabetes is 612 billion US dollars ("IDF Diabetes Atlas Sixth Edition 2014 Update," 2014).
The incidence of type 2 diabetes has grown with an increased prevalence of obesity and other metabolic diseases. Diabetes is associated with cardiovascular disease, hyperglycemic crisis, diabetic ketoacidosis, end stage renal disease, peripheral arterial disease, ulcer formation, infections, neuropathy, and visual impairment (Centers for Disease Control and Prevention, 2014). Diabetes is the leading cause of blindness, kidney failure, and non-traumatic amputations (Colon, 2010). Considering these striking correlations, it is no surprise that proper management of diabetes creates an improved health state for individual patients and a decreased societal impact.
The high prevalence of diabetes means that advanced practice nurses (APN)s and physicians can expect to see an abundance of diabetic related health problems in clinical practice. Due to the negative implications of diabetes for the patient and society, it is of the utmost importance for the health care professional to control the disease and delay the development of co-morbid conditions. The practitioners will be challenged to update regularly and implement state-of-the-art practice guidelines that meet or exceed the current standards of care for patients with diabetes.
The nurse practitioner profession has shown through a multitude of studies that their clinical abilities have a positive effect on patient satisfaction and overall cost savings related to diabetes. A study by Colon in 2010 demonstrated that nurse practitioners' interventions controlling diabetes lowered hemoglobin A1C and glucose to a greater extent compared to physician counterparts. Overall, the nurse practitioner group had more patients obtain a stable weight than the physician group. It is evident that nurse practitioners can have a significant impact on our nation's health, especially considering America's current primary care provider shortage. Regarding diabetes in particular, research indicates that the clinical expertise of advanced practice nurses can create better metabolic control, congruent with the standards of practice and expertise recommendations put forth by the American Diabetes Association. “Death is unavoidable, but the prevalence of chronic illnesses and the decline and disability commonly associated with them can be reduced (Centers for Disease Control and Prevention, 2013).”
PUTTING IT ALL TOGETHER: A CASE STUDY APPROACH
Patient Background Information:
Practice setting: The patient is being treated in an outpatient clinic setting. Specific Problem: A patient with type II diabetes who has uncontrolled blood sugars and is non-compliant with diabetes medication. He has not engaged in any behavior modification since being diagnosed one year ago. |
Solution using the Health Promotion Model
Lorenzo is a 50-year-old Italian male who works as a waiter at Olive Garden to support his wife and three children. He works very hard to make sure he will be able to send his children to college, an opportunity he never had growing up. Lorenzo was diagnosed with Type II diabetes mellitus about a year ago and was prescribed a medication to control his blood sugar. He saves a large portion of his income for his children and at times has had to sacrifice refilling his prescription to make ends meet at home with the bills. He has been noncompliant with his medication because he says he does not feel any different whether he takes it or not and he feels his children’s future is more important than his own. Identifying barriers to compliance is vital to create a plan that encourages proper disease management. Lorenzo’s blood sugar is now considered to be uncontrolled. Before skipping steps and prescribing insulin for the patient, we will use the Health Promotion Model to come up with a plan to assist Lorenzo in taking his medications and achieving a healthier lifestyle.
The advanced practice nurse should begin by assessing personal factors and prior behaviors that may influence Lorenzo's management of his blood sugar. The advanced practice nurse already knows that Lorenzo is the breadwinner for his family and puts them first. Lorenzo has also expressed that he does not find exercise to be of any benefit. When Lorenzo was asked how likely it would be that we could help him achieve medication compliance, he expressed that it was important for him to see his children grow up and move on to do bigger and better things in life. He also stated that he was motivated to comply with a new routine. This lets the health care provider understand Lorenzo's perceived benefits of complying with medication and diabetes management, which is an aspect of the Health Promotion Model (Peterson & Bredow, 2013). Prior behavior that contributed to noncompliance was identified when Lorenzo expressed that his wife encourages him to take his medication regularly, but does not hold him accountable if he misses doses. Lorenzo stated that he figured if his wife did not push him to take his medications, then it really was not a big deal. He also previously expressed that he did not feel any different whether or not he took his medication.
Together the advanced practice nurse, Lorenzo, and his wife sat down to construct a plan to encourage medication compliance using the information discovered in the initial assessment. The advanced practice nurse requested that Lorenzo's wife be present in order to engage family and social support. Self-efficacy was granted in this situation by allowing Lorenzo and his wife to develop a feasible plan of action (Peterson & Bredow, 2013). The advanced practice nurse informed Lorenzo and his wife that there were Prescription Assistance Programs that could help with filling prescriptions. They filled out the forms together and sent it to be processed right there in the office. Encouraging Lorenzo to take an active participatory role can promote positive emotions and feelings of self-efficacy and accomplishment. Since Lorenzo identified money as a perceived barrier to taking his medications, the Prescription Assistance Program is an intervention that the advanced practice nurse utilized to overcome this barrier. The advanced practice nurse then informed Lorenzo that it may be helpful to keep a chart to document his daily blood sugars, food consumed, and a check box to indicate whether his pills were taken. Lorenzo then created the chart with the provider assisting when needed to make sure all aspects of compliance were included. The advanced practice nurse encouraged Lorenzo to create a chart in order to enhance his self-efficacy. The chart also helps Lorenzo to perceive the benefits of good blood sugar control by linking blood sugar numbers and physical symptoms. The chart looked like this:
The advanced practice nurse should begin by assessing personal factors and prior behaviors that may influence Lorenzo's management of his blood sugar. The advanced practice nurse already knows that Lorenzo is the breadwinner for his family and puts them first. Lorenzo has also expressed that he does not find exercise to be of any benefit. When Lorenzo was asked how likely it would be that we could help him achieve medication compliance, he expressed that it was important for him to see his children grow up and move on to do bigger and better things in life. He also stated that he was motivated to comply with a new routine. This lets the health care provider understand Lorenzo's perceived benefits of complying with medication and diabetes management, which is an aspect of the Health Promotion Model (Peterson & Bredow, 2013). Prior behavior that contributed to noncompliance was identified when Lorenzo expressed that his wife encourages him to take his medication regularly, but does not hold him accountable if he misses doses. Lorenzo stated that he figured if his wife did not push him to take his medications, then it really was not a big deal. He also previously expressed that he did not feel any different whether or not he took his medication.
Together the advanced practice nurse, Lorenzo, and his wife sat down to construct a plan to encourage medication compliance using the information discovered in the initial assessment. The advanced practice nurse requested that Lorenzo's wife be present in order to engage family and social support. Self-efficacy was granted in this situation by allowing Lorenzo and his wife to develop a feasible plan of action (Peterson & Bredow, 2013). The advanced practice nurse informed Lorenzo and his wife that there were Prescription Assistance Programs that could help with filling prescriptions. They filled out the forms together and sent it to be processed right there in the office. Encouraging Lorenzo to take an active participatory role can promote positive emotions and feelings of self-efficacy and accomplishment. Since Lorenzo identified money as a perceived barrier to taking his medications, the Prescription Assistance Program is an intervention that the advanced practice nurse utilized to overcome this barrier. The advanced practice nurse then informed Lorenzo that it may be helpful to keep a chart to document his daily blood sugars, food consumed, and a check box to indicate whether his pills were taken. Lorenzo then created the chart with the provider assisting when needed to make sure all aspects of compliance were included. The advanced practice nurse encouraged Lorenzo to create a chart in order to enhance his self-efficacy. The chart also helps Lorenzo to perceive the benefits of good blood sugar control by linking blood sugar numbers and physical symptoms. The chart looked like this:
During the appointment, the advanced practice nurse provided education regarding type II diabetes and medication management. She provided education to Lorenzo and gave him written information about symptoms of hypo-/hyperglycemia and carbohydrate counting. The advanced practice nurse set up a follow-up appointment for Lorenzo two weeks later to assess his health. Lorenzo was sent home with the blank recording chart, additional information on diabetes management, and a calendar with follow up appointments. A week later, the advanced practice nurse called Lorenzo to check in and make sure he did not face any additional barriers in taking his medications. A component of The Health Promotion Model is follow up - ensuring compliance regarding the plan (Peterson & Bredow, 2013). By checking in with Lorenzo, he was given opportunities to ask for help or modify the plan he created for himself. Lorenzo had been successfully completing his chart and stated that he was still committed to monitoring his blood sugar, counting his carbohydrates, and taking his medications daily.
Potential Problems
Potential problems when implementing the Health Promotion Model may include non-compliance resulting from poor understanding about the disease process of diabetes and limitations to self efficacy. The Health Promotion Theory is based on perceived barriers, decision making, and benefits of action (Sakraida, 2010). When an individual is unable to make necessary changes to accomplish goals which are matched to their strengths, it often leads self-doubt and hopelessness. Self-doubt and hopelessness lead to non-compliance with the program. For example, given Lorenzo's educational background, the advanced practice nurse should provide educational materials he can understand. Educating him about the health promotion model may be a complex idea. Therefore, the advanced practice nurse must focus on empowering health promoting behavior and focus less on elements of the model. Another problem with applying this model is the financial burden on the patient. Financial limitations were one reason that Lorenzo was unable to comply with his previously prescribed regimen. Providing Lorenzo with social service resources might be beneficial.
Behaviors such as diet and activity are embedded in our sense of culture and personality. Many behaviors that influence health are so deeply engrained in an individual's way of life that the individual is unwilling to change their habits. Therefore, when an advanced practice nurse educates a patient to change or modify the aforementioned traits, he or she must reinforce the good habits using appraisal.
Prior to using this model, the advanced practice nurse should understand that commitment and success in the Health Promotion Model is highly dependent on self-awareness and efficacy on the part of the patient. Knowing that people with poor health status have the worst health outcomes, the advanced practice nurse can tailor health promotion behavior that meets the individual's needs (Ho, Berggren, & Dahlborg‐Lyckhage, 2010). It is also important that the advanced practice nurse recognizes when the patient is in the decision making stage versus the action stage and provide resources according to the patient's stage. For example, providing diabetes supplies to a patient in the decision making phase might elucidate feelings of incompetence and worthlessness and increases chances that they will be non-complaint with the program. The advanced practice nurse in this case should provide resources to Lorenzo, including teaching about diabetes and making sure he expresses full knowledge of the benefits and consequences of following the health promoting behavior related to diabetic care. Tailoring programs to achieve long term behavior modification reduces patient stress, empowers the patient, and increases the likelihood of adhering to the program.
Although sociopolitical and economic influences are infrequently addressed in the Pender model, the advanced practice nurse must understand that these factors are highly critical to the patient’s behavior and ability to comply. Individuals may be unable to engage in health promoting behaviors due to lack of money, time, transportation, support, or resources. Competing demands in the environment, such as war or political turmoil, are not easily modified and frequently take precedence over healthy behaviors. In the planning and decision making phase, the advanced practice nurse should use a holistic framework to guide interventions in order to increase understanding of the patient’s situation and behavior.
Behaviors such as diet and activity are embedded in our sense of culture and personality. Many behaviors that influence health are so deeply engrained in an individual's way of life that the individual is unwilling to change their habits. Therefore, when an advanced practice nurse educates a patient to change or modify the aforementioned traits, he or she must reinforce the good habits using appraisal.
Prior to using this model, the advanced practice nurse should understand that commitment and success in the Health Promotion Model is highly dependent on self-awareness and efficacy on the part of the patient. Knowing that people with poor health status have the worst health outcomes, the advanced practice nurse can tailor health promotion behavior that meets the individual's needs (Ho, Berggren, & Dahlborg‐Lyckhage, 2010). It is also important that the advanced practice nurse recognizes when the patient is in the decision making stage versus the action stage and provide resources according to the patient's stage. For example, providing diabetes supplies to a patient in the decision making phase might elucidate feelings of incompetence and worthlessness and increases chances that they will be non-complaint with the program. The advanced practice nurse in this case should provide resources to Lorenzo, including teaching about diabetes and making sure he expresses full knowledge of the benefits and consequences of following the health promoting behavior related to diabetic care. Tailoring programs to achieve long term behavior modification reduces patient stress, empowers the patient, and increases the likelihood of adhering to the program.
Although sociopolitical and economic influences are infrequently addressed in the Pender model, the advanced practice nurse must understand that these factors are highly critical to the patient’s behavior and ability to comply. Individuals may be unable to engage in health promoting behaviors due to lack of money, time, transportation, support, or resources. Competing demands in the environment, such as war or political turmoil, are not easily modified and frequently take precedence over healthy behaviors. In the planning and decision making phase, the advanced practice nurse should use a holistic framework to guide interventions in order to increase understanding of the patient’s situation and behavior.