NURS 8114 Week 5 Framework Selection Paper Example

Three Candidates, One Problem: Selecting a Framework for Poor Glycemic Control Among Adults at a Rural Clinic

Student Name

College of Nursing, Walden University

NURS 8114: Theoretical and Scientific Foundations of Nursing

Instructor Name

Month Day, Year

Three Candidates, One Problem: Selecting a Framework for Poor Glycemic Control Among Adults at a Rural Clinic

The Problem Restated

At a composite rural family clinic, adults living with type 2 diabetes have poorer glycemic control than the clinic's quality targets, and the pattern persists despite regular visits and prescribed medications. The description written earlier in the course identified plausible mechanisms: patients who understand their treatment but do not carry out daily self-management; distances that make education classes hard to attend; long work days in agriculture and manufacturing; and a clinic model in which most teaching happens in brief visits. This paper weighs three frameworks against that problem and selects one to carry forward.

Criteria Named in Advance

Four criteria were named before any framework was examined, so that the choice would not be justified after the fact. Coverage: do the framework's concepts address the problem's main mechanisms? Level: does its level of abstraction match the problem's, which is a problem of individual daily behavior shaped by circumstances? Predictive value: do its propositions predict a change that a clinic could realistically produce? Measurability: have its central concepts been measured before in people with diabetes?

Orem's Self-Care Deficit Theory

Orem's theory holds that people have self-care requisites, that nursing is needed when a person's capacity for self-care, called self-care agency, falls short of what the situation demands, and that nursing systems range from wholly compensatory to supportive-educative (Orem, 2001). It covers the problem well at a descriptive level: adults with diabetes have therapeutic self-care demands, such as monitoring glucose and adjusting diet, and a deficit exists where they do not meet them. Its level is broader than the problem, since it describes the whole of self-care. Its central proposition, that a supportive-educative system can close a deficit, is plausible but general. Self-care agency has been measured, though instruments vary and are not always specific to diabetes.

King's Theory of Goal Attainment

King's theory describes nurse and patient as interacting systems who perceive, judge and act, and it proposes that when they mutually set goals and agree on means, goals are more likely to be attained (King, 1981). Its strength here is the clinic visit itself: goal setting between nurse and patient is something the clinic already does, if informally. Its weakness is coverage. The problem's main mechanisms occur between visits, in patients' daily routines, and King's theory focuses on the transaction within the visit. Its concepts have been used in studies, but measurement of mutual goal setting is less developed than for the other candidates.

Bandura's Self-Efficacy Construct

Bandura (1977) proposed that people's beliefs about their ability to carry out a behavior, their self-efficacy, shape whether they try it at all and how hard and how long they keep at it, and that self-efficacy is built through mastery experiences, vicarious experience, verbal persuasion and physiological and emotional states. The construct comes from psychology, not nursing, but it addresses the problem's central mechanism directly: patients who know what to do but do not do it daily. In adults with diabetes, higher self-efficacy has been associated with better self-management behaviors across racial and ethnic groups and levels of health literacy (Sarkar et al., 2006). Diabetes self-efficacy has been measured with brief scales used in community programs, including a peer-led self-management trial (Lorig et al., 2009).

Why Not Combine All Three?

A tempting response to three partly fitting frameworks is to combine them: Orem for the deficit, King for the visit and Bandura for daily behavior. The analysis resists that move for two reasons. First, the frameworks rest on different assumptions about what drives behavior. Orem locates it in capacity and demand, King in the interaction between nurse and patient and Bandura in the person's beliefs about their own ability. Combining them without reconciling those assumptions produces an eclectic list rather than a framework, and a list cannot predict which change should come first. Second, a project with three frameworks needs measures for each, which a small rural clinic is unlikely to sustain.

Selecting one framework and naming a secondary lens is a more honest compromise. It commits the project to one set of predictions while acknowledging, in advance, the part of the problem that framework is least able to explain.

Criteria Table

Table 1 rates each framework against the four criteria.

Table 1

Frameworks Rated Against Four Criteria

Selection and Its Limits

Bandura's self-efficacy construct is selected. It best matches the problem's level, offers the most specific predictions and is the easiest to measure. Its main gap is access: self-efficacy does not explain why a patient who feels capable cannot attend a class forty miles away. The analysis therefore keeps Orem's theory in view as a secondary lens, since its notion of self-care agency includes the resources a person has, and a later mapping may use Orem to describe the access barriers self-efficacy does not reach.

Choosing a framework from outside nursing is legitimate when it fits the problem better, and self-efficacy has been widely used in nursing research and practice. The choice does commit the project to certain assumptions, notably that beliefs drive behavior more than circumstances, which the project must test rather than assume.

What the Selection Commits the Project To

Selecting self-efficacy commits the later project to three things. Its intervention should aim at the sources of efficacy Bandura named, for example by building mastery through small, achievable goals and by using peers with diabetes as models. Its measures should include diabetes self-efficacy as well as glycemic results, so that the mechanism, not only the outcome, can be tracked. And its evaluation should look for patients whose self-efficacy rose but whose control did not, since that pattern would point back to the access barriers the chosen framework does not cover. If two frameworks had fit equally well, the analysis would have preferred the one with better measures, since a framework that cannot be measured cannot guide an evaluation.

References

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. https://doi.org/10.1037/0033-295X.84.2.191

King, I. M. (1981). A theory for nursing: Systems, concepts, process. Wiley.

Lorig, K., Ritter, P. L., Villa, F. J., & Armas, J. (2009). Community-based peer-led diabetes self-management: A randomized trial. Diabetes Educator, 35(4), 641-651. https://doi.org/10.1177/0145721709335006

Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). Mosby.

Sarkar, U., Fisher, L., & Schillinger, D. (2006). Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy? Diabetes Care, 29(4), 823-829. https://doi.org/10.2337/diacare.29.04.06.dc05-1615