Application of Middle-Range Theory in Caring for Mr.

Duran

Application of Middle-Range Theory in Caring for Mr. Duran

Elizabeth M. Jarry
American International College

Elizabeth.Jarry@aic.edu

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Introduction

It is known that patients with a co-morbidity of diabetes are representative of

a large subgroup of the global population. Their plan of care is complex and
requires specific programs such as implementation of self-management theories
that can take account their needs for managing this chronic disease (Wu, Chang,
2014). According to Lynch, Fernandez, Lighthouse, Mendenhall, and Jacobs
(2012): Mexican Americans are almost twice as likely as non-Hispanic whites to
be diagnosed with type 2 diabetes. They are also more likely to suffer from
diabetic complications. I chose to discuss a middle-range theory because of its
simplicity when following the framework and it can be applied into practice for
caring for Mr. Duran. Middle-range theories tend to be "user friendly" in language
and style (McEwen & Wills, 2014, pg. 225). Mr. Duran has had difficulty with
comprehension so it is important to use a theory that is not complex in nature. A
middle-range theory that can be applied to Mr. Duran's situation is the Integrated
Theory of Health Behavior Change (ITHBC). This theory suggests that a patient
can change his health behavior by fostering knowledge and beliefs, increasing selfregulation skills and abilities, and enhancing social facilitation (Ryan, 2009). By
using this theoretical framework, Jenny can focus her assessment, improve
communication with other disciplines and manage Mr. Duran's condition with

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holistic care. Research has shown that personal behavior causes more that 50% of
illnesses and that while everyday management of these chronic conditions are the
responsibility of the person and/or family, the person and family are usually not
prepared to take on this responsibility (Ryan, 2009). Also, by using this middlerange theory we can attempt to understand the situation and evaluate Mr. Durans
knowledge and use this information to guide towards application. The assessment
can be more focused by identifying an explanation for Mr. Durans response to his
condition. The ITHBC is a blend of concepts from evidence-based studies and
multiple theories. By applying this theory to Mr. Duran, Jenny will be able to
assess his knowledge about diabetes and factors associated with treatment. Jenny
can then provide person-centered interventions to further increase his knowledge
while helping to develop self-regulation behaviors (changing his health behaviors
such as diet) and social facilitation such as social support (Ryan, 2010). In this
case study, I will apply the middle-range theory, ITHBC, to care for Mr. Duran. I
will discuss why Jenny should apply this theory and how a plan of care can be
developed with its use. I will also explore other theories that may have been
applied to this case study.

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Middle-Range Theory of Integrated Theory of Health Behavior Change (ITHBC)

Jenny should apply this theory in caring for Mr. Duran because she needs to
promote a health behavior change for him to self-manage his diabetes. This theory
suggests that in order to change health behaviors, knowledge and beliefs, selfregulation skills and abilities, and social facilitation needs to be enhanced (Ryan,
2010). She is able to do this by giving him the knowledge of how to administer his
own insulin and better managing his diabetes of 10 years. This allows for selfregulation of self-control. Jenny can also use the social support from Jenny O
Connell, Jim Carlson, and also Mrs. Duran. All of theses people involved are major
role players in identifying Mr. Durans unhealthy behaviors and helping to prepare
and apply interventions needed for his self-regulation in diabetic management. The
American Association of Diabetic Educators have identified seven behaviors that
should be managed by the patient. They are: medication use, exercise, diet or
weight loss, and managing the psych-social dimension of diabetes (Lynch,
Fernandez, Lighthouse, Mendenhall, & Jacobs, 2012). This theory is applicable to
Mr. Duran because when used, his behavior will change so that he can manage his
diabetes. Jenny uses this theory by combing all of the concepts in this theory:
knowledge, self-regulation process, and social facilitation to promote selfmanagement.

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Assessment, Plan of Care, and Education

It is important when applying this theory that Jenny understands how health
behavior change is made and how she can encourage and support that change. She
needs to be sensitive to Mr. Durans age and culture when imparting knowledge.
He is sixty years old and although he speaks English, his wife who will also be a
participant in his care, does not. Jenny also needs to be aware that diabetic patients
with depression can have higher rates of disabling and fatal complications (Osborn,
Kozak, & Wagner, 2010). His depression from the murder of his daughter can
affect him physically as well as mentally. It will be important in her plan of of care
to consider that in one study, it was found that Mexican Americans consider
barriers to taking medications to be their language, cost of medication, and lack of
insurance (Lynch, Fernandez, Mendenhall, and Jacobs, 2012). Knowing that with
any behavioral change, the highest rate of relapse is early on, Jenny will have to
have all resources available to support Mr. Duran. In order to fully apply this
theory, Jenny would have to assess what is Mr. Durans current level of knowledge,
what are his goals, how is he able to incorporate the new behaviors successfully
into his life, who can support him, and how can he manage his depression. After
obtaining this data, the diagnosis in the plan of care would be: Alteration in self-

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care due to difficulty accepting lifestyle change; knowledge deficit; insufficient

resources and dysfunctional grieving. Jenny will educate Mr. Duran and his
support system on how to self-manage his diabetes. She can do this by instructing
in an age appropriate and culturally sensitive way the patho-physiology of diabetes
and by teaching him and Mrs. Duran how to monitor blood glucose levels and then
safely-administer insulin.

Alternate Theory

Jenny may have been able to use an alternate middle-range theory with a
positive patient-outcome for Mr. Duran. The Bandura self-efficacy theory is a selfmanagement program and would provide a solid foundation for diabetic
management. The key construct in this theory is self-efficacy, what one thinks and
feels influences how they act. Because Mr. Duran is depressed and confused, he
may have low efficacy and not able to have the confidence to solve a problem,
such as managing diabetes. This theory builds self-efficacy through mastery (find
out what Mr. Duran knows now so that can be focused upon), vicarious experience
(show Mr. Duran that other Mexican American adults can manage diabetes), verbal
persuasion (positive feedback), and self-appraisal (helping Mr. Duran recognize his
thoughts about his grief of the loss of his daughter and give strategies to manage

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feelings). This theory can be applied to any patient of any ethnicity to change their
behavior for positive outcome (Wu, Chang, 2014).

Conclusion

I have gained new knowledge from writing this paper on how a nurse can
help to support and empower a family dealing with diabetes. By helping to educate
a patient and promote self-management while still giving support, we are providing
high-quality care with the best expected outcome. I think this is so important in our
community because Mr. Duran is a perfect example of a typical patient that I
would care for at Baystate Medical Center in Springfield. By applying either one
of these middle-ranged theories I can help that patient gain the confidence they
need to recognize their behavior and work towards changing it so that they can
better manage their chronic illness. I have also learned some strategies on how to
apply self-efficacy information to my patients. For example, I learned that mastery
is the most influential source of self-efficacy. If I could show Mr. Duran how to
self-administer insulin and am present when he did it, all while providing praise, he
would have a high-efficacy which would result in a continued positive behavior
health care change. These theories are congruent with my holistic approach to
nursing and I plan on applying them when caring for my patients.

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References
Lynch, E., Fernandez, A., Lighthouse, N., Mendenhall, E., & Jacobs, E. (2012). Concepts of
diabetes self-management in Mexican American and African American low-income
patients with diabetes. Oxford Journals, (27)5, 814-824. doi: 10.1093/her/cys058
McEwen, M., & Wills, M.E., (2014). Theoretical Basis for Nursing (4th ed.) Philadelphia, PA:
Lippincott, WIlliams, & Wilkins.
Osborn, C., Kozak, C., Wagner, J. (2010). Theory in practice: Helping providers address
depression in diabetes care. Journal of Continuing Education in the Health
Professions,

30(3), 172-179. doi: 10.1002/chp.20078

Ryan, P., (2010). Integrated Theory of Health Behavior Change: Background and Intervention
Development. Clin Nurse Spec, 23(3), 161-172. doi:
10.1097/Nur.0b013e3181a42373
Wu, C. J., & Chang, A.M. (2014). Application of a theoretical framework to foster a cardiac
diabetes self-management program. International Nursing Review, 61(3), 336-343.
doi:10.1111/inr.12104

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